TJTES 2018-4

ISSN 1306 - 696X

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

Volume 24 | Number 4 | July 2018

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) Publication Secretary (Yayın Sekreteri) Emblem (Amblem) Correspondence address (Yazışma adresi)

Tel Fax (Faks)

Kaya Sarıbeyoğlu Kaya Sarıbeyoğlu M. Mahir Özmen Kerem Ayar 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): March (Mart) 2018 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)

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 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 24

Number - Sayı 4 July - Temmuz 2018

Contents - İçindekiler Deneysel Çalışma - Experimental Experimental Studies - DeneyselStudy Çalışma 281-286 Effects of peritoneal lavage and dry cleaning on bacterial translocation in a model of peritonitis developed using cecal ligation puncture Çekal ligasyon puncture ile oluşturulan peritonit modelinde periton lavajı ve kuru temizliğin bakteri translokasyonuna etkisi Koç TR, Tarhan ÖR, Sarıcık B 287-293 Effect of β-glucan on serum levels of IL-12, hs-CRP, and clinical outcomes in multiple-trauma patients: a prospective randomized study Çoklu travma hastalarda β-glukanın serum IL-12, hs-CRP değerleri ve klinik sonuçları üzerine etkisi: İleriye yönelik randomize çalışma Fazilaty Z, Chenari H, Shariatpanahi ZV

Original Articles - Orijinal Çalışma 294-302 Top 100 cited articles in traumatology: A bibliometric analysis Travmatolojide en sık alıntılanan 100 makale: Bibliyometrik bir analiz Dokur M, Uysal E 303-310 The epidemiology of acute occupational hand injuries treated in emergency departments in Foshan City, South China Güney Çin Foshan ilinde acil servislerde tedavi edilen mesleksel akut el yaralanmalarının epidemiyolojisi Wu Z, Guo Y, Gao J, Zhou J, Li S, Wang Z, Huang S, Huang S, Li Y, Chen J, He M 311-315 Emergency computed tomography for the diagnosis of acute appendicitis: How effectively we use it?

Akut apandisit tanısında bilgisayarlı tomografi ne kadar etkili kullanılıyor?

Yazıcı P, Öz A, Kartal K, Battal M, Kabul Gürbulak E, Akgün İE, Yetkin SG, Mihmanlı M 316-320 Multislice computed tomographic measurements of optic nerve sheath diameter in brain injury patients Beyin hasarı olan hastalarda çok kesitli bilgisayarlı tomografide optik sinir kılıfı ölçümleri Özsaraç M, Düzgün F, Gölcük Y, Pabuşcu Y, Bilge A, İrik M, Yılmaz H 321-326 Effects of temporary abdominal closure methods on mortality and morbidity in patients with open abdomen Open abdomen uygulanan hastalarda geçici batın kapama yöntemlerinin mortalite ve morbidite üzerine etkisi Kılıç E, Uğur M, Yetim İ, Temiz M 327-332 Utility of HAPS for predicting prognosis in acute pancreatitis Akut pankreatit prognozunu tahmin etmede HAPS’nin değeri Sayraç AV, Cete Y, Yiğit Ö, Aydın AG, Sayrac N 333-336 Efficacy of laboratory tests and ultrasonography in the diagnosis of acute appendicitis in gravid patients according to the stages of pregnancy Gebeliğin evresine göre ultrasonografi ve laboratuvar testlerin akut apandisit tanısına etkisi Başkıran A, İnce V, Çiçek E, Şahin T, Dirican A, Balıkçı Çiçek İ, Işık B, Yılmaz S 337-342 Adherence to vaccination recommendations after traumatic splenic injury Travmatik dalak yaralanmalarından sonra aşılama rehberlerine uyum Belli AK, Dönmez C, Özcan Ö, Dere Ö, Dirgen Çaylak S, Dinç Elibol F, Yazkan C, Yılmaz N, Nazlı O

Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

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TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 24

Number - Sayı 4 July - Temmuz 2018

Contents - İçindekiler

343-350 Antivenom use in bite and sting cases presenting to a public hospital Bir devlet hastanesine başvuran ısırma ve sokma olgularında antivenom kullanımı Şahin A, Arıcı MA, Hocaoğlu N, Kalkan Ş, Tunçok Y 351-358 Initial inferior vena cava and aorta diameter parameters measured by ultrasonography or computed tomography does not correlate with vital signs, hemorrhage or shock markers in trauma patients Ultrason ve bilgisayarlı tomografi ile travma hastalarının başvurusu esnasında ölçülen inferior vena kava ve aort çap parametreleri vital bulgular, kanama ve şok belirteçleri ile korele değildir Çelik ÖF, Akoğlu H, Çelik A, Asadov R, Ecmel Onur Ö, Denizbaşı A 359-363 Comparison of the functional results of radial head resection and prosthesis for irreparable mason type-III fracture Mason tip III parçalı radius başı kırıklarında rezeksiyon ve protez uygulamalarının fonksiyonel sonuçlarının mukayese edilmesi Ünlü MC, Güven MF, Arslan L, Aydıngöz Ö, Bilgili MG, Bayrak A, Babacan M, Kaynak G, Botanlıoğlu H

Case Series - Olgu Serisi 364-368 Reconstruction of extensive scalp defects with anterolateral thigh flap Geniş saçlı deri defektlerinin serbest anterolateral uyluk flebi ile onarımı Altınkaya A, Yazar Ş, Sağlam İ, Gideroğlu K 369-375 Three-dimensional printing-assisted surgical technique with limited operative exposure for both-column acetabular fractures Asetabulumun her iki kolon kırığına kısıtlı cerrahi ekspozür sağlayan üç boyutlu yazıcı yardımlı cerrahi teknik Shon HC, Choi S, Yan JY

Case Report - Olgu Sunumu 376-378 Strangulated Morgagni hernia in an adult: Synchronous prolapse of the liver and transverse colon Bir yetişkinde strangüle Morgagni hernisi: Karaciğer ve enine kolonun eş zamanlı prolapsusu Lee SY, Kwon JN, Kim YS, Kim KY

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EXPERIMENTAL STUDY

Effects of peritoneal lavage and dry cleaning on bacterial translocation in a model of peritonitis developed using cecal ligation and puncture Turgut Reis Koç, M.D.,

Ömer Rıdvan Tarhan, M.D.,

Bekir Sarıcık, M.D.

Department of General Surgery, Süleyman Demirel University Faculty of Medicine, Isparta-Turkey

ABSTRACT BACKGROUND: Currently, all progress in diagnostic techniques, surgical techniques, antibiotherapy, and intensive care units is accompanied by a decrease in the mortality due to severe secondary peritonitis; however, the rate is still unacceptably high. To remove the source of peritonitis, a surgeon has several options, such as closure, exclusion, and resection, depending on the preference of the surgeon and the condition of the patient. The aim of this study is to determine the rates of bacterial translocation by comparing the dry cleaning method (gauze squeezed with saline) and peritoneal lavage method (cleaning with saline), which are among the peritoneal cleaning methods.

METHODS: A total of 64 rats were studied as sham, control, dry cleaning, and saline cleaning groups. Only laparotomy was performed in the sham group, and cecal ligation puncture was performed in the control group. After ligation puncture operations in the other two groups, one of them was subjected to dry cleaning and the other to isotonic cleaning. The samples obtained from the liver, spleen, and mesothelium were sacrificed and cultured under aerobic and anaerobic environments.

RESULTS: There was no significant difference in the anaerobic bacterial counts, although there was a significant difference in the results of the aerobic bacterial counts in liver, spleen, and mesothelium samples on comparing the dry cleaning and saline cleaning groups.

CONCLUSION: According to our study, the cleaning of intraabdominal infections with dry gauze is more effective than the cleaning with physiological saline for the elimination of aerobic bacteria. There is no difference observed with respect to the anaerobic bacterial counts.

Keywords: Intraabdominal infection; peritoneal lavage; peritonitis.

INTRODUCTION Peritonitis is the inflammation of the peritoneal cavity. A form of peritonitis more commonly encountered by surgeons is secondary peritonitis, which is defined as the spillage of the intestinal content into the peritoneal cavity due to impaired integrity of the gastrointestinal tract.[1] At present, all progress in diagnostic techniques, surgical techniques, antibiotherapy, and intensive care units is accompanied by a decrease in the mortality due to severe secondary peritonitis, the rate of which is still unacceptably high.

The treatment of peritonitis comprises both surgical and sup-

portive therapy. The most important rule for the success of treatment is to conduct the surgery as early as possible to prevent the release of bacteria and helper pathogens into the peritoneal cavity.

Bacterial intestinal translocation occurs when the gastrointestinal microflora passes through the lamina propria into the local mesenteric lymph nodes and then into other organs (liver, spleen, etc.).[2] The enteric bacteria can then spread throughout the body through the systemic circulation and cause death as a result of sepsis, shock, and multi-organ failure. Therefore, surgical treatment of secondary peritonitis should be based on the control of the infection site, reduc-

Cite this article as: Koç TR, Tarhan ÖR, Sarıcık B. Effects of peritoneal lavage and dry cleaning on bacterial translocation in a model of peritonitis developed using cecal ligation puncture. Ulus Travma Acil Cerrahi Derg 2018;24:281-286.

Address for correspondence: Bekir Sarıcık, M.D. Süleyman Demirel Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Isparta, Turkey Tel: +90 246 - 211 92 80 E-mail: drbekirsaricik@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(4):281-286 DOI: 10.5505/tjtes.2017.97838 Submitted: 01.08.2017 Accepted: 15.11.2017 Online: 26.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Koç et al. Peritoneal dry cleaning

tion of contamination, and prevention of recurrent infections.

To remove the source of peritonitis, the surgeon has several options, such as closure, exclusion, and resection, depending on the preference of the surgeon and the clinical condition of the patient. However, the resection of the infiltrated tissue is considered to be the best method if it is possible.[1,3] The second target in the surgical treatment of severe peritonitis is the removal of all necrotic and purulent material from the abdominal cavity. Although it is very popular among surgeons, the effect of intraoperative peritoneal lavage has not been found to be sufficient so far.[4] The aim of this study was to determine the rates of bacterial translocation by comparing two of the intraperitoneal cleaning methods: dry cleaning (with gauze made wet by saline and squeezed later) and cleaning with saline.

MATERIALS AND METHODS This study was conducted on 64 female, 12–14-week-old Wistar albino rats weighing 190–250 g. These rats were provided with free food and water and kept at room temperature prior to the study. These 64 adult rats were randomly divided into four groups (n=16). The rats were obtained from Süleyman Demirel University Experimental Study and Experimental Animal Laboratory. The study was initiated after obtaining the Experimental Animals Research Ethics Board Approval. All procedures were applied to the rats under general anesthesia performed by administrating 90 mg/kg of ketamine hydrochloride and xylazine into the peritoneum. Rats were not given any food and drink for 14 hours before the surgery.

Group 1 (Sham Group) Peritoneal slides were obtained from this group after laparotomy. After 48 hours, the second laparotomy was performed and liver, spleen, and mesothelium tissue samples were obtained. Aerobic and anaerobic blood samples were obtained from the inferior vena cava and aorta and sacrificed.

Group 2 (Control Group) After laparotomy, ligation was performed from 3/0 silk to the side wall of the cecum.

An 18-gauge was drilled through the end of the ligation junction with the injector tip to create perforation. After 48 hours, the abdomen was opened and liver, spleen, and mesothelium samples were obtained. Additionally, samples of aerobic and anaerobic blood cultures were obtained from the inferior vena cava and sacrificed.

Group 3 (Dry Cleaning Group) İn this group, after laparotomy, ligation was performed with 3/0 silk to the lateral wall of the cecum. An 18-gauge was drilled through the end of the ligation junction with the injec282

tor tip. After some feces were allowed to infiltrate into the abdomen, the fascia and the skin were closed. After 10 hours, the abdomen was opened again and the cecum was resected.

The abdominal cavity, back of the liver and spleen, right and left paracolic areas, and pelvis were cleaned using sterile gauze. Fascia and skin were closed. After 48 hours, the liver was opened again and liver, spleen, and mesothelium tissue samples were obtained and sacrificed.

Group 4 (Saline Washed Group) In this group, after laparotomy, ligation was performed with 3/0 silk to the side wall of the cecum. An 18-gauge was drilled through the end of the ligation junction with the injector tip. After some feces were allowed to infiltrate into the abdomen, the fascia and the skin were closed. After 10 hours, the abdomen was opened again and the cecum was resected.

The abdominal cavity, back of the liver and spleen, the right and left paracolical areas, and pelvis were washed with 5 cc saline physiologically kept at room temperature (25 °C); then, the fluid was aspirated with an aspirator. This process was repeated five times. Fascia and skin were closed. After 48 hours, tissue samples were obtained and sacrificed

Microbiological Evaluation A total amount of 2cc-systemic blood sample from the inferior vena cava was immediately placed in blood culture bottles and taken to the microbiology laboratory for incubation.

Microorganisms began to signal in 2 days. Those that were incubated and grew in Bactec 9120 BD automated blood culture system were cultured onto suitable solid media (for aerobic bacteria, blood eosin methylene blue (EMB) and chocolate agar; for anaerobic bacteria, Schadler Agar and chocolate agar) and then incubated at 37 ºC for 24–72 hours. Bacteria grown on plaque were identified by BDTM BBLTM Crystal System.

Tissue specimens were weighed on a precision scale under sterile conditions, and their weight was recorded. Then, the samples to prevent deterioration during transport were placed in liquid media containing 6 ml of thiogluconate vigor and brain–heart broth, and brought to the microbiology laboratory.

The tissue samples were homogenized, and then aerobic and anaerobic microorganisms were cultured in duplicate with 0.1 ml of the blood EMB agar, chocolate agar, and Schadler media.

At 37 ºC, 24–72 hours of incubation was allowed in aerobic and anaerobic environment. After 24 hours, the plates were separated for colony counting and typing. Non-reproductive plaques were allowed to complete the 72-hour period. The colony counts on the reproductive plates were recorded.

Gram staining was performed for aerobic and anaerobic bacterial colonies. Bacteria that were grown in aerobic medium and classified as gram negative were typed with BDTM BBLTM Crystal E/NF semi-automated identification system.

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Koç et al. Peritoneal dry cleaning

The following formula was used to calculate the number of microorganisms per gram of tissue as a bacterial translocation index in tissues where colonization was detected.

Number of colonies per gram of tissue (cfu/gr) = (N × D × a × b)/W, where the indications are as follows: N, plate colony count D, inoculum dilution value a, the amount of liquid medium in which the specimen is dispensed b, the amount of inoculum W, specimen weight

and the saline washed group (p=0.746) and the saline washed group and the dry cleaning group (p=0.495) in the evaluation of microorganisms grown in the spleen anaerobic medium (Fig. 4).

Number of anaerobic bacteria in the liver

Bacteria grown in anaerobic medium were typed with BDTM BBLTM Crystal semi-automated identification system and colony counts were recorded.

RESULTS

50000.00

p=0.053

40000.00 30000.00 20000.00 10000.00 0.00 Dry Cleaning

p=0.110 p=0.063

120000.00

p=0.055

p=0.014

100000.00 80000.00 60000.00

p=0.680

40000.00 20000.00 p=0.034

0.00 Sham

Control

Dry Cleaning

Saline Washed

Groups

Figure 1. Statistics of bacterial count (aerobic) in the liver.

Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Saline Washed

Figure 2. Statistics of bacterial count (anaerobic) in the liver.

Number of aerobic bacteria in the bpleen

A significant difference was found in both the saline and dry cleaning groups (p=0.011) as well as between the control group and the dry cleaning group (p=0.013) in the evaluation of bacterial growths in the spleen aerobic medium (Fig. 3). Statistically significant difference (p=0.040) was found between the control group and the dry cleaning group, whereas there was no significant difference between the control group

p=0.664

Groups

120000.00 100000.00

p=0.27

p=0.536

p=0.011

p=0.027 p=0.013

80000.00 60000.00 40000.00 20000.00 p=0.034

0.00 Sham

Control

Dry Cleaning

Saline Washed

Groups

Figure 3. Statistics of bacterial count (aerobic) in the spleen.

Number of anaerobic bacteria in the bpleen

With respect to the counts of bacteria in the aerobic and anaerobic media in the liver, there was no significant difference in serum bacterial counts between the saline washed group and the dry cleaning group (p=0.680 and p=0.664, respectively) in the evaluation of microorganisms grown in aerobic and anaerobic medium in liver (Figs. 1 and 2).

Number of aerobic bacteria in the liver

p=1.00

Sham

The experimental group was divided into four sub-groups as: sham group, control group, dry cleaning group, and saline washed group. There were three levels of organ factor: liver, spleen, and mesothelium. Mann-Whitney U test was used for the comparison of the binary groups.

140000.00

60000.00

120000.00

p=0.746

100000.00 80000.00

p=0.040

p=0.495

60000.00 40000.00 20000.00 0.00 Control

Dry Cleaning

Saline Washed

Groups

Figure 4. Statistics of bacterial count (anaerobic) in the spleen.

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Number of aerobic bacteria in the meso.

Koç et al. Peritoneal dry cleaning

400000.00

p=0.24 p=0.002

300000.00

p=0.025

p=0.767 p=0.005

200000.00

100000.00

p=0.40

0.00 Sham

Control

Dry Cleaning

Saline Washed

Groups

Number of an aerobic bacteria in the meso.

Figure 5. Statistics of bacterial count (aerobic) in the mesothelium.

600000.00 500000.00 400000.00 300000.00

p=0.275

200000.00

p=0.040

p=0.664

100000.00 0.00 Control

Dry Cleaning

Saline Washed

Groups

Figure 6. Statistics of bacterial count (anaerobic) in the mesothelium.

There was no significant difference between the control group and the saline washed group (Fig. 5), although there was a significant difference between the control group and dry cleaning group and between saline washed group and dry cleaning group in the evaluation of the aerobic bacterial growth at mesothelium.

When the number of anaerobic bacteria at mesothelium was evaluated, there was a significant difference between the control group and the dry cleaning group (p=0.040), but no significant difference was found in binary comparisons of other groups (Fig. 6).

DISCUSSION The treatment of intraabdominal infections continues to be a problem today despite improvements in surgery. The common etiological factors are perforation of hollow organs and/or intestine and pancreatic necrosis. In our study, we used cecal ligation puncture to develop peritonitis. The cecal ligation puncture model is widely used for the modeling of sepsis and septic 284

shock. This model has advantages such as containing diversity of cecal microorganism, originating from the focal infection, producing septicemia, and disseminated peripheral bacterial products. Using cecal ligation puncture, it is possible to investigate chronic sepsis as well as acute sepsis and to change the severity of sepsis. Furthermore, by ligating the cecum, tissue necrosis observed in clinical sepsis after severe trauma may also be developed. Cecal ligation puncture largely resembles intraabdominal abscess formation. Another advantage of the cecal ligation puncture model is that the inoculated microbial agents are obtained from the host rather than exogenously.

For the reasons mentioned above, we believe that it is a suitable model for frequently encountered situations.

In peritonitis, depending on the resistance of the organism, intraabdominal cavity abscess formation, fistula, or diffuse peritonitis may occur. The methods currently in use are improving day-by-day, but they lead to some intolerable problems. Traditionally, the importance of drainage and lavage in the treatment of intraabdominal infections has long been known.[5,6] Currently, these two methods are widely used to control the source of infection and reduce peritoneal contamination.[7,8] We compared the currently accepted and used lavage methods for the clinical significance of our results.

The removal of the source of infection usually requires repairing of the related organ or resection, if repair is not possible.

Infectious or necrotic material must be removed from the peritoneal cavity after the removal of the source of infection. Additional materials such as foreign body, necrotic tissue, fibrin, bile, blood, and intestinal contents increase the number of bacteria when it is in the abdominal cavity and cause an increase in infection severity by deteriorating the function of macrophages and neutrophils. Because the drainage of dense contents may be difficult and insufficient,[9–11] the peritoneal cavity should be cleaned simultaneously during the operation. There are various alternatives for this. Classically, gas compresses, dry cleaning, lavage, debridement, and postoperative irrigation are applied.

In the cases where peritoneal contamination is localized partially, dry cleaning of the area with gas compresses during operation may allow removal of most of the contaminated material from the environment, avoiding the spread to the clean peritoneal area.

Thus, it is possible to lavage the abdominal cavity more safely.

There are also several studies which report that lavage does not increase bacterial spread.[12,13] Intraoperative lavage is a standard procedure for intraabdominal infections.

The main aim of the lavage applied during the operation is to reduce the number of bacteria as much as possible and to remove harmful foreign substances from the infiltrated area.

In this way, the defense mechanisms of the organism are also Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Koç et al. Peritoneal dry cleaning

supported.[8,9] Many of the studies in literature aimed to improve the effectiveness of currently used lavage methods by changing the content of the liquid. There are a few number studies comparing lavage with other methods.

Recently, high-volume intraoperative lavage has also been recommended.[14] This process should be continued until the wash water is clean. Usually, 8–12 liters of physiological saline is sufficient. Antimicrobial agents may also be added to the lavage solution, but there is an ongoing debate about its effectiveness. The view that this is not necessary in patients who receive appropriate systemic antibiotic therapy has become more popular in recent years. It has been experimentally determined that lavage does not increase bacterial spread.[13,14] It is also argued that intraoperative debridement should be performed in a limited as well as in a radical manner. Perforations after radical debridement have also been reported to be more frequent.[1,3] The presence of fibrin and platelets in the peritoneal cavity may weaken bacterial clearance by blocking the diaphragmatic lymphatic system.

It also causes the prematurity of peritoneal neutrophils and prevents phagocytosis of bacteria. The clearance of fluid, particulates, and microorganisms in the peritoneal cavity is usually through the diaphragmatic and parietal peritoneal lymphatic system.[15,16] Small diaphragmatic stomata are found around the mesothelial cells of the peritoneum covering the muscular part of the diaphragm. The presence of peritoneal inflammation increases the efficiency of these stomata and the mechanism of diaphragmatic clearance.[17] Fluids and particles that cannot be absorbed through peritoneal and diaphragmatic lymphatic drainage are cleared from the peritoneal cavity through these stomata.[18] In animal studies, it has been shown that clearance of fluids and particles with diaphragmatic lymphatic drainage is a very fast-acting mechanism.

Presence of microorganisms in the thoracic duct could be demonstrated at 6 minutes after intraperitoneal injection of microorganisms, but it is only possible to isolate the caval system at the 12th minute. The other mechanism of clearance is via the peritoneal macrophages. Dunn et al.[19] demonstrated that half of the intraperitoneal bacteria were physically cleared by diaphragmatic lymphatic drainage and the other half underwent phagocytosis by the peritoneal macrophages.

These two effective mechanisms are the primary mechanisms of clearance after bacterial contamination. If these mechanisms are inadequate, the peritoneal neutrophil concentration and activity increases as an inflammatory response that targets to eliminate or localize the infection.

Experimental models in the study of Zaleznik et al.[20] have shown that microorganisms frequently isolated from intraabUlus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

dominal infections such as Enterobacteriaceae and Bacteroides fragilis have the ability to adhere to the mesothelial surfaces and that these organisms cannot be removed from the peritoneum by peritoneal lavage or via other cleaning methods. Another study reported that bacteria still remain in the mesothelial surface after extended peritoneal lavage.[21] Abbasoglu et al.[22] found that intraoperative peritoneal lavage increases survival in experimental peritonitis cases. But it has been shown that performing it intermittently in the postoperative period does not affect the survival time. In addition, it was also shown that bactericidal activity of peritoneal fluid decreases in the same period due to lavage, and it recovers after just 4 hours.

Another study by Abbasoglu et al.[22] has shown that the effect of intraperitoneal povidoneiodine on the peritoneal defense mechanisms is due to toxicity and that 1% povidone iodine solution does not disrupt the local defense mechanisms of the peritoneum. The addition of antibiotics or antiseptics to irrigation solutions has shown to have a positive effect on the process of intraabdominal infections.[23] According to the data obtained from this study, it was found that intraoperative dry cleaning of the abdominal cavity reduced the duration of stay in surgical clinics and the number of complications. Also, in terms of drainage requirement in the surgical treatment of intraabdominal infections, it was observed that intraoperative dry cleaning provided significantly better results by decreasing the bacterial translocation rates compared to saline washing.

Conflict of interest: None declared.

REFERENCES 1. Nathens AB, Rotstein OD. Therapeutic options in peritonitis. Surg Clin North Am 1994;74:677–92.

2. Hudspeth AS. Radical Surgical Debridement in the Treatment of Advanced Generalized Bacterial Peritonitis. Arch Surg 1975;110:1233–6.

3. Polk HC, Fry DE. Radical peritoneal debridement for established peritonitis. The results of a prospective randomized clinical trial. Ann Surg 1980;192:350–5.

4. Hupfeld L, Burcharth J, Pommergaard HC, Rosenberg J. The best choice of treatment for acute colonic diverticulitis with purulent peritonitis is uncertain. BioMed Research International 2014:2014:1–4.

5. Ragetly GR, Bennett RA, Ragetly CA. Septic peritonitis: etiology, pathophysiology, and diagnosis [Article in German]. Tierarztl Prax Ausg K Kleintiere Heimtiere 2012;40:290–7.

6. Teichmann W, Pohland C, Mansfeld T, Herbig B. Peritonitis: attempt to evaluate therapeutic surgical options [Article in German]. Chirurg 2008;79:282–9.

7. Wittmann DH, Schein M, Condon RE. Management of Secondary Peritonitis. Ann Surg 1996;224:10–8.

8. Culp W, Holt D. Septic peritonitis. Compend Contin Educ Vet 2010;32:E1–15.

9. Ponzano C, Hüscher CGS, Overi D. Laparoscopic Lavage Is Feasible and Safe for the Treatment of Perforated Diverticulitis With Purulent Peritonitis: The First Results From the Randomized Controlled Trial DILALA. Ann Surg 2017;265:e66–7.

10. Cirocchi R, Trastulli S, Vettoretto N, Milani D, Cavaliere D, Renzi C, et al. aparoscopic peritoneal lavage: a definitive treatment for diverticular

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11. Toorenvliet BR, Swank H, Schoones JW, Hamming JF, Bemelman WA. Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review. Colorectal Dis 2010;12:862–7.

12. Normann E, Aune S. Absorption of ampicillin from the peritoneal cavity.

In patients with diffuse peritonitis. Arch Surg 1971;102:469–70.

13. Autio V. The spread of intraperitoneal infection. Studıes wıth roentgen contrast medıum. Acta Chir Scand Suppl 1964;36:SUPPL321:1–31.

14. Kujath P, Eckmann C, Esnaashari H, Bruch HP. The value of different lavage treatment patterns in diffuse peritonitis. Zentralbl Chir 2007;132:427–32.

15. Yamamoto T, Nagasue K, Okuno S, Yamakawa T. The role of peritoneal lavage and the prognostic significance of mesothelial cell area in preventing encapsulating peritoneal sclerosis. Perit Dial Int 2010;30:343–52.

16. Scheingraber S, Bauerfeind F, Böhme J, Dralle H. Limits of peritoneal cytokine measurements during abdominal lavage treatment for intraabdominal sepsis. Am J Surg 2001;181:301–8.

17. Yao V, Platell C, Hall JC. Role of peritoneal mesothelial cells in peritoni-

tis. Br J Surg 2003;90:1187–94.

18. Abu-Hijleh MF, Habbal OA, Moqattash ST. The role of the diaphragm in lymphatic absorption from the peritoneal cavity. J Anat 1995;186:453– 67.

19. Dunn DL, Barke RA, Knight NB, Humphrey EW, Simmons RL. Role of resident macrophages, peripheral neutrophils, and translymphatic absorption in bacterial clearance from the peritoneal cavity. Infect Immun 1985;49:257–64.

20. Zaleznik DF, Kasper DL. The Role of Anaerobic Bacteria in Abscess Formation. Annu Rev Med 1982;33:217–29.

21. Edmiston CE Jr, Goheen MP, Kornhall S, Jones FE, Condon RE. Fecal peritonitis: microbial adherence to serosal mesothelium and resistance to peritoneal lavage. World J Surg 1990;14:176–83.

22. Abbasoglu O, Sayek I, Hasçelik G. Effect of povidone-iodine lavage on peritoneal defence mechanisms in rats. Eur J Surg 1993;159:521–4.

23. Wang ZW, Jin HS, Luo ZD, Xie SK, Hu SX, Liu XT, et al. Effect of peritoneal lavage with povine-iodine on prevention of postoperative sepsis after exposure of peritoneal cavity to sea water in rat [Article in Chinese]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 2004;16:103–5.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Çekal bağlama ve delmeyle oluşturulan peritonit modelinde periton lavajı ve kuru temizliğin bakteri translokasyonuna etkisi Dr. Turgut Reis Koç, Dr. Ömer Rıdvan Tarhan, Dr. Bekir Sarıcık Süleyman Demirel Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Isparta

AMAÇ: Günümüzde, tanı yöntemlerindeki, cerrahi tekniklerdeki, antibiyoterapi ve yoğun bakım ünitelerindeki ilerlemeler, şiddetli sekonder peritonitin mortalitesini azaltmasına rağmen, mortalite hala kabul edilemeyecek kadar yüksektir. Peritonit kaynağını ortadan kaldırmak için cerrahın kapatma, dışa alma ve rezeksiyon gibi çeşitli seçenekleri vardır. Bu yöntemlerin hangisinin uygulanacağı cerrahın tercihine ve hastanın durumuna bağlıdır.

Bu çalışmanın amacı peritoneal temizleme yöntemleri arasında yer alan kuru temizleme (izotonikle ıslatılıp sıkılmış gazlı bezler=kuru temizlik) ile izotonikle peritoneal lavaj yöntemini karşılaştırılarak bakteriyel translokasyon oranlarını belirlemektir.

GEREÇ VE YÖNTEM: Sham, kontrol, kuru temizlik ve izotonikle temizlik grubu olarak toplam 64 sıçan üzerinde çalışma yapıldı. Sham grubunda sadece laparotomi, kontrol grubuna çekal bağlama ve delme işlemi uygulandı. Diğer iki gruba bağlama ve delme işlemi sonrası birinde kuru temizlik diğerinde izotonikle temizleme işlemi yapıldı. Sakrifiksayon sonrası karaciğer, dalak ve mezodan elde edilen örnekler aerobik ve anaerobik ortamlarda kültüre alındı.

BULGULAR: Karaciğer, dalak ve mezo örneklerinin kültür sonuçlarında aerob bakteri ölçümlerinde kuru temizlikle izotonik grubu arasındaki değerlendirmede anlamlı fark bulunmasına rağmen anaerob bakterilerde ise anlamlı fark saptanmadı.

TARTIŞMA: Yaptığımız çalışmaya göre karıniçi enfeksiyonların tedavisinde, karın temizliği açısından ıslatılıp sıkılmış gazlı bezle yapılan temizlik serum fizyolojikle yapılan temizliğe göre aerobik bakteriler açısından daha efektif olduğu söylenebilir. Anaerob bakteriler açısından her iki yöntem arasında fark görülememektedir.

Anahtar sözcükler: İntraabdominal enfeksiyon; peritoneal lavaj; peritonit.

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doi: 10.5505/tjtes.2017.97838

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EXPERIMENTAL STUDY

Effect of β-glucan on serum levels of IL-12, hs-CRP, and clinical outcomes in multiple-trauma patients: a prospective randomized study Zakyeh Fazilaty, MSc,1 Hamid Chenari, M.D.,2 Zahra Vahdat Shariatpanahi, M.D., Ph.D1 1

National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology,

Shahid Beheshti University of Medical Sciences, Tehran-Iran 2

Department of Anesthesiology and Critical Care, Haftometir Hospital, Iran University of Medical Sciences, Tehran-Iran

ABSTRACT BACKGROUND: Trauma is associated with a profound immunological dysfunction. This predisposes patients to infections and adverse outcomes. β-glucan has been implicated in the initiation of anti-microbial immune response. The present study aimed to evaluate the effects of an enteral diet containing β-glucan on serum levels of IL-12 and highly-sensitive C-reactive protein (hs-CRP), occurrence of infection, and clinical outcomes in critically ill multiple-trauma patients.

METHODS: Forty multiple-trauma patients requiring enteral nutrition for at least 10 days were randomly assigned to the intervention group (n=20) or the placebo group (n=20). The intervention group received a high-protein enteral diet providing 3 g β-glucan, and the control group received a similar diet, except for 3 g of maltodextrin as a placebo. Serum levels of IL-12 and hs-CRP were measured on days 0, 10, and 21.

RESULTS: The β-glucan group showed significantly higher serum levels of IL-12 on day 21 compared to the control group. Infection frequency and duration of mechanical ventilation were significantly lower in the β-glucan group. A significant difference was found in the Sequential Organ Failure Assessment (SOFA) score in favor of the β-glucan group. No difference was found in the serum levels of hs-CRP, length of ICU stay, occurrence of infection, and mortality rates between the two groups.

CONCLUSION: β-glucan may increase serum levels of IL-12, shorten the duration of mechanical ventilation, and reduce organ failure in critically ill multiple-trauma patients.

Keywords: Enteral nutrition; ICU; infection; prebiotic.

INTRODUCTION Due to weakened immune systems and gut barriers, trauma patients admitted to intensive care unit (ICU) frequently exhibit elevated levels of infection and inflammation compared to other ICU patients. Additionally, critical illness, coupled with invasive devices and procedures, increases such patients’ exposure to pathogens in the hospital environment or mixed with their microflora. A trauma patient’s length of stay in ICU can be influenced by infection, pulmonary complications, sepsis, respiratory failure, and multiple-organ dysfunction

(MODS), resulting in an overall proinflammatory response and immunosuppression.[1,2] Studies have shown that that interleukin-12 (IL-12) is essential for the differentiation, proliferation, and maintenance of T-helper 1 responses, leading to the production of interferon gamma, and IL-2. Trauma causes a reduction in IL-12 production.[3,4] In turn, these cytokines promote T-cell responses and macrophage activation.[5,6] Furthermore, reduced IL-12 production promotes T-cell commitment toward a T-helper 2 pattern that correlates with adverse clinical outcomes in patients.[3,4]

Cite this article as: Fazilaty Z, Chenari H, Shariatpanahi ZV. Effect of β-glucan on serum levels of IL-12, hs-CRP, and clinical outcomes in multiple-trauma patients: a prospective randomized study. Ulus Travma Acil Cerrahi Derg 2018;24:287-293.

Address for correspondence: Zahra Vahdat Shariatpanahi, M.D. 3, Baran, West Arghavan, Farahzadi Blvd., Shahrak Qods Tehran, İran.

Tel: +98(21)22357483-4 E-mail: nutritiondata@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(4):287-293 DOI: 10.5505/tjtes.2017.34514 Submitted: 01.01.2017 Accepted: 15.11.2017 Online: 21.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Some studies have shown that the prebiotic consumption can result in the production of colonic small chain fatty acids; have beneficial effects on endotoxemia, inflammatory cytokine production,[7] and probiotics including isomaltooligosaccharides and fructooligosaccharide; and increased the IL-12 production in mice.[8,9] Prebiotics such as β-glucan are non-digestible food ingredients that stimulate probiotic bacterial growth or activity in the colon healthy ways.[10] β-glucan also enhances IL-12 production in human blood dendritic cells (DCs) and monocytes-derived DCs.[11] Animal studies have shown that oral or parenteral administration of oat βglucan can prevent parasitic, bacterial, and viral infections.

[12,13] Some in vitro studies have also supported the beneficial effects of β-glucan on the immune system.[14,15] Studies on humans have shown that the administration of soluble fiber or intravenous β-glucan in trauma patients and in patients with severely acute pancreatitis reduced the infection, length of ICU stay, and septic morbidity.[16–18]

Data Collection

Unfortunately, most studies have been done in vitro or on animals. Moreover, the few studies conducted on humans have been limited to intravenous administration of β-glucan. In the present study, we investigated the clinical outcomes of oral β-glucan supplementation with respect to serum levels of IL12 and hs-CRP in trauma patients admitted to ICU.

Wound infection was defined as a positive result of bacterial growth of more than 1×105 colony-forming units per gram of tissue.[22]

MATERIALS AND METHODS This randomized, double-blind, controlled, clinical trial was conducted in a tertiary care university hospital between June 2013 and November 2015. Informed consent for the participation of patients in the study was obtained from first-degree relatives. Patients were enrolled if they were older than 18 years of age, had two or more organ-system traumas, had life expectancy of more than 21 days after randomization, had normal weight (body mass index = 18.5–29.9), were not immunosuppressed or did not have previous infection, and were in need of mechanical ventilation. All patients were to receive more than 75% of total energy within 48 hours. After inclusion, a computer-generated random number with a ratio of 1:1 assigned the patients to the β-glucan group or control group.

Acute Physiology and Chronic Health Evaluation III (APACHE III) Score, and Injury Severity Score (ISS) were recorded for all patients. All patients were fed a hospital-prepared, high-protein, standard kitchen formula. Daily energy consumption was calculated by 25-30 kcal/kg for each patient based on weight and metabolic condition. The distribution of macronutrients was as follows: 20% protein, 30% lipid, and 50% carbohydrate.

The β-glucan group received 3 g of oat β-glucan (Arian Salamat Sina Company, Tehran, Iran) daily, and the control group received 3 g of maltodextrin as placebo daily. The patients did not consume any other product or food containing prebiotics during the trial. The energy intake from tube feeding during the study period was recorded for each patient daily. The patients, investigators, and all clinical personnel were blinded to the randomization throughout the study.

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We collected the following data from each patient: occurrence of infection, ventilator-associated pneumonia (VAP), MODS, number of mechanical ventilation days, length of ICU stay, and mortality.

Infection Sepsis and bacteremia were defined according to a consensus panel convened by the American College of Chest Physicians and the Society of Critical Care Medicine (SCCM).[19] Central nervous system (CNS) infection was diagnosed according to the Centers for Disease Control’s definitions for nosocomial infections.[20] Urinary tract infection was diagnosed by examining urine culture.[21]

VAP was defined as a new infiltrate on chest X-rays occurring more than 48 hours after endotracheal intubation plus two or more of the following: fever (body temperate >38.3°C), leukocytosis (white blood cell count >12×109/ml), leucopenia (white blood cell count <4×109/ml), and purulent tracheobronchial secretions.[23]

Organ Failure Occurrence of MODS was monitored during the hospitalization. The Sequential Organ Failure Assessment (SOFA) score was used to determine the extent of organ function in patient. Each patient was evaluated for cardiovascular failure (systolic blood pressure ≤ 90 mmHg or requiring vasopressor support), CNS failure (Glasgow coma score ≤12), coagulation failure, hepatic failure (bilirubin ≥2 mg/dL), and renal failure (serum creatinine ≥2 mg/ dL or 25% increase from the baseline).[24]

Laboratory Data To measure hs-CRP and IL-12 levels, blood samples were taken on study days 0 (before starting enteral nutrition), 10, and 21 (unless the patient was discharged or expired before day 21).Sera were frozen at −80°C. They were subsequently analyzed in duplicate using enzyme-linked immunoassay (ELISA) in dilutions that allowed interpolation from simultaneously run standard curves. IL-12 was measured using human high sensitivity IL-12 ELISA kit (Diaclone, France). The minimum detectable dose of IL-12 was <0.75 pg/ml, with an inter-assay precision of 7.9% and an intra-assay precision of 16.1%. hs-CRP was measured using commercially available ELISA (Diagnostics Biochem Canada Inc). The minimum detectable concentration for hs-CRP is 0.001 mg/dL serum Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Fazilaty et al. Effect of β-glucan on serum levels of IL-12, hs-CRP, and clinical outcomes in multiple-trauma patients

levels of IL-12; hs-CRP were determined according to manufacturer’s instructions.

Assessed for eligibility (n=68)

Statistical Analysis The minimum sample size estimated for each group was 15 at a power (1–β) of 80% and α=0.05 for a parallel interventional study with two-tailed testing to detect the reduction of ICU length of stay with a pooled standard deviation of 7.3 days, according to the study by Min Tan et al.[25] Demographic data, baseline values, and outcome measures were compared using Student’s t-test or Mann–Whitney test for all continuous variables. Categorical data between the groups were compared using Fisher’s exact test. Paired t-tests or Wilcoxon test were applied for comparisons of variables before and after intervention. Results were reported as mean±standard deviation for parametric tests and as median (Q1−Q3) for nonparametric tests. P-values of <0.05 were considered significant; all statistical analyses were performed using SPSS version 18.

Excluded (n=28) Refusal to continue (n=2) Discharge or death before day 10 (n=16) Supplemental PN (n=10)

Total randomized (n=40)

β-glucan group (n=20)

Control group (n=20)

Figure 1. CONSORT flow diagram of the trial.

tients’ baseline characteristics are shown in Table 1. No significant differences in baseline characteristics were observed between the two groups.

RESULTS Study Population Characteristics Overall, 68 patients were included in the study; 13 patients from the control group and 15 patients from the β-glucan group were excluded because of refusal to continue the study, discharge, or death before 10 days of intervention and refusal to initiate supplemental parenteral nutrition during intervention. Therefore, finally, 20 patients in the β-glucan group and 20 patients in the control group completed the study. The patients’ mean age was 38.8±13.9 years. The pa-

Nutritional Variables No significant difference was observed in the amount of feeding tolerance between the β-glucan group and control group during the study period (1710.5±117.03 kcal vs.

1718.2±182.4 kcal, p=0.6). For all patients, enteral feeding was initiated within 24–48 hours of admission. In addition, No significant difference in the serum albumin levels were observed between the β-glucan group and control group on

Table 1. Baseline characteristic of the patients

β-glucan Placebo p (n=20) (n=20)

Age, median (Q1–Q3)*

43 (29–53)

32 (25.5–43)

0.1

Gender, n (%)** 1

Male

18 (90)

18 (90)

Female

2 (10)

2 (10)

GCS, median (Q1–Q3) *

7 (5–7)

6 (5–7)

Serum albumin (Mean±SD)*** 3±0.3 APACHE III, median (Q1–Q3)* ISS (Mean±SD)*** Energy intake (Mean±SD)***

62 (56.25–67)

0.7

3.1±0.4 0.9

62 (53.25–64.75)

0.7

38.75±13.7 36.75±14.7 0.6 1710.5±117 kcal

1718.2±182.4 kcal

0.64

Type of surgery, n (%)** 1

Abdominal surgery

5 (25)

4 (20)

Neurosurgery

14 (70)

14 (70)

Orthopedic surgery

6 (30)

7 (35)

No surgery

5 (25)

4 (20)

Mann-Whitney U test; **Fisher exact test; ***Student’s t-test. GCS: Glasgow Coma Scale; SD: Standard deviation.

*

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Fazilaty et al. Effect of β-glucan on serum levels of IL-12, hs-CRP, and clinical outcomes in multiple-trauma patients Table 2. Changes in serum levels of IL-12 and hs-CRP in study period

β-glucan Placebo p* (n=20) (n=20)

IL-12 (pg/dL), median (Q1–Q3)

Day 0

86.6 (61.5–104.8)

70.25 (59.3–98.2)

0.47

Day 10

67.4 (41.3–77.5)

50.6 (35.05–59.6)

0.14

Day 21

129.65 (73.7–181.0)

73.85 (40.7–107.9)

0.03

hs-CRP (mg/dL), (Mean±SD)

Day 0

14.08±0.5

14.02±0.31

0.7

Day 10

14.04±0.47

13.88±0.38

0.2

Day 21

9.96±0.44

10.15±0.37

0.1

P with Mann-Whitney for IL-12 and Student’s t-test for hs-CRP. hs-CRP: Nighly-sensitive C-reactive protein.

*

Table 3. Comparison of clinical outcomes in the two groups

β-glucan (n=20)

Placebo p* (n=20)

Length of ICU stay (Mean±SD)* 27.55±7.8

31.2±15.8 0.07

SOFA score, median (Q1–Q3)**

5 (4.25–6)

9 (6–10)

<0.001

15 (10–22.5)

28 (11–39.75)

0.01

1 (5%)

4 (20%)

0.1

Ventilator days, median (Q1–Q3) **

Mortality, n (%)***

Student’s t-test; **Mann-Whitney U Test; ***Fisher exact test. SD: Standard deviation. SOFA: Sequential Organ Failure Assessment; ICU: Intensive care unit.

*

Table 4. Type and number of infection

β-glucan Placebo p (n=20) (n=20)

Type of infection, n (%)* Ventilator Associated Pneumonia

4 (20)

4 (20)

1

0

4 (20)

0.1

Urinary tract Wound

2 (10)

4 (20)

0.6

Sepsis

0

2 (10)

0.4

0

3 (15)

0.2

Infection rate, n (%)*

Central nervous system

5 (25)

11 (55)

0.1

Infection frequency

5 times

26 times

0.03

**

Fisher exact test; **Mann-Whitney U Test.

*

day 0 (3±0.3 mg/dL vs. 3.1±0.4 mg/dL, p=0.9), day 10 (2±0.5 mg/dL vs. 1.8±0.4 mg/dL, p=0.7), or day 21 (2.1±0.2 mg/dL vs.

2±0.2 mg/dL, p=0.9).

Biochemistry Changes in serum levels of IL-12 and hs-CRP in the study period are shown in Table 2. Baseline serum levels of IL-12 and hs-CRP were not significantly different between the βglucan group and the control group. Serum levels of IL-12 on 290

days 21 were significantly higher in the β-glucan group than in the control group. Serum levels of hs-CRP decreased in both groups on day 21 with no significant difference between the β-glucan group and the control group.

Clinical Outcomes The patients’ clinical outcomes are shown in Table 3. The SOFA score for developing organ failure was significantly lower in the β-glucan group than in the control group. There Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Fazilaty et al. Effect of β-glucan on serum levels of IL-12, hs-CRP, and clinical outcomes in multiple-trauma patients

was no difference in the mean length of ICU stay between the two groups (p=0.07). Duration of mechanical ventilation was significantly lower in the β-glucan group (p=0.01). The overall in-ICU mortality rate was 12.5%. There was no difference in mortality rate between the two groups (p=0.1).

Forty percent of all patients developed infection, of which 25% were in the β-glucan group and 55% in the control group, without showing any significant difference. It was noted that infection frequency was significantly higher in the control group (Table 4).

DISCUSSION Results of the present study indicated that patients who were fed an enteral diet with β-glucan, showed a significantly lower duration of mechanical ventilation, higher IL-12 production, lower rates of organ failure, and lower rates of infection. We did not find any difference in the ICU length of stay and mortality rate between the two groups. Several in vitro and in vivo studies have shown that β-glucan increases IL-12 production. It has been shown that β-glucan can induce human peripheral blood mononuclear cell proliferation and phenotypic and functional maturation of DCs, with significant IL-12 and IL-10 production.[11] In addition, β-(1, 4) glucan can induce significant IL-12 production by in vitro macrophage cell lines.

[26] In Qi et al.[27] study, particulate β-glucan induced DCs to produce high levels of IL-12 but low amounts of IL-6 and IL10. In a clinical trial comprising women with breast cancer, 21 days of administration of oral β-glucan significantly increased the serum levels of IL-12.[28] CRP is a positive, acute-phase protein produced by hepatocytes in response to inflammatory conditions. CRP levels quickly increase in response to trauma, inflammation, and infection and decrease just as quickly as the body condition improves. Therefore, CRP levels are widely used to monitor various inflammatory conditions.[29,30] In our study, although the decrease in serum levels of CRP was not significant between the two groups, serum levels of IL-12 in the β-glucan group increased significantly on day 21 compared to that in the control group, which may have contributed to the improvement in clinical outcomes. These results indicate that even in situations involving inflammation, β-glucan may play an important role in immune system modulation.

Literature review suggests that β-glucan administration could reduce infection. Animal studies have shown that β-glucan reduces parasitic and bacterial infection in infected mice.[12] In an experimental model of sepsis, administration of β-glucan indicated reduced serum levels of TNF-α, IL-6, and IL-1β and decreased mortality rate.[31] In mice infected with Staphylococcus aureus and Candida albicans, oral administration of β-glucan increased the expression of dectin-I and Toll-like receptors (β-glucan receptors) in immune cells, with the elevation of serum levels of IL-12, thereby resulting in higher resistance to infection.[32] Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

A review study concluded that the oral and parenteral administrations of β-glucan have the same efficacy on enhancing resistance to pathogen infections.[33] Three clinical trials showed that the pretreatment of high-risk surgical patients with intravenous PGG-glucan can shorten the length of ICU stay, reduce rates of infection, decrease need for antibiotic therapy, and reduce mortality rate.[34–36] A review study evaluating the role of immune-enhancing enteral diet in perioperative patients showed significance reduction inmortality and complications compared to standard formulas.[37] In a study of patients with severe acute pancreatitis, enteral nutrition containing soluble and insoluble prebiotic fiber was compared with the standard enteral solution. The intervention group exhibited a decreased mean duration of APACHE II normalization, decreased mean duration of CRP normalization, decreased length of ICU stay, and decreased overall complications compared to the control group.[16] One clinical trial explored the prevention of nosocomial pneumonia and sepsis by treating patients with intravenous administration of β-glucan. The results showed a significant decrease in the occurrence of pneumonia and sepsis in the β-glucan group compared to the control group.

Moreover, the mortality rate related to infection was significantly higher in the control group.[17] A separate randomized controlled clinical trial in trauma patients showed that after the intravenous administration of β-glucan for 7 days, total mortality and septic morbidity rates were significantly lower in the β-glucan group.[18] We noted significantly shorter duration of mechanical ventilation dependency in the β-glucan group than in the control group. In general, for patients needing mechanical ventilation, respiratory and diaphragmatic muscles were weakened and mucociliary motility is diminished.[38,39] β-glucan can reportedly improve pulmonary function[40,41] and increase the production of lysozyme in respiratory mucosal secretion.[42] In addition, there is growing evidence that β-glucan improves brain function, as demonstrated in terms of neuroprotection and improvements in cognition and mood.[43] In the present study, organ failure involvement was significantly lower in the β-glucan group than in the control group.

Multiple hypotheses have been proposed to explain this outcome. Bacterial translocation due to the disruption in the gut-barrier function may contribute to the development of organ failure. Therefore, consumption of foods that improve the gut-barrier function may prevent bacterial translocation.

Prebiotics enhance immune system functions by enhancing the gut-barrier function, reducing the intestinal colonization of pathogenic bacteria to decrease proinflammatory cytokines, improving the balance of the peripheral immune system, and improving the production of bacteriocins and immunoglobulin A (IgA) levels in the small intestine and caecum.

[44,45] This may explain the lower incidence of organ failure in the β-glucan group.

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Most studies on critically ill patients have investigated the effect of probiotic or symbiotic formulas. Because probiotics are living organisms, their administration may cause infection in the host. Bloodstream infections resulting from probiotics can be attributed to the bacterial translocation across gut mucosa.[46,47] ASPEN guidelines do not make a recommendation at this time for the routine use of probiotics across the general population of ICU patients.[48] In contrast, β-glucan, a prebiotic, does not introduce the risk of bloodstream infections. Therefore, given their beneficial contribution to enhance immune system and gut-barrier functions, which in turn contribute to reduce mortality and morbidity rates, βglucan could be included as a source of carbohydrates in the enteral formula for critically ill multiple-trauma patients.

The present study has some limitations and therefore should be considered as a pilot study. It was a single center study wirh small sample size. Therefore, larger, multicenter studies are further required to test the effect of β-glucan on serum levels of IL-12 and clinical outcomes.

Acknowledgments We convey our gratitude to the National Nutrition and Food Technology Research Institute, Tehran, Iran and the ICU staff at Haftom-e-tir Hospital Funding of this study was provided by the National Nutrition and Food Technology Research Institute. There are no conflicts of interest.

The following authors contributed to this study: Zakiyeh Fazilaty for experiment design and data collection; Zahra Vahdat Shariatpanahi for experiment design, consultation, and writing the draft report; and Hamid Chenari for data collection.

Conflict of interest: None declared.

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41. Talbott S, Talbott J. Effect of BETA 1, 3/1, 6 GLUCAN on upper respiratory tract infection symptoms and mood state in marathon athletes. J Sports Sci Med 2009;8:509–15.

42. Vetvicka V, Richter J, Svozil V, Rajnohová Dobiášová L, Král V. Placebo-driven clinical trials of yeast-derived β-(1-3) glucan in children with chronic respiratory problems. Ann Transl Med 2013;1:26.

43. Nelson ED, Ramberg JE, Best T, Sinnott RA.. Neurologic effects of exogenous saccharides: A review of controlled human, animal, and in vitro studies. Nutritional Neuroscience 2012;15:149–62.

44. Morrow LE, Gogineni V, Malesker MA. Probiotic, prebiotic, and synbiotic use in critically ill patients. Curr Opin Crit Care 2012;18:186–91.

45. Marik PE. What is the best way to feed patients with pancreatitis? Curr Opin Crit Care 2009;15:131–8.

46. Whelan K, Myers CE. Safety of probiotics in patients receiving nutritional support: a systematic review of case reports, randomized controlled trials, and nonrandomized trials. Am J Clin Nutr 2010;91:687–703.

47. Lolis N, Veldekis D, Moraitou H, Kanavaki S, Velegraki A, Triandafyllidis C, et al. Saccharomyces boulardii fungaemia in an intensive care unit patient treated with caspofungin. Crit Care 2008;12:414.

48. McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2016;40:159–211.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Çoklu travma hastalarda β –glukanın serum IL-12, hs-CRP değerleri ve klinik sonuçları üzerine etkisi: İleriye yönelik randomize çalışma Zakyeh Fazilaty,1 Dr. Hamid Chenari,2 Dr. Zahra Vahdat Shariatpanahi1 1 2

Ulusal Beslenme ve Gıda Teknolojisi Araştırma Enstitüsü, Beslenme ve Gıda Teknolojisi Fakültesi, Shahid Beheshti Tıp Bilimleri Üniversitesi, Tahran-İran Anesteziyoloji ve Kritik Bakım Bölümü, Haftometir Hastanesi, İran Tıp Bilimleri Üniversitesi, Tahran-İran

AMAÇ: Travma yoğun immünolojik işlev bozukluğuyla ilişkilidir. Bu durum hastaları enfeksiyonlara ve olumsuz sonuçlara yatkınlaştırır. Beta-glukan antimikrobiyal immün yanıtın başlamasıyla ilişkilendirilmiştir. Bu çalışma kritik çoklu travma hastalarında β-glukan içeren enteral diyetin serum IL-12 ve yüksek derecede duyarlı C-reaktif protein (hs-CRP) düzeyleri, enfeksiyon oluşumu ve klinik sonuçlar üzerine etkilerini değerlendirme amaçlanmıştır.

GEREÇ VE YÖNTEM: En az 10 gün enteral beslenmesi gereken 40 çoklu travma hastası girişim grubu (n=20) veya plasebo grubuna (n=20) randomize edildi. Girişim grubuna 3 g β-glukan içeren yüksek proteinli enteral diyet, kontrol grubuna ise benzer bir diyet ve plasebo olarak 3 g maltodekstrin verildi. Başlangıçta (0. gün), 10. ve 21. günde serum IL-12 ve hs-CRP düzeyleri ölçüldü.

BULGULAR: Kontrol grubuna göre beta-glukan grubu 21. günde anlamlı derecede daha yüksek serum IL-12 düzeyleri sergiledi. Beta-glukan grubunda enfeksiyon sıklığı ve mekanik ventilasyon süresi anlamlı derecede daha düşüktü. SOFA (Sequential Organ Failure Assessment, Ardışık Organ Yetersizliği Değerlendirme) skorunda β-glukan grubu lehine anlamlı derecede olumlu bir farklılık mevcuttu. İki grup arasında serum hs-CRP düzeyleri, yoğun bakım ünitesinde kalış süresi, enfeksiyon oluşumu ve mortalite oranları arasında herhangi bir farklılık saptanmadı.

TARTIŞMA: Beta-glukan kritik çoklu travma hastalarda serum IL-12 düzeylerini yükseltebilir, mekanik ventilasyon süresini kısaltabilir ve organ yetersizliğini hafifletebilir.

Anahtar sözcükler: Enfeksiyon; enteral beslenme; prebiyotik; yoğun bakım ünitesi.

Ulus Travma Acil Cerrahi Derg 2018;24(4):287-293

doi: 10.5505/tjtes.2017.34514

Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

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ORIGIN A L A R T IC L E

Top 100 cited articles in traumatology: A bibliometric analysis Mehmet Dokur, M.D.,1

Erdal Uysal, M.D.2

1

Department of Emergency Medicine, Biruni University Faculty of Medicine, İstanbul-Turkey

2

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

ABSTRACT BACKGROUND: In this bibliometric study, we aimed to conduct multi-dimensional citation analysis of the top 100 cited articles in traumatology.

METHODS: We analyzed the top 100 cited articles among 56.980 trauma articles published between 1975 and 2017, which we obtained from databases in Web of Science and PubMed based on their citation rates and publication years, countries of origin, institutions or organizations, the most common subjects, funding status, article types, and levels of evidence.

RESULTS: In the top 100 cited articles, the number of total authors was 649 and average authorship was 6.49±5.46 (1–32); group author or study group number was eight, and the number of total collaborators was 1241. USA was the top country in terms of country of origin and institutions or organizations and also the number of proceedings papers in scientific activities. We found that 70 of the top 100 cited articles were supported by funding agencies in developed countries. In the present study, the three most common subjects were central nervous system trauma (21 articles), major trauma–hemorrhage–bleeding control–transfusion–early coagulopathy (18 articles), and trauma care and systems (eight articles), respectively. The average level of evidence of the top 100 cited articles was 2.45±1.05 (range: 1–4). We also found that 66 of the 100 most frequently cited articles in traumatology were published in scientific journals that had an impact factor of ≥2.6 (range: 2.648–72.406). We found that the most commonly preferred article type by authors is clinical research (92 articles) and sub-type is prospective comparative studies (27 articles). Evidence groups of classical papers in traumatology were B (54 articles), A (26 articles), and C (20 articles), respectively.

CONCLUSION: Despite some flaws in determining the scientific values of articles, citation analysis of classical papers in traumatology can provide important scientific contributions.

Keywords: Articles; bibliometric; top-cited; traumatology.

INTRODUCTION Trauma is the most prominent cause of death in children and young people.[1] Approximately 5.8 million people die each year as a result of injuries. This accounts for 10% of the deaths worldwide.[2] For this reason, traumatic injuries, which are frequently encountered in emergency services and surgical clinics, are important clinical and surgical problems that require a multidisciplinary approach.[3,4] Trauma is generally accepted as preventable mortal and/or morbid problems. However, in a 25-year evaluation, Campbell WB et al.[5] reported that the number of all emergency admissions

increased with time, whereas mortality rates and hospitalization time reduced significantly. In this context, traumatology is a subject of study for scientific researches in epidemiological, diagnostic, therapeutic, and prognostic fields.[6,7] Initially, in 1987, Garfield E introduced the concept of “citation classics” for the best-cited articles published in JAMA. In later years, many bibliometric article analyses were conducted in different fields of medicine.[8] Citation analysis of classical or top-cited articles regarding traumatology can significantly contribute to this field in terms of exhibiting up-to-date academic information, progress, and tendencies. However, there

Cite this article as: Dokur M, Uysal E. Top 100 cited articles in traumatology: A bibliometric analysis. Ulus Travma Acil Cerrahi Derg 2018;24:294-302.

Address for correspondence: Mehmet Dokur, M.D. Biruni Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Beşyol Mah., No: 10, 34295 Florya, İstanbul, Turkey.

Tel: +90 212 - 411 39 00 / 1008 E-mail: mdokur@biruni.edu.tr Ulus Travma Acil Cerrahi Derg 2018;24(4):294-302 DOI: 10.5505/tjtes.2017.74857 Submitted: 21.09.2017 Accepted: 13.12.2017 Online: 20.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

294

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Dokur et al. Top 100 cited articles in traumatology: A bibliometric analysis

are few bibliometric studies related to traumatology in the current literature.[9–11] In the present study, we systematically analyzed the top 100 cited articles “key papers or classic papers” according to data obtained from PubMed and Web of Science (WoS) in the field of traumatology. We determined the number of citations with ranking, citations and publications by years, publishing journals, type and sub-type of articles, institutions and countries of origin, the most common topic of frequently cited articles, and authorship status of classical papers in this bibliometric research.

MATERIALS AND METHODS Study Design Study type: Retrospective clinical research Level of evidence: 3 or Group B (Scottish Intercollegiate Guidelines Network; SIGN).[12]

Data Collection and Inclusion Criteria Data used in this bibliometric citation analysis was obtained from Thomson Reuters’ WoS Core Collection database (Philadelphia, Pennsylvania, USA) and PubMed (US National Library of Medicine-National Institutes of Health). We accessed the WoS database (accessed date: 23.03.2017) using the keyword “trauma” between 1975 and 2017. Consequently, we obtained 56.980 articles and conducted analysis of the top 100 cited articles among these results. We accessed the remaining data pertaining to the analyzed articles via PubMed. Two of the authors (M.D. and E.U.) independently identified the top 100 cited articles with consensus.

Being a first author or co-author was accepted as the authorship criterion in the present study. To shorten the obtained table, we limited quantitative values to “2 or more and 3 or more.” The level of evidence of the top 100 cited articles was detected in accordance with SIGN criteria.[12] Accordingly, Group A evidence (levels 1a and 1b) comprised randomized clinical trials (RCT) or meta-analysis of RCT. Group B evidence (levels 2a, 2b, and 3) comprised cohort studies, case–control studies, and comparison of two or more groups where data were collected retrospectively, as well as semiexperimental studies. Group C evidence (level 4) comprised case series and expert opinions or expert committee reports (excluding levels 1 and 3 evidence). Group D evidence (level 5) comprised case reports.

Statistical Analysis Descriptive statistical methods were used in the present study. All data are expressed as a percentage, number, bar chart, or mean±standard deviation in the tables.

Ethical Statement All authors declare that the research was conducted according to the principles of the World Medical Association Declaration Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

of Helsinki “Ethical Principles for Medical Research Involving Human Subjects.” This study did not need to be approved by an ethics committee because it performed a bibliometric analysis or citation analysis of existing published classical studies.

RESULTS Contributions, Attributions, and Research Groups We detected the citation average of the top 100 cited articles in traumatology as 430.06±172.7 (range: 257–1108), and the sum of self-citation was 139 (according to Thomson Reuters’ WoS Core Collection). The publishing language was English for all articles. We found that the most cited article (times cited: 1108) in traumatology is the review by Boyd CR et al. on trauma scoring systems with the following topic: “Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma 1987;27:370–8.” The least cited article (times cited: 257) in traumatology was another review

by Leker RR and Shohami E who studied different etiological approaches on cerebral ischemia and trauma with the following title: “Cerebral ischemia and trauma-different etiologies yet similar mechanisms: neuroprotective opportunities.

Brain Res Rev 2002;39: 55-73’’ (Appendix 1). Among the 100 most influential manuscripts, the number of group authors or study groups was eight (CRASH-2 Trial Collaborators with two studies, 39 authors, and 1128 collaborators; Pediatric Emergency Care Applied Research Network with one study, 32 authors, and 109 collaborators; Working Group on Polytrauma of the German Trauma Society with one study, nine authors, and four collaborators; RECORD Trial Group with one study and 14 authors; EURODEM Risk Factors Research Group with one study and 10 authors; AG Polytrauma of the German Trauma Society (DGU) with one study and nine authors; Novoseven Trauma Study Group with one study and eight authors; and National Emergency X-Radiography Utilization Study Group with one study and five authors). In addition, the number of total authors and collaborators was 126 and 1241, respectively, in these study groups (according to Thomson Reuters’ WoS Core Collection). Analyses of the publications (between 1980 and 2013) and citation rates in 8 7 6 5 4 3 2 1 0 1975

1980

1985

1990

1995

2000

2005

2010

2015

Years

Figure 1. The top 100 cited articles published in each year (1980– 2013).

295

Dokur et al. Top 100 cited articles in traumatology: A bibliometric analysis

our study was 649, and average authorship in the classics in traumatology was 6.49±5.46 (1–32) (according to Thomson Reuters’ WoS Core Collection and PubMed). We analyzed the distribution of 20 authors who were included in more than three articles among the top 100 cited articles and found that the first three ranks were shared by Hoyt DB, Moore EE, and Moore FA, with five articles each. In addition to this, we observed that the most frequent first author of key papers included in our research was Campion HR with four articles, and Hoyt DB, Moore EE, and Copes WJ were detected to be the most frequent co-authors, with four articles each. In addition, Hoyt DB and Moore EE were included as first authors in one article. In addition, we also found that the number of authors included in two articles was 53 (Table 1).

3000

2500

2000

1500

1000

500

19 9 19 8 2099 0 20 0 2001 2002 0 20 3 2004 0 20 5 2006 0 20 7 2008 0 20 9 1 20 0 20 11 2012 1 20 3 1 20 4 2015 1 20 6 17

0

Figure 2. Citations in each year (last 20 years, source: Web of Science database).

each year (between 1998 and 2017) of “key papers” in traumatology found that the highest number of publications was seen in 2007 (seven publications) and the highest number of citations was seen in 2016 (2875 citations) (Figs. 1 and 2).

Authorship The total number of authors of “classic papers” included in

Countries and Institutions Or Organizations The three most common listed countries with two or more publications in the top 100 cited articles were USA (69%), England (13%), and Germany (11%), respectively. In total, 20 countries were listed 155 times in the top 100 cited articles (range: 2–69) (Table 2). In the present study, we determined that the most common listed institution or organization was the University of California (USA), and it was listed 34 times in the top 100 cited articles. Moreover, the number of institutions or organizations that published three or more publications was determined to be 21/31 (67.7%) of them were in USA (Table 3).

Table 1. The most common authors with two or more in the top 100 cited articles Author Affliation

296

Number

Hoyt DB

University of Maryland Medical Center, Baltimore (USA)

5

Moore EE

Denver Health Medical Center, Colorado (USA)

5

Moore FA

USAISR, Fort Sam Houston, TX 78234-6315 (USA)

5

Bouillon B

RWTH University Hospital Aachen, Aachen (Germany)

4

Brohi K

University of Maryland Medical Center, Baltimore (USA)

4

Champion HR

USAISR, Fort Sam Houston, TX 78234-6315 (USA)

4

Jurkovich GJ

Johns Hopkins Bloomberg School of Public Health, Baltimore (USA)

4

Trunkey DD

University of North Carolina, North Carolina (USA)

4

Copes WS

Washington Hospital Center, Washington DC (USA)

4

Hunt BJ

RWTH University Hospital Aachen, Aachen (Germany)

4

Croce MA

University of Tennessee, Memphis (USA)

3

Fabian TC

University of Tennessee, Memphis (USA)

3

Hall ED

Parke-Davis Pharmaceutical Research, Michigan (USA)

3

Holcomb JB

University of Maryland Medical Center, Baltimore (USA)

3

Lefering R

Ludwig-Maximilians-University, Munich (Germany)

3

Neugebauer E

RWTH University Hospital Aachen, Aachen (Germany)

3

Rivara FP

Johns Hopkins Bloomberg School of Public Health, Baltimore (USA)

3

Rossaint R

RWTH Aachen University Hospital, Aachen, (Germany)

3

Sacco WJ

Washington Hospital Center, Washington, DC (USA)

3

Wade CE

United States Army Institute of Surgical Research, Tt Sam Houston (USA)

3

Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Dokur et al. Top 100 cited articles in traumatology: A bibliometric analysis

Table 2. The most common listed countries with two or more in the top 100 cited articles

Table 3. Institutions of origin with three or more in the top 100 cited articles

Country Number*

Rank Institution

The United States of America

69

1

University of California, (USA)

34

The United Kingdom

Number*

13

2

University of Colorado (USA)

21

Germany 11

3

University of Washington (USA)

12

Canada 9

4

University of Toronto (Canada)

6

Netherlands 6

5

Witten Herdecke University (Germany)

6

France 5

6

University of Maryland (USA)

6

Scotland 5

7

University of Michigan (USA)

6

Switzerland 5

8

Harvard University (USA)

5

Denmark 4

9

San Fransisco General Hospital Medical

Israel 4

Center (USA)

5

Australia 3

10

Boston University (USA)

4

Austria 3

11

Denver Health Medical Center (USA)

4

Spain 3

12

Oregon University (USA)

4

Sweden 3

13

Sunnybrook Research Institue (Canada)

4

Belgium 2

14

University of Pennsylvania (USA)

4

Czech Republic

2

15

Washington Hospital Center (USA)

4

Finland 2

16

Ludwig Boltzmann Institute (Germany)

3

Italy 2

17

Mayo Clinic (USA)

3

Japan 2

18

Oregon Health & Science University (USA)

3

Slovenia 2

19

Pennsylvania Commonwealth System

of Higher Education-PCSHE (USA)

3

20

Pfizer Co. (USA)

3

21

Royal London Hospital (England)

3

22

RWTH Aachen University (Germany)

3

23

State University of New York (USA)

3

24

United States Army (USA)

3

25

United States Department of Defense (USA)

3

26

University of Glascow (UK)

3

27

University of Medicine and Dentistry

of New Jersey (USA)

3

28

University of Pittsburgh (USA)

3

29

University of Southern California (USA)

3

30

University of Tennessee (USA)

3

31

University Hospital Zurich (Switzerland)

3

*

Number of times listed of total 20 countries in the top 100 cited articles.

Funding In addition to this, we also detected that 70 of the top 100 cited articles in traumatology, which are considered “topic trends,” received funding support from 47 different funding agencies, and it was observed that the funding agencies that supported these scientific studies were NINDS NIH HHS (seven studies), NIGMS NIH HHS (six studies), and PHS HHS (four studies) (according to Thomson Reuters’ WoS Core Collection).

Journals and Proceedings Papers In the present study, 66 of the top 100 cited articles were published in journals that had an impact factor (IF) of ≥2.6 (range: 2.648–72.406, according to Clarivate Analytics, 2017).

In addition, we also found that “The Journal of Trauma and Acute Care Surgery” (previously known as “The Journal of Trauma Injury Infection and Critical Care,” which was sponsored from the beginning by the American Association for the Surgery of Trauma; AAST) had the highest number of publications (23 publications; Table 4). Moreover, we observed that the number of proceedings papers among the top 100 articles in 16 national and international scientific activities was 17, and the most presented proceedings paper was at the “56th Annual Meeting of the AAST” (date: September, 19–21, Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

*

Number of times listed of total 31 institutions in the top 100 cited articles.

1996; Houston TX, USA) (according to Thomson Reuters’ WoS Core Collection).

Main subjects The three most common topics among the top 100 cited articles in traumatology were central nervous system (CNS) trauma (21 articles), major trauma–hemorrhage–bleeding control–transfusion–early coagulopathy (18 articles), and 297

Dokur et al. Top 100 cited articles in traumatology: A bibliometric analysis

Table 4. List of journals in which two or more published articles Rank

Journal

Number of articles

Impact Factor (2016)*

1

The Journal of Trauma and Acute Care Surgery

23

2.802

2

Annals of Surgery

9

8.980

3

The Lancet

8

47.831

4

The New England Journal of Medicine

6

72.406

5

Journal of The American Medical Association

5

44.405

6

The Journal of Critical Care

3

2.648

7

Critical Care Medicine

2

7.050

8

Free Radical Biology & Medicine

2

5.606

9

Journal of Neuroscience

2

5.988

10

Journal of Neurotrauma

2

5.190

11

Neurology

2 7.592

12

Science

2 37.205

*

2016 Journal Citation Reports® (Clarivate Analytics, 2017).

trauma care–trauma care systems (eight articles), respectively (Table 5).

Study Types and Levels of Evidence In addition, among the top 100 “classic papers” in traumatology, the most preferred study type among researchers was clinical studies (92 articles) and the most preferred sub-type was prospective comparative studies (27 articles). In our study, the mean level of evidence was found to be 2.45±1.05 (1–4). In addition, evidence group of 54 articles were (prospective/retrospective comparative studies, retrospective cohort studies, case–control studies, descriptive studies, cross-sectional studies, and validation studies), and evidence group of 26 articles was A (meta-analysis of RCT, systematic review, RCT, and prospective cohort study). Lastly, the level of evidence of 20 articles were C group (reviews, expert committee reports, and expert opinions) (Table 6).

DISCUSSION Trauma or injury with its beforemath and aftermath is a complex series of events that include victims. In recent years, new concepts that prioritize cost-effectiveness, such as damage control resuscitation and damage control surgery, are increasingly becoming widespread.[13,14] Trauma has different types of etiologies and pathophysiological mechanisms based on its type.[15,16] Moreover, acoustic trauma should not be forgotten. However, very few bibliometric studies have been conducted in the field of traumatology. Thus, we prioritized conducting a study on this subject.

We preferred to conduct such a bibliometric study for the beginning in the field of traumatology. Although frequently criticized, particularly in terms of its statistical results, bibliometric citation analyses provide important clues about 298

the current best-cited or landmark articles to researchers because it reflects scientific improvements in the respective field and landmark papers and topic trends in a chronological perspective and in a systematic manner.[8,17,18] In the last 30 years, many bibliometric article analyses have been conducted in the field of clinical medicine.[19–21] Scientometric analyses, which include altmetric scores at different publication levels or values, have also been added to these studies in recent years.[22] We utilized current medical databases, primarily the WoS database and PubMed, in our bibliometric analysis. Despite the fact that many international medical databases (including PubMed, ScienceDirect, Medline, Scopus, Embase, EBSCO Host, etc.) have been used in citation analysis studies, the most frequently used source is Thomson Reuters’ WoS Core Collection. The WoS database includes important information in terms of detecting citations and researching other relevant academic effects.[23] Thus, to conduct this bibliometric study on the 100 most influential manuscripts, as in many similar types of researches.

It is also evident that the citation rates of articles are high and the citation range has a narrow distribution in this bibliometric study. This may be because studies conducted on attractive subjects of traumatology, such as evaluating trauma care, which has multiple effects and results, are high in number and also that produced articles are published in journals with high IFs; therefore, there are many citations. A scientific article being cited frequently and being published in journals with high IFs might be a significant indicator of its quality. In addition to this, there are many factors apart from the number of citations.[24] Being the first and original article in the respective field, which provides insight to researchers working in that field, is only of these other factors.[25] In a research Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Dokur et al. Top 100 cited articles in traumatology: A bibliometric analysis

Table 5. The most common topics among the top 100 cited articles Topic Number Central nervous system trauma

21

Major trauma–hemorrhage–bleeding control– transfusion–early coagulopathy

18

Trauma care

8

Major trauma–infection–sepsis

6

Abdominal trauma–feeding–septic mortality– gut bacterial translocation–decontamination

6

Fracture–dislocation–extremity trauma–hand wrist cumulative trauma disorder

6

Trauma score

3

Spinal cord trauma

3

Acoustic trauma

3

Trauma–venous thromboembolism

3

Traumatic deaths

2

between productivity in terms of scientific activity and high citation is also not necessary.[27] Some authors have even suggested scientist’ IF and metric evaluation scores in addition to the H-index, total IF, and citation number for evaluating a researcher’s scientific activity.[28] Factors such as the number of citations being in favor of old journals and publications, scientific articles not cited within 1–2 years after their publication, and post-publication citation peak being between 3 and 10 years and articles losing their importance after that period are the main limitations in determining the value of articles in citation classics studies.

[8,25] This effect was only partially displayed in our bibliometric research because researches cited in 2016, in which the number of citations peaked, were published 5–15 years ago.

The highest cited article and the second most common type of article being review studies in this bibliometric research is a typical example of that assumption. In his study, Garfield E[17] underlined that most of the highly cited articles were review studies.

Severe blunt trauma–ARDS–hemorrhagic shock–cytokine patterns

2

Trauma–postoperative fibrinolytic shutdown

2

Abdominal trauma–abdominal compartment syndrome

1

Abdominal trauma–staged laparotomy

1

Hepatic blunt trauma management

1

Major trauma–parachute use

1

Torture–trauma–posttraumatic stress disorder

1

Vascular trauma–endothelial precursors

1

Major trauma–plasma fibronectin (opsonic glycoprotein) levels

1

Trauma–surgery–the stress response

1

Multiple trauma–sedation–mortality

1

Trauma–whole body CT–survivre

1

Trauma–rheumatoid arthritis–matrix metalloproteinases 1 Obstetric trauma–vaginal delivery

1

Blunt aortic injury

1

Accidental and intentional injuries

1

Trauma–orthopedic–spinal implants–PEEK biomaterials 1 Trauma hypothermia

1

Trauma–inflammation–microbes–thymic stromal lymphopoietin 1

on 5-year citation reports of cardiovascular articles, Ranasinghe I et al.[26] stated that few citations might be due to many factors, including article and publication period. However, the fact that many have cited an article does not necessarily indicate a high level of evidence, and a positive correlation Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Articles analyzed in our bibliometric study had a relatively higher average authorship rate [6.83±5.49 (1–32)] because the level of evidence was predominantly A and B groups (80%).

Moreover, there were fewer observational studies, and most of these studies were extensive, while some of them were multi-centered. Furthermore, author groups were conducted with collaborators. A study by Tilak G et al.[29] on authorship increments in scientific researches revealed that the number of observational studies decreased in three major international journals between 1960 and 2010, whereas there was a significant increase in single- and multi-center RCTs; however, the rate of author per article increased more than three times for observational studies (2.6 to 10.1). In this context, the results of our study are partially compatible with the results of the research conducted by Tilak G et al. particularly in terms of the increment reported in observational researches.

According to our research data, among the 100 most influential manuscripts in traumatology both in terms of the number of authors who were included in more than one article and the number of presented proceedings papers and scientific activities, USA is at the forefront.[23,30] The publication language of all classics papers included in our citation analysis research was English. The official language of the country of origin of publications is an important factor for the selection of language for articles. Although different languages were used, most of the articles in the recent medicine literature were in English.[31] We have underlined in our bibliometric study that institutions or organizations located in USA are more prominent both in terms of the number of institutions producing publications and in terms of the number of publications per institution. USA has 299

Dokur et al. Top 100 cited articles in traumatology: A bibliometric analysis

Table 6. Study design and levels of evidence by SIGN of the top 100 cited articles Study type and sub-type

Level of evidence

Group

Number

1

A

2

Clinical research

Meta-analysis of RCT

Systematic review

1

A

4

Randomized controlled trial

1

A

14

Prospective cohort study

1

A

6

Prospective comparative study (clinical)

2

B

18

Retrospective comparative study (clinical)

3

B

3

Retrospective cohort study

3

B

11

Case–control study

3

B

6

Observational–descriptive study

3

B

2

Cross-sectional–correlation study

3

B

4

Validation study

3

B

1

Review

4

C

15

Expert committee report

4

C

2

Expert opinion (editorial, letter, and note)

4

C

3

2

B

9

Experimental animal study

Prospective comparative study

SIGN: Scottish Intercollegiate Guidelines Network; RCT: Randomized control trial.

the highest production of scientific publications, including in medicine and other health science fields. USA has the highest number of scientific publications in many fields.[23,30,31] The result of our bibliometric study, which displays that most of the 70% of the 100 most influential manuscripts are being supported by funding agencies in USA and the EU, is a solid indicator of this hypothesis. Although the amount of allowance has reduced in recent years, educational and scientific studies are generally supported with funding at a greater extent in developed countries relative to developing countries.[32,33] A high IF is an important scientometric criterion that demonstrates the quality of a journal.[34] As in our research, most of the top 100 cited articles in traumatology were included in journals with an IF of ≥2.6, which is an important indicator that displays that key papers pertaining to trauma are preferred by journals with higher IFs. The most common topic in our study was CNS trauma.

Traumatic brain injury (TBI) is a particularly important problem with socioeconomical and medical consequences among the young population in terms of its result.[35] Abusive head trauma is a typical example of this.[36] According to geographical regions, various incidences have been reported on the epidemiology of TBI.[37,38] Nguyen R et al.[39] conducted a systematic review and meta-analysis regarding this phenomenon; according to this, the international cumulative incidence rate of the TBI among all age groups is reported to be 295 300

of 100.000 people. The pooled annual incidence proportion for all ages was 295 per 100,000 (95% confidence interval: 274–317), and the international cumulative annual incidence speed is reported to be 349 of 100.000 people among all age groups. In light of this important information obtained from these studies, we conclude that CNS trauma is important among the fields of traumatology.

These were the second and third most common topics of our bibliometric study, and both of these trauma research subjects are based on the cost effectivity increasing concerns on traumatology. During the last few years, the correlation between trauma and bleeding and control of the bleeding earned an importance in the field of trauma research. Therefore, Damage Control Resuscitation and Damage Control Surgery concepts, which are related to trauma resuscitation can be seen as a typical reflection of this.[8,9] Again, in the last few years, trauma care and trauma care systems can be stated as other important trending traumatology subjects.[40]

Strengths The strength of this study is the provision of a quick and direct reach to determine topic trends and up-to-date information regarding traumatology with no requirements of any advanced analysis or statistical methods.

Limitations Only the total number of citations (excluding self-citations) Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Dokur et al. Top 100 cited articles in traumatology: A bibliometric analysis

and the total number of self-citations are presented in this study, and no article-based self-citation analyses was performed, which is a limitation of this study. In addition, conducting bibliometric analyses based on citations is a subjective constraint to prove the quality of research and to determine the number of publications by year as well as to evaluate authors’ scientific efficiency.

Future Directions Occasional bibliometric analyses for different medical disciplines and sub-specialties demonstrate the improvements in that field from a nominative perspective, in contrast with advanced research methods. The data of current studies may provide cost effectivity in planning and funding of future research projects. Bibliometric studies are relatively subjective initial and basic researches in terms of scientific value. In the last decade, altmetric studies including multiple evaluations of classical articles were preferred as they are scientifically more objective.

Conclusion Traumatology is an important surgical medicine discipline that is the subject of many topic trend researches. Despite its flaws, bibliometric citation analyses in traumatology, as in many scientific fields, enables the systematic identification of true landmark publications and the distribution of citations of these publications by years, main topics, institutions of influential papers, published scientific journals, research types and subtypes, and level of evidence, thus resulting in great academic contribution to traumatology.

Financial disclosure: The authors declare no financial support.

Conflict of interest: None declared.

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14. Gupta A, Kumar S, Sagar S, Sharma P, Mishra B, Singhal M,et al. Damage control surgery: 6 years of experience at a level I trauma center. Ulus Travma Acil Cerrahi Derg 2017;23:322–7.

15. Kayahan C,Uzar AI. Travma kinematiği. In: Ertekin C, Taviloglu K, Guloglu R,editors. Travma. 1st ed. Istanbul: İstanbul Medikal Yayıncılık; 2005. p. 33–45.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Travmatolojide en sık alıntılanan 100 makale: Bibliyometrik bir analiz Dr. Mehmet Dokur,1 Dr. Erdal Uysal2 1 2

Biruni Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İstanbul Sanko Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Gaziantep

AMAÇ: Bu bibliyometrik çalışmada, travmatoloji alanındaki en sık alıntılanan 100 makalenin çok yönlü analizini yapmayı amaçladık.

GEREÇ VE YÖNTEM: Biz bu çalışmada, Web of Science ve PubMed’teki veri tabanlarından elde ettiğimiz, 1975 ile 2017 yılları arasında yayınlanmış 56.980 travma makalesi içinden en çok alıntılanan ilk 100’ünü alıntılanma sayılarına ve yayın yıllarına, köken aldığı ülkelere ve kurum veya organizasyonlarına, en sık tercih edilen konularına, fonlanma durumlarına, makale tiplerine ve kanıt düzeylerine göre analiz ettik.

BULGULAR: Travmatoloji alanında en sık alıntılanan 100 makaledeki toplam yazar sayısını 649 ve yazar sayısı ortalamasını 6.49±5.46 (dağılım: 1–32), toplam çalışma grubu sayısını 8 ve eşlik eden çalışmacı sayısını ise 1241 olarak saptadık. Amerika Birleşik Devletleri, yayınlarda en sık yer alan ülke ve kurum ya da organizasyon olma ve bilimsel aktivitede sunulan makale sayısı bakımlarından ilk sırada idi. En çok alıntılanan 100 makalenin 70’inin, gelişmiş ülkelerdeki fon desteği veren kuruluşlar tarafından desteklendiğini belirledik. Travmatoloji ile ilgili en çok alıntılanan 100 makalede en sık tercih edilen ilk üç konu başlığını santral sinir sistemi travması (21 makale), majör travma-kanama-kanama kontrolü-transfüzyon-erken koagülopati (18 makale) ve travma bakımı ve sistemleri (8 makale) olarak saptadık. En sık alıntılanan 100 travmatoloji makalesinin kanıt ortalaması 2.45±1.05 (dağılım: 1–4) idi. Ayrıca biz en çok alıntılanan 100 makalenin 66’sının etki faktörü 2.6 daha yüksek olan bilimsel dergilerde (dağılım: 2.648–72.406) yayınlandığını belirledik. Araştırmacılar tarafından en sık tercih edilen çalışma tipinin klinik araştırma (92 makale) ve çalışma alt tipinin ise karşılaştırmalı ileriye yönelik çalışmalar (27 makale) olduğunu saptadık. Travmatolojideki klasik makalelerin kanıt gruplarının dağılımlarını ise sırasıyla B (54 makale), A (26 makale) ve C (20 makale) olarak belirledik.

TARTIŞMA: Makalelerin bilimsel değerini saptamadaki bazı eksikliklerine rağmen travmatoloji alanındaki klasik makalelerin alıntılanma analizleri, önemli akademik katkılar sağlayabilir.

Anahtar sözcükler: Bibliyometrik; makaleler; travmatoloji; yüksek sayıda alıntılanma.

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doi: 10.5505/tjtes.2017.74857

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ORIGIN A L A R T IC L E

The epidemiology of acute occupational hand injuries treated in emergency departments in Foshan City, South China Zhixin Wu, M.D.,1* Yueming Guo, M.D.,2 Junqing Gao, M.D.,2 Jianyi Zhou, R.N.,1 Shufang Li, R.N.,1 Zhaohui Wang, M.D.,2 Shangming Huang, M.D.,1 Shaojuan Huang, R.N.,1 Yingying Li, M.D.,1 Jingli Chen, M.D.,1 Mingfeng He, M.D.1* 1

Department of Critical Care and Emergency Medicine, Foshan Hospital of Traditional Chinese Medicine, Foshan-China

2

Department of Orthopedic Surgery, Foshan Hospital of Traditional Chinese Medicine, Foshan-China

*Zhixin Wu and Mingfeng He contributed equally and share the first authorship.

ABSTRACT BACKGROUND: Despite the magnitude of occupational hand injuries, there are no authoritative guidelines for hand injury prevention, and little research has been done to investigate the epidemiology of acute occupational hand injuries in South China or other developing areas. In this study, the epidemiology of acute occupational hand injuries treated in emergency departments (EDs) in Foshan City, South China, was examined and data were supplied to assist with preventive strategies in similar developing regions.

METHODS: A multicenter study was prospectively designed and conducted in 5 large hospital EDs in Foshan City from July 2010 to June 2011. An anonymous questionnaire was designed specifically to collect the data for this study.

RESULTS: A total of 2142 patients with acute occupational hand injury completed the questionnaire within the 1-year study period.

Results indicated that most occupational hand injuries were caused by machinery. Hand injury type and site of the injury did not correspond to age, but were related to gender and job category. July and August 2010 were the peak periods of admission to EDs, while January and February 2010 were the trough periods.

CONCLUSION: Epidemiological data enhance our knowledge of acute occupational hand injuries and could play a role in the prevention and treatment of future occupational hand injuries.

Keywords: Emergency department; epidemiology; hand; occupational injury; trauma.

INTRODUCTION Hand injuries are costly, and a major cause of morbidity in China and around the world. The incidence of occupational hand injury varies across different industries, ranging from 4 to 11 per 100 workers per year. Occupational hand injury is one of the top causes of lost days from work, and it imposes a great economic burden on the country.[1â&#x20AC;&#x201C;6] In the US, the annual cost of treating upper extremity disorders, including hand injuries, was over $18 billion.[2] The Center for Disease Control and Prevention reported that an estimated 30% of

occupational injuries treated in US emergency departments (EDs) are hand injuries.[6] However, very few papers have been published worldwide on the epidemiology of acute occupational hand injuries treated in the ED in China or other developing regions. Despite the magnitude of occupational hand injuries, there are no authoritative guidelines for hand injury prevention, and little research has been done to investigate the epidemiology of acute occupational hand injuries in South China.

Cite this article as: Wu Z, Guo Y, Gao J, Zhou J, Li S, Wang Z, et al. The epidemiology of acute occupational hand injuries treated in emergency departments in Foshan City, South China. Ulus Travma Acil Cerrahi Derg 2018;24:303-310.

Address for correspondence: Zhixin Wu, M.D. D6# Qinren Rd, Department of Critical Care and Emergency Medicine, Foshan Hospital of Traditional Chinese Medicine, Foshan City 528000, Guangdong Province, China.

Tel: +086-135-289-96895 E-mail: seaguardsums@msn.com Ulus Travma Acil Cerrahi Derg 2018;24(4):303-310 DOI: 10.5505/tjtes.2016.59020 Submitted: 27.10.2015 Accepted: 06.12.2016 Online: 19.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Wu et al. The epidemiology of acute occupational hand injuries treated in emergency departments in Foshan City, South China

Foshan City is a major metropolis and typical developing area in South China with substantial industrial activity, and occupational hand injuries are the leading work-related injury.[7] The purpose of this study was to identify the epidemiology of acute occupational hand injuries treated in EDs in Foshan City, South China, and to provide a series of hand injury prevention suggestions for similar developing areas.

MATERIALS AND METHODS Setting Foshan City is located in the mid-south of Guangdong Province, South China. It governs 5 districts: Chancheng, Nanhai, Shunde, Gaoming and Sanshui. The city covers a total area of 3848.49 km2 and has a population of at least 5.923 million, including 3.611 million registered permanent residents. The largest hospital EDs in each district are Foshan Hospital of Traditional Chinese Medicine (FSTCM), Foshan Nanhai District Hospital of Traditional Chinese Medicine, Shunde District Longjiang Hospital, Gaoming District People’s Hospital and Sanshui District People’s Hospital. Approximately 80,000 patients are assessed per year in each ED. A multicenter study was prospectively designed and conducted in these 5 large hospital EDs in the period between July 2010 and June 2011.

Patient Selection Study participants were those presenting to these hospital EDs with injuries to the fingers, hand, or wrist, including laceration, crush, avulsion, puncture, fracture, contusion, amputation, or dislocation. Informed verbal consent was obtained from eligible participants when they arrived at the ED. Some were unable to provide written consent at admission due to the nature of the injury; however, patients who agreed to participate in the study were provided with the relevant information and gave consent.

Exclusion Criteria Patients who were younger than 14 years of age or who presented with hemodynamically unstable polytrauma were excluded from the study.

Data Collection An anonymous questionnaire (Appendix 1) was designed to collect data regarding background demographics, detailed exposure information, assessment of hand injury, and health insurance status. If the hand injury occurred at work, occupational information was recorded, including training record, mechanism of injury, and average salary. Twenty non-medical investigators received a 6-hour investigation training course.

These investigators administered the questionnaire in the ED. The document was written in Chinese, in order to avoid misunderstanding.

304

Ethical Approval All procedures performed in this study involving human participants were approved by the ethics committee of FSTCM and were conducted in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Statistical Analyses Study data were entered into a Microsoft Excel (Microsoft Corp., Redmond, WA, USA) database and analyzed using SPSS for Windows, Version 13.0. (SPSS, Inc., Chicago, IL, USA). Descriptive statistics of mean and SD were provided for numerical variables, while categorical variables were given as frequency (n) and percentage. Categorical variables were compared using chi-square test. Differences were considered statistically significant at a level of p<0.05.

RESULTS Demographics During the study period, there were 2186 Chinese patients with acute occupational hand injury assessed by physicians in an ED, of which 2142 (98%) met the study criteria (mean age: 31.33±11.00 years, range: 14–71 years; 81.56% male).

They were divided into subgroups according to age, medical insurance status, job category, job tenure, education level, and other characteristics. In this study, 1109 (51.78%) patients were between 25 and 44 years of age and 116 (5.42%) patients were minors. Of the total, 1935 (90.34%) had medical insurance, and 856 (39.96%) patients had 1 to 3 years of job tenure. The education level of the majority was graduation from secondary school (1706; 79.64%). The majority had an annual salary ranging from $3,000 to $4,000 (1006; 46.97%). Most worked at a private business (1961; 91.54%). Only half of the patients (1076; 50.23%) had safety training before beginning work, a mean of 84.74±39.51 safety training hours. Employees had a mean of 4.11±0.35 days of work training. When the hand injury occurred, they had been working mean of 5.06±1.04 hours without rest.

For 1163 (54.30%) patients, the interval from hand injury to ED arrival was less than 30 minutes. Emergency hand surgery was indicated for 1445 (67.46%) patients on admission (Table 1).

Characteristics of Injuries Most occupational hand injuries were caused by machinery (2112; 99.6%). The most common types of injury were caused by pressing and cutting machinery (42.11% and 29.41%, respectively). Most patients had finger injury (1760; 82.16%).

The most commonly injured fingers were the thumb, index, and middle finger, especially on the right hand. There were 26 study participants suffering from injuries to both hands. The hand injury type and the site of the injury were not related Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Wu et al. The epidemiology of acute occupational hand injuries treated in emergency departments in Foshan City, South China

Table 1. General characteristic of the study patients

Table 1. General characteristic of the study patients (cont.)

Characteristics

Characteristics

n %

Gender

Male

Female

1747 81.56 395 18.44

Age-group (years) <15

8

0.37

15–24

726 33.89

25–44

1109 51.78

45–64

294 13.73

≥65

5

0.23

Health insurance

Social security insurance

1935

90.34

None

196 9.15

11

Other insurance

Food handling

826 38.56 72

3.36

Maintenance/repair

256 11.95

104

Wood work

4.86

Construction

104 4.86

Textile

153 7.14

Printing

73

Others

554 25.86

3.41

Job tenure

<1 yr

588

27.45

1–3 yr

856

39.96

>3 yr

698

32.59

Experience of safety training Yes

1076 50.23

No

1066 49.77

Education level Illiterate

25

1.17

Primary school

314

14.66

Secondary school

1706

79.64

Post-secondary and above

97

4.53

40

1.86

Annual wage <$2,000

Total

1163 504 262 213

54.30 23.53 12.23 9.94

664 1445 29 4

31.00 67.46 1.35 0.19

2142 100.00

ED: Emergency departments.

0.51

Job category Metal-machinery

Interval from the injury onset to ED arrival <30 min 30 min–60min 60 min–120min >120 min Disposition Discharge Admission Transfer to another hospital Discharge against medical advice

n %

$2,000–$3,000

474 22.13

$3,000–$4,000

1006 46.97

$4,000-$6,000

492 22.97

>$6,000

130 6.07

The nature of business

Private business

1961

91.54

State-owned business

73

3.41

Foreign-funded business

25

1.17

Table 2. Characteristics of occupational hand injuries Characteristics Type of injury (n=2142) Cutting Laceration Puncture Amputation Compression Contusion Crushing injury Fracture Burning Unknown mechanical equipment Non-machine1 Injury site (n=2142) Wrist Hand Finger Multiple Injury finger (n=1855) Thumb Index Middle Ring Little Multiple Injury hand (n=2142) Right Left Both

n %

630 35 101 157 902 129 52 8 20 78 30

29.41 1.64 4.72 7.33 42.11 6.02 2.43 0.37 0.93 3.64 1.40

46 191 1760 145

2.15 8.92 82.16 6.77

427 515 502 143 213 55

23.02 27.76 27.07 7.71 11.48 2.96

1146 53.50 970 45.29 26 1.21

The nature of business

Joint venture

47

2.20

Other partnership

20

0.93

16

0.75

Other

to age, but did correlate to gender and job category. In all, 80.52% of patients were wearing gloves when the injury occurred (Tables 2–4).

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Wu et al. The epidemiology of acute occupational hand injuries treated in emergency departments in Foshan City, South China

Table 3. Comparison of injury site with demographic variables and job category Variable

Injury site

Wrist (n=46)

Hand (n=191)

Finger (n=1760)

Multiple (n=145)

n % n % n % n %

p

Gender Male

40

2.29

165

9.44

1422

81.40

120

6.87

Female

6

1.52

26

6.58

338

85.57

25

6.33

<0.001

Age-group (years)

<15

0 0.00 0 0.00 7 87.50 1 12.50

15–24

20

2.75

72

9.92

588

80.99

46

6.34

25–44

16

1.44

96

8.66

925

83.41

72

6.49

45–64

10

3.40

23

7.82

236

80.27

25

8.51

65+

0 0.00 0 0.00 4 80.00 1 20.00

0.406

Health insurance

Social security insurance

41

2.12

171

8.84

1599

82.63

124

6.41

None

5

2.55

20

10.20

153

78.06

18

9.19

Other

0 0.00 0 0.00 8 72.73 3 27.27

0.082

Job category Metal-machinery

15

1.82

75

9.08

2

2.78

10

1

0.39

27

1

0.96

9

Food handling

Maintenance/repair

Wood work

Construction

692

83.78

44

5.32

13.89

56

10.55

218

77.78

4

5.55

85.15

10

3.91

8.66

85

81.73

9

8.65

0.001

5 4.81 12 11.54 73 70.19 14 13.46

Textile

1

0.65

4

2.61

138

90.20

10

6.54

Printing

1

1.37

6

8.22

62

84.93

4

5.48

20

3.61

48

8.66

436

78.70

50

9.03

Peak and Trough Periods in Admission to ED During the period of July 2010 to June 2011, July and August 2010 was the peak period of admission to the ED, while January and February 2010 was the trough period (Fig. 1). There was no obvious peak period with respect to day of the week (Monday through Sunday) during the entire year (Fig. 2).

DISCUSSION To the best of our knowledge, this is the first multicenter study to analyze and describe the epidemiology of acute occupational hand injuries in South China. There are no authoritative reports about the epidemiology of acute occupational hand injuries in China. Current occupational safety standards are inadequate, and many employers don’t pay attention to 306

400 350 300 250 200 150 100 50 0

367 267 176

197 145

186 127 76

187

160

181

73

l Au y 20 10 Se gu pt st 2 em 01 b 0 O er 2 ct 0 ob 1 N er 0 ov em 201 0 D ec ber em 20 be 10 Ja r 2 01 nu Fe ary 0 20 br ua 1 ry 1 M 2 ar 01 ch 1 2 Ap 011 ril 2 M 011 ay 2 Ju 011 ne 20 11

All of the patients were asked about the perceived cause of hand injury. “Distraction” was response selected by 1152 (53.78%) participants, while 330 (15.41%) selected “pure accident,” and 257 (12.00%) selected “no protection” (Table 5).

safety management training for work-related tasks. Relevant laws need improvement to protect employees’ rights.[7] The present study provides useful information for the national health service and local labor department to use to develop strategies and decrease the risk of occupational hand injury.

The social and economic impact of hand injury on society highlights the importance of prevention of these injuries.

[7–10] Several studies have reported on the epidemiology and prevention of acute occupational hand injury in developed countries.[11–17] In Chow’s study, statistically significant associNumber of hand injuries

Perceived Cause of Occupational Hand Injuries

Ju

Others

Figure 1. Distribution of occupational hand injuries by month.

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Wu et al. The epidemiology of acute occupational hand injuries treated in emergency departments in Foshan City, South China

Table 4. Comparison of some injury types by sex, age group, and job category Variable

Injury type Cutting Puncture Amputation Compression Contusion Other p (n=630) (n=101) (n=157) (n=902) (n=129) (n=223) n % n % n % n % n % n %

Gender Male

533 30.51 63 3.61 138 7.90 726 41.56 107 6.12 180 10.30 <0.001

Female

97 24.55 38 9.62 19 4.81 176 44.56 22 5.57 43 10.89

Age-group (years) <15

1 12.50 0 0.00 1 12.50 5 62.50 0 0.00 1 12.50

15–24

213 29.33 42 5.79 57 7.85 306 42.15 40 5.51 68 9.37

25–44

322 29.04 53 4.78 73 6.58 468 42.20 71 6.40 122 11.00 0.706

45–64

91 30.95 6 2.04 26 8.84 121 41.16 18 6.12 32 10.89

65+

3 60.00 0 0.00 0 0.00 2 40.00 0 0.00 0 0.00

Health insurance

Social security insurance

548

28.32

94

4.86

143

7.39

839

43.36

108

5.58

203

10.49

None

81 41.33 6 3.06 13 6.63 57 29.08 19 9.69 20 10.21 <0.001

Other insurance

1 9.09 1 9.09 1 9.09 6 54.55 2 18.18 0 0.00

Job category Metal-machinery

202 24.45 30 3.63 82 9.93 381 46.13 41 4.96 90 10.90

Food handling

50 69.44 1 1.39 1 1.39 7 9.72 1 1.39 12 16.67

Maintenance/repair

65 25.39 4 1.56 11 4.29 123 48.05 24 9.38 29 11.33

Wood work

61 58.65 3 2.89 9 8.65 18 17.31 5 4.81 8 7.69

Construction

32 30.77 22 1.92 9 8.65 43 41.35 10 9.62 8 7.69 <0.001

Textile

31 20.26 37 24.18 10 6.54 53 34.64 10 6.54 12 7.84

Printing

19 26.03 3 4.11 4 5.48 39 53.42 2 2.74 6 8.22

Others

170 30.69 21 3.79 31 5.60 238 42.96 36 6.50 58 10.46

121

5.65

Fatigue

63 2.94

No idea

34

1.59

2142

100

Total

Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

50 0 nd ay

Poor cooperation

100

Su

6.44

da y

138

on

Unfamiliar with machine

150

M

1152 53.78

Number of hand injuries

Distraction

200

da y

2.19

270

250

ur

47

293

St

Faulty machine

312

309

id ay

12.00

322

Fr

257

327

309

300

da y

No protection

350

ur s

15.41

ay

330

Th

Pure accident

sd

%

ay

n

sd

Patient’s idea of the cause

W ed ne

Table 5. Perceived cause of occupational hand injury

injury is controversial. Schaub and Chung found that the use of gloves alone in industry has been reported to reduce the risk of hand injury by as much as 60%.[11] However, Chow found that the use of gloves had insignificant protective effect on the incidence of hand injury.[1] In 19% of the injuries that occurred while gloves were worn, they did not protect against mechanical energy transferred to the hand. Glove use may reduce the

Tu e

ations were found between the incidence of hand injury and exposure to these 7 factors: using malfunctioning equipment/ materials, using a different work method, performing an unusual task, working overtime, feeling ill, being distracted, and rushing.[1] Whether the use of gloves can protect against hand

Figure 2. Distribution of occupational hand injuries by day of the week.

307

Wu et al. The epidemiology of acute occupational hand injuries treated in emergency departments in Foshan City, South China

risk of laceration and puncture injury, but not crush, fracture, avulsion, or amputation.[1,10] In this study, 80.52% of the participants were wearing gloves when the hand injury occurred.

According to several published articles, other factors found to influence occupational hand injury include using defective materials, presence of cardiovascular disease, extended work hours/lack of sleep, age of less than 25 years, smoking, regular consumption of alcohol, and long work hours. It has also been demonstrated that most occupational hand injuries occur in the morning, with a peak before lunchtime.[11,18–21] In our study, most of the patients were young men. Most of the hand injuries were caused by machinery used for cutting and pressing. The treatment of hand injuries is often of long duration, and frequently results in variable but persistent disability. Injuries of this nature can preclude patients from returning to their previous occupation.[20] Fortunately, most of the patients in this study had medical insurance guaranteed and supported by the government, and could access adequate medical treatment.[7] However, some patients (9.15%) had no medical insurance due to the economic burden it entails and did not understand the risks of being uninsured. They may have a heavy economic and psychological burden as a result of long-term prognosis of hand injury.

In China, some private businesses disobey the law and do not provide any kind of insurance to employees in order to reduce costs. Most of the patients in this study had achieved secondary school education level (79.64%) and were qualified for their job. Most (72.55%) had work experience of more than 1 year. However, half of participants lacked safety training, which has been shown to be a potential risk factor for occupational hand injury.[10] Most had lower annual wage compared with average income in South China.

As we know, Foshan City is an advanced industrial city with thousands of labor-intensive industrial factories, and is representative of developing areas in China.[7] Tens of thousands of employees are working on the production assembly line every day. Their jobs are repetitive: performing the same manufacturing process again and again. It’s very easy, but boring. Most factories have instituted a series of management programs to improve production efficiency. Workers have limited time for rest. In our study, subjects had been working mean of 5.06±1.04 hours without rest when the hand injury occurred. The main cause of injury was “distraction,” according to 53.78% of participants. In this 1-year study period, July and August 2010 were the peak period for admissions to EDs. In Foshan City, most factories are very busy with rush production orders during these 2 months. January and February were trough periods in number of admissions to EDs, due to the Spring Festival holiday. July and August are also the months when the weather is hottest in South China. However, few factories have air-conditioners or adequate fans to cool the work environment. In this uncomfortable situation, workers may be more prone to “distraction” than in other months and make mistakes.

308

Based on the results of our study, we suggest the following: First, all businesses must provide basic medical insurance for their employees, according to the national law. In China, there is a compulsory social security insurance law. Second, we noticed that about 5.42% of patients in the study were minors. The law prohibits any business from employing workers younger than 16 years of age in China. It is necessary for the national health service and local labor department to improve supervision and see that all businesses strictly follow the law. Third, safety training needs to be emphasized. All workers should regularly complete a series of safety training and education courses. The national health service and local labor department should provide authoritative guidelines for education and create risk assessment tools for occupational safety to identify potential hazards in the workplace. Fourth, business managers should improve the work environment, including providing a work-rest schedule and decreasing rush production orders. Fifth, the country should encourage enterprises to improve technologies and engineering safety devices to further reduce the risk of occupational trauma. The country should also authoritatively publish a series of recommendations on safeguards, design, and proper use of various machines and protective equipment that meet the standards for anticipated hazards.

Our study has some limitations. We analyzed patients with occupational hand injuries treated in EDs, which underestimates the actual incidence of such injuries, since some subjects do not present to an ED. An anonymous questionnaire was designed for collection of study data, and thus, the investigators could not recognize a participant who returned to the ED due to reoccurrence. Patients who visited the ED on multiple occasions for hand injury may have been included in this study. This topic needs further research.

Conclusion Epidemiological data enhances our knowledge of acute occupational hand injuries and may play a role in the prevention and treatment of future occupational hand injuries, with the end result of reducing lost work time and economic burden.

Acknowledgements We thank Paula Brazil, M.A. (Arizona Department of Health Services, 150 North 18th Avenue, Suite 540, Phoenix, AZ 85007, USA) for her assistance with this manuscript. We also thank Mrs. Deng Huiru (Shunde District Longjiang Hospital), Mrs. Guan Weiqun (Gaoming District People’s Hospital), Mrs. Huang Xuelan (Sanshui District People’s Hospital), Mrs. Chen Xiaomei (Nanhai District TCM Hospital) and Mrs. Liu Yanghui (Chancheng District Foshan Hospital of TCM) for their research work for this study.

Funding Sources Funding for this study was provided by the Internal Grants Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Wu et al. The epidemiology of acute occupational hand injuries treated in emergency departments in Foshan City, South China

from Science and Technology Foundation of Foshan City, China (no. 2014AG10005) and the Municipal Clinical Key Specialty Construction Project Funds of Foshan City (No. Fspy2-2015004 and No.FSGSPZD135018).

Conflict of interest: None declared.

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2. Dias JJ, Garcia-Elias M. Hand injury costs. Injury 2006;37:1071–7.

3. Rosberg HE, Carlsson KS, Cederlund RI, Ramel E, Dahlin LB. Costs and outcome for serious hand and arm injuries during the first year after trauma - a prospective study. BMC Public Health 2013;13:501.

4. Kingston GA, Judd J, Gray MA. The experience of medical and rehabilitation intervention for traumatic hand injuries in rural and remote North Queensland: a qualitative study. Disabil Rehabil 2015;37:423–9.

5. Leixnering M, Quadlbauer S, Szolarcz C, Schenk C, Leixnering S, Körpert K. Prevention of hand injuries - current situation in Europe. Handchir Mikrochir Plast Chir 2013;45:339–43.

6. Centers for Disease Control and Prevention (CDC). Nonfatal occupational injuries and illnesses among workers treated in hospital emergency departments--United States, 2003. MMWR Morb Mortal Wkly Rep 2006;55:449–52.

7. Huang SJ, Li SF,Ke YH. Epidemiological survey of patients with traumatic hand injury in emergency department. Journal of Nursing(China) 2011;18:23–5.

8. Kaya Bicer E, Kucuk L, Kececi B, Murat Ozturk A, Cetinkaya S, Ozdemir O, et al. Evaluation of the risk factors for acute occupational hand injuries.

Chir Main 2011;30:340–4.

9. Sorock GS, Lombardi DA, Hauser RB, Eisen EA, Herrick RF, Mittleman MA. A case-crossover study of occupational traumatic hand injury:

methods and initial findings. Am J Ind Med 2001;39:171–9.

10. Sorock GS, Lombardi DA, Hauser R, Eisen EA, Herrick RF, Mittleman MA. A case-crossover study of transient risk factors for acute occupational hand injury. Occup Environ Med 2004;61:305–11.

11. Schaub TA, Chung KC. Systems of provision and delivery of hand care, and its impact on the community. Injury 2006;37:1066–70.

12. de Jong JP, Nguyen JT, Sonnema AJ, Nguyen EC, Amadio PC, Moran SL. The incidence of acute traumatic tendon injuries in the hand and wrist: a 10-year population-based study. Clin Orthop Surg 2014;6:196–202.

13. Ootes D, Lambers KT, Ring DC. The epidemiology of upper extremity injuries presenting to the emergency department in the United States.

Hand (N Y) 2012;7:18–22.

14. Panagopoulou P, Antonopoulos CN, Dessypris N, Kanavidis P, Michelakos T, Petridou ET. Epidemiological patterns and preventability of traumatic hand amputations among adults in Greece. Injury 2013;44:475–80.

15. Hey HW, Seet CM. Hand injuries seen at an emergency department in Singapore. Eur J Emerg Med 2010;17:343–5.

16. Serinken M, Karcioglu O, Sener S. Occupational hand injuries treated at a tertiary care facility in western Turkey. Ind Health 2008;46:239–46 17. Larsen CF, Mulder S, Johansen AM, Stam C. The epidemiology of hand injuries in The Netherlands and Denmark. Eur J Epidemiol 2004;19:323–7.

18. Chung KC. Volunteering in the developing world: The 2003-2004 Sterling Bunnell Traveling Fellowship to Honduras and Cambodia. J Hand Surg Am 2004;29:987–93.

19. Lombardi DA, Sorock GS, Hauser R, Nasca PC, Eisen EA, Herrick RF, et al. Temporal factors and the prevalence of transient exposures at the time of an occupational traumatic hand injury. J Occup Environ Med 2003;45:832–40.

20. Trybus M, Lorkowski J, Brongel L, Hladki W. Causes and consequences of hand injuries. Am J Surg 2006;192:52–7.

21. Garg R, Cheung JP, Fung BK, Ip WY. Epidemiology of occupational hand injury in Hong Kong. Hong Kong Med J 2012;18:131–6.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Güney Çin Foshan ilinde acil servislerde tedavi edilen mesleksel akut el yaralanmalarının epidemiyolojisi Dr. Zhixin Wu,1 Dr. Yueming Guo,2 Dr. Junqing Gao,2 Dr. Jianyi Zhou,1 Dr. Shufang Li,1 Dr. Zhaohui Wang,2 Dr. Shangming Huang,1 Dr. Shaojuan Huang,1 Dr. Yingying Li,1 Dr. Jingli Chen,1 Dr. Mingfeng He1 1 2

Geleneksel Çin Tıbbı Foshan Hastanesi, Tıbbi Bakım ve Acil Tıp Bölümü, Foshan-Çin Halk Cumhuriyeti Geleneksel Çin Tıbbı Foshan Hastanesi, Ortopedik Cerrahi Bölümü, Foshan-Çin Halk Cumhuriyeti

AMAÇ: Mesleksel el yaralanmalarının kapsamına rağmen el yaralanmalarını korunmasına ilişkin yetkin kılavuzlar mevcut olmadığı gibi Güney Çin veya diğer gelişmekte olan alanlarda akut mesleksel el yaralanmalarının epidemiyolojisi az sayıda çalışmada araştırılmıştır. Bu çalışmada Güney Çin Foshan ilindeki acil servislerde tedavi edilmiş akut mesleksel el yaralanmalarının epidemiyolojisini araştırdık ve gelişmekte olan benzer alanlarda koruyucu stratejilere ilişkin veriler sağladık.

GEREÇ VE YÖNTEM: Foshan ilinde beş büyük hastanenin acil bölümlerinde ileriye yönelik ve çok merkezli çalışma tasarlanıp yürütüldü. Bu çalışmada verileri toplamak için özellikle tasarlanmış bir adsız anket formu kullanıldı.

BULGULAR: Akut mesleksel el yaralanması olan toplam 2142 denek bir yıllık çalışma dönemi içinde anket formlarını doldurmuştur. Mesleksel el yaralanmalarının çoğuna makineler neden olmuştu. El yaralanmasının tipi ve yaralanmanın yeri yaş farklılıklarıyla değil cinsiyet ve işin kategorisiyle ilişkiliydi. Acil servislere en çok Temmuz ve Ağustos 2010 aylarında en az Ocak ve Şubat 2010 aylarında hasta kabulü olmuştur.

TARTIŞMA: Epidemiyolojik veriler akut mesleksel el yaralanmalara ait bilgimizi artırmakta ve gelecekte mesleksel el yaralanmalarının engellenmesi ve tedavisinde rol oynayabilir.

Anahtar sözcükler: Acil bölüm; el; epidemiyoloji; mesleksel yaralanma; travma.

Ulus Travma Acil Cerrahi Derg 2018;24(4):303-310

doi: 10.5505/tjtes.2016.59020

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Wu et al. The epidemiology of acute occupational hand injuries treated in emergency departments in Foshan City, South China

Appendix 1.

Acute Hand Injury Questionnaire - Foshan City No: ...................

Gender: ...................

Age: ...................

1. Date of injury: .............................

Day of the week: ..............................

Interval from the hand injury to Emergency Department arrival: .................... minutes ❑ Disposition: A. Treatment and release

B. Admission

C. Transfer to another hospital

D. Discharge against medical advice

A. Traffic accident

B. Activity of daily life

C. Injured by other people D. Self-injury

E. Occupational injury

F. Other

❑ 2. Cause of injury:

❑ 3. Place of injury: A. At work

B. At home

C. On streets or roads

D. Sports venue

B. Shunde

C. Nanhai D. Gaoming

E. Other

❑ 4. Place of work (District): A. Chancheng

E. Sanshui

F. Other ❑ 5. Was the patient treated at another hospital?

A. Yes

B. No

❑ 6. Handedness: A. Left-handed

B. Right-handed

C. Both

❑ 7. Injured hand: A. Left

B. Right

❑ 8. Type of injury: A. Crush

B. Cut

C. Laceration

D. Contusion

E. Other specified (puncture, tear, strain, fracture, burn, compression, amputation)

F. Other unspecified

❑ 9. Injury site: A. Wrist

B. Hand

C. Finger (Multiple choice)

B. Index

C. Long

D. Ring

B. Primary school

C. Secondary school

D. Post-secondary and above

B. None

C. Other

❑ 10. Injured finger(s): A. Thumb E. Little (Multiple choice) ❑ 11. Education level: A. Illiterate ❑ 12. Social security: A. Medical insurance

❑ 13. If the injury is occupational hand injury: ❑ 1. Job category: A. Metal-machinery

B. Food handling

C. Maintenance/repair

D. Woodwork

E. Construction

F. Textiles

G. Printing

H. Other:........................

A. Pure accident

B. No protection

C. Faulty machine

D. Distraction

E. Unfamiliar with machine

F. Poor cooperation

G. Fatigue

H. No idea (Multiple choice)

❑ 2. Cause of injury:

❑ 3. Safety training: A. Yes - Training hours: ...................

B. No

❑ 4. When the hand injury occurred, patient had been working ................... hours ❑ 5. Work experience: ................... years ❑ 6. Nature of enterprise: A. Private

B. State-owned

E. Other partnership

F. Other ......................

C. Foreign-funded

D. Joint-venture

C. $3,000-$4,000

D. $4,000-$6,000

❑ 7. Annual salary: A. <$2,000

310

B. $2,000-$3,000

E.>$6,000

Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

ORIGIN A L A R T IC L E

Emergency computed tomography for the diagnosis of acute appendicitis: How effectively we use it?

Pınar Yazıcı, M.D., Ayhan Öz, M.D., Kinyas Kartal, M.D., Esin Kabul Gürbulak, M.D., İsmail Ethem Akgün, M.D., Sıtkı Gürkan Yetkin, M.D., Mehmet Mihmanlı, M.D.

Muharrem Battal, M.D.,

Department of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Technological developments support using ultrasonography (US) in all patients, if available, and advanced diagnostic methods such as abdominal computed tomography (CT) in case of clinical suspicion during diagnostic process of acute appendicitis.

We aimed to investigate whether CT was appropriately and efficiently used in the diagnosis of acute appendicitis.

METHODS: Between May 2013 and February 2016, 811 patients who underwent appendectomy were retrospectively reviewed from an IRB-approved database, and those who underwent a preoperative CT were enrolled into the study. Results of Alvarado scores and US were recorded in addition to which clinic requested the CT (general surgery or emergency department).

RESULTS: The frequency of CT use in the diagnostic process was 25% (n=208/811). Ultrasound was negative for appendicitis in 53% of these patients. The mean Alvarado score was 5±1.5 (range: 3–8). General surgeons requested 57% of CTs. Alvarado scores were significantly higher in patients whose CT was requested by general surgery than in those whose CT was requested by the emergency clinic (5.6 vs. 4.7, p=0.013). Regarding histopathological results, age and Alvarado scores were significantly lower (p=0.015 and 0.037, respectively), whereas the frequency of negative CT was significantly higher (p=0.042) in those with negative appendectomy (n=29, 14%).

CONCLUSION: Most patients who underwent CT in the diagnostic process had an Alvarado score between 5 and 8 and negative ultrasound for appendicitis preoperatively. These findings may provide efficient use of CT in the diagnosis of appendicitis with an acceptable rate of 25% compared with the findings in current literature. However, further research is needed to ensure more efficient use of CT because negative appendectomy has been a concern in our series despite promising results of this study.

Keywords: Acute abdomen; acute appendicitis; Alvarado score; computed tomography.

INTRODUCTION Acute appendicitis is usually diagnosed on the basis of a patient’s clinical history in conjunction with physical examination and laboratory and radiological studies. In early times, the main aim was to perform surgery as early as possible to prevent any appendiceal rupture or severe peritonitis; hence, patients underwent immediate surgery in case of typical findings without radiological evaluation. However, in the current era, where radiology has become surgeon’s main helper, almost all patients are examined using ultrasonography (US)

prior to making a surgical decision. In addition, computed tomography (CT) remains the next preferred diagnostic test to determine the problem in patients with a clinical suspicion of appendicitis because it is the most accurate imaging study for the evaluation of appendicitis and differential diagnosis of acute right lower quadrant pain.

Advanced imaging is advisable in patients with atypical symptoms, which can occur in infants, small children, elderly, and young women. Many gynecologic conditions can mimic acute appendicitis, making the diagnosis unclear. Alvarado scoring

Cite this article as: Yazıcı P, Öz A, Kartal K, Battal M, Kabul Gürbulak E, Akgün İE, et al. Emergency computed tomography for the diagnosis of acute appendicitis: How effectively we use it? Ulus Travma Acil Cerrahi Derg 2018;24:311-315.

Address for correspondence: Pınar Yazıcı, M.D. Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey.

Tel: +90 212 - 373 50 00 E-mail: drpinaryazici@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(4):311-315 DOI: 10.5505/tjtes.2017.36390 Submitted: 24.03.2017 Accepted: 10.11.2017 Online: 20.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Yazıcı et al. Emergency computed tomography for the diagnosis of acute appendicitis

system has been established for use in patients with suspected appendicitis and used since it was first reported in 1986.[1] This score helps clinicians to determine the better candidate for further diagnostic imaging (mostly CT). In case of an Alvarado score between 5 and 7, CT is indicated.

In recent years, CT has become more widespread, accessible, and affordable in addition to being performed quickly. Its use has also expanded for appendicitis, and this can sometimes be unnecessary. One of the highest rated causes of increasing use of advanced radiological studies is clinicians’ intolerance for uncertainty which is related to growing clinical indications.[2] Whether clinicians use it appropriately and efficiently for suspicion of appendicitis is still questionable. We aimed to investigate the role of CT in our emergency practice and whether we apply it correctly in a tertiary health care center in Istanbul.

Data Analysis The sonographic and CT examinations from 208 patients were retrospectively reviewed by the consensus of two radiologists with 6 and 10 years of abdominal imaging experience.

During both review sessions, the radiologists were asked to classify each appendix as normal or perforated appendicitis.

The other possible causes of right lower quadrant pain other than appendicitis were also recorded.

Statistical Analysis

MATERIALS AND METHODS

IBM SPSS version 20 (IBM, Chicago) was used for analysis.

Continuous variables were represented as mean±standard deviation or median and range. Categorical variables were represented as percentages. Continuous and categorical parameters were analyzed using independent sample t-tests or Mann–Whitney U-test and chi-square tests, respectively.

Kruskal–Wallis test was used for multiple comparisons. P values <0.05 were considered statistically significant.

Patient Selection

RESULTS

The local ethical committee of Sisli Hamidiye Etfal Training and Research Hospital approved this study. Informed consent was waived from all patients. Between May 2013 and February 2016, 811 consecutive adult patients (aged >18 years) with a history of appendectomy were reviewed. Among these patients, we only selected patients who underwent abdominal CT during preoperative assessment. A total of 208 patients (25%) met this criterion. Data collection included patients’ demographic features, radiological (US and CT) findings, and histopathological examinations. Patients were evaluated by comprehensive history, clinicopathological examination, and Modified Alvarado Score.[3] In addition, information about which clinic (general surgery or emergency service) requested the CT scan was recorded.

Sonography and CT All sonographic examinations were performed with an ultrasound (US) system equipped with a 2–5-MHz convex, 5–8-MHz curved, or a 5–12-MHz linear transducer (Siemens S2000, Siemens Healthcare, Erlangen, Germany). Abdominal radiologists with 2–6 years of experience performed the sonographic studies. For normal appendix definition, the entire length of the appendix is required to be visualized with a transverse outer diameter of ≤6 mm. US criteria for acute appendicitis is defined as an incompressible appendix with a diameter of ≥6 mm and a mural thickness of >2 mm and having periappendiceal hyperechoic fat and free fluid.[4,5] Computed tomography was performed using a 16- or 64-slice multidetector CT scanner (Somatom Sensation Open; Siemens, Germany) only with IV contrast. Acute appendicitis was defined as an enlarged appendix (≥7 mm in outer diameter), peri-appendiceal fatty infiltration, and a thickened appendiceal wall with enhancement.[6] 312

There were 63 female and 145 male patients with a mean age of 36.6±12 years (range, 18–79 years). Indications for CT after sonography were as follows: (1) radiologist’s recommendation for additional CT because of equivocal sonographic findings or evaluation of the inflammatory extension (n=49); (2) clinician’s recommendation due to atypical abdominal pain or a discrepancy between sonographic and laboratory results (n=68); and (3) emergency clinician’s decision for a differential diagnosis of suspected pathology of appendicitis that could not be detected by US (n=91).

Table 1. Demographic and radiological features of the patients (n=208, 25%) Age, years (Mean±SD)

36.6±12

Gender (Male/Female) 145/63 *

Alvarado score (Mean±SD)

5±1.5

Alvarado score 1–4

59

5–8

149, 71.6%

9, 10

0

Ultrasonography (+)

47

(–)

112

Equivocal

49

Computed tomography request

Emergency clinician

91 (43.7%)

General surgeon

117 (56%)

Alvarado score was significantly higher in females who underwent CT preoperatively (5.6±1.4 vs 4.8±1.6, p<0.001). SD: Standard deviation.

*

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Yazıcı et al. Emergency computed tomography for the diagnosis of acute appendicitis

Table 2. Radiological findings and Alvarado scores on the basis of which clinic requested Variables

No of patients

Ultrasonography (+/– /0*) Computed tomography (+/–)

p

47/112/49 175/33 (15%)

Distribution of Alvarado scores**

General surgery (57%)

5.6±0.6

Emergency medicine (42%)

4.7±1.2

0.013

Can not be visualized; **Regarding the clinics requested the computed tomography.

*

Most of the patients (66%) had an Alvarado score between 5 and 8 (Table 1). US findings were negative for appendicitis in 112 (53%) patients; however, other reports recommended abdominal CT in case of suspicion of appendicitis. General surgeons requested most of the abdominal CTs (53%). Alvarado score was significantly higher in patients with CT ordered by general surgeons (5.6 vs 4.7, p=0.013) (Table 2). CT was negative for appendicitis in 33 cases.

All patients underwent surgery within 12 h following CT. Histopathological examinations revealed negative findings for acute appendicitis in 29 (14%) of patients. In these patients, age and Alvarado scores were significantly lower than those with positive pathological examination results (Table 3). The rate of negative CT findings in these patients was significantly higher (58% vs. 9%, p<0.001).

In 12 patients, whose CT revealed positive findings despite negative US results, histopathological results were negative for appendicitis. Sensitivity and specificity of CT were 92% and 58%, respectively.

DISCUSSION The differential diagnosis of right lower-quadrant pain includes several disorders including gastrointestinal, gynecologic, and ureteric pathology. Imaging studies are beneficial in evaluating right lower-quadrant pain. However, growth in use and

overuse of diagnostic imaging significantly impacts the quality and costs of health care services.[7] CT is currently popular for the differential diagnosis of right low quadrant pain, particularly in the suspicion of acute appendicitis. In our center, one-fifth of patients with suspected appendicitis underwent CT to determine the underlying etiology. More than half of the patients, who underwent CT scan, had negative or equivocal findings in US regarding appendicitis. The mean Alvarado score in our series was about 5 with a significantly higher value in female patients. This latter finding could be related to the wide range of possible disorders which resulted in right lower quadrant pain that needs differential diagnosis, particularly in female patients. In an algorithm to guide CT use for appendicitis, this difference was also noted. The score was determined as ≤8 for female patients, whereas it was 6 for male patients.[8] Strategies for improvement in the decision-making process include the use of diagnostic scoring systems, laboratory markers, and advanced imaging modalities including CT. Despite several disadvantages such as high cost, radiation exposure, and time-consuming, CT is proved to be the dominant imaging method given that ultrasound proved to be ineffective in the suspicion of appendicitis.[9] Utilization of high-technology has decreased the rate of negative appendectomy.[10,11] In the present study, the rate of negative appendectomy was quite higher when compared to our series including whole patients who underwent appendectomy with or without preoperative CT,[12,13] but it was comparable with the literature.[11] However, this could be attributed to the fact that the present study included patients whose clinical presentation was suspicious for appendicitis and who underwent advanced imaging method (CT). Most of the patients with negative appendectomy were younger and had significantly lower Alvarado scores. This relation could be due to the higher possibility of lymphoid hyperplasia in this population and subsequent subtle clinical findings. Therefore, initial medical management should be considered in such group of patients that may result in clinical improvement soon after a short observation period.

How clinicians use these strategies depends on many factors related to the practice setting, population served, and clinical

Table 3. Comparative analysis of clinical and radiological findings regarding

pathological results

Pathology (–)

Pathology (+)

(n=29, 14%)

(n=179)

p

Gender (Famale/Male)

13/16

51/128

Age

29±12

38±12 0.015

Alvarado score

4.9±1.5

Ultrasonography (+/– /0*)

8/6/15

Computed tomography** (+/–)

12/17

5.6±1.3

0.192 0.037

39/106/34 0.023 163/16 (9%)

<0.001

*Can not be visualized. **The rate of negative CT was around 10%.

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goals. In our study, compared with the emergency clinicians, the patients who were requested CT by general surgeons had significantly higher Alvarado scores. A plausible explanation for this includes the clinical goal of the surgeons and need for surgical decision-making process of appendicitis. Although emergency clinicians aim to determine the underlying disorder of right lower quadrant pain and refer patients to the right clinic, general surgeons mostly use CT to eliminate pitfalls and focus on the differential diagnosis of plausible acute appendicitis.

In a meta-analysis of 6 prospective studies, CT demonstrated superior sensitivity (91%) and specificity (90%) compared with US (sensitivity 78%; specificity, 83%) in the diagnosis of acute appendicitis.[14] US was beyond the scope of this study; however, 90% sensitivity of CT was compatible with the current literature, whereas a specificity of 53% was quite low.

This issue can be related to these limited patient series of whose diagnosis was suspected for appendicitis. Nevertheless, in most patients, clinical decision was based on physical examination findings that integrated with laboratory and imaging study results.

Limitations of the study were its retrospective design, lack of cost analysis, and adverse effects of radiation exposure or radiopaque use. Further limitations include the lack of observer-blindness regarding disease status and CT results; this may have resulted in overestimation of the validity and reliability of this study.

In conclusion, the use of abdominal CT in case of clinical suspicion of acute appendicitis or indeterminate diagnostic scores was particularly performed for patients with inconclusive or negative appendicitis ultrasound results and an Alvarado score between 5 and 8. These promising results may support the efficient use of CT. However, the rate of negative appendectomy still remained quite high. Therefore, further studies are required to determine how CT can be more efficiently used for patients with a preliminary diagnosis of acute appendicitis.

Acknowledgments: There are no acknowledgements to declare.

Conflict of interest: None declared.

314

REFERENCES 1. Alvarado A. A practical score for the early diagnosis of acute appendicitis.

Ann Emerg Med 986;15:557–64.

2. Lysdahl KB, Hofmann BM. What causes increasing and unnecessary use of radiological investigations? A survey of radiologists’ perceptions. BMC Health Serv Res 2009 Sep 1;9:155.

3. Fenyö G, Lindberg G, Blind P, Enochsson L, Oberg A. Diagnostic decision support in suspected acute appendicitis: validation of a simplified scoring system. Eur J Surg 1997;163:831–8.

4. Poortman P, Lohle PN, Schoemaker CM, Oostvogel HJ, Teepen HJ, Zwinderman KA, et al. Comparison of CT and sonography in the diagnosis of acute appendicitis: a blinded prospective study. AJR Am J Roentgenol 2003;181:1355–9.

5. Krishnamoorthi R, Ramarajan N, Wang NE, Newman B, Rubesova E, Mueller CM, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology 2011;259:231–9.

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

7. Baker L, Birnbaum H, Geppert J, Mishol D, Moyneur E. The relationship between technology availability and health care spending. Health Aff (Millwood) 2003;Suppl Web Exclusives:W3-537–51.

8. Tan WJ, Acharyya S, Goh YC, Chan WH, Wong WK, Ooi LL, et al.

Prospective comparison of the Alvarado score and CT scan in the evaluation of suspected appendicitis: a proposed algorithm to guide CT use. J Am Coll Surg 2015;220:218–24.

9. Koo HS, Kim HC, Yang DM, Kim SW, Park SJ, Ryu JK. Does computed tomography have any additional value after sonography in patients with suspected acute appendicitis? J Ultrasound Med 2013;32:1397–403.

10. Drake FT, Florence MG, Johnson MG, Jurkovich GJ, Kwon S, Schmidt Z, et al; SCOAP Collaborative. Progress in the diagnosis of appendicitis: a report from Washington State’s Surgical Care and Outcomes Assessment Program. Ann Surg 2012;256:586–94.

11. Seetahal SA, Bolorunduro OB, Sookdeo TC, Oyetunji TA, Greene WR, Frederick W, et al. Negative appendectomy: a 10-year review of a nationally representative sample. Am J Surg 2011;201:433–7.

12. Bostancı Ö, Okul S, Yazıcı P, Işıl RG, Demir U, Işıl CT, et al. Retrospective evaluation of open and laparoscopic surgery outcomes in acute appendicitis. SETB 2014;48:208–12.

13. Kartal K, Yazıcı P, Ünlü TM, Uludağ M, Mihmanlı M. How to avoid negative appendectomies: Can US achieve this? Ulus Travma Acil Cerrahi Derg 2017;23:134–8.

14. 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.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut apandisit tanısında bilgisayarlı tomografi ne kadar etkili kullanılıyor?

Dr. Pınar Yazıcı, Dr. Ayhan Öz, Dr. Kinyas Kartal, Dr. Muharrem Battal, Dr. Esin Kabul Gürbulak, Dr. İsmail Ethem Akgün, Dr. Sıtkı Gürkan Yetkin, Dr. Mehmet Mihmanlı Şi̇ şli Hamidiye Etfal Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

AMAÇ: Gelişen teknolojik imkanlar ve bunlara kolay ulaşım ile birlikte akut apandisit hastalarının tanısında hemen her hastada kullanılan ultrasonografi (USG) -özellikle klinik şüphede kalınan hastalarda- bilgisayarlı tomografi (BT) ile desteklenmektedir. Biz bu çalışmada özellikle Alvarado skorlaması ve US sonuçları göz önüne alınarak akut apandisit tanısında kullanılan BT’nin ne kadar etkin kullanıldığını araştırmayı hedefledik.

GEREÇ VE YÖNTEM: Mayıs 2013 ve Şubat 2016 tarihleri arasında acil serviste değerlendirilerek tedavisi düzenlenen akut apandisit hastaları etik kurul onaylı veriler analiz edilerek geriye dönük tarandı. Ameliyat öncesi BT kullanılan hastalar çalışmaya alındı. Hastaların demografi verileri, Alvarado skorları, USG ve BT raporları, BT istenen bölüm (acil servis-cerrahi), ameliyat notları ve patoloji sonuçları kayıt edildi.

BULGULAR: Çalışma sürecinde tedavi edilen 811 akut apandisit hastasından 208’ine (%25) BT çekildiği saptandı. Hastaların hepsine en az bir kez USG yapılmıştı ve %53’ünde (n=112) USG negatif idi. Alvarado skorları ortalama 5±1.5 (dağılım: 3–8) idi. Bilgisayarlı tomografi istemlerinin %42’si acil hekimleri tarafından %57’si cerrahlar tarafından istenmişti. Acil servis ve cerrahi branşlarının BT istemi yaptıkları hastaların ortalama Alvarado skorları sırasıyla 4.7 ve 5.6 olarak bulundu (p=0.013). Apendiks patolojisi normal saptanan (n=29, %14) hastalarda negatif BT oranı anlamlı yüksek (p=0.042); yaş ve Alvarado skoru anlamlı düşük (sırasıyla, p=0.015 ve 0.037) saptandı.

TARTIŞMA: Alvarado skorunun BT çekilen hastaların çoğunda 5–8 arasında olması ve çoğunlukla USG negatif hastalarda olmak üzere %25 oranında uygulanması ameliyat öncesi BT’nin apandisit tanısında etkin kullanıldığı lehine yorumlanabilir. Bu sonuçlar ışığında çalışmamızdaki negatif apendektomi oranları göz önüne alındığında BT’nin daha etkin kullanımını sağlamak için ileri çalışmalara ihtiyaç vardır.

Anahtar sözcükler: Akut apandisit; akut batın; Alvarado skoru; bilgisayarlı tomografi.

Ulus Travma Acil Cerrahi Derg 2018;24(4):311-315

doi: 10.5505/tjtes.2017.36390

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ORIGIN A L A R T IC L E

Multislice computed tomographic measurements of optic nerve sheath diameter in brain injury patients Murat Özsaraç, M.D.,1 Fatih Düzgün, M.D.,2 Yalçın Gölcük, M.D.,1 Adnan Bilge, M.D.,1 Mehmet İrik, M.D.,1 Halil Yılmaz, M.D.1 1

Department of Emergency Medicine, Celal Bayar University Faculty of Medicine, Manisa-Turkey

2

Department of Radiology, Celal Bayar University Faculty of Medicine, Manisa-Turkey

Yüksel Pabuşcu, M.D.,2

ABSTRACT BACKGROUND: Currently, the measurement of optic nerve sheath diameter (ONSD) has been offered as a possible indicator of intracranial pressure (ICP). Increased ICP is observed during intracranial injury. The objective of this study was to evaluate the relationship between increased ONSD and positive intracranial findings from multislice computed tomography (CT) of the brain.

METHODS: In total, CT scans of 161 patients were retrospectively reviewed. The image that showed the largest ONSD was magnified five times.

RESULTS: The CT scan revealed intracranial lesions in 54 patients and no intracranial lesions in 107 patients. A significant relationship was observed between positive CT findings and increased ONSD: 5.60±0.75 mm vs. 5.35±0.75 mm (p=0.038). The area under the receiver operating characteristic curve was 0.600 (95% confidence interval, 0.508–0.692; p<0.039). A cut-off value of ≥5.0 mm had a sensitivity and specificity of 80% and 36%, respectively.

CONCLUSION: This study demonstrated a significant yet poor relationship between intracranial injury and increased ONSD from the multislice CT scan. Severe structural changes in the brain and trauma that causes bleeding have only limited effects on the extension of the optic nerve.

Keywords: Brain injury; computed tomography, intracranial hypertension; intracranial pressure; optic nerve sheath diameter.

INTRODUCTION Intracranial hypertension is a critical syndrome and is caused by a variety of neurological problems. If elevated intracranial pressure (ICP) is undetected and left untreated, progressive deterioration of neuronal activity and even death may occur.

[1] Intracranial compliance deteriorates quickly with the expansion of space-occupying lesions, cerebral edema, hypoxia, tumor complications, head trauma, or hematoma due to the rigid structure of the skull and restricted compensatory growth.[2] Patients with these conditions may require expeditious surgical or medical intervention to prevent a poor outcome.[3] In traumatic brain injuries (TBIs), the mass effect of hematoma, loss of autoregulation, and increased internal

pressure of the thorax and abdomen due to mechanical ventilation promote the development of intracranial hypertension.

[4] The diagnosis of ICP is very important because prompt treatment is essential for limiting neuronal injury, but physical examination has its limitations.[5] Methods including lumbar puncture, ventriculostomy, magnetic resonance imaging (MRI), or computed tomography (CT) may be used in ICP diagnosis; however, these options are invasive, time-consuming, expensive, and often not feasible. Currently, the measurement of optic nerve sheath diameter (ONSD) by ultrasonography has been offered as a possible indicator for ICP.[6–9] The optic nerve is a component of the brain and is enveloped by cerebrospinal fluid and a subarachnoid membrane. Intracranial trauma and elevated pressure can arise from a variety of

Cite this article as: Özsaraç M, Düzgün F, Gölcük Y, Pabuşcu Y, Bilge A, İrik M, et al. Multislice computed tomographic measurements of optic nerve sheath diameter in brain injury patients. Ulus Travma Acil Cerrahi Derg 2018;24:316-320.

Address for correspondence: Murat Özsaraç, M.D. Celal Bayar Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Manisa, Turkey.

Tel: +90 236 - 233 85 86 E-mail: mozsarac@msn.com Ulus Travma Acil Cerrahi Derg 2018;24(4):316-320 DOI: 10.5505/tjtes.2017.27985 Submitted: 28.06.2016 Accepted: 18.10.2017 Online: 26.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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reasons, such as bleeding, tumor, and hydrocephalus, which directly affect the optic nerve through the subarachnoid area, causing dilation of the nerve body.[6,10] A prospective study on emergency medicine and critical care unit patients with TBI suggested that an increase in ONSD of >5.0–6.3 mm (measured 3 mm behind the globe) is an indicator of increased ICP.[5,7,8,11–20] On the other hand, the reported average ONSD measurement is uncertain. The experience level of the medical practitioner, variation in ultrasound technique, artifacts in the image, and the small structural size of the nerve may all contribute to a wide variation in the exact cut-off value.

[11–22] Ultrasonographic attenuation artifacts can originate from the optic disc and lens, causing incorrect evaluation of ONSD. The imprecise, homogeneous, hypoechoic, bandshape appearance of these artifacts and the need to perform millimetric measurements within a narrow area both affect the reliability of measurement. Moreover, dynamic variations in ICP are not frequently considered.[21] CT is considered a more effective method for the evaluation of increased ICP on the optic nerve, especially that which arises from severe head trauma and which causes severe brain hemorrhage. An accurate visualization of the size of the optic nerve from thinslice CT images may provide more precise results. It may also be beneficial in determining more accurate threshold values of the optic nerve. The objective of this study was to evaluate the relationship between increased ONSD and positive intracranial findings from multislice CT scans of the brain.

MATERIALS AND METHODS This retrospective study was conducted at a university hospital in the emergency department, with an approximate patient volume of 60000 per year. The protocol for this study was reviewed and approved by the institutional ethics committee of Manisa Celal Bayar University. Brain CT images (minimum of 300 sequences) over a 2-year period from January 2014 to March 2016 were obtained from the emergency department and reviewed. The inclusion criteria comprised patients (male or female) aged >17 years and who were diagnosed with a focal brain injury. Positive CT findings were defined as intraventricular or subarachnoid hemorrhage; epidural, subdural, or parenchymal hematoma; or cerebral contusion. Patients were identified using the International Classification of Diseases Ninth Revision diagnosis codes for concussion, epidural hematoma, subdural hemorrhage, subarachnoid hemorrhage, intracranial injury, and skull fracture (ICD codes S00, S02, S06).

Brain CT images, reports, and ONSD measurements of all patients were reviewed. Non-trauma patients with spontaneous intracranial hemorrhage were also included. Asymmetric scans with a low number of image section scans (such as 40 or 50 sections) and/or with artifacts for any reason (severe fracture, abnormal eye motion, or foreign bodies) that could cause inaccuracies in the ONSD evaluation and create CT images with unusual ophthalmic findings were excluded. Besides these, patients with optic nerve trauma and a history of intracranial mass were excluded from this study. Among the patients Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

included in the ICD list (registered as a preliminary diagnosis), patients who did not have any type of intracranial injury apparent on CT were evaluated as the normal CT group. Every brain CT image was interpreted and reported by an expert radiologist. The results of the ONSD measurements taken from the brain CT images were evaluated by emergency physicians.

The mean ONSD of the patients’ left and right eyes was calculated to yield the median value. The width of ONSD was also determined from the CT images and evaluated perpendicularly to the axial CT image. The images were evaluated through the only “brain window,” which demonstrated ONSD in complete and greatest detail. ONSD was measured 3 mm behind the globe in a perpendicular vector, with reference to the linear axis of the nerve (Fig. 1). Measurements were evaluated using a picture archiving and communication system workstation by Probel®. The image that demonstrated the largest ONSD was magnified five times.

Statistical Analysis All data were analyzed using the software SPSS Statistics Version 15.0 for Windows. Categorical data were presented as percentages. Numerical data were presented as mean±standard deviation as well as median (min–max), and the assumption of normality was tested using the Kolmogorov–Smirnov test. The Mann–Whitney U test was also performed to evaluate the relationship between intracranial findings and ONSD. The significance was set to p≤0.05. The receiver operating characteristic (ROC) curves were drawn to determine the performance of increased ONSD to predict positive intracranial finding and its area under the curve was used. In addition, once the best cut-off value had been determined from graphical data, sensitivity and specificity were calculated with 95% confidence intervals (CIs).

RESULTS Between January 2014 and March 2016, a total of 2,700 patients were examined in the emergency department for head trauma and intracranial injury (ICD codes S00: superficial injuries of the head and face; S02: skull fractures; and S06: intracranial hemorrhage). In total, data from 161 patients with an injury or fracture were analyzed. CT was performed in these patients to identify trauma or symptoms. The age range

Figure 1. Multislice computed tomography measurements of bilateral optic nerve sheath diameter.

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Table 1. Brain computed tomography (CT) findings and mean optic nerve sheath diameter measurement

Intracranial lesion positive Intracranial lesion negative (n=54) (n=107)

Mean diameter (mm)

5.60±0.75

5.35±0.75

Normal computed tomography findings

94 (58.4%)

Isolated fracture (i.e., nasal, maxilla and mandibula)

13 (8.1%)

Epidural hematoma

8 (5%)

Subdural hematoma

18 (11.2%)

Subarachnoid hemorrhage

p

0.038

6 (3.7%)

Parenchymal hematoma, contusion, and mixed type injuries

22 (13.7%)

*Mann-Whitney U Test.

of patients was 17–86 years, with an average of 40.1 years; 114 patients were males (70.8%) and 47 were females (29.2%). The (a)

ROC Curve

1.0

Sensitivity

0.8

Table 2. Optimal threshold for optic nerve sheath diameter in previous studies

0.6

Author

0.4

0.0

0.2

0.4

0.6

0.8

1.0

1 - Specificity

(b) 12.5 10.0

Negative

7.5 Frequency

5.0 2.5

Intracranial lesion

0.0 12.5 10.0

15

Optimal cut-off (optic nerve) 5.0 mm (sensitivity 88% and

specificity of 93%)

Blaivas et al.[11]

6.3 mm (sensitivity 100%

35

and specificity 95%)

Tayal et al.[12]

5.0 mm (sensitivity 100% and

59

specificity 63%)

Frumin et al.[13]

5.2 mm (sensitivity 83% and

27

specificity 100%)

Sekhon et al.[14]

6.0 mm (sensitivity 97% and

57

specificity 42%)

Geeraerts et al.[15]

5.7 mm (sensitivity 100% and

31

specificity 100%)

Soldatos et al.[17]

5.7 mm (sensitivity 74% and

76

specificity 100%)

Moretti et al.[18]

5.2 mm (sensitivity 94% and

53

specificity 76%)

5.0

Rajajee et al.[19]

5.2 mm (sensitivity 67% and

2.5

specificity 98%)

0.0

Amini et al.[20]

5.5 mm (sensitivity 100% and

Positive

7.5

3.00

4.00

5.00

6.00

7.00

8.00

Optic nerve sheath diameter

Figure 2. (a, b) Receiver-operator characteristic curves of the performance of optical nerve sheath diameter to predict positive CT findings.

318

Number of patients

Kimberly et al.[5]

0.2

0.0

initial brain CT scan revealed intracranial lesions (i.e., epidural hematoma, subdural hematoma, subarachnoid hemorrhage, contusion, or mixed types of injury) in 54 patients (33.5%) and no intracranial lesions in 107 patients (66.5%). The type of injury was trauma in 40 cases (74.1%) and non-trauma in 14 cases (25.9%). A summary of the patients’ radiological data is presented in Table 1. A significant relationship was observed

65 50

specificity 100%)

Caffery et al.[26]

5.0 mm (sensitivity 75% and

51

specificity 44%)

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between positive CT findings and increased ONSD: 5.60±0.75 mm vs. 5.35±0.75 mm (p=0.038). An ROC curve was placed to evaluate the diagnostic significance of ONSD (Fig. 2a and b). Comparing positive and negative intracranial findings on CT, the positive findings presented more signs of increased ONSD. The area under the ROC curve was 0.600 (95% CI, 0.508–0.692; p<0.039). A cut-off value of ≥5.0 mm had a sensitivity and specificity of 80% and 36%, respectively.

DISCUSSION The traditional indicators for elevated ICP in brain CT include cisternal compression, sulcal effacement, changes in vertical sizes, midline shift with a mass effect of at least 3 mm, transtentorial herniation, and changes in the rate of gray/ white matter.[23] CT remains the most commonly available tool for intracranial hypertension diagnosis, and ONSD measurements by MRI are shown in correlation with direct ICP measurements.[5,7,14] ONSD measurements via MRI and CT are compatible, with the latter method being widely available for patients with TBI.[5,6,9] However, these modalities require the transfer of a patient in critical condition away from the resuscitation area.[24] A previous study on healthy individuals and glaucoma patients reported high correlation between tomographic and ultrasonographic ONSD measurements.[25] Numerous contemporary reports have found that ONSD is correlated with elevated ICP, as measured by invasive ICP monitoring.

[7,8,15,18–21] Besides, ultrasound may be of use in the assessment of patients with suspected intracranial hypertension. Simple bedside ONSD measurements have been developed for faster assessment of high ICP risk. The non-invasive and rapid quality of bedside ultrasound has resulted in an increase in its use for detecting intracranial hypertension by the emergency department and critical care unit. Unfortunately, there has been no agreement on the optimal thresholds of normal and increased ONSD indicating intracranial hypertension.

[2,5,7,8,11–15,18–21] Recent studies on the subject are summarized in Table 2. Previous studies have considered the cut-off range for ONSD in predicting elevated ICP to be 5.0–6.3 mm. In the literature, the sensitivity and specificity widely ranged from 74%–100% and 48%–100%, respectively. The normal limits in one study might not be normal in another study.[5,11–26] Amini et al. determined that the threshold value of ONSD at higher sensitivity and specificity levels was 5.5 mm in patients with an elevated lumbar puncture opening pressure of >20 cm H2O.[20] In addition, Caffery et al. reported that the threshold value of 5.0 mm did not have adequate sensitivity and specificity, despite using the same methodology.[26] Regarding the ultrasonographic image quality in particular, artifacts and user experience are the most significant factors for presenting different threshold values.[11] Increased ICP can be observed during the natural period of intracranial injury. In cases of head injury, ONSD can be a Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

valuable tool for analysis in broader prospective trials and in the determination of critical cases. For patients with head injuries, there is a need for combined clinical studies in which ultrasound measurements are corroborated with thin-slice CT measurements. Additional prospective studies on ultrasonography and CT may be justified to evaluate diagnostic performance and risk stratification.

In this study, an analysis of CT images with 5× magnification could allow for sharper appearance of optic nerve borders and a more accurate evaluation of sizes. In this study, statistical differences were found between ONSDs of patients with intracranial injury and patients without; however, the differences did not present much clinical significance (5.60 mm vs.

5.35 mm). Finally, current clinical and radiological studies do not provide a precise ONSD cut-off value for measuring increased ICP.[7,22]

Conclusion This study demonstrated a significant yet poor relationship between intracranial injury and increased ONSD from the initial multislice brain CT scan. Severe structural changes in the brain and severe trauma that causes bleeding have only limited effects on the extension of the optic nerve.

Acknowledgments We thank Dr. Hatice Uluer (Ege University, Biostatistics And Medical Informatics, İzmir) for their assistance in data analysis and table editing.

Conflict of interest: None declared.

REFERENCES 1. Stein DM, Hu PF, Brenner M, Sheth KN, Liu KH, Xiong W, et al. Brief episodes of intracranial hypertension and cerebral hypoperfusionare associated with poor functional outcome after severe traumaticbrain injury.

J Trauma 2011;71:364–73; discussion 373–4.

2. Treggiari MM, Schutz N, Yanez ND, Romand JA. Role of intracranial pressure values and patterns in predicting outcome in traumatic brain injury: a systematic review. Neurocrit Care. 2007;6:104–12.

3. Münch EC, Bauhuf C, Horn P, Roth HR, Schmiedek P, Vajkoczy P. Therapy of malignant intracranial hypertension by controlled lumbar cerebrospinal fluid drainage. Crit Care Med 2001;29:976–81.

4. Rangel-Castilla L, Gopinath S, Robertson CS. Management of intracranial hypertension. Neurol Clin 2008;26:521–41.

5. Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med 2008;15:201–4.

6. Chen H, Ding GS, Zhao YC, Yu RG, Zhou JX. Ultrasound measurement of optic nerve diameter and optic nerve sheath diameter in healthy Chinese adults. BMC Neurol 2015;15:106.

7. Geeraerts T, Newcombe VF, Coles JP, Abate MG, Perkes IE, Hutchinson PJ, et al. Use of T2-weighted magnetic resonance imaging of the optic nerve sheath to detect raised intracranial pressure. Crit Care 2008;12:R114.

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9. Kalantari H, Jaiswal R, Bruck I, Matari H, Ghobadi F, Weedon J, et al. Correlation of optic nerve sheath diameter measurements by computed tomography and magnetic resonance imaging. Am J Emerg Med 2013;31:1595–7.

10. Killer HE, Laeng HR, Flammer J, Groscurth P. Architecture of arachnoid trabeculae, pillars, and septa in the subarachnoid space of the human optic nerve: anatomy and clinical considerations. Br J Ophthalmol 2003:777–81.

11. Blaivas M, Theodoro D, Sierzenski PR. Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath.

Acad Emerg Med 2003;10:376–81.

12. Tayal VS, Neulander M, Norton HJ, Foster T, Saunders T, Blaivas M. Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med 2007;49:508–14.

13. Frumin E, Schlang J, Wiechmann W, Hata S, Rosen S, Anderson C, et al.

Prospective analysis of single operator sonographic optic nerve sheath diameter measurement for diagnosis of elevated intracranial pressure. West J Emerg Med 2014;15:217–20.

14. Sekhon MS, Griesdale DE, Robba C, McGlashan N, Needham E, Walland K, et al. Optic nerve sheath diameter on computed tomography is correlated with simultaneously measured intracranial pressure in patients with severe traumatic brain injury. Intensive Care Med 2014;40:1267– 74.

15. Geeraerts T, Launey Y, Martin L, Pottecher J, Vigué B, Duranteau J, et al. Ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. Intensive Care Med 2007;33:1704–11.

16. Legrand A, Jeanjean P, Delanghe F, Peltier J, Lecat B, Dupont H. Estimation of optic nerve sheath diameter on an initial brain computed tomography scan can contribute prognostic information in traumatic brain injury

patients. Crit Care 2013;17:R61.

17. Soldatos T, Karakitsos D, Chatzimichail K, Papathanasiou M, Gouliamos A, Karabinis A. Optic nerve sonography in the diagnostic evaluation of adult brain injury. Crit Care. 2008;12:R67.

18. Moretti R, Pizzi B. Optic nerve ultrasound for detection of intracranial hypertension in intracranial hemorrhage patients: confirmation of previous findings in a different patient population. J Neurosurg Anesthesiol 2009;21:16–20.

19. Rajajee V, Vanaman M, Fletcher JJ, Jacobs TL. Optic nerve ultrasound for the detection of raised intracranial pressure. Neurocrit Care 2011;15:506–15.

20. Amini A, Kariman H, Arhami Dolatabadi A, Hatamabadi HR, Derakhshanfar H, Mansouri B, et al. Use of the sonographic diameter of optic nerve sheath to estimate intracranial pressure. Am J Emerg Med 2013;31:236–9.

21. Moretti R, Pizzi B. Ultrasonography of the optic nerve in neurocritically ill patients. Acta Anaesthesiol Scand 2011;55:644–52.

22. Shevlin C. Optic nerve sheath ultrasound for the bedside diagnosis of intracranial hypertension: pitfalls and potential. Critical Care Horizons 2015;1:22–30.

23. Miller MT, Pasquale M, Kurek S, White J, Martin P, Bannon K, et al.

Initial head computed tomographic scan characteristics have a linearrelationship with initial intracranial pressure after trauma. J Trauma 2004 May;56:967–72.

24. Romagnuolo L, Tayal V, Tomaszewski C, Saunders T, Norton HJ. Optic nerve sheath diameter does not change with patient position. Am J Emerg Med 2005;23:686–8.

25. Boles Carenini B, Tettoni E, Brogliatti B. CT and a echography of optic nerve in glaucoma. Acta Ophthalmol Scand Suppl 2002;236:40–1.

26. Caffery TS, Perret JN, Musso MW, Jones GN. Optic nerve sheath diameter and lumbar puncture opening pressure in nontrauma patients suspected of elevated intracranial pressure. Am J Emerg Med 2014;32:1513–5.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Beyin hasarı olan hastalarda çok kesitli bilgisayarlı tomografide optik sinir kılıfı ölçümleri Dr. Murat Özsaraç,1 Dr. Fatih Düzgün,2 Dr. Yalçın Gölcük,1 Dr. Yüksel Pabuşcu,2 Dr. Adnan Bilge,1 Dr. Mehmet İrik,1 Dr. Halil Yılmaz1 1 2

Celal Bayar Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Manisa Celal Bayar Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Manisa

AMAÇ: Günümüzde, kafa içi basıncın (KİB) belirlenmesinde, optik sinir kılıfı çapı (OSKÇ) ölçümlerinden faydalanılabileceği belirtilmektedir. KİB artışı, intrakraniyal yaralanmaların doğal bir sonucudur. Bu çalışmada, çok kesitli bilgisayarlı beyin tomografisindeki, pozitif intrakraniyal bulgular ve OSKÇ genişlemesi arasındaki ilişki değerlendirildi.

GEREÇ VE YÖNTEM: Toplam 161 hastanın çok kesitli BT görüntüleri geriye dönük incelendi. Ölçümler, kesitlerde optik sinirin en geniş görüldüğü bölge beş kez büyütülerek yapıldı.

BULGULAR: Çok kesitli beyin tomografisi görüntülerinde, 54 hastada kafa içi hasar tespit edilirken, 107 hastada edilmedi. Pozitif tomografi bulguları ile OSKÇ artışı arasında anlamlı ilişki olduğu belirlendi, 5.60±0.75 mm ve 5.35±0.75 mm (p=0.038). ROC eğrisinin altında kalan alan, 0.600 (%95 güven aralığında 0.508–0.692; p<0.039). OSKÇ eşik değeri ≥5 mm, duyarlılık %80, özgüllük %36 olarak belirlendi.

TARTIŞMA: Bu çalışma, çok kesitli tomografilerde incelenen kafa içi hasar ile OSKÇ artışı arasında anlamlı ancak zayıf bir ilişki olduğunu gösterdi.

Beyinde ciddi yapısal değişikliklere ve kanamaya yol açacak travmalar, optik sinirin genişlemesi üzerinde ancak sınırlı bir etkiye sahiptir.

Anahtar sözcükler: Beyin hasarı; bilgisayarlı tomografi; kafa içi basınç; kafa içi hipertansiyon; optik sinir kılıfı çapı.

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doi: 10.5505/tjtes.2017.27985

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ORIGIN A L A R T IC L E

Effects of temporary abdominal closure methods on mortality and morbidity in patients with open abdomen Erol Kılıç, M.D.*,

Mustafa Uğur, M.D.*,

İbrahim Yetim, M.D.,

Muhyittin Temiz, M.D.

Department of General Surgery, Mustafa Kemal University Faculty of Medicine, Hatay-Turkey *Two authors contributed equally to the work.

ABSTRACT BACKGROUND: Open abdomen (OA) in which the abdomen is closed with temporary abdominal closure methods is the most effective in patients who develop severe abdominal sepsis or abdominal compartment syndrome. Major techniques used are VacuumAssisted Closure Method (VACM) and non-vacuum assisted closure method (NVACM). In the present study, the effects of different abdominal closure methods on morbidity and mortality were evaluated.

METHODS: In the study, the temporary abdominal closure methods of the patients with OA during 2013–2016 were studied retrospectively. OA etiopathologies, mortality prediction scores, final abdominal closure periods and methods, hospitalization periods, complications (enteroatmospheric fistula, mesh infection, and incisional hernia), and mortality rates of patients who underwent VACM and NVACM were determined and compared.

RESULTS: The present study included 123 patients who underwent VACM (n=65) and NVACM (n=58). There was no difference between the groups in terms of age, gender, and etiopathogenesis (p>0.05). The mean APACHE 4 and Multiple Organ Dysfunction Score (MODS) scores in the VACM/NVACM groups in treatment period were 47/63 and 11/14, respectively (p<0.05). The mean intensive care and hospitalization periods in the VACM/NVACM groups were 11/16 (days) and 22/28 (days), respectively (p<0.05). The collection and abscess development rates in the VACM and NVACM groups were 46.2% and 77.6%, respectively (p<0.05). The rate of enteroatmospheric fistula (EAF) development in the VACM and NVACM groups were 15.4% and 56.9%, respectively (p<0.05). The mean abdominal closure times in the VACM and NVACM groups were 13 and 17 days, respectively (p<0.05). Mortality rate in the VACM and NVACM groups were 18% (n=18) and 55% (n=32), respectively (p<0.05).

CONCLUSION: In patients with OA, the temporary abdominal closure technique VACM has lower complication and mortality rates and shorter hospitalization period than other methods. Therefore, it is an effective and safe method for the treatment of OA. Keywords: Baker method; Bogota bag; Non-vacuum assisted closure method (NVACM); open abdomen; temporary abdomen closure; acuum-Assisted Closure Method (VACM).

INTRODUCTION The aim of open abdomen (OA) is to prevent abdominal sepsis and the development of abdominal compartment syndrome.

The fascia or skin of the abdomen is not primarily closed, and the abdomen is left open with various methods and instruments.[1] Abdominal visceral organ edema and complete infection therapy cannot be achieved in patients with severe sepsis originating from abdomen.[2] This can lead to paralytic

ileus and intraabdominal hypertension (IAH). Consequently, the patient, who is already in critical condition, can develop multiorgan failure.[3] To prevent the development of such consequences, patients with severe abdominal sepsis and at risk of IAH are commonly treated with OA methods.[4] OA is followed by temporary abdominal closure methods. Various materials and methods like sterile serum packs, aspiration devices, and application of negative pressure are used for this purpose.

Cite this article as: Kılıç E, Uğur M, Yetim İ, Temiz M. Effects of temporary abdominal closure methods on mortality and morbidity in patients with open abdomen. Ulus Travma Acil Cerrahi Derg 2018;24:321-326.

Address for correspondence: Erol Kılıç, M.D. Mustafa Kemal Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Hatay, Turkey Tel: +90 326 - 221 33 17 E-mail: ekkilic55@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(4):321-326 DOI: 10.5505/tjtes.2017.95038 Submitted: 09.11.2017 Accepted: 08.12.2017 Online: 04.04.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Kılıç et al. Effects of temporary abdominal closure methods on mortality and morbidity in patients with open abdomen

In the present study, the relation between temporary abdominal closure techniques used in patients with OA after urgent abdominal surgery and their morbidity and mortality was evaluated.

MATERIALS AND METHODS Data of the patients with open abdomen after urgent abdominal surgical treatment during 2013–2016 were compiled, and the relation between temporary abdominal closure methods and morbidity and mortality were studied. Furthermore, intensive care unit and in hospital stay duration, peritonitis, collection, abscess, drainage application, and enteroatmospheric fistula (EAF) development were also studied. The patients who died within the first postoperative 24 hours were excluded.

The patients were divided into two groups depending on temporary abdominal closure techniques; vacuum-assisted closure method (VACM) and non-vacuum assisted closure method (NVACM). Demographic features, OA etiopathologies, and mortality prediction scores of the groups were evaluated. They were studied for graft infection and graft excision.

The methods used for final abdominal closure were VACM with mesh, primary fascial closure, planned ventral herniation, and interposition mesh methods, and the differences among the groups were studied.

Acute Physiological and Chronic Health Evaluation (APACHE 4) scores of the patients were estimated on the first day in intensive care unit. The mean APACHE 4, Sequential Organ Failure Assessment (SOFA), Systemic Inflammatory Response Syndrome (SIRS), and Multiple Organ Dysfunction Score (MODS) scores; intensive care unit and in hospital stay duration; and mortality rates were compared. APACHE 4 scores were calculated using https://intensivecarenetwork.com/Calculators/Files/Apache4.html network.[5] Preoperative and postoperative findings of the groups were evaluated for peritonitis, postoperative collection, abscess development, distribution of drainage application, locations and flow rates of EAF, and EAF treatment methods.

In both groups, the patients whose abdominal closures were performed with graft were evaluated for the rates of graft infection and excision (removal) of infected grafts.

Surgical Technique On admission, all patients were examined by a general surgeon; all surgeries were performed by a general surgeon. An infectious disease specialist was consulted at admission and in postoperative period, and antibiotic therapy was initiated according to the recommendations.

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NVACM group comprised patients who underwent Baker and Bogota bag after OA. In Baker system, lavage was performed with 0.9% saline and subsequently, OA was closed with sterile vaseline gauze pad and aspirated. In Bogota bag method; as it has been reported in previous studies, necrotic tissues were removed, perforations were repaired, the abdomen was washed and aspirated, drain was placed into the abdomen via laparotomy in the operation room every 48–72 hours, and sterile nutrition or urinary flush bags were attached to the fascia one by one with nonabsorbable suture.[6] In this group, if the fascia of the patient was close enough, the final closure was performed with primary closure, but if the fascia was stretched, onlay nonabsorbable graft was placed on to the fascia, and the fascia was pressed medially in every 3 days. If the fascia could not be closed completely, closure was achieved either by undersizing or by trimming the graft.

In VACM group, (TOPİVAC®) closed vacuum system was used to assist the postoperative vacuum-assisted closure performance. With the vacuum system, a protective and fluid permeable membrane was laid over the abdominal organs to prevent the adhesion; next, a spongy material allowing fluid absorption was placed over the membrane; finally, whole abdomen was covered with a drape for closure. A 3-cm² opening was left on the drape, and through this opening, 50–150 mmHg negative pressure was administered with a closedcircuit system continually or at intervals. Second look was performed at 48–72 hours. In this group, after second look, final closure was performed with early primary fascial closure depending on the condition of fascia. If primary fascial closure could not be performed, the same procedure was performed again for 72 hours. After the second 72 hours, primary fascial closure (delayed primary fascial closure) or vacuum-assisted closure and mesh-mediatedfascial closure (VACMM) was performed depending on the condition of fascia. If none of these were possible, it was left for ventral hernia.

VACMM is a vacuum-assisted closure method which is combined with a polypropylene patch. It was performed as described by Petersson et al.[7] On the postoperative sixth day, if the edges of the fascia could not be brought together, a polypropylenepatch was fixed to the edges of fascia and subsequently stretched by performing full-thickness plication. It is plicated over itself in the middle with the help of continuous nonabsorbable suture. In every 3 days, the graft is sutured medially over itself by full-thickness continuous suture to tighten the mesh; therefore, the edges of the fascia are brought closer in the operation room. In patients whose fascia was close enough, the fascia was primarily closed with continuous nonabsorbable sutures or the mesh was undersized and revised to close the abdomen.

Statistical Method Data were analyzed using IBM SPSS V23 (Chicago, USA).

Compliance of quantitative data with normal distribution was Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Kılıç et al. Effects of temporary abdominal closure methods on mortality and morbidity in patients with open abdomen

assessed using Shapiro–Wilk test. To compare the quantitative data with non-normal distribution, Mann–Whitney U test was used for non-parametric tests. To compare the qualitative data of the groups, Chi-square test was used. Quantitative data with non-normal distribution were presented as median (minimum–maximum). Qualitative data were presented as frequency (percentage). Significance level was taken as p<0.05.

RESULTS Overall, 123 patients were included in the study (VACM group, n=65; NVACM group, n=58). Those who died within the first postoperative 24 hours were excluded from the study.

There was no statistically significant difference between the groups in terms of age, gender, and etiopathogenesis. The mean APACHE 4 scores in both groups during admission to intensive care unit and in the postoperative period were similar (Table 1) (p>0.05).

The mean APACHE 4 and MODS scores in the VACM/ NVACM groups in treatment period were 47/63 and 11/14, respectively. APACHE 4 and MODS values in the VACM

group were lower and statistically significant (p<0.05); however, there was no difference between the groups in terms of SIRS and SOFA scores (Table 1) (p>0.05).

The mean intensive care and hospitalization periods in the VACM/NVACM groups were 11/16 (days) and 22/28 (days), respectively, which were significantly shorter in the VACM group (Table 1) (p<0.05).

Mortality rate in the NVACM group was 55% and in the VACM group was 18%, and it was statistically significantly lower in the VACM (Table 1) (p<0.05).

Peritonitis rate in both groups was 89% in preoperative period, and there was no statistically significant difference (p>0.05). In the postoperative period, the collection and abscess development rates in the VACM and NVACM groups were 46.2% and 77.6%, respectively; it was significantly lower in the VACM group (p<0.05). External drainage application for abscess/collection development was 18.5% in the VACM group and 79.6% in the NVACM group. Drainage application rate in the VACM group was significantly lower (Table 2) (p<0.05).

Table 1. Demographic data, APACHE 4, SOFA, SIRS values, and mortality rates of the groups

VACM (n=65)

NVACM (n=58)

p

44 (68)

37 (64)

>0.05*

Sex (%)

Male

Female

Age (year)

21 (32)

21 (36)

42 (18–85)

40.5 (18–76)

0.966**

40 (61)

36 (62)

>0.05*

Primer pathology (%)

Intestinal perforation

Evisceration

9 (14)

9 (15.5)

Necrotizing pancreatitis

5 (7.7)

5 (8.6)

Mesenteric ischemia

2 (3.1)

2 (3.4)

Bile duct injury

4 (6.2)

3 (5.2)

Liver injury

5 (7.7)

3 (5.2)

Critical care (day)

11 (2–42)

16 (4–31)

0.003**

Hospitalization time(day)

22 (3–138)

28 (17–94)

0.036**

75 (15–178)

78 (21–178)

0.253**

11 (2–22)

13 (4–26)

0.102**

3 (0–5)

3 (2–5)

0.063**

Mortality predicting Score

Apache 4 (/286)

SOFA (0-24)

Sırs/Septic shock (0-5)

MODS (0-24)

11 (2–22)

14 (5–22)

0.045**

Apache 4 (/286)

47(11–77)

63 (16–88)

0.037**

18 (28)

32 (55)

0.004**

#

Mortality (%)

Chi-square test; **Man-Whitney U Test. VACM: Vacuum-assisted closure method; NVACM: Hon vacuum assisted closure method; APACHE 4: Acute Physiological and Chronic Health Evaluation scores; SOFA: Sequential Organ Failure Assessment; SIRS/Septic shock: Systemic Inflammatory Response Syndrome; MODS: Multiple Organ Dysfunction Score; #: Postoperative mean APACHE 4 score. *

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The rate of EAF development was 15.4% in the VACM group and 56.9% in the NVACM group. The localization of EAF in small and large intestines was similar in both groups. However, when evaluated for fistula flow rate, EAF flow rate in the VACM group was <250 ml in 6.2% patients, 250–500 ml in 3% patients, and >500 ml in 6.2% patients and EAF flow rate in the NVACM group was <250 ml in 22.4% patients, 250–500 ml in 20.7% patients, and >500 ml in 13.8% patients. Fistula flow rates were significantly lower in the VACM group (Table 2) (p<0.05).

Spontaneous EAF closure rate was 50% (21%) higher in the VACM group than in the NVACM group (p<0.05). Surgical

closure of EAF was 30% in the VACM group and 49% in the NVACM group. Surgical closure of EAF was lower in the VACM group (p<0.05). in the VACM and NVACM groups were 20% and 30%, respectively, and unclosed EAF rate was higher in the NVACM group (Table 2) (p<0.05).

The mean abdominal closure times in the VACM and NVACM groups were 13 and 17 days, respectively. It was statistically shorter in the VACM group (p<0.05). The methods used for abdominal closure were primary fascial closure, fascial closure with grafting, and planned ventral hernia with skin-only repair.

The rates of closure techniques in the VACM and NVACM groups were 31% and 17% for primary fascial closure, 38%

Table 2. Complication rate of the groups

VACM (n=65)

NVACM (n=58)

p

58 (89)

52 (89)

>0.05*

Collection/Abscess (%)

30 (46.2)

45 (77.6)

<0.001*

Drenage (%)

12 (18.5)

46 (79.3)

<0.001*

EAF (%)

10 (15.4)

33 (56.9)

<0.001* 0.575*

Peritonitis preop (%)

Fistula localization (%)

Small bowel

8 (80)

30 (90.9)

Colon

2 (20)

3 (9.1)

EAF (ml/24h)

Non-fistula

55 (84)

25 (43)

<250 ml

4 (6.2)

13 (22.4)

250–500 ml

>500 ml

2 (3)

12 (20.7)

4 (6.2)

8 (13.8)

<0.001*

EAF Closed method (%)

Spontaneous

5 (50)

7 (21)

Surgical

3 (30)

16 (49)

Persistant fistula none-closed

2 (20)

10 (30)

0.001*

Chi-square test; **Man-Whitney U Test. VACM: Vacuum assisted closure method; NVACM: Non vacuum assisted closure method, EAF: Enteroatmospheric fistula. APACHE 4: Acute Physiological and Chronic Health Evaluation scores; SOFA: Sequential Organ Failure Assessment; SIRS: Systemic Inflammatory Response Syndrome. *

Table 3. Abdominal closing time and greft infection/removed rate of grups

Abdominal closed time (day)

VACM (n=65)

NVACM (n=58)

p

13 (3–196)

17 (11–24)

0.011** <0.001*

Abdominal closure method (%)

Gm fascial closure

25 (38)

14 (24.1)

Primer fascial closure

20 (31)

10 (17)

Planned ventral hernia

20 (31)

34 (59)

Greft infection (%)

13 (20)

9 (15.5)

0.680*

Greft removed (%)

2 (3.1)

9 (15.5)

<0.05*

Chi-square test; **Man-Whitney U Test. VACM: Vacuum-assisted closure method; NVACM: Non-vacuum assisted closure method; Gm: Graft mediated.

*

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and 24.1% for fascia-abdomen closure with grafting, and 31% and 59% for planned ventral herniation, respectively. While the rates of primary fascial closure and closure with grafting were significantly higher in the VACM group, the rate of planned ventral hernia was higher in the NVACM group (Table 3) (p<0.05).

Infection development rates in the VACM and NVACM groups after grafting were 20% and 15.5%, respectively (p>0.05), and it was quite similar. The rates of graft excision due to infection in the VACM and NVACM groups were 3.1% and 15.5%, respectively. In the NVACM group, grafts of all patients who developed graft infection were excised. Graft excision was significantly low in the VACM group (Table 3) (p<0.05).

DISCUSSION The main aim of OA is to prevent abdominal sepsis and the development of IAH. Mainly temporary abdominal closure methods used after OA are Bogota bag, Baker, interpositional mesh placement, and VACM.[4,8] The priority in OA treatment is to determine the etiology of peritonitis, drain the intraabdominal fluid, and control the abdominal sepsis source. In patients with severe abdominal sepsis, such as necrotizing soft tissue infections (necrotizing fasciitis), intraabdominal abscess, infected pancreatic necrosis, intestinal infarction, or fecal peritonitis, abdominal visceral organ edema treatment and complete infection eradication cannot be achieved; OA is employed in them. Recently, it has become the standard procedure in the treatment of patients with diffuse peritonitis who are in need of urgent abdominal surgery.[2,3,9] The diagnoses of patients who were treated with OA in our study were consistent with those in the literature.

Various temporary and final abdominal closure methods have been described for patients with OA. Methods such as skinonly closure, closure with sterilized urinary irrigation or parenteral nutrition bags (Bogota bag), closure with absorbable/ nonabsorbable meshes, negative pressure wound therapy, or Wittmann patch technique can be used.[10,11] The ideal procedure in patients with OA is to perform the final abdominal closure within the first 10 days either with direct fascial closure or biologic/synthetic mesh.[12,13] If closure could not be achieved in early days, ventral incisional hernia developed due to the lateral retraction of fascia edges. Moreover, both hospitalization period and morbidity and mortality increase because of adhesions.[14] Vacuum methods used in OA wounds eliminate the necessity of fascial closure. The mechanical effect they generate causes the wound edges and the oblique muscles to come closer to the midline. This effect also helps the fascial primary closure occur in higher rates.[5,15] In our study, the rates of primary fascial closure and fascial-abdominal closure with graft were found to be higher in the VACM group than in the NVACM group, which is consistent with the literature.

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In patients with OA major complications, such as multiple organ dysfunction (30%–40%), enterocutaneous fistula (2%– 25%), intraabdominal bacterial colonization (83%), and ventral hernia (25%), are encountered. The mortality rate of patients with OA with intraabdominal infection is higher than that of the patients with trauma, and patients with infected OA have a mortality rate that reaches up to 50%. If the intraabdominal infection cannot be completely eradicated, paralytic ileus develops, which leads to intraabdominal tension, fluid collection, and intraabdominal hypertension (IAH). IAH negatively affects various systems and organs, particularly cardiovascular and renal systems. Consequently, the patient who is already in critical condition, may develop multiorgan failure.[3,16–18] The advantages of VACM method over NVACM methods are as follows: increase in the blood flow at the wound site by decreasing the interstitial pressure and reduction in the severity of inflammation and infection by removing the exudate. Furthermore, it increases angiogenesis and granulation by stimulating the cell reproduction and proliferation, thereby positively contributing to wound healing. Its disadvantages are as follows: it is expensive, it may cause pain and bleeding due to continuous negative pressure, and it may occasionally lead to toxic shock syndrome and thrombosis.[5] In the present study, EAF, multiple organ dysfunction, and mortality were significantly lower and intensive care unit and in hospital stay duration were shorter in the VACM group than in the NVACM group. In addition, mesh infections were encountered less frequently in the VACM group. EAF flow rate was lower and spontaneous closure rate was higher in the VACM group. Therefore, we believe that VACM achieves these effects by removing exudate and inflammatory mediators at the site.[19] VACM decreases the mortality, morbidity, and complication rates in patients with OA. It also positively contributes to the final abdominal closure in the early period, thereby shortening the intensive care unit and in hospital stay duration.

Because of these positive effects, it is an effective and safe method in OA treatment.

No funding has been provided for this work.

Conflict of interest: None declared.

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11. Tieu BH, Cho SD, Luem N, Riha G, Mayberry J, Schreiber MA. The use of the Wittmann Patch facilitates a high rate of fascial closure in severely injured trauma patients and critically ill emergency surgery patients. J Trauma 2008;65:865–70.

12. López-Cano M, Pereira JA, Armengol-Carrasco M. “Acute postoperative

open abdominal wall”: nosological concept and treatment implications.

World J Gastrointest Surg 2013;5:314–20.

13. Regner JL, Kobayashi L, Coimbra R. Surgical strategies for management of the open abdomen. World J Surg 2012;36:497–10.

14. Refinetti RA, Martinez R. Pancreatite necro-hemorrágica: atualização e momento de operar. ABCD. ABCD, Arq Bras Cir Dig 2010;23:122–7.

15. Boele van Hensbroek P, Wind J, Dijkgraaf MG, Busch OR, Goslings JC. Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen. World J Surg 2009;33:199–207.

16. Balogh Z, McKinley BA, Holcomb JB, Miller CC, Cocanour CS, Kozar RA, et al. Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of multiple organ failure.

J Trauma 2003;54:848–61.

17. Perez D, Wildi S, Demartines N, Bramkamp M, Koehler C, Clavien PA. Prospective evaluation of vacuum-assisted closure in abdominal compartment syndrome and severe abdominal sepsis. J Am Coll Surg 2007;205:586–92.

18. Nicholas JM, Rix EP, Easley KA, Feliciano DV, Cava RA, Ingram WL, et al. Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same. J Trauma 2003;55:1095–110.

19. Plaudis H, Rudzats A, Melberga L, Kazaka I, Suba O, Pupelis G. Abdominal negative-pressure therapy: a new method in countering abdominal compartment and peritonitis - prospective study and critical review of literature. Ann Intensive Care 2012;20 Suppl 1:S23.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Açık karın (open abdomen) uygulanan hastalarda geçici karın kapama yöntemlerinin mortalite ve morbidite üzerine etkisi Dr. Erol Kılıç, Dr. Mustafa Uğur, Dr. İbrahim Yetim, Dr. Muhyittin Temiz Mustafa Kemal Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Hatay

AMAÇ: Ciddi abdominal sepsis ve abdominal kompartman sendromu gelişen hastalarda günümüzde uygulanan en önemli tedavi yöntemi abdomenin geçici karın kapama yöntemleri ile kapatıldığı açık karın (AK) uygulamasıdır. Bu amaçla kullanılan başlıca yöntemler Vacum Asisted Closure Method (VACM) ve non-vacum asisted closure (NVACM) teknikleridir. Bu çalışmada farklı karın kapama yöntemlerinin morbidite ve mortalite üzerine olan etkileri incelendi.

GEREÇ VE YÖNTEM: Çalışmada 2013–2016 yılları arasında AK uygulanan hastaların geçici karın kapama yöntemleri geriye dönük olarak incelendi.

VACM ile NVACM uygulanan hastaların AK etiyopatolojisi, mortalite tahmin skorları, nihai karın kapama süresi ve yöntemleri, hastanede yatış süresi, gelişen komplikasyon (enteroatmosferik fistül, mesh enfeksiyonu, insizyonel herni) ve mortalite oranları belirlenerek karşılaştırıldı.

BULGULAR: Bu çalışmaya VACM (n=65) ve NVACM (n=58) uygulanan 123 hasta dahil edildi. Grupların (VACM ve NVACM) yaş, cinsiyet ve etiyopatogenezleri arasında fark yoktu (p>0.05). Tedavi döneminde ortalama APACHE 4 ve MODS skorları sırasıyla 47/63 ve 11/14’tü (p<0.05).

Grupların yoğun bakım ünitesi ve hastanede ortalama yatış süreleri sırasıyla 11/16 ve 22/28 gündü (p<0.05). Apse, koleksiyon gelişme oranı sırasıyla %46.2 ve %77.6 idi (p<0.05). Enteroatmosferik fistül gelişme oranı sırasıyla %15.4 ve %56.9’du. Ortalama karın kapama zamanı sırasıyla 13 ve 17 gündü (p<0.05). VACM grubunda 18 (%28), NVACM grubunda 32 (%55) hasta kaybedildi (p<0.05).

TARTIŞMA: Açık karın uygulanan hastalarda geçici karın kapama yöntemi olan VACM diğer yöntemlere göre daha düşük komplikasyon ve mortalite oranına sahiptir. Ayrıca hastanede yatış süresi daha kısadır. Açık karın tedavisinde etkili ve güvenli bir uygulama yöntemidir.

Anahtar sözcükler: Baker yöntemi; Bogota-bag; geçici karın kapama yöntemleri; non-vacuum assisted closure (NVACM); open abdomen; Vacuum Assisted Closure Method (VACM).

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ORIGIN A L A R T IC L E

Utility of HAPS for predicting prognosis in acute pancreatitis Ali Vefa Sayraç, M.D.,1 Alp Giray Aydın, M.D.,3

Yıldıray Cete, M.D.,2 Özlem Yiğit, M.D.,2 Neslihan Sayrac, M.D.1

1

Department of Emergency Medicine, Antalya Training and Research Hospital, Antalya-Turkey

2

Department of Emergency Medicine, Akdeniz University Faculty of Medicine, Antalya-Turkey

3

Department of Emergency Medicine, Koç University Faculty of Medicine Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Acute pancreatitis (AP) is a common abdominal disorder, which requires early diagnosis and treatment. Several prognostic scoring systems introduced to clinical practice are not suitable in emergency department (ED) because these require much time and complex parameters. Recently, the harmless acute pancreatitis score (HAPS) has been introduced to identify AP with a nonsevere course. The aim of this study was to determine the utility of HAPS in predicting the severity of AP. METHODS: All patients aged >16 years who were diagnosed as AP in ED were enrolled in this retrospective study. The study included 144 patients with a mean age of 58.7±15.4 years, and 69 (47.9%) of them were males and 75 (52.1%) were females. Patient data were collected from hospital database. The utility of HAPS was analyzed and compared using the Ranson’s score.

RESULTS: HAPS was statistically significant for predicting mild disease (p=0.008) and has demonstrated a specificity of 81%, a positive predictive value (PPV) of 96%, and an odds ratio of 5.57 (1.51–20.50). The predictability of Ranson’s scores was not significant.

The measure of agreement (κ) between the two scores was 0.15, indicating a low agreement.

CONCLUSION: HAPS is a simple and useful scoring algorithm to predict the non-severe course of AP in ED. HAPS-0 patients did not require early aggressive treatments and advanced radiological screening tools during the early stages of the disease.

Keywords: Acute pancreatitis; emergency medicine; HAPS; prognosis.

INTRODUCTION Acute abdominal pain is a common complaint for emergency department (ED) visits and accounts 6.5% of all ED visits.[1] Acute pancreatitis (AP) usually presents with acute abdominal pain and requires immediate diagnosis and treatment. Approximately 80% of patients with AP have a mild, uncomplicated course and resolve without severe morbidity, whereas the remaining 20% develop severe disease and accounts significant morbidity and mortality with local and systemic complications.[2] Deaths occur in approximately 5% of all patients; however, patients with multi-organ failure carry a mortality

risk of up to 47%. Sixty five percent of all deaths occur in the first 14 days and 80% in 30 days.[3] When AP is diagnosed, it is important to predict the severity of disease early after hospital admission, with objective parameters. If the prediction is truly considered and aggressive management strategies are started immediately, then the mortality and morbidity will decrease.

Because of limited data on patients at ED arrival, an ideal scoring system that involves fewer parameters is easy to recall, and is effective in predicting severe AP early in the evaluation of patients is warranted.[4] Although numerous clinical scoring systems are available to measure and pre-

Cite this article as: Sayraç AV, Cete Y, Yiğit Ö, Aydın AG, Sayrac N. Utility of HAPS for predicting prognosis in acute pancreatitis. Ulus Travma Acil Cerrahi Derg 2018;24:327-332.

Address for correspondence: Özlem Yiğit, M.D. Akdeniz Üniversitesi Hastanesi, Acil Tıp Anabilim Dalı, Dumlupınar Bulvarı, Kampüs, 07059 Antalya, Turkey.

Tel: +90 242 - 249 22 85 E-mail: ozlemyigit@akdeniz.edu.tr Ulus Travma Acil Cerrahi Derg 2018;24(4):327-332 DOI: 10.5505/tjtes.2017.50794 Submitted: 20.06.2017 Accepted: 04.12.2017 Online: 26.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Sayraç et al. Utility of HAPS for predicting prognosis in acute pancreatitis

dict disease severity, most are of limited use to emergency physicians. Several of these scoring systems include complex and multiple calculation parameters, require long periods of hospitalization, and represent inadequate sensitivities.

Recently, the harmless acute pancreatitis score (HAPS) has been introduced to identify AP with a non-severe course.

[5] The algorithm contains three parameters, including signs of peritonitis or guarding and levels of serum creatinine and hematocrit. The disease course is very likely to be non-severe if all these parameters are normal at the time of admission to the hospital. Compared with the previous scoring algorithms, HAPS is simple and can be assessed within the first hour of the clinical examination of a patient with AP and can help stratify non-severe harmless disease. Therefore, HAPS may be used to identify patients that may not require intensive therapy or imaging studies and may show promise in the simple assessment of AP and consideration for discharge from ED.[6] The aim of this study was to determine the utility of HAPS in predicting the severity of AP in ED.

MATERIALS AND METHODS Study Design and Setting This study was conducted as a retrospective chart review in an academic ED of a tertiary care university hospital with an annual census of approximately 90, 000 adult patient visits.

The study was approved by the local ethics committee. After receiving the permission for data collection from the hospital director, ED hospital records for the previous 4 years were searched to identify all patients recorded to the database as acute pancreatitis–code K85 according to the International Classification of Disease-10 (ICD-10) system. Demographic data of patients, physical examination, laboratory and imaging findings, and hospitalization and discharge notes were evaluated, and data were recorded to the study form.

Exclusion Criteria Patients aged <16 years and those with traumatic pancreatitis were excluded. Patients not diagnosed as pancreatitis but incorrectly coded as acute pancreatitis–code K85 and those with incomplete data from the charts were also excluded.

Second admission to ED in 7 days was accepted as the same attack with the previous one, and these second admissions were excluded.

Data Collection Signs of peritonitis (either rebound tenderness or guarding), abdominal ultrasound (US) and computed tomography (CT) findings (gallstones and pancreatic necrosis), laboratory findings, the length of hospitalization, need for intensive care unit (ICU), and in-hospital mortality were recorded. The need for ICU care, in-hospital mortality, and hospitalization of >5 days were classified as poor prognosis and severe AP. 328

HAPS was defined as an absence of signs of peritonitis, serum creatinine levels of <2 mg/dL, and hematocrit levels of <43% for males and <39.6% for females at the time of admission.

Patients were classified as HAPS-0 (zero) if they fulfilled all three criteria and as HAPS+ if any of these were present.

Ranson’s score data were collected, and first admission scores were calculated. Patients with Ranson’s score of ≥3 were suspected to have severe AP.

Statistical Analysis Data were analyzed using SPSS 20.0 for Windows statistical package. Continuous data are presented as mean ± SD, and categorical data are presented as frequencies and percentiles.

Univariate analyses between two groups for categorical data were performed using chi-square test and Mann–Whitney U test for ordinal data. A two-sided p value of <0.05 was considered significant. The measure of agreement Cohen’s Kappa (κ) between the two scores (Ranson’s score and HAPS) was calculated.

RESULTS The study included 144 patients diagnosed with AP. The mean age was 58.7±15.4 years and median age was 61 (range; min.

18, max. 93) years, with a female:male ratio of nearly 1:1 [75 (52.1%) females and 69 (47.9%) males]. The most common etiology of AP among the study group was gallstones disease (n=89, 61.8%). Other etiologies and their distributions of sex are shown in Table 1.

HAPS and Ranson’s scores were calculated for all patients.

There were 75 (52.1%) patients in the HAPS-0 mild pancreatitis group and the remaining 69 (47.9%) had at least one parameter positive and were grouped as HAPS+. According to the Ranson’s scores, 122 (84.7%) patients were classified as low risk (0–2 points) and 22 (15.3%) as high risk. The measure of agreement (κ) between the two scores was 0.15, which estimates a slightly low agreement.

All patients in the study group underwent USG examination, and 43 (29.8%) had an abdominal CT imaging. Pancreatic necrosis was present in 12 (8.3%) patients, and 4 (30%) of Table 1. Etiology of acute pancreatitis attacks Diagnosis

Patient (%)

Male (%)

Female (%)

Gallstone

89 (61.8)

39 (27.1)

50 (34.7)

Alcohol

2 (1.4)

2 (1.4)

–

Pancreas cancer

7 (4.9)

3 (2.1)

4 (2.8)

Hyperlipidemia

2 (1.4)

1 (0.7)

1 (0.7)

Drugs

3 (2.1)

1 (0.7)

2 (1.4)

Other

41 (28.4)

23 (15.9)

18 (12.5)

Total

144 (100)

69 (47.9)

75 (52.1)

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Sayraç et al. Utility of HAPS for predicting prognosis in acute pancreatitis

these died during hospitalization (Table 2). HAPS was statistically significant for predicting pancreatic necrosis (p=0.047).

Predefined poor prognosis criteria were found in 68 (47.2%) patients among the total 144 patients (Table 3). Of these severe AP patients, 38 were males and 30 were females, and the average age (63±13 years) was significantly higher of patients in this group than the whole study patients (p=0.001). Severe AP was more common in pancreatitis etiologies other than gallstones (p=0.04). HAPS was statistically significant for predicting poor prognosis and pancreatitis severity (p=0.013).

The statistical significance of HAPS was better than whole, if poor prognosis is considered only as the need for ICU care Table 2. Predictability of HAPS for pancreatic necrosis

Pancreatic necrosis

Yes (%)

No (%)

HAPS-0

3 (4)

72 (96)

HAPS +

9 (13)

60 (87)

12 (8.3)

132 (91.7)

Total *

p*

0.047

Table 3. Patients with poor prognosis

n

Poor prognosis

68

% 47.2*

Death

8

5.6

Intensive care unit (ICU) transfer

14

9.7

>5 hospitalizations

62

43.1

Six patients died in the first 5 days after hospitalization and three died in the general ward before getting transferred to the ICU. 9 patients who were cared in the ICU were discharged from hospital with healing.

*

Table 4. Predictability of HAPS for poor prognosis

Poor prognosis (All) Absent (%)

Yes (%)

HAPS-0

47 (62)

28 (41)

HAPS +

29 (38)

40 (59)

p*

0.013

Poor prognosis (in-hospital mortality and ICU care) Absent (%)

Yes (%)

HAPS-0

72 (56)

3 (19)

HAPS +

56 (44)

13 (81)

Logistic regression analysis was performed for defining parameters that can be used for predicting poor prognosis in HAPS+ patients. Age (p=0.023) and the presence of pancreatic necrosis (p=0.018) were significant independent variables. In particular, pancreatic necrosis had a significantly high odds ratio, and the difference between upper and lower limits at 95% confidence interval was very high. The presence of peritonitis signs on physical examination had a high odds ratio, although not significant (Table 6). If age <65 years was included as a new variable to the HAPS, then p value became significant (p=0.004).

DISCUSSION

Chi-square test. HAPS: Harmless acute pancreatitis score.

and in-hospital mortality (p=0.004) (Table 4). The specificity and positive predictive value (PPV) of HAPS were 81% and 96%, respectively, and the odds ratio was 5.57 (1.51–20.50, p=0.009). High Ranson’s scores were statistically significant for only long hospitalization times (p=0.00). Predicting inhospital mortality and the need for ICU care were not significant (p=0.43 and 0.50, respectively). Detailed data of the eight patients who died in hospital are provided in Table 5.

0.004

Chi-square test. HAPS: Harmless acute pancreatitis score; ICU: Intensive care unit.

*

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AP usually presents with acute persistent upper abdominal pain, nausea, and vomiting. The two most common etiologies for AP are gallstones and alcohol consumption.[7] Gallstones are the most common etiology for AP in our study as it was shown in the previous study findings. Gallstones were common in females in our study. Alcoholic pancreatitis was rare (1.4%) in our study population, in contrast to previous knowledge, and these patients were males. The most reasonable factor for this result is the low chronic alcohol consumption ratios for Turkey.

Although AP usually begins as a mild disease and the majority of patients run a mild course, detecting the small portion of patients who will progress to a severe disease is important.

It is essential to identify this subgroup of patients who will go on to develop adverse outcomes and severe disease early on in the disease course. If appropriate aggressive treatment modalities are administered in the early stage of the disease, then the mortality rates can be lowered.[8] Over the recent years, various single- and multi-parameter scoring systems have been identified and tested in patients for predicting the severe course of AP. In 1974, Ranson[9] and colleagues first presented a prognostic scoring system. The Atlanta Classification system, the Balthazar score, Modified Glasgow (Imrie), and APACHE II and III scoring systems were then developed. Several authors have compared these various scoring systems in their studies.[10,11] The major problem for these scoring systems is the length of time needed for calculation and their not easily obtainable several complex component requirements. Another problem is administering aggressive treatment modalities to all patients until calculating the entire score trying to find the severe AP. A majority of AP patients who will run a mild course unnecessarily undergo aggressive 329

Sayraç et al. Utility of HAPS for predicting prognosis in acute pancreatitis

Table 5. Etiology of pancreatitis, risk scores, detailed imaging data, and clinical course of the in-hospital mortality patients Age/ Sex

Etiology of pancreatitis

HAPS

Ranson

CT findings

ICU

Death

40/F

Hyperlipidemia

HAPS-0

2 (low risk)

Blurring of peripancreatic

No

Syncope after standing from the bed in the ward,

fat and fluid

62/M

62/M

Drug (steroid)

HAPS +

1 (low risk)

Blurring of peripancreatic fat,

Devic syndrome Gallstone

Yes

pancreatic necrosis

HAPS + 3 (high risk)

Pancreatic necrosis,

Yes

followed by dyspnea. Cardiac arrest due to possible massive pulmonary embolism and exitus.

Dyspnea, followed by respiratory arrest.

Cardiac arrest in ICU and exitus.

Acute renal failure and dialysis,

free fluid in abdomen

surgical operation (necrosectomy, colectomy,

T-tube drainage), recurrent abdominal lavages,

exitus in the ICU with multi-organ failure

80/F

Unknown

HAPS +

2 (low risk)

Pancreatic necrosis,

free fluid in the abdomen,

58/F

Periampullary

HAPS-0

No

Irregulated blood glucose levels, sudden cardiac arrest and exitus

pleural fluid (bilateral)

1 (low risk)

Gas densities in pancreas,

No

tm

ampullary tm,

cholecystitis

All vital signs are normal, sudden hypotension at the first day of hospitalization in general ward.

Cardiac arrest due to possible massive pulmonary

embolism or acute myocardial infarction and exitus.

64/F

Surgical operation, perforation of gallbladder duct,

Unknown

HAPS +

2 (low risk)

Coledoccal dilatation,

Yes

gallbladder normal,

free fluid in the abdomen

56/M

Unknown

HAPS + 3 (high risk) Blurring of peripancreatic fat,

Yes

pancreatic necrosis,

free fluid in the abdomen

exitus in the ICU with multi-organ failure.

Acute renal failure and dialysis, surgical operation (necrosectomy and recurrent abdominal lavages),

exitus in the ICU with multi-organ failure

75/M

COPD acute exacerbation, fever, dyspnea,

Gallstone

HAPS +

2 (low risk)

Blurring of peripancreatic fat,

Yes

calcifications, atherosclerosis

exitus in the ICU with multi-organ failure.

M: Male; F: Female; ICU: Intensive care unit; CT: Computed tomography; HAPS: Harmless Pancreatitis Score; COPD: Chronic obstructive pulmonary disease.

Table 6. Logistic regression analysis for defining parameters that can be used for predicting poor prognosis in HAPS+ patients Variable Odds ratio

95% CI for odds

p*

Lower Upper

Sex

1.741

0.752

4.034

0.196

Age

1.032

1.004

1.060

0.023

Guarding

1.497 0.605 3.701 0.383

Rebound tenderness

7.621

Creatinine

1.427 0.800 2.544 0.228

0.844

68.775

0.070

Hematocrit

0.955 0.884 1.032 0.244

Pancreatic necrosis

14.064

1.586

124.705

0.018

Chi-square test and Mann-Whitney U test; HAPS: Harmless acute pancreatitis score; CI: Confidence interval.

*

modalities. The stated problems make these scores useless to the emergency physicians. Newer scoring systems, such 330

as BISAP, Panc 3 score and Japanese severity score, seem to address the need for risk stratification during the ED stay and are potentially more useful to emergency physicians; however, they remain inadequate.[4] Differently from the other scoring systems, the aim of HAPS is to differentiate harmless AP patients who do not need intensive care from those with a severe AP course. In the initial study of Lankisch and colleagues including 394 patients, HAPS could identify patients who would have a mild disease with a specificity of 97% and a PPV of 98% within approximately 30 min of admission. The multicenter validation set including 452 patients confirmed the initial set results.[5] A few additional retrospective and prospective studies have reported similar results and confirmed and concluded on the usability of HAPS.[6,12â&#x20AC;&#x201C;15] Our present study confirmed the significant predictability of HAPS with a high specificity and PPVs (81% and 96%, respectively).

In the HAPS-0 group, two patients died in hospital. Detailed investigation of all records of these two patients revealed that both died on the first day of their hospital admission. The first patient had recurrent AP attacks due to hyperlipidemia, and the second patient had a tumor and got an additional Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Sayraç et al. Utility of HAPS for predicting prognosis in acute pancreatitis

AP attack. Both patients carry high risk for sudden death, independent from the AP attack, and deaths occurring on the first hospitalization day seem to be caused by their underlying conditions rather than the present AP attack and complications. These findings are also supporting evidence for the usefulness of HAPS for predicting mild AP. In a recent pilot study, authors evaluated the feasibility of home monitoring instead of hospitalization for patients who were classified as having mild AP using HAPS and Imrie scores.

They have shown that home monitoring of patients with mild non-alcoholic AP is as safe and effective as hospitalization and is associated with significantly less costs.[16] Although this was a pilot study and needs validation with further studies, it has a promising result for using HAPS to find the cost-effective home treatment option that is feasible for patients and can protect them from aggressive management modalities and additional problems that may occur during hospitalization.

Observing mild AP patients in a ward bed instead of in the ICU or early oral feeding can be other options. New reviews on AP treatment recommend similar modalities.[7] Because of the retrospective design of our present study, these options could not be evaluated.

We have calculated first admission Ranson’s scores of patients. The predictability of Ranson’s score was not statistically significant. Only two patients among the eight who had in-hospital mortality had a high risk Ranson’s score. Further, the measure of agreement (κ) between HAPS-0 and Ranson’s low-risk group estimated a slightly low agreement. These findings suggest that HAPS can be more useful for ED than is Ranson’s score. Because, for predicting disease severity, the first hours after the patient is admitted to ED is more important, the 48-h Ranson’s scores were not calculated. It is also well known that only admission calculations of Ranson’s scores, without combining with the score at 48-h, is inadequate.

Logistic regression analysis of our present study revealed age and pancreatic necrosis as significant independent variables.

The prognostic value of pancreatic necrosis was shown in the previous studies.[17–19] However, peri-pancreatic fluid and necrosis cannot be seen in the early stage of the disease.

Also, imaging all patients in the early phase result in unnecessary radiation exposure to mild AP patients and is not a cost-effective approach for healthcare systems. Therefore, imaging with CT is recommended at 48–72 h after the diagnosis.[20] Detecting localized pancreatic complications on abdominal CT scan cannot predict systemic mortality and AP outcomes. In a recent study determining the role of HAPS and BISAP score and CRP value together for predicting the presence of pancreatic necrosis on CT at 72 h revealed that all scores significantly correlated with the occurrence of CT findings. They suggested that CT abdomen can be avoided in patients in whom the scores are not predictive of severe disease, thereby limiting radiation exposure and expenses in Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

AP.[13] HAPS was statistically significant for predicting pancreatic necrosis in our present study.

Logistic regression analysis of our present study revealed age as another significant independent variable. Patients with a poor prognosis were significantly older than the whole population. Including age <65 years as a new and easy variable to HAPS made p values more significant. Thus, we suggest using HAPS plus age <65 years scoring system as modified HAPS. The usefulness of modified HAPS should be studied in further prospective studies.

In conclusion, HAPS is a simple and useful scoring algorithm to predict the non-severe course of AP in ED. HAPS-0 patients did not require early aggressive treatments and advanced radiological screening tools in the early stages of the disease.

Conflict of interest: None declared.

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A randomized controlled trial of home monitoring versus hospitalization for mild non-alcoholic acute interstitial pancreatitis: a pilot study. Pancreatology 2014;14:174–8.

Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990;174:331–6.

Bollen TL, Singh VK, Maurer R, Repas K, van Es HW, Banks PA, et al.

Comparative evaluation of the modified CT severity index and CT severity index in assessing severity of acute pancreatitis. AJR Am J Roentgenol 2011;197:386–92.

Simchuk EJ, Traverso LW, Nukui Y, Kozarek RA. Computed tomography severity index is a predictor of outcomes for severe pancreatitis. Am J Surg 2000;179:352–5.

Tenner S, Baillie J, DeWitt J, Vege SS; American College of Gastroenterology. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013;108:1400–15.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut pankreatit prognozunu tahmin etmede HAPS’nin değeri Dr. Ali Vefa Sayraç,1 Dr. Yıldıray Cete,2 Dr. Özlem Yiğit,2 Dr. Alp Giray Aydın,3 Dr. Neslihan Sayrac1 1 2 3

Sağlık Bilimleri Üniversitesi Antalya Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Antalya Akdeniz Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Antalya Koç Üniversitesi Tıp Fakültesi Hastanesi, Acil Tıp Anabilim Dalı, İstanbul

AMAÇ: Akut pankreatit (AP), erken tanı ve tedavi gerektiren bir karın ağrısı nedenidir. Hastalarda prognozu öngörmede kullanılan birçok skorlama sistemi acil servis gibi az sayıda veri ve hızlı karar verme gerekliliği olan alanlarda kullanışlı değildir. Son dönemde HAPS (Harmless Acute Pancreatitis Score) prognoz tahmin sisteminin güvenilir olduğunu söyleyen çalışmalar yapılmıştır. Bu çalışmanın amacı, acil serviste AP tanısı koyulan hastalarda erken dönemde prognozu tahmin etmede HAPS’nin değerliliğini saptamaktır.

GEREÇ VE YÖNTEM: Bu çalışmada, acil serviste akut pankreatit tanısı alan 16 yaş üstü hastalar geriye dönük olarak incelendi. Çalışmaya 69’u (%47.9) erkek, 75’i (%52.1) kadın, yaş ortalaması 58.7±15.4 olan 144 hasta alındı. Hastaların arşiv dosyalarından bilgilerine ulaşıldı. HAPS’nin hafif seyirli pankreatit olgularını saptamadaki başarısı test edildi. Hastaların Ranson skorları da hesaplanarak HAPS ile uyumluluğu karşılaştırıldı.

BULGULAR: HAPS ile pankreatit prognozunu tahmin etme arasındaki ilişki anlamlı bulundu (p=0.008). HAPS spesifitesi %81, pozitif prediktif değeri %96, odds oranı 5.57 (1.51–20.50, p=0.009) olarak hesaplandı. Ranson skorlarına göre bakıldığında ise istatistiksel anlamlı fark saptanmadı. HAPS ile Ranson skorlarının uyumluluğu için hesaplanan kappa değeri 0.15 – zayıf uyumluluk olarak bulundu.

TARTIŞMA: HAPS acil servise başvuran ve klinik olarak hafif seyredecek pankreatit hastalarını tespit etmede, basit ve kolay uygulanabilir değerli bir skorlama sistemi olabilir. HAPS-0 olan hastalarda, agresif tedavi girişimlerine ve erken dönemde ileri görüntüleme incelemelerine ihtiyaç yoktur.

Anahtar sözcükler: Acil servis; akut pankreatit; prognoz; zararsız akut pankreatit skoru.

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Efficacy of laboratory tests and ultrasonography in the diagnosis of acute appendicitis in gravid patients according to the stages of pregnancy Adil Başkıran, M.D.,1 Volkan İnce, M.D.,1 Egemen Çiçek, M.D.,1 Tolga Şahin, M.D.,1 Abuzer Dirican, M.D.,1 İpek Balıkçı Çiçek, M.D.,2 Burak Işık, M.D.,1 Sezai Yılmaz, M.D.1 1

İnönü University, Institute of Liver Transplantation, Turgut Özal Medical Center, Malatya-Turkey

2

Department of Biostatistics and Bioinformatics, İnönü University Faculty of Medicine, Malatya-Turkey

ABSTRACT BACKGROUND: Normal physiologic changes during pregnancy result in similar laboratory and symptomatology changes as those during acute appendicitis (AA), making the diagnosis extremely difficult. The aim of the present study was to analyze the efficacy of conventional laboratory and radiologic tests in the diagnosis of AA according to different stages of pregnancy.

METHODS: Twenty-five pregnant patients with pathologically confirmed AA operated at our department between 2012 and 2017 were retrospectively analyzed in terms of changes in conventional laboratory parameters as well as neutrophil-to lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios to aid the diagnosis of AA according to different stages of pregnancy.

RESULTS: There were no significant changes in C-reactive protein levels, leukocyte and neutrophil counts, and accuracy of ultrasonography between patients in the first (group 1) and second + third trimesters (group 2) (p>0.05). Lymphocyte count was significantly lower (p>0.05), whereas NLR and PLR were significantly higher in group 2 (p<0.05).

CONCLUSION: Laboratory values change significantly during pregnancy, and NLR and PLR seems to be valuable tools for evaluating AA in a stage-specific manner in pregnant patients.

Keywords: Acute appendicitis;neutrophil-to-lymphocyte ratio; platelet-to-lymphocyte ratio; pregnancy.

INTRODUCTION The most common non-obstetric surgical emergency in a pregnant patient is acute appendicitis (AA), with its incidence ranging from 1/766 to 1/1440.[1] The diagnosis of AA during pregnancy is extremely difficult, and any delay in the diagnosis may result in significant morbidity for the mother and fetus. Therefore, the workup of pregnant patients should be meticulous, and the analysis should be performed in detail.

The symptoms and findings encountered during the natural course of pregnancy usually mask the symptoms of AA and make the diagnosis complicated. Leukocytosis [increased white blood cell (WBC) count]; elevated C-reactive protein

(CRP) levels; and symptoms such as nausea, vomiting, and anorexia are frequently encountered in the natural course of pregnancy and make the diagnosis difficult for the physicians.

The displacement of the appendix according to the stages of pregnancy makes the ultrasonography evaluation difficult in pregnant women than in normal individuals. Use of abdominal computed tomography is not recommended due to the associated risks of radiation exposure; MRI, although very useful in the diagnosis, is not routinely employed or available at all centers. Alvarado scoring system has not been found to be efficient in the evaluation of pregnant patients due to the associated physiological symptoms.[2]

Cite this article as: Başkıran A, İnce V, Çiçek E, Şahin T, Dirican A, Balıkçı Çiçek İ, et al. Efficacy of laboratory tests and ultrasonography in the diagnosis of acute appendicitis in gravid patients according to the stages of pregnancy. Ulus Travma Acil Cerrahi Derg 2018;24:333-336.

Address for correspondence: Adil Başkıran, M.D. İnönü Üniversitesi Turgut Özal Tıp Merkezi, Karaciğer Nakil Enstitüsü, Malatya, Turkey Tel: +90 422 - 341 06 60 E-mail: dr.adil.baskiran@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(4):333-336 DOI: 10.5505/tjtes.2017.23693 Submitted: 16.08.2017 Accepted: 25.10.2017 Online: 19.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Uncomplicated AA is associated with a morbidity and mortality of 5%; however, in perforated AA, mortality increases to 40%.[3] McGory et al.[4] have reported a fetal loss rate of 20% in patients with perforated appendicitis during pregnancy. Furthermore, they reported an increased fetal loss rate in patients in whom negative laparotomies were performed.[4] There is no specific parameter for diagnosing AA. WBC count and CRP levels are the commonly used parameters for diagnosis; however, these are physiologically elevated during pregnancy. WBC count increases with gestational weeks and reaches its peak during labor; therefore, it is not a specific parameter for diagnosing AA in pregnant patients.[5] CRP levels have also been shown to be increased in healthy pregnant women.[6] Because the diagnosis of AA during pregnancy using the conventional diagnostic tests is extremely difficult, the resources for diagnosis should be utilized efficiently and in detail. Yazar et al.[1] reported that neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios are superior in terms of diagnosis of AA for pregnant patients compared with that for non-pregnant patients.

Physiologic changes are continuous throughout the course of pregnancy (i.e., first, second, and third trimesters). The aim of the present study was to retrospectively analyze the efficacy of conventional laboratory and radiologic tests in the diagnosis of AA according to different stages of pregnancy.

MATERIALS AND METHODS Study Design and Allocation of Patients to the Study Groups Between 2012 and 2017, pregnant patients who were evaluated in the Emergency Department of the Inonu University Turgut Ozal Medical Center with the suspicion of AA and were operated upon were evaluated, and 25 patients with pathologically confirmed diagnosis of AA were included in the study. All the patients were evaluated by the Department of Gynecology and Obstetrics together with the Department of Surgery. The distribution of the patients according to the stage of pregnancy is summarized in Table 1. Because the patient number in the third trimester was low, we formed two study groups: group1 comprising patients in the first trimester and group 2 comprising patients in the second and third trimesters.

Study parameters included WBC count, NLR, PLR and ultrasonography findings that were retrospectively collected from the patient charts. We tried to evaluate the efficacy of each test in diagnosing AA in different stages of pregnancy.

Statistical Analysis The distribution of the data was assessed using Shapiro–Wilk 334

test. Data were expressed as median (range) and mean±standard deviation. Percentage ratios were provided when necessary. Statistical analysis of the dependent and independent data was performed using Mann–Whitney U test, independent sampling t-test, and Fisher’s exact χ2 test. Any p value <0.05 was considered significant. During the analysis, Statistical Program for Social Sciences software was used (SPSS v20, IBM, USA).

RESULTS The median age of the patients was 25 (19–38) years. The median gestational week was 17 (6–31) weeks. The median leukocyte count was 12.4 (6.3–22.4) cells/mm3. The median PLR was 235 (101–404) and median NLR was 5.73 (2.22– 38.5). The median CRP level was 1.62 (0.33–19.1) mg/L. Ultrasonography was positive in 60% of the patients. Neither maternal or fetal loss nor serious complications were observed in our study. The demographic data of the patients are summarized n Table 2.

The distribution of the demographic data according to the study groups are summarized in Table 3. The changes in the study variables are shown in Figure 1. Briefly, the ultrasonogTable 1. The distribution of the patients according to the stage of pregnancy Stage of the pregnancy

Number of patients

First trimester (0–14 weeks)

11

Second trimester (14–26 weeks)

11

Third trimester (26–40 weeks)

3

Total

25

Table 2. The demographic data are summarized

Mean±SD

Median (Min.-Max.)

Age (n=25)

26.2±5.33

25 (19–38)

Neutrophil (n=25)

10.66±4.40

9.5 (3.3–20.27)

Lymphocyte (n=25)

Platelet (n=25) N/L (n=25)

1.66±0.65

1.8 (0.4–3)

240.6±69.95

235 (101–404)

8.8±8.36

5.73 (2.22–38.5)

182.74±145.73

149.23 (78.88–765)

MPV (n=25)

9.06±1.78

8.8 (5.4–12.7)

Gebelik haftası (n=25)

16.56±6.91

17 (6–31)

CRP (n=25)

4.32±5.17

1.62 (0.33–19.1)

WBC (n=25)

13.36±3.88

12.4 (6.3–22.4)

Yatış süresi (n=25)

2.44±2.32

2 (1–13)

PLT/LN (n=25)

SD: Standard deviation; Min.: Minimum; Max.: Maximum; N/L: Neutrophil/ lymphocyte; PLT: Platelet; MPV: Mean platelet volume; CRP: C-reactive protein; WBC: White blood cell.

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Başkıran et al. Acute appendicitis according to the stages of pregnancy

300 238.7

250 200

182.7

150 111.5

100 50 0

11.84 14.55 13.36

2.9

5.38

4.3

4.4

12.2

8.8

WBC

CRP

N/L

Group 1

11.84

2.9

4.4

111.5

Group 2

14.55

5.38

12.2

238.7

All patient

13.36

4.3

8.8

182.7

PLT/L

Laboratory correlation stage of pregnancy

Figure 1. The changes in leukocyte count, CRP levels, and NLR and PLR according to the study groups.

raphy findings did not vary significantly between group 1 and group 2 (p>0.05). Mean platelet volume; neutrophil, platelet, and leukocyte counts; and CRP levels were not significantly different between the study groups (p>0.05). However, lymphocyte counts were significantly lower in group 2 than in group 1 (1.3 vs 2.08 cells/mm3, p<0.05). NLR was significantly higher in group 2 than in group 1 (12.2 vs 4.4, p<0.05). The mean PLR in group 1 and 2 was 111.5 and 238.7, respectively, and this difference was significant (p<0.05).

DISCUSSION AA is seen in approximately 1 in 1700 pregnancies and is most frequently observed in the second trimester of pregnancy. Diagnosis and appropriate management of AA in pregnancy is vital to reduce the potential risks to both mother and fetus.

[7] Ueberrueck et al.[8] reported an overall appendicitis perforation rate of 14% in pregnant patients. Furthermore, distriTable 3. The demographic data of the study groups are summarized

Group 1

Group 2

Number

11

14

Mean age

26.9

25.6

Mean pregnancy week

10.3

21.4

Mean white blood cell

11.854

14.55

2.9

5.38

2

2.7

Mean C-reactive protein Mean stay hospital Mean oral start

1.2

1.07

Mean neutrophil/lymphocyte

4.4

12.2

111.5

238.7

7/4

8/6

Mean platelet/lymphocyte Ultrasonography +/–

227.5

250.8

Mean neutrophil

Mean platelet

8.8

12.11

Mean lymphocyte

2.08

1.3

Mean mean platelet volume

9.4

8.7

General anesthesia/spinal anesthesia

6/5

12/3

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bution of the perforation rates was 8.7%, 12.5%, and 26.1 % in first, second, and third trimesters, respectively. They concluded that the diagnosis of appendicitis became more difficult as the pregnancy advanced. The Alvarado scores are usually inconclusive during pregnancy, and there are no validated diagnostic scores or criteria to aid the diagnosis in pregnant patients.[7] He negative laparotomy rates for appendicitis in pregnant patients were 25%–50%, whereas these were 15%– 35% in non-pregnant counterparts. Mortality associated with appendicitis during pregnancy is a result of complications arising due to delay in the intervention in these patients. Delay in management also possesses considerable risk for the fetus.

Fetal loss rate in patients with uncomplicated appendicitis is 1.5%–4%; however, it reaches 21%–35% in patients with perforated appendicitis.[9] We found that NLR and PLR were particularly increased in second and third trimesters of pregnancy, and this may be used for the diagnosis of AA in this special subgroup of the patients. Recent studies have also suggested NLR and PLR as markers of inflammation and that they can aid the diagnosis of AA in the pregnant patients. When NLR and PLR are combined with WBC count, CRP levels, and lymphocyte count, an accurate diagnosis of AA could be established with a 90.5% accuracy.[1] Early diagnosis is the best strategy for reducing the complication rates. We aimed to evaluate the efficacy of conventional laboratory tests in the diagnosis of AA according to the stages of pregnancy and observed differences in the levels of abovementioned parameters between patients in the first and second + third trimesters. The low patient number in our study mandated the evaluation of patients in the second and third trimester in the same group. Lymphocyte counts were reduced in the second and third trimesters than in the first trimester, resulting in higher NLR and PLR in the second and third trimesters; this can be used to aid the diagnosis of AA in these patients. Furthermore, the threshold level for NLR and PLR should be reduced for evaluation of the patients in the first trimester.

Uterus becomes an abdominal organ starting from the 12th week of gestation and starts compressing the surrounding viscera. Study results regarding sensitivity of ultrasound during pregnancy vary significantly, and indeterminate results have been reported to be between 7% and 96%.[10] This wide variation in the indeterminate results may be due to both operator-dependent and patient-related factors such as the trimester, obesity, and anatomical variations of the appendix.

There was no difference regarding the success rate of ultrasonography among group 1 (63.6%) and group 2 (57.1%) in our study.

Laparoscopic appendectomy during pregnancy is associated with low rate of intraoperative complications in all the trimesters. However, it is associated with significantly higher 335

Başkıran et al. Acute appendicitis according to the stages of pregnancy

rates of fetal loss than appendectomy.[11] A serious risk associated with laparoscopy in pregnant patients is injury to the gravid uterus. Furthermore, pneumoperitoneum results in absorption of CO2 by both mother and fetus. We chose open approach in all of our patients and performed the surgery through a Mc Burney incision in all of them. Furthermore, we did not encounter any maternal or fetal mortality.

The patient number in our study was low; therefore, we were not able to determine which scoring systems could be effectively used for the diagnosis of AA during pregnancy. To the best of our knowledge, this is the first study to evaluate the efficacy of conventional laboratory techniques as well as NLR and PLR in the diagnosis of AA in different stages of pregnancy. We strongly believe that NLR and PLR will become a part of scoring system specific for the pregnant patient in the diagnosis of AA. This study will serve as a guide for future, multi-institutional, large-volume studies to reach such a goal.

2. Liu W, Wei Qiang J, Xun Sun R. Comparison of multislice computed tomography and clinical scores for diagnosing acute appendicitis. J Int Med Res 2015;43:341–9.

3. Türkan A, Yalaza M, Kafadar MT, Değirmencioğlu G. Acute Appendicitis in Pregnant Women: Our Clinical Experience. Clin Invest Med 2016;39:27521.

4. McGory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY, Cryer HM. Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss. J Am Coll Surg 2007;205:534–40.

5. Lurie S, Rahamim E, Piper I, Golan A, Sadan O. Total and differential leukocyte counts percentiles in normal pregnancy. Eur J Obstet Gynecol Reprod Biol 2008;136:16–9.

6. Watts DH, Krohn MA, Wener MH, Eschenbach DA. C-reactive protein in normal pregnancy. Obstet Gynecol 1991;77:176–80.

7. Flexer SM, Tabib N, Peter MB. Suspected appendicitis in pregnancy.

Surgeon 2014;12:82–6.

8. Ueberrueck T, Koch A, Meyer L, Hinkel M, Gastinger I. Ninety-four appendectomies for suspected acute appendicitis during pregnancy. World J Surg 2004;28:508–11.

Conflict of interest: None declared.

9. Brown JJ, Wilson C, Coleman S, Joypaul BV. Appendicitis in pregnancy: an ongoing diagnostic dilemma. Colorectal Dis 2009;11:116–22.

REFERENCES

10. Kapan S, Bozkurt MA, Turhan AN, Gönenç M, Alış H. Management of acute appendicitis in pregnancy. Ulus Travma Acil Cerrahi Derg 2013;19:20–4.

1. Yazar FM, Bakacak M, Emre A, Urfalıoglu A, Serin S, Cengiz E, et al.

Predictive role of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios for diagnosis of acute appendicitis during pregnancy. Kaohsiung J Med Sci 2015;31:591–6.

11. Arer İM, Alemdaroğlu S, Yeşilağaç H, Yabanoğlu H. Acute appendicitis during pregnancy: case series of 20 pregnant women. Ulus Travma Acil Cerrahi Derg 2016;22:545–8.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Gebeliğin evresine göre ultrasonografi ve laboratuvar testlerin akut apandisit tanısına etkisi Dr. Adil Başkıran,1 Dr. Volkan İnce,1 Dr. Egemen Çiçek,1 Dr. Tolga Şahin,1 Dr. Abuzer Dirican,1 Dr. İpek Balıkçı Çiçek,2 Dr. Burak Işık,1 Dr. Sezai Yılmaz1 1 2

İnönü Üniversitesi Turgut Özal Tıp Merkezi, Karaciğer Nakil Enstitüsü, Malatya İnönü Üniversitesi Tıp Fakültesi, Biyoistatistik Anabilim Dalı, Malatya

AMAÇ: Gebelik sürecinde olan fizyolojik değişiklikler akut apandisit semptom bulgular ile benzerlik gösterdiği için tanıyı zorlaştırmaktadır. Bu sebeple gebelik süresince tanıya yardımcı olabilecek özgün radyolojik ve laboratuvar testleri yoktur. Bu çalışmada amacımız gebelik trimesterlerine göre laboratuvar ve radyolojik testlerin hangi evrede daha etkili olduğunu araştırmaktır.

GEREÇ VE YÖNTEM: 2012–2017 yılları arasında kliniğimizde ameliyat edilen ve patoloji raporlarıyla onaylı akut apandisit tanısı alan gebe hastaların laboratuvar verilerinden nötrofil lenfosit oranı (NLO), platelet lenfosit oranı (PLO) analiz edilerek gebeliğin hangi evrelerinde daha anlamlı olduğu araştırıldı.

BULGULAR: Ortalama yaş 25 (19–38) yıl. Ortalama gebelik haftası 17 (6–31) ortalama lenfosit sayısı 12.4 (6.3–22.4) hücre/m3 ultrasonografi %60 hastada apandisit ile uyumlu bulgular saptandı. Lenfosit sayıları, C-reaktif protein değerleri, nötrofil sayıları ve ultrasonografi değerleri açısından 1. tirmester (grup 1) ve 2 ve 3 üncü trimester (grup 2) hastalar arasında anlamlı bir fark saptanmadı (p>0.05). Lenfosit sayısı grup 2’de belirgin düşük izlendi (p>0.05). Nötrofil lenfosit oranı ve PLO oranları grup 2’de belirgin yüksek izlendi (p<0.05).

TARTIŞMA: Gebelik süresince önemli laboratuvar değişiklikleri olmaktadır. Nötrofil lenfosit oranı ve PLO akut apandisit değerlendirmesinde ve gebeliğin evresine göre tanıya kolay ulaşmak için önem kazanmaktadır.

Anahtar sözcükler: Akut apandisit; gebelik; nötrofil lenfosit oranı; platelet lenfosit oranı.

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Adherence to vaccination recommendations after traumatic splenic injury Ahmet Korkut Belli, M.D.,1 Cem Dönmez, M.D.,1 Önder Özcan, M.D.,1 Özcan Dere, M.D.,1 Selmin Dirgen Çaylak, M.D.,2 Funda Dinç Elibol, M.D.,3 Cenk Yazkan, M.D.,1 Nevin Yılmaz, M.D.,4 Okay Nazlı, M.D.1 1

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

2

Department of Infectious Disease, Muğla Sıtkı Koçman University Faculty of Medicine, Muğla-Turkey

3

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

4

Department of Gastroenterology, Muğla Sıtkı Koçman University Faculty of Medicine, Muğla-Turkey

ABSTRACT BACKGROUND: The occurrence of a serious infection called overwhelming post-splenectomy infection (OPSI) increases more than 50 times in patients who have hyposplenia. The aim of this study was to investigate the adherence to vaccination recommendations after traumatic splenic injury.

METHODS: We identified patients who underwent total splenectomy due to abdominal trauma between May 2012 and March 2016. We recorded the clinical, laboratory, and pathological features of the patients. We calculated the vaccination proportions before discharge, after discharge, and final.

RESULTS: Twenty-seven patients underwent total splenectomy. For the vaccination status before discharge, after discharge, and final, the number of patients who received all the three vaccinations were 0 (0%), 0 (0%), and 8 (18.5%) and those who received none were 13 (48.2%), 11 (40.8%), and 9 (33.4%), respectively. The data of 17 patients were available for developing OPSI. The median follow-up time was 17.8 (4.4–41.2) months, and no OPSI cases were observed.

CONCLUSION: Adherence to vaccination recommendations remains still low. Establishing a vaccination tracking system and following vaccination recommendations will be helpful to prevent serious infections, such as OPSI, after traumatic splenectomy.

Keywords: Gastroenterology; infection; microbiology; spleen; trauma; vaccination.

INTRODUCTION The spleen is the most vulnerable organ in blunt abdominal trauma.[1] It has critical functions according to its histological regions, i.e., the red and white pulp. Using the red pulp, it filters and removes senescent erythrocytes in the circulation and recycles iron for the production of new erythrocytes. Using the white pulp, it functions as a secondary lymphoid organ and generates both humoral and cellular immune responses.[2] The occurrence of a serious infection called overwhelming

post-splenectomy infection (OPSI) increases more than 50 times in patients with hyposplenia.[3,4] Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae Type b (HIB) are encapsulated bacteria that can potentially cause severe sepsis, meningitis, or pneumonia after splenectomy.[5] OPSI is an emergent condition which may develop as a mild infection and rapidly progress to sepsis with 50%–70% risk of mortality despite treatment.[6] Although the true incidence of OPSI has not been completely identified, Newland et al.[7] reported that the incidence was 0.18%–0.42% per year, with a lifetime risk of 5% after splenectomy.

Cite this article as: Belli AK, Dönmez C, Özcan Ö, Dere Ö, Dirgen Çaylak S, Dinç Elibol F, et al. Adherence to vaccination recommendations after traumatic splenic injury. Ulus Travma Acil Cerrahi Derg 2018;24:337-342.

Address for correspondence: Ahmet Korkut Belli, M.D. Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Menteşe, 48000 Muğla, Turkey Tel: +90 252 - 211 10 00 E-mail: ahmetbelli@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(4):337-342 DOI: 10.5505/tjtes.2017.84584 Submitted: 20.03.2017 Accepted: 10.11.2017 Online: 21.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Belli et al. Adherence to vaccination recommendations after traumatic splenic injury

To avoid OPSI, vaccination against S. pneumoniae, N. meningitidis, and HIB are recommended in addition to a yearly influenza vaccine. However, the administration of these vaccines is recommended after the postoperative day 14 to increase the immune response in patients who have undergone splenectomy due to trauma. Moreover, a booster dose is needed for pneumococcal and meningococcal vaccines after the fifth year of vaccination.[8–11] However, the adherence to vaccination recommendations and timing of the vaccinations vary depending on surgeons’ practice.

To the best of our knowledge, there are few studies which reported the vaccination adherence after splenectomy in the literature. The aim of this study was to investigate the adherence to vaccination recommendations after traumatic splenic injury by our surgeons and to analyze the factors that affect the vaccination status.

Patients Underwent Total Splenectomy after Trauma May 2012–March 2016 (n=36) Patients Treated with NOM or Partial Splenectomy (n=3)

Per-operative Deceased Patients (n=6)

Patients who had missing contact information or did not answer phone calls No follow-up data available (n=10)

MATERIALS AND METHODS Patient Selection We identified patients who underwent total splenectomy due to abdominal trauma between May 2012 and March 2016 by questioning the surgical code of total splenectomy from the database of our institution. Informed consent was obtained from each patient before the surgery. We investigated each patient’s records and recorded patient name, sex, date of surgery, duration of hospital stay, intensive care unit (ICU) transfer status, Glasgow coma scale (GCS), initial and control vital sign, hemograms, number of transfusions, erythrocyte suspension (ES), and fresh frozen plazma (FFP) packs.

We excluded the patients who had nontraumatic splenectomy, nonoperative management, or partial splenectomy and who deceased during per- or postoperative period (Fig. 1).

We searched for additional organ injuries other than those of the spleen from the patient charts and identified the organ injury scale (AIS) scores. Then, we calculated ISS scores for each patient according to the calculator defined by Baker et al.[12] Patients who had a mean arterial pressure (MAP) of <65 mm Hg in the control vital signs and/or Hct decrease of >20% were defined as hemodynamically unstable. Our radiologist reevaluated the CT images of all the patients according to the American Association for the Surgery of Trauma (AAST) grading system.

Vaccination Status We investigated both doctors’ directives and nursery notes from the patients’ charts during the hospital stay to identify whether vaccinations for S. pneumoniae, N. meningitidis, and HIB were administered. The ideal categorization of the patients was grouping them into those vaccinated in 14 days and after 14 days of splenectomy. However, we did not have 338

Remaining patients for the study (n=27)

Patients remained to determine developing OPSI (n=17)

Figure 1. Study population selection criteria and the time period.

any vaccination tracking system; hence, we could not find the exact dates of the vaccinations after discharge. If a patient had any of the recommended vaccinations before or after discharge, we considered that patient to be vaccinated to analyze the effective factors for vaccination status.

For pneumococcal vaccine, 23 valent pneumococcal polysaccharide vaccine (PPSV-23) and 13 valent pneumococcal conjugate vaccine (PCV-13) statuses were separately recorded and categorized into 3 groups: before discharge, which was recorded from the patient charts; after discharge, which was determined by calling the patients who had missing vaccinations before discharge; and final, which displayed the maximum completion of vaccination by inviting and prescribing the missing vaccines. Furthermore, we categorized all possible combinations of the 3 vaccines and displayed them in Table 1.

Identification of OPSI Development While we called the patients to determine the missing vaccinations after discharge, we also asked if they had any severe infection, such as pneumonia, meningitis, or sepsis-related disease, or any condition which required hospitalization. The time period between the interview with the patients and discharge date was recorded as the follow-up time.

Statistical Analysis We compared two categorical data with either the Pearson Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Belli et al. Adherence to vaccination recommendations after traumatic splenic injury

Chi-Square or Fischer’s exact test. We used parametric or nonparametric independent samples t tests to compare categorical variables and scale data according to the normality analysis. For the comparison between two scale data, we used the Pearson correlation test. We classified the grades I–III and IV–V as mild and severe grades, respectively, for statistical analysis.

RESULTS We identified 36 patients with traumatic splenic injury between May 2012 and March 2016. Of these, 2 were treated nonoperatively, 1 underwent partial splenectomy, and 33 underwent total splenectomy. Six patients had deceased peror postoperatively due to injuries other than those of the spleen. Of the remaining 27 patients, 19 (70.4%) were male and 8 (29.6%) were female. The median age was 33 (7–49) years. The median hospital stay duration was 8 (0–31) days.

The numbers of patients who had at least one of the recommended vaccinations before discharge, after discharge, and final were 14 (51.8%), 16 (59.3%), and 18 (66.7%), respectively.

For the vaccination status before discharge, after discharge and final, the number of patients who received all the three vaccinations were 0 (0%), 0 (0%), and 8 (18.5%) and those who received none were 13 (48.2%), 11 (40.8%), and 9 (33.4%), respectively. Other combinations of the vaccines administered to the patients are given in Table 1.

For the 14 (51.8%) vaccinated and 13 (48.2%) unvaccinated patients before discharge, the median age was 32 (22–48) and 40 (7–49) years (p>0.05), male/female ratio was 8:5 and 11:3 (p>0.05), number of patients requiring intensive care was 6 (22.2%) and 6 (22.2%) (p>0.05), median hospital stay durations was 8.5 (5–31) and 8 (0–20) days (p>0.05), median ISS score was 19 (4–75) and 25 (4–75; p>0.05), and median GCS score was 15 (3–15) and 15 (3–15; p>0.05), respectively. The data of 17 patients who developed OPSI were available. The median follow-up duration was 17.8 (4.4–41.2) months, and no OPSI cases were observed (Table 2).

DISCUSSION We investigated the adherence to vaccination recommendation after traumatic splenic injury in our institution and found that patients did not receive all the recommended vaccines after splenectomy due to trauma.

Splenectomy decreases the number of memory B cells and marginal zone monocytes, thereby deteriorating the immune response to capsulated bacteria.[13] Although vaccinations are recommended at least 14 days before splenectomy for nontraumatic cases, they are recommended after postoperative day 14 for traumatic causes when splenectomy is not foreseeable.[14]

Table 1. Vaccination statuses of the patients before discharge, after discharge, and final Vaccine Before discharge After discharge Final status Number of patients

n (%) n (%) n (%) followed for OPSI

after discharge

Median follow-up OPSI time (months) (min-max)

Pneumococ

8 (29.6)

7 (25.9)

5 (18.5)

4

29.4 (4–41.2)

–

PPSV-23

5 (18.5)

4 (14.8)

2 (7.4)

3

33.1 (4–41.2)

–

PCV-13

3 (11.1)

3 (11.1)

3 (11.1)

1

25.7

–

0 (0)

0 (0)

0 (0)

–

–

–

Meningococ

0 (0)

0 (0)

0 (0)

–

–

–

Pneumococ+Meningococ

HIB

1 (3.7)

4 (14.8)

7 (25.9)

4

12.2 (11.2–15.2)

–

PPSV-23+Meningococ

1 (3.7)

3 (11.1)

4 (14.8)

3

11.2 (11.2–13.3)

–

PCV-13+Meningococ

0 (0)

1 (3.7)

3 (11.1)

1

15.2

–

Pneumococ+HIB

5 (18.5)

5 (18.5)

1 (3.7)

4

23.4 (14.2–36.3)

–

PPSV-23+HIB

4 (14.8)

4 (14.8)

1 (3.7)

3

14.5 (14.2–36.3)

–

PCV-13+HIB

1 (3.7)

1 (3.7)

0 (0)

1

32.3

–

0 (0)

0 (0)

0 (0)

–

–

–

Meningococ+HIB Pneumococ+Meningococ+HIB

0 (0)

0 (0)

5 (18.5)

–

–

–

PPSV-23+Meningococ+HIB

0 (0)

0 (0)

4 (14.8)

–

–

–

PCV-13+Meningococ+HIB

0 (0)

0 (0)

1 (3.7)

–

–

–

Unvaccinated

13 (48.2)

11 (40.8)

9 (33.4)

5

29.4 (5.2–36.9)

–

Total

27 (100)

27 (100)

27 (100)

17

17.8 (4.4–41.2)

–

HIB: Hemophilus Influenza type b; PPSV-23: 23 valent pneumococcal polysaccaride vaccine; PVC-23: 23 valent pneumococcal polysaccharide vaccine; OPSI: Overwhelming post-splenectomy infection; Min: Minimum; Max: Maximum.

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Table 2. Clinical and pathological features of the vaccinated and unvaccinated patients before discharge

Vaccinated

Unvaccinated

p

Number of patients

14 (51.8%)

13 (48.2%)

Age

32 (22–48)

40 (7–49)

0.45 0.29

Gender

Male

8 (29.6%)

11 (40.7%)

Female

5 (18.5%)

3 (11.1%)

AAST grade

I–III

8 (29.6%)

8 (29.6%)

IV-V

6 (22.2%)

5 (18.5%)

Total erytrocyte suspension

3 (0–10)

3 (0–18)

0.75

Total fresh frozen plazma

2 (0–6)

2 (0–6)

0.96

Duration of surgery (minutes)

0.56

105 (50–165)

120 (60–150)

0.59

Injury Severity Score

19 (4–75)

25 (4–75)

0.61

Glasgow Coma Scale

15 (3–15)

15 (3–15)

0.44 0.43

Hemodynamic Status

Stable

9 (33.3%)

7 (25.9%)

Unstable

5 (18.5%)

6 (22.2%)

6 (22.2%)

6 (22.2%)

Intensive care unit status

Required

Not required

Hospital stay Number of consultations

0.58

8 (29.6%)

7 (25.9%)

8.5 (5–31)

8 (0–20)

0.48

3 (1–7)

3 (1–7)

0.79

AAST: American Association for Surgery of Trauma.

Several studies reported the adherence to vaccination recommendations after splenectomy. Martino et al.[15] reported in their series that 15.1% of the patients had one of the recommended vaccines, and vaccination proportions against S. pneumoniae, N. meningitides, and HIB were 12.6%, 7.8%, and 6%, respectively. Nived et al.[16] stated that of the 79 patients who had splenectomy in their series, vaccination proportions against S. pneumoniae, N. meningitides, and HIB were 81%, 22.8%, and 51.9%, respectively.

The first guideline for infection prevention in hyposplenia was determined by the British Committee for Standards in Hematology. The following items were the key recommendations for patients with hyposplenia: 1) Patients should have any document which indicates that they have hyposplenia and are in a high-risk infection condition to alert health professionals 2) Education should be given regarding traveling to infection endemic areas, such as those for malaria 3) Patient records should be marked to display the potential risk of infection 4) All patients should receive pneumococcal, meningococcal, HIB, and yearly influenza vaccinations. 5) Revaccination times for pneumococcal, meningococcal, and influenza vaccines should be clearly identified 6) Lifelong prophylactic antibiotics, oral penicillin, or macrolides should be advised to patients at high risk of pneumococcal infection. 7) Patients 340

must carry adequate antibiotics for an emergency infection 8) Patients should be educated to avoid animal bites and tick- or mosquito-borne diseases.[10] For pneumococcal and meningococcal vaccines, the CDC Advisory Committee on Immunization Practices suggests a repeat dose after the fifth year of splenectomy for both adults and children.[8,9] Kealey et al.[17] assessed the initial and revaccination proportions in patients who underwent splenectomy due to trauma. They reported that initial vaccination proportions were 76%, 75%, and 68% for S. pneumoniae, N. meningitides, and HIB, respectively, and the revaccination proportions were 39% and 15% for S. pneumoniae and N. meningitides, respectively. Therefore, education of health care workers and patients is crucial and establishing a vaccination tracking system can improve the completion of the vaccination course. Booster administration of the vaccines was also evaluated by Wang et al.;[3] they reported it to be 76.9% between 2 and <10 years, 82.2% between 10 and <30 years, and 76.7% for ≥30 years after splenectomy. Boam et al.[18] studied the adherence to vaccination recommendations after splenectomy for all indications and reported that 91.5% of their patients received HIB, meningococcus C, and pneumococcus vaccinations peri-operatively, with 84% booster dose administrations for pneumococcus and that 95% of the Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Belli et al. Adherence to vaccination recommendations after traumatic splenic injury

patients received annual influenza vaccine. They stated that utilizing electronic health records by general practitioners improved the documentation of health records so that vaccinations can be better administered. However, we do not have any vaccination tracking system currently to improve the vaccination status of our patients.

We also investigated the effective factors for the vaccination status after traumatic splenic injury before the patients were discharged and found no difference. We observed in our clinical experience that some surgeons prescribed either only pneumococcal or all the vaccines, but the administration of the vaccines depended on the availability in the pharmacy. For example, HIB vaccine has been available at different time periods in the Turkish Pharmacy because of the import policy. On the other hand, some surgeons referred their patients to infectious disease clinic for the prescription of necessary vaccines, however, the completion of vaccination depended on the proportion of patients visiting such a clinic. Furthermore, we observed that many physicians did not recommend yearly influenza vaccine and booster doses for PPSV-23 and meningococcal vaccines in this patient group. Nevertheless, this was out of scope of our study, but further investigations on this topic or the establishment of a vaccination tracking system may be helpful to improve the completion of the vaccination course in adequate time.

The benefits of this study included creating awareness regarding missing vaccinations or timing of the vaccination after traumatic splenic injury. Moreover, to the best of our knowledge, there has been no study that reported the ratio of administered vaccines and identified OPSI development according to the combinations of the vaccines, except our study. Furthermore, we limited our study population to only those with traumatic splenic injury, unlike other studies which also included nontraumatic cases. The limitations of our study were as follows: Most patients who had low-grade injury with hemodynamic stability underwent total splenectomy instead of nonoperative management; we had relatively less number of patients and designed our study retrospectively because traumatic splenectomy is not a frequent procedure; and the follow-up time for developing OPSI was <5 years.

Conclusion Adherence to vaccination recommendations after traumatic splenic injury remains low in our practice. Establishing a vaccination tracking system and following vaccination recommendations will be helpful to prevent serious infections, such as OPSI, after traumatic splenectomy.

Financial Support: None Conflict of interest: None declared.

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REFERENCES 1. Cirocchi R, Boselli C, Corsi A, Farinella E, Listorti C, Trastulli S, et al. Is non-operative management safe and effective for all splenic blunt trauma?

A systematic review. Crit Care 2013;17:R185.

2. Fraker DL. Spleen. In: Doherty GM, editor. Current Diagnosis & Treatment: Surgery. 13th ed. Columbus, OH: The McGraw-Hill Companies, Inc; 2010.

3. Wang J, Jones P, Cheng AC, Leder K. Adherence to infection prevention measures in a statewide spleen registry. Med J Aust 2014;200:538–40.

4. Hansen K, Singer DB. Asplenic-hyposplenic overwhelming sepsis: postsplenectomy sepsis revisited. Pediatr Dev Pathol 2001;4:105–21.

5. Sinwar PD. Overwhelming post splenectomy infection syndrome - review study. Int J Surg 2014;12:1314–6.

6. Morgan TL, Tomich EB. Overwhelming post-splenectomy infection (OPSI): a case report and review of the literature. J Emerg Med 2012;43:758–63.

7. Newland A, Provan D, Myint S. Preventing severe infection after splenectomy. BMJ 2005;331:417–8.

8. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1997;46:1–24.

9. Cohn AC, MacNeil JR, Clark TA, Ortega-Sanchez IR, Briere EZ, Meissner HC, et al; Centers for Disease Control and Prevention (CDC).

Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013;62:1–28.

10. Davies JM, Lewis MP, Wimperis J, Rafi I, Ladhani S, Bolton-Maggs PH; British Committee for Standards in Haematology. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standards in Haematology by a working party of the Haemato-Oncology task force. Br J Haematol 2011;155:308–17.

11. Carlino C, Zaratti L, Lucciola G, Franco E. National Vaccine Prevention Plan (PNPV) 2012-2014 in the Italian Regions. Ig Sanita Pubbl 2013;69:131–43.

12. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187–96.

13. Leone G, Pizzigallo E. Bacterial Infections Following Splenectomy for Malignant and Nonmalignant Hematologic Diseases. Mediterr J Hematol Infect Dis 2015;7:e2015057.

14. Shatz DV, Schinsky MF, Pais LB, Romero-Steiner S, Kirton OC, Carlone GM. Immune responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy. J Trauma 1998;44:760–5.

15. Martino C, Gallone MS, Quarto M, Germinario C, Tafuri S. Immunization coverage among splenectomized patients: Results of an ad hoc survey in Puglia Region (South of Italy). Hum Vaccin Immunother 2016;12:1277–9.

16. Nived P, Jørgensen CS, Settergren B. Vaccination status and immune response to 13-valent pneumococcal conjugate vaccine in asplenic individuals. Vaccine 2015;33:1688–94.

17. Kealey GP, Dhungel V, Wideroff MJ, Liao J, Choi K, Skeete DA, et al.

Patient education and recall regarding postsplenectomy immunizations. J Surg Res 2015;199:580–5.

18. Boam T, Sellars P, Isherwood J, Hollobone C, Pollard C, Lloyd DM, Dennison AR, Garcea G. Adherence to vaccination guidelines post splenectomy: A five year follow up study. J Infect Public Health; 2017;10:803–8.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Travmatik dalak yaralanmalarından sonra aşılama rehberlerine uyum Dr. Ahmet Korkut Belli,1 Dr. Cem Dönmez,1 Dr. Önder Özcan,1 Dr. Özcan Dere,1 Dr. Selmin Dirgen Çaylak,2 Dr. Funda Dinç Elibol,3 Dr. Cenk Yazkan,1 Dr. Nevin Yılmaz,4 Dr. Okay Nazlı1 Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Muğla Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi, Enfeksiyon Hastalıkları Anabilim Dalı, Muğla Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Muğla 4 Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi, Gastroenteroloji Anabilim Dalı, Muğla 1 2 3

AMAÇ: Postsplenektomi sepsis hiposplenizm gelişen hastalarda 50 kat artan ciddi bir enfeksiyondur. Bu çalışmanın amacı travmatik dalak yaralanmalarından sonra aşılama rehberlerine ne kadar uyulduğunun tespit edilmesidir.

GEREÇ VE YÖNTEM: Mayıs 2012–Mart 2016 tarihleri arasında karın travması sebebiyle total splenektomi yapılan hastalar çalışmaya dahil edildi.

Hastların klinik, labaratuvar ve patoloji verileri kaydedildi. Taburculuk öncesi, sonrası ve de nihai aşılanma oranları ayrı ayrı belirlendi.

BULGULAR: Yirmi yedi hastaya total splenektomi yapılmıştı. Taburculuk öncesi, sonrası ve nihai aşılama oranları sırasıyla şu şekildeydi: Her üç aşının yapılma oranı 0 (%0), 0 (%0) ve 8 (%18.5) idi. Hiç aşılama yapılmama oranları ise 13 (%48.2), 11 (%40.8) ve 9 (%33.4) idi. Postsplenektomi sepsis gelişmesi açısından 17 hastanın verisi mevcuttu. Ortanca takip süresi 17.8 (4.4–41.2) aydı ve hiçbir olguda postsplenektomi sepsis gelişmedi.

TARTIŞMA: Aşılama rehberlerine uyum düşük seyretmektedir. Aşılama takip sistemi kurulması ve aşılama rehberlerine daha fazla uyum sağlanması postsplenektomi sepsis gibi ciddi enfeksiyonları önleyecektir.

Anahtar sözcükler: Aşılama; dalak; enfeksiyon; gastroenteroloji; mikrobiyoloji; travma.

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doi: 10.5505/tjtes.2017.84584

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ORIGIN A L A R T IC L E

Antivenom use in bite and sting cases presenting to a public hospital Aynur Şahin, M.D.,1 Şule Kalkan, M.D.,2

Mualla Aylin Arıcı, M.D.,2 Yeşim Tunçok, M.D.2

Nil Hocaoğlu, M.D.,2

1

Department of Emergency Medicine, Karadeniz Technical University Faculty of Medicine,Trabzon-Turkey

2

Department of Medical Pharmacology, Dokuz Eylül University Faculty of Medicine,İzmir-Turkey

ABSTRACT BACKGROUND: To evaluate the distribution of bite and sting cases presenting to a district public hospital and the use of antivenom in scorpion sting and snake bite cases.

METHODS: The demographic characteristics of patients with bites/stings reporting to a public hospital in 2014, the agent involved, the season of reporting, severity of clinical findings during presentation, and use of antivenom in scorpion sting and snake bite cases were evaluated retrospectively. χ2 test was used for statistical analysis.

RESULTS: Bite and sting cases comprised 0.5% of all the patients reporting to the hospital’s emergency department, with scorpion sting cases comprising almost half (54.2%) of these hospital presentations, followed by Hymenoptera (bee and wasp) sting (30.8%) and snake bite (5.5%) cases. Unnecessary antihistamine administration was found to be significantly high in asymptomatic patients (p=0.00006). Furthermore, antivenom use was found to be significantly high in patients with scorpion sting and snake bite despite the absence of systemic or local indications (p<0.0001, χ2=80.595).

CONCLUSION: The study results showed that antivenom was used in scorpion sting and snake bite cases even when it was not indicated. Therefore, primary practitioners should be provided training for management of envenomation cases and should be made aware of the updated guidelines and references to raise their knowledge levels.

Keywords: Antivenom; scorpion; snake; sting,bite.

INTRODUCTION Background Poisonous animal bites and stings are one of the causes for patients visiting the emergency departments. Animals such as scorpions, snakes, bees/wasps, and centipedes are some of the agents involved in bite and sting cases, and such cases are particularly common in spring and summer. The prevalence and causes of these cases exhibit regional variation, and mortality may be observed, particularly in association with snake bites and scorpion stings.[1] The proportion of bites and stings among all poisoning cases

is 2.1% according to the American Association of Poison Control Centers’ National Poison Data System Report for 2015, 1.8% according to a National Poisons Information Center report for 2008, and 2.4% according to the Dokuz Eylul University (DEU) Faculty of Medicine Drug and Poison Information Center report for 2007.[2–4] Bites and stings generally occur in the extremities.[5] The severity of poisoning and clinical symptoms vary across all bites and stings, depending on the site of the bite or sting, the agent, the amount of venom and its potency, the presence of any underlying cardiovascular disease such as diabetes, and age.[6] The commonly encountered bites and stings include scorpion and Hymenoptera (bee and wasp) stings and snake bites. In

Cite this article as: Şahin A, Arıcı MA, Hocaoğlu Aksay N, Kalkan Ş, Tunçok Y. Antivenom use in bite and sting cases presenting to a public hospital.

Ulus Travma Acil Cerrahi Derg 2018;24:343-350.

Address for correspondence: Aynur Şahin, M.D. Karadeniz Teknik Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Trabzon, Turkey Tel: +90 462 - 373 00 09 E-mail: dr-aynursahin@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(4):343-350 DOI: 10.5505/tjtes.2017.99692 Submitted: 18.03.2017 Accepted: 10.11.2017 Online: 24.04.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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addition to pain, erythema, and swelling that are generally observed locally around the bite or sting area, clinical findings such as nausea, vomiting, hypotension, hypertension, tachycardia, seizure, anaphylaxis, and bleeding disorders may be seen, depending on the characteristics of the venom. Severe systemic findings and even mortality may be observed in pediatric patients, particularly in scorpion envenomation cases.

[7,8] The neurotoxins present in the snake venom can cause direct tissue injury, damage to cellular components, and nerve signaling disorders.[1,9] The general approach in all bite and sting cases involves symptomatic support therapy in addition to local wound site care, analgesic therapy, and tetanus prophylaxis. Antivenom must be administered in accordance with appropriate systemic and local indications in scorpion sting and snake bite cases.

Although antivenoms represent the basic step of treatment in life-threatening envenomation cases, particularly scorpion sting and snake bite cases, they also cause severe side-effects.

Mild clinical findings such as nausea, vomiting, fever, and urticaria or severe findings such as anaphylaxis, hypotension, cyanosis, and loss of consciousness may occur in association with antivenom use.[10] Few studies have investigated the epidemiologıcal characteristics of bite and sting cases in Turkey. There are no recorded data concerning non-indicated antivenom administration in snake bite and scorpion sting vases. We investigated the prevalence of bite and sting cases, the information concerning presentations of which to emergency departments in Turkey is limited, among envenomation cases presenting to a public hospital. Furthermore, we investigated the prevalence of inappropriate antivenom use in scorpion sting and snake bite cases.

Importance The number of studies investigating the epidemiological characteristics of bite and sting cases is very limited. In particular, there is no previous research concerning the prevalence of non-indicated, unnecessary antivenom use in snake bite and scorpion sting cases in Turkey.

Goals of This Investigation The purpose of this study was to determine the epidemiological characteristics of bite and sting cases. Little is known about the prevalence of emergency department presentations of bite and sting cases in Turkey, their general characteristics, and the level of unnecessary antivenom use.

MATERIALS AND METHODS Approval for this cross-sectional, descriptive research was granted by the DEU Non-Interventional Research Ethical Committee. This study was performed at the Dr. Faruk Ilker Bergama Public Hospital Emergency Department in the province of Izmir in the Aegean region of Turkey, the 344

emergency department of which receives approximately 70,000 cases per year. All bite and sting cases presenting to the emergency department in 2014 were identified by scanning International Classification of Diseases ICD-10 codes on the hospital’s electronic medical record system. Patient files were extracted from the archives. Bite and sting cases were evaluated in terms of the agent involved; the patient’s age and sex; the month, season, and location of bite/sting; time elapsed since the bite/sting; presence of local and systemic clinical findings; treatment administered (antihistamine therapy and antivenom use in snake bites and scorpion stings); and length of hospital stay. Clinical findings were evaluated as mild, moderate, or severe based on the severity of envenomation scores (European Association of Poison Centers and Clinical Toxicologists/International Programme on Chemical Safety).[11] Antivenom use was also assessed depending on the presence of systemic and local indications in patients with snake bites or scorpion stings (Table 1).[12,13]

Statistical Analysis All the data collected were recorded onto a prepared patient record form and then entered onto Statistical Package for the Social Sciences 15.0 (SPSS Inc., Chicago, IL, USA) software.

Patients aged under 18 years were classified as children and those over 18 years as adults. χ2 and Fisher’s exact tests were used for the statistical analysis of the numerical data. P<0.05 was regarded as significant.

RESULTS Bite and sting cases comprised 0.5% (n=273) of all the patients presenting to the hospital’s emergency department in 2014. The female/male ratio in all bite and sting cases was 0.9; mean ages were 38.8±1.4 years in males and 40.5±1.5 in females. The child age group comprised 9.5% (n=26) of these presentations.

The majority (n=140, 51.3%) of presentations to the emergency department occurred between 13:00 and 17:59 pm.

In addition, 74.7% of the cases presented to the emergency department within 1 h of the sting or bite, with all the cases presenting within 6 h. In terms of season, 65.2% (n=178) of the patients presented in the summer, 19.4% (n=53) in the spring, and 15.4% (n=42) in the fall.

Scorpion stings comprised more than half of the presentations in both children and adults (54.5%, n=149). Bee stings were the second most common cause of the presentations to the emergency department (30.8%, n=84). The rates of presentation to the emergency department due to snake and spider bites were 5.5% (n=15) and 1.1% (n=3), respectively (Table 2). Additionally, among all the cases, those presenting to the emergency department due to bites/stings in the upper extremity were 70.3%, in the lower extremity were 20.2%, in the head were 20.2%, and in the trunk were 2.2%.

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Table 1. Indications for antivenom administration depending on the presence of local and clinical findings in scorpion sting and snake bite cases Antivenom indications Systemic

Local

Scorpion

CVS symptoms: heart failure, cardiogenic shock, pulmonary edema,

Rapid extension of swelling involving

envenomation

tachycardia, arrhythmia, dyspnea, hypertension, hypotension, electrocar-

more than half of the bitten limb

diographic abnormalities, and priapism.

Hypersecretory syndrome: salivation, sweating, bronchorrhea, nausea, vomiting, diarrhea, and urination.

GIS symptoms: abdominal distension and abdominal cramps NMS symptoms: dysfunction of either skeletal or cranial muscles: confusion, agitation, fasciculation, dystonia, vision disorders, ptosis, and aberrant eye movements dysfunction of both skeletal and cranial muscles: convulsions, paralysis, and Glasgow score ≤6 (in absence of sedation).

Snake

Hemostatic abnormalities: Spontaneous systemic bleeding (clinical),

Local swelling involving more than half

envenomation

coagulopathy (20WBCT or other laboratory tests such as prothrombin

of the bitten limb (in the absence of a

time), or thrombocytopenia

tourniquet) within 48 h of the bite

NMS symptoms: Ptosis, external ophthalmoplegia, paralysis etc. and gen-

Swelling after bites on the digits (toes

eralized rhabdomyolysis (muscle aches and pains, hyperkalemia)

and especially fingers). Rapid exten-

CVS symptoms: Hypotension, shock, cardiac arrhythmia (clinical), and

sion of swelling (for example, beyond

abnormal ECG

the wrist or ankle within a few hours

Acute kidney injury (renal failure): Oliguria/anuria (clinical), rising

of bite on the hands or feet)

blood creatinine/ urea (laboratory). Hemoglobinuria, myoglobinuria dark

Development of an enlarged tender

brown urine (clinical), or other evidence of intravascular hemolysis

lymph node draining the bitten limb

CVS: Cardiovascular system; GIS: Gastrointestinal system; NMS: Neuromuscular system.

Pain was present in the bite or sting area in 52.8% (n=159) of the cases; nausea was present in 7.7% (n=21), hypotension in 6.2% (n=17), hypertension in 4.0% (n=11), tachycardia in 3.7% (n=10), and vomiting in 1.5% (n=4) cases. When all bite and sting agents were evaluated separately, pain was found to Table 2. Distribution of bite and sting agents in children and adults Agents

Children (0–17 y)

Adults (≥18 y)

All age groups

n % n % n %

Scorpion 13 50.0 136 55.0 149 54.5 Snake

2 7.7 13 5.3 15 5.5

Spider

0 0 3 1.2 3 1.1

Bee

7 26.9 77 31.2 84 30.8

Centipede 2 7.7 16 6.5 18 6.6 Unknown 2 7.7 2 0.8 4 1.5 Total

26 100.0 247 100.0 273 100.0

Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

be present in the wound area in 80.0% of snake bite, 66.7% of snake and centipede bite, 65.5% of Hymenoptera (bee and wasp) sting, and 51.0% of scorpion sting cases; furthermore, pain was the most common finding (Table 3). When clinical findings were assessed according to the envenomation severity scores, mild clinical findings were observed in 57.5% (n=157) and moderate clinical findings in 1.8% (n=5) of the cases, whereas 40.7% (n=111) cases were asymptomatic.

Treatment of Bites and Stings Local wound care and tetanus prophylaxis were applied to all the bite and sting cases (100%, n=273), and antihistamines were administered to 97.1% (n=265) cases. Furthermore, antihistamines were administered to 92.8% (n=103) of asymptomatic patients. Notably, unnecessary antihistamine administration in asymptomatic cases was significantly high (p<0.0001).

Antivenom was used in 28.2% (n=42) of scorpion sting cases and in 60% (n=9) of snake bite cases. The rate of antivenom administration in the presence of local and/or systemic indications in scorpion sting cases was 100.0% (n=11); however, 345

Şahin et al. Antivenom use in bite and sting cases presenting to a public hospital

Table 3. Distribution of clinical findings by agents Findings

Scorpion

Spider

Snake

Bee

Centipede Unknown

Total

n % n % n % n % n % n % n %

Pain in the bite area

76

Nausea

11 7.4 0 0.0 0 0.0 9 10.7 1 5.6 0 0.0 21 7.7

Hypotension

10 6.7 0 0.0 1 6.7 4 4.8 2 11.1 0 0.0 17 6.2

Hypertension

6 4.0 0 0.0 1 6.7 2 2.4 0 0.0 0 0.0 11 4.0

Tachycardia

4 2.7 0 0.0 2 13.4 2 2.4 2 11.1 0 0.0 10 3.7

Vomiting

2 1.3 0 0.0 0 0.0 1 1.2 1 5.6 0 0.0 4 1.5

51.0

2

66.7

12

80.0

55

65.5

12

66.7

2

50.0

159

58.2

Table 4. Antivenom use depending on presence of systemic and/or local indications in scorpion sting and snake bite cases

Scorpion sting

Snake bite

Total

Systemic Antivenom Antivenom Antivenom Antivenom Antivenom Antivenom and/or local administered not administered not administered not indications administered administered administered

n % n % n % n % n % n %

Yes

11 100.0 0 0.0 3 100.0 0 0.0 14 100.0 0 0.0

No

31 22.5 107 77.5 6 50.0 6 50.0 37 24.7 113 25.3

Total

42 28.2 107 71.8 9 60.0 6 40.0 51 31.1 113 68.9

Table 5. Distribution of bite and sting agents by length of hospital stay Agent

Length of hospital stay (hours) 0–6

7–12 13–24 24–48

Total

n % n % n % n % n %

Scorpion 128 85.9 18 12.1 1 0.7 2 1.3 149 100.0 Snake

7 46.7 8 53.3 0 0.0 0 0.0 15 100.0

Spider

3 100.0 0 0.0 0 0.0 0 0.0 3 100.0

Bee

84 100.0 0 0.0 0 0.0 0 0.0 84 100.0

Centipede 16 88.9 2 11.1 0 0.0 0 0.0 18 100.0 Unknown 4 100.0 0 0.0 0 0.0 0 0.0 4 100.0 Total

242 88.6 28 10.3 1 0.4 2 0.7 273 100.0

antivenom was also used in 22.5% (n=31) of scorpion sting cases with no systemic and/or local indication. The rate of antivenom use in snake bite cases in the presence of the indications was 100.0% (n=3); this rate was 50% (n=6) in the absence of the indications. Antivenom use in the absence of local and/or systemic indications was significantly high (p<0.0001, χ2=80.595) (Table 4).

The length of hospital stay was 6 h in 88.6% (n=242), 12 h in 10.3% (n=28), 24 h in 0.4% (n=1), and 48 h in 0.7% of all bite and sting cases (Table 5). Of all the patients, 85% were dis346

charged as fully healed, while 15% were referred to a higherlevel health facility for advanced treatment; we were unable to follow-up these referred patients. However, in the remaining 85% patients who were followed-up, no severe clinical findings based on the envenomation severity scores were observed. No patient died due to bites or stings in our hospital during the study period.

DISCUSSION In addition to evaluating the epidemiological and clinical charUlus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Ĺ&#x17E;ahin et al. Antivenom use in bite and sting cases presenting to a public hospital

acteristics of bite and sting cases presenting to a district public hospital providing primary health services, this study also investigated the use of antivenom in terms of its indication in scorpion sting and snake bite cases.

Bite and sting cases comprised 0.5% of all the envenomation cases presenting to the emergency department. The proportion of bite and sting cases among the emergency presentations as per the epidemiological data in different studies is approximately 0.7%.[14,15] Although our results are compatible with the data from the literature, the true incidence cannot be calculated exactly. This is because a significant part of bite and sting cases, which are more commonly encountered in rural areas, are treated at home using traditional methods only and such patients do not visit a hospital.[9] In our study, we determined that scorpion sting cases comprised a large part of emergency presentations due to stings. Scorpion sting cases were followed by Hymenoptera (wasp and bee) sting cases. One study involving a retrospective analysis of bite and sting cases over a 17-year period at the Dokuz Eylul University Poison Information Center reported that scorpion sting cases represent approximately one in three such cases, followed by snake bite, centipede sting, spider bite, and Hymenoptera (bee and wasp) sting cases;[16] the proportion of snake bite cases was found to be low. In the majority of research performed to date, scorpion stings have been found to comprise a large proportion of envenomations, with Hymenoptera (bee and wasp) stings comprising another commonly encountered envenomation. However, one epidemiological study on all bite and sting cases presenting to all emergency departments in the USA in 2001â&#x20AC;&#x201C;2004 reported that insect bites and stings were the most common causes for these cases at 39.0%, followed by bee and wasp stings at 17.0% and spider bites at 13.5%. In contrast to our results, the same study reported levels of 0.8% and 1% for scorpion stings and snake bites, respectively.[15] Factors such as regional climatic features, vegetation cover, and the socioeconomic and cultural variations in the presenting population may underlie the variations in the abovementioned levels among these studies.

As also reported in previous studies, bite and sting cases largely occurred in the summer, when the weather is considerably warmer; when people spend more time outside; and when snakes, scorpions, and other bite and sting agents are active.[15,17] The fact that bites and stings frequently occurred in the upper extremities is another finding compatible with those of the previous studies.[18] The most common clinical finding in bite and sting cases, when agents were analyzed separately and together, was pain in the bite/sting area. Toxin-related pain, erythema, and swelling are the most common local findings in scorpion and bee/wasp sting and snake bite cases.[7,19] Because our study was a retrospective analysis, no data regarding the development of erythema and swelling were available in the patient Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

records; however, the common observation of pain was compatible with that in the literature.

The most common clinical findings following pain in our patients with scorpion stings included nausea, hypotension, and hypertension. There are two species of poisonous scorpion in Turkey: Mesobuthus gibbosus and Androctonus crassicauda.[20] Digestive enzymes and neurotoxins present in scorpion venom are responsible for the clinical findings present in scorpion sting cases. In addition to local findings, severe systemic clinical findings such as hypertension, hypotension, tachycardia, sweating, muscle weakness, double vision, nystagmus, convulsion, and coma may be seen. Moderate toxic findings such as hypotension and tachycardia were observed in our study. This also suggests that although species screening is not possible, M. gibbosus species scorpions, which are widely found in the Aegean region and give rise to moderate toxic findings, are responsible for majority of scorpion envenomations.[20] Similarly, systemic findings in snake bite cases included hypotension, hypertension, and tachycardia. Approximately 50.0% of snake bites are dry bites, resulting in no clinical findings.[21,22] The venom of viper-type snakes in Turkey contains large numbers of proteolyic enzymes, anticoagulants, cardiotoxins, hemotoxins, and neurotoxins and can cause direct tissue damage, cellular blood component compromise, and signal transmission disorders.[23] The number of snake bites in Turkey is low, and the great majority of findings are thought to develop in association with dry bites or bites from non-venomous snakes, even though species screening has not been possible.[24] The most severe systemic finding associated with Hymenoptera stings is anaphylaxis, a potentially fatal allergic reaction. The prevalence of bee/wasp sting-related anaphylaxis varies between 1.2% and 3.5%.[19] Although moderate systemic findings such as hypotension and tachycardia were recorded in association with Hymenoptera stings in our study, no serious anaphylactic reaction was observed.

For the treatment of patients with bites and stings, the patient must first be stabilized and wound care and tetanus prophylaxis must be administered. All cases in our study were recorded as receiving wound site care and tetanus prophylaxis. However, antihistamines and corticosteroids were administered to almost all the patients with no clinical findings.

Systemic antihistamine and corticosteroid administration has been reported to be effective in the presence of extensive local reaction or urticaria in the bite/sting area.[25] Additionally, this combination has been reported to exhibit no acute efficacy in anaphylaxis that may result due to both venom and antivenom.[9,19,26,27] Clinical studies have also shown that antihistamine and steroid therapy is not effective in preventing anaphylaxis that may develop particularly before antivenom use.[28,29] We determined that antihistamine therapy was used 347

Şahin et al. Antivenom use in bite and sting cases presenting to a public hospital

unnecessarily in our studied cases. Therefore, physicians in emergency departments need to be made aware of antivenom use only where indicated through professional training seminars.

Various clinical classification systems have been established to guide treatment and facilitate follow-up in scorpion sting and snake bite cases. If antivenom is administered in the light of these indications, unnecessary antivenom use and complications arising from antivenom use can be avoided. In our study, we found that significantly high levels of antivenom were used in conditions where no relevant clinical findings were observed, in both scorpion sting and snake bite cases.

Antivenom, or passive immunotherapy, is obtained through enzymatic purification of IgG antibodies separated from plasma components of animals that are hyperimmunized against snake or scorpion venoms, and there are indications for its use in selected patients with systemic clinical findings, depending on the species involved.[12] This is because antivenoms, frequently obtained using sera from different animal species such as horses, may cause allergic reactions when they are administered to humans. The most serious and life-threatening of these allergic reactions is early anaphylactic reaction proceeding with hypotension, bronchospasm, and angioedema developing within approximately 10–180 min of antivenom administration. Pyrogenic reaction developing within 1–2 h of antivenom administration and proceeding with fever, shivering, and hypotension is another more moderate reaction, but one that can prolong the length of hospital stay if not treated. In addition, delayed-type hypersensitivity reactions may also be observed 1–12 days after antivenom administration.[9] There is no scientific evidence for antihistamine and steroid administration for prophylactic purposes to prevent antivenom use-related complications. Therefore, antivenom use when not indicated may lead to a risk of severe, life-threatening complications. There is a lack of sufficient information concerning inappropriate antivenom use in the literature. One study conducted on emergency physicians in Japan regarding knowledge levels concerning indications for antivenom use and snake bite management reported physicians’ knowledge levels to be inadequate.[30] The reasons for antivenom use when not indicated in this study may include the emergency department where the study was performed being a primary emergency department attached to a public hospital; the great majority of physicians working in the emergency department being general practitioners; and the inability to perform advanced procedures such as local nerve blockage for severe pain, particularly in scorpion sting cases. General practitioners serving in emergency departments, therefore, need to be provided professional training seminars accompanied by updated guidelines to raise awareness regarding appropriate management of such cases. Additionally, the number of emergency medicine physicians who have completed specializations in emergency medicine, who monitor the contemporary guidelines, and 348

who are capable of managing all forms of invasive and noninvasive procedures that may be required in the emergency department needs to be increased.

All bite and sting cases presenting to the Dr. Faruk Ilker Bergama Public Hospital resolved completely. Mortality and morbidity in bite and sting cases vary across regions. Mortality rates in Asia and Africa vary between 4 and 162 people in 100,000, whereas only 6000 deaths occur annually in India and Bangladesh.[31,32] Because bites and stings are more common in regions with warm tropical climates, mortality and morbidity levels are also higher in such regions. Difficulties in accessing emergency health services in rural areas and interruptions to services also increase these rates. The absence of mortality in our study may be attributed to the great majority of envenomations being mild or moderate. Although we were unable to access the results of cases transferred to advanced centers, we doubt that any bite or sting-related mortality occurred in these patients, with no severe clinical findings observed during referral.

Conclusion The great majority of bite and sting cases can be treated with local wound care, analgesics, and tetanus prophylaxis without causing significant systemic effects, and genuine antivenom use indications are present in only a very few cases.

In this study, we determined that antivenom was used when not indicated in scorpion sting and snake bite cases. General practitioners working in primary institutions, therefore, need to be provided training in managing such cases in the light of contemporary guidelines and references to raise their knowledge levels. Non-indicated antivenom use causes various complications in patients and also imposes medical and economic losses on the health system by creating difficulties in obtaining antivenom when it is genuinely indicated.

Limitations Out study is retrospective, cross-sectional, single center, and time-limited and, therefore, does not entirely represent the entire population. Because the study was performed by scanning records, only the limited amount of data recorded in those records could be analyzed. Patients could not be evaluated in terms of antivenom use-related delayed reactions after discharge or referral.

Conflict of interest: None declared.

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3. Özcan N, İkincioğulları D. Ulusal Zehir Danışma Merkezi. 2008

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5. Ertem K, Esenkaya I, Kaygusuz MA, Turan C. Our clinical experience in the treatment of snakebites. Acta Orthop Traumatol Turc 2005;39:54–8.

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7. Goldfrank L, Flomenbaum N, Lewin N, Howland MA,Hoffman R, Nelson L, editors. Goldfrank’s Toxicologic Emergencies, tenth edition, McGraw-Hill, New York, NY; 2013.

8. Warrell DA, Cox TM, Firth JD, editors. Oxford Textbook of Medicine, Vol 2, 2nd ed. Oxford: Oxford University Press 2003:1202–8.

9. Warrell DA. Venomous bites, stings, and poisoning. Infect Dis Clin North Am 2012;26:207–23.

10. de Silva HA, Ryan NM, de Silva HJ. Adverse reactions to snake antivenom, and their prevention and treatment. Br J Clin Pharmacol 2016;81:446–52.

11. Casey PB, Dexter EM, Michell J, Vale JA. The prospective value of the IPCS/EC/EAPCCT poisoning severity score in cases of poisoning. J Toxicol Clin Toxicol 1998;36:215–7.

12. Chippaux JP. Emerging options for the management of scorpion stings.

Drug Des Devel Ther 2012;6:165–73.

13. Warrell DA. Guidelines for the management of snake-bites. Guidelines for the management of snake-bites. WHO Regional Office for SouthEast Asia: 2010. Available at: http://apps.searo.who.int/PDS_DOCS/ B4508.pdf, Accessed 16.04.2018.

14. Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997-2007. JAMA 2010;304:664–70.

15. O’Neil ME, Mack KA, Gilchrist J. Epidemiology of non-canine bite and sting injuries treated in U.S. emergency departments, 2001-2004. Public Health Rep 2007;122:764–75.

16. Arici A, S. Hocaoglu, N. Tuncok Y. Bites and stings reported to the Dokuz Eylul University Drug and Poison Information Center. Turkish Pharmacology Association, 21st National Pharmacology Congress, 2011, Eskisehir, Turkey.

17. Sinclair CL, Zhou C. Descriptive epidemiology of animal bites in Indiana, 1990-92-a rationale for intervention. Public Health Rep. 1995;110:64– 7.

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20. Tuncok Y. Scorpion Sting. Guides for Diagnosis and Treatment in Poisoning. 1st Edition; p. 143–6. The Ministry of Health of Turkey 2007.

21. Theakston RD, Warrell DA, Griffiths E. Report of a WHO workshop on the standardization and control of antivenoms. Toxicon 2003;41:541– 57.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Bir devlet hastanesine başvuran ısırma ve sokma olgularında antivenom kullanımı Dr. Aynur Şahin,1 Dr. Mualla Aylin Arıcı,2 Dr. Nil Hocaoğlu,2 Dr. Şule Kalkan,2 Dr. Yeşim Tunçok2 1 2

Karadeniz Teknik Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Trabzon Dokuz Eylül Üniversitesi Tıp Fakültesi, Tıbbi Farmakoloji Anabilim Dalı, İzmir

AMAÇ: Bir ilçe devlet hastanesine başvuran ısırma ve sokma olgularının dağılımı ve akrep sokmalarında ve yılan ısırmalarında antivenom kullanımının değerlendirilmesi.

GEREÇ VE YÖNTEM: Devlet hastanesine 2014 yılı içerisinde bildirilen ısırma-sokma olgularının demografik özellikleri, ısırma sokma etkeni, mevsim, başvuru sırasında klinik bulguların ciddiyeti, akrep sokmalarında ve yılan ısırmalarında antivenom kullanımı geriye yönelik olarak değerlendirildi. İstatistiksel analizde ki-kare testi kullanıldı.

BULGULAR: Tüm olgular arasında, ısırma ve sokmaların oranı %0.5 idi. Akrep sokma olguları, hastane başvuruların yarısından fazlasını (%54.2) oluştururken, akrep sokmalarını, arı sokmaları (%30.8) ve yılan ısırmaları (%5.5) izliyordu. Semptomsuz hastalarda, gereksiz antihistaminik uygulaması istatistiksel olarak anlamlı oranda yüksekti (p=0.00006). Akrep sokmalarında ve yılan ısırmalarında, sistemik ya da lokal endikasyon olmamasına rağmen antivenom kullanımı anlamlı oranda yüksekti (p<0.0001, χ2=80.595).

TARTIŞMA: Çalışmamızda, akrep sokmalarında ve yılan ısırmalarında, endikasyon olmadığı durumlarda da antivenom kullanıldığını saptadık. Bu nedenle, ısırma sokma olgularının yönetiminde, birinci basamakta çalışan pratisyen hekimlere güncel kılavuzlar ve kaynaklar eşliğinde bilgilendirme amaçlı eğitimler verilmelidir.

Anahtar sözcükler: Akrep; antivenom; ısırma-sokma; yılan.

Ulus Travma Acil Cerrahi Derg 2018;24(4):343-350

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doi: 10.5505/tjtes.2017.99692

Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

ORIGIN A L A R T IC L E

Initial inferior vena cava and aorta diameter parameters measured by ultrasonography or computed tomography does not correlate with vital signs, hemorrhage or shock markers in trauma patients Ömer Faruk Çelik, M.D.,1 Özge Ecmel Onur, M.D.,2 1

Haldun Akoğlu, M.D.,2 Arzu Denizbaşı, M.D.2

Ali Çelik, M.D.,2

Ruslan Asadov, M.D.,3

Department of Emergency Medicine, Cizre State Hospital, Şırnak-Turkey

2

Department of Emergency Medicine, Marmara University Pendik Education and Research Hospital, İstanbul-Turkey

3

Department of Radiology, Marmara University Pendik Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Ultrasonography (US) is noninvasive, readily available, and cheap. The diameter of inferior vena cava (dIVC) and its respiratory variation were proposed as a good surrogate of the hemodynamic state. However, recent studies have shown conflicting results, and the value of IVC-derived parameters in the estimation of fluid status and hemorrhage remains unclear.

METHODS: This was an observational study of trauma patients who presented to emergency department. dIVC and aorta diameter (dAorta) were measured at the initial US and CT in all patients. The correlation of these measurements and all parameters derived from those measurements along with the initial vital signs and laboratory values of hemorrhage (hemoglobin, hematocrit) and shock (lactate, base excess) were assessed. US and CT values were also compared for accuracy using Bland–Altman analysis.

RESULTS: The final study population was 140, with a mean age of 38 years and 79.3% were male. dIVC and dAorta did not have any clinically significant correlation with any of the vital signs or laboratory values of hemorrhage or shock when measured by US or CT. A good and significant correlation was observed between dIVC and dAorta measured by US and CT. CONCLUSION: The value of an initial and single measurement of IVC and aorta parameters in the evaluation of trauma patients should be questioned. However, the change in the measured parameters may be of value and should be investigated in further studies.

Keywords: Aorta; aortacaval index; caval index; collapsibility index; diameter; distensibility index; inferior vena cava; shock; trauma.

INTRODUCTION Evaluation of the hemodynamic and perfusion status of a trauma patient is extremely important. Blood pressure and mean arterial pressure (MAP) have been used to define shock state since the advent of medical manometers; central venous pressure (CVP) has been used for monitoring treatment in those patients.

Inferior vena cava diameter (dIVC) and its respiratory variability [collapsibility (dIVC-CI) and distensibility (dIVC-DI) indexes] were defined in the early 80’s.[1,2] Then, in the late 80’s, the utility of dIVC to noninvasively estimate mean right atrial (RA) pressure was studied and reported as a promising index.[3,4] In the 90’s, first reports supporting the use of dIVC to estimate the dry weight and fluid status of patients were published.[5–9] However, with the millennium, a paradigm

Cite this article as: Çelik ÖF, Akoğlu H, Çelik A, Asadov R, Onur ÖE, Denizbaşı A. Initial inferior vena cava and aorta diameter parameters measured by ultrasonography or computed tomography does not correlate with vital signs, hemorrhage or shock markers in trauma patients. Ulus Travma Acil Cerrahi Derg 2018;24:351-358.

Address for correspondence: Haldun Akoğlu, M.D. Marmara Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Pendik, İstanbul, Turkey Tel: +90 216 - 625 45 45 E-mail: drhaldun@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(4):351-358 DOI: 10.5505/tjtes.2017.72365 Submitted: 14.07.2017 Accepted: 17.10.2017 Online: 19.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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shift has begun in the evaluation of fluid status. In place of RA pressures, a new approach called fluid responsiveness has emerged to guide the fluid therapy.[10] Several methods to evaluate fluid responsiveness were tested including the above mentioned sonographic IVC-related indexes.[10–15] Furthermore, the utility of sonographic IVC indexes to estimate the degree of anemia or blood loss or the hemodynamic response to hemorrhage was also tested. Lyon et al.[11] in their study of healthy blood donors, reported dIVC as a reliable indicator of blood loss. Yanagawa et al.[16] confirmed those findings and found dIVC to correlate with hypovolemia and hemoglobin level of trauma patients with class 3 and 4 shock states. Carr et al.[13] reported that the value of dIVC was correlated with CVP measurements in the intensive care unit (ICU). Other sonographic indexes such as cava-aortic diameter index (dIVC/dAorta) were also tested to find a better IVC-derived parameter.[15] However, recently, negative studies conflicting with these previous reports were published. Resnick et al.[17] denied to observe a significant change in IVC indexes in their study of blood donors for class 1 shock. Juhl-Olsen et al.[18] also denied to observe a significant correlation between the hemodynamic response to hemorrhage and dIVC or dIVC-CI in a similar cohort. Similarly, Sobczyk et al.[19] reported that dynamic IVC-derived parameters and CVP were not reliable predictors of fluid responsiveness in the first 6 h after cardiac surgery. However, the value of IVC-derived parameters in the estimation of fluid status and its correlation with hemorrhage markers or vital signs in trauma patients is still not clear, since different and incomparable cohorts were used in previous research.

Therefore, the aim of this study is to evaluate the utility and correlation of IVC-derived parameters measured by US and CT with vital signs and biomarkers of hemorrhage and shock in trauma patients.

MATERIALS AND METHODS Design and Setting This is a prospective, observational clinical study with convenience sampling conducted at the emergency department (ED) of a level 1 trauma center with an annual volume of 200.000 patients between August 2014 and December 2015.

Selection of Participants The study sample consisted of adult patients (≥18 years) who presented to ED with multiple traumas, underwent contrast-enhanced thoracoabdominal CT, and met the inclusion criteria. The attending emergency medicine physicians (EPs) decided the eligibility of the patients based on history and physical examination and managed them according to the latest ATLS guidelines. Multiple trauma was defined according to ATLS as more than one anatomical area being affected.

Unstable [systolic blood pressure (SBP) <100 mmHg and/or heart rate (HR) >100 beats/min and/or ≥4 U of packed red 352

blood cells transfused in the trauma bay] vital signs, lack of informed consent, difficulty in sonographic examination, or anatomical defect(s) at the site of sonographic imaging, pregnancy, inability to perform CT (unable to leave the trauma bay for CT, died in ED, referred to the operating room before CT), intubation, and known allergies to contrast materials were the exclusion criteria.

Data Collection and Study Procedure All multiple trauma patients were evaluated and managed in the trauma bay of ED by EPs. Vital signs [HR, SBP, diastolic blood pressure (DBP), respiratory rate (RR), peripheral oxygen saturation (SpO2)] were electronically measured and recorded. Complete blood count, blood type and match, blood gases, biochemistry, and electrolytes were ordered according to the departmental trauma protocols. Demographics (age, sex), history (trauma type and mechanism, past medical history), results of the laboratory examinations, and official radiology reports were retrospectively collected from the hospital information system.

Measurements US Measurements All bedside US examinations were performed by two certified EPs (OFC, AC). Before the patient recruitment period, a two-hour theoretical video-assisted lecture and hands-on training on ICU patients were performed. A certified US performer instructed the lecture on techniques to adequately visualize IVC and aorta, to detect the timing of measurements according to respiratory cycle, anatomical landmarks, and to explain measurements to be conducted. EPs performing the US measurements had at least 3 years of experience in protocols such as e-FAST, RUSH, or POCUS with an average of 500 bedside US examinations per year. In all patients with a decision to obtain thoracoabdominal CT by the attending EP, IVC and aorta-derived US parameters were measured during the e-FAST examination before the patient left ED for CT. All measurements were recorded in a data collection form by EP performing US. Diameters were measured in maximal inspiration and expiration while the patients were supine with 3.5 Mhz abdominal probes of the two ultrasound machines (Mindray M5, Mindray, P.R.C., and Aloka Prosound 6, Aloka AG, Swiss). Maximum (during expiration, dIVCe) and minimum (during inspiration, dIVCi) IVC diameters were measured 2 cm proximal to the trifurcation of the hepatic vein, and maximum aortic diameter (dAorta) was measured at the ostium of the renal arteries using real-time B-mode images between the internal anteroposterior walls. Three separate measurements were made and the average was used for the final analysis for each diameter. The IVC collapsibility index (dIVC-CI) indicates the relative decrease in diameter during the respiratory cycle and is calculated as follows: (dIVCe− dIVCi)/dIVCe. The IVC distensibility index (IVC-DI) indicates the increase in diameter during inspiration and is calculated Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

Çelik et al. Utility of IVC and aorta measurements in trauma

All CT measurements were performed by an academic radiology specialist who was blinded to the results of US examinations on Picture Archiving and Communication System on contrast-enhanced images taken according to the trauma protocol. The specialist had a 5-year experience in abdominal CT reporting and read approximately 30 CT examinations per day. A dedicated MDCT was used for all ED imaging (Siemens®Somatom® Definition Flash CT Scanner, 2×128 slice stellar detectors with isotrophic resolution of 0.33 mm and cross-plane resolution of 0.30 mm, Siemens AG, Erlangen, Germany). IVC diameters (dIVC-CT) were measured 2 cm proximal to the trifurcation of the hepatic vein on axial images, and the aortic diameter (dAorta-CT) was measured at the proximal plane of the ostium of the renal arteries between the internal anteroposterior walls. Three separate measurements were made and the average was used for the final analysis for each diameter.

Other Measurements and Calculations The shock index (SI) was defined as HR/SBP. A patient with SI >0.9 was considered to have high risk.[20] dIVCe was defined as flat if ≤9 mm and normal if >9 mm according to a previous research.[16] All US and CT measurements and collected patient data were retrospectively reviewed from the electronical records for accuracy by a blinded research assistant.

Outcome Measures The primary outcome measures were the correlation coefficients between the US indexes, vital parameters, and hemorrhage markers. The secondary outcome measure was the consistency between US and CT measurements.

Statistical Analysis Continuous variables were reported as means and standard deviations with 95% confidence intervals (CI) or as medians and interquartile ranges (IQR) according to distribution patterns. Student’s t or sign tests were used to compare the independent groups. Categorical variables were reported as proportions and counts and compared using Fisher’s exact test. Correlations were calculated as defined by Pearson, and their effect sizes were named according to Dancey and Reidy.

[21] Differences of the measurements performed by US and CT were plotted against the averages of the two techniques as defined by Bland and Altman.[22] The sample size was estimated as 82 for the statistical significance of a correlation coefficient of 0.3 with a type 1 error of 5% and power of 80%.

We decided to enroll two times of this number to achieve the sufficient number of patients at the end of the study. The achieved power of this study for the correlation coefficient of IVC/aorta ratios measured by US and CT was 100%. Type Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

RESULTS The total number of patients enrolled into this study was 164. Nineteen patients (11.6%) were excluded because of incomplete data and five (3%) due to other exclusion criteria.

The final study population was 140 (85.4%). The median age of the study population was 38 years, and 111 (79.3%) were male. Demographic characteristics, vital signs, and radiological measurements are presented in Table 1.

We found that dIVC and dAorta and all indexes derived from them did not have any clinically important correlation with neither vital parameters (HR, SBP, DBP, MAP) nor hemorrhage (Hg, Hct) or shock (Lactate, BE) markers when mea8 IVCmax (US) (mm) - IVC (CT) (mm)

CT Measurements

1 error was accepted as 5%. This study was approved by the ethics committee and was one of the two trials conducted on the same study population. MedCalc Statistical Software version 17 (MedCalc Software bvba, Ostend, Belgium; https:// www.medcalc.org) was used for all analysis.

6

+1.96 SD 4.9

4 2 0

Mean -1.0

-2 -4 -6

-1.96 SD -6.8 SD

-8

-10

5

15 20 25 30 10 Geometric mean of IVCmax (US) (mm) and IVC (CT) (mm)

Figure 1. Bland–Altman analysis of dIVC measured by US and CT (US: Ultrasonography; CT: Computed tomography).

4

+1.96 SD 3.2

2 Amax (US) - A (CT)

as follows: (dIVCe−dIVCi)/dIVCi. Those indexes were retrospectively calculated from the dataset.

0

Mean -0.3

-2 -1.96 SD

-4

-3.8

-6 -8

-10

10

12

14 16 18 20 22 24 Geometric mean of Amax (US) and A (CT)

28

Figure 2. Bland–Altman analysis of dAorta measured by US and CT (US: Ultrasonography; CT: Computed tomography).

353

Ă&#x2021;elik et al. Utility of IVC and aorta measurements in trauma

Table 1. Demographic and clinical characteristics of the study population according to flat IVC status IVC Demographics

Total

Flat IVC

Normal IVC

P*

Age (years), median (IQR)

38 (29, 49)

36

38

0.4524

Male, n (%)

111 (79.3)

8 (72.7)

103 (79.8)

0.5774

Vital Signs, median (IQR)

Systolic blood pressure (mmHg)

127.5 (114.0, 141.0)

115

128

0.0054

Diastolic blood pressure (mmHg)

79.0 (70.0, 87.5)

75

79

0.4665

Mean arterial pressure (mmHg)

93.7 (84.8, 105.5)

86.7

93.7

0.0730

Heart rate (bpm)

89.8 (15.7)

93

90

0.9506

Temperature (C)

36.6 (36.5, 36.7)

36.6

36.6

0.5475

Respiratory rate (/min)

16 (14, 18)

16

16

0.2492

pSO2 (%)

98 (97, 100)

98

98

0.9091

0.72 (0.17)

0.74

0.71

0.0712

Shock index

Laboratory values

Hemoglobin (g/dL), mean (SD)

13.8 (1.6)

14.3

13.9

3

0.6588

Hematocrit (%/mm ), mean (SD)

41.3 (4.4)

42.2

41.9

0.7188

Lactate (mmol/L), median (IQR) (n=69)

2.3 (1.9, 3.1)

3.3

2.3

0.3882

Base Excess (mEq/L), median (IQR) (n=68)

0.6 (-1.3, 2.2)

0.4

0.6

0.9225

Ultrasonography measurements and indexes, median (IQR)

dIVCe (mm)

16.0 (13.0, 19.0)

8

17

<0.0001

dIVCi (mm)

8.0 (6.5, 11.0)

3

8

<0.0001

dAorta (mm)

16.0 (15.0, 18.0)

15

16

0.1567

IVC-CI (%)

47.4 (37.5, 56.1)

57.1

47.4

0.0932

IVC-DI (%)

90.0 (60.0, 127.9)

133.3

90.0

0.0932

dIVCe/dAorta

1.00 (0.81, 1.14)

0.50

1.00

<0.0001

CT measurements and indexes, median (IQR)

dIVC-CT (mm)

17.0 (14.0, 20.0)

10.0

17.0

<0.0001

dAorta-CT (mm)

16.0 (15.0, 18.0)

16.0

17.0

0.2141

dIVC/dAorta-CT

1.00 (0.87, 1.18)

0.64

1.05

<0.0001

*Mann-Whitney U test. IVC: Inferior vena cava; IQR: Interquartile ranges; dIVCe: Inferior vena cava diameter during expiration; dIVCi: Inferior vena cava diameter during inspiration; dAorta: Aortic diameter; IVC-CI: Inferior vena cava-collapsibility index; IVC-DI: Inferior vena cava-distensibility index; CT: Computed tomography; pSO2: peripheral oxygen saturation; SD: Standard deviation.

sured by either US or CT (Table 2). The highest statistically significant correlation coefficient was 0.28, which was poor.

Both median dIVCe (16 vs. 17 mm, p=0.0890) and dAorta (16 vs. 16 mm, p=0.1926) were similar between US and CT measurements. Blandâ&#x20AC;&#x201C;Altman analysis of the measurements is shown in Figures 1 and 2. Correlational analysis was in accordance with the findings; a good and significant correlation was observed between dAorta (r=0.73) and dIVC (r=0.71) measured by US and CT (Table 3).

When we compared the patients with a flat IVC on US examination with patients with normal IVC, we found SBP to be significantly lower (Table 1). However, no significant differences were found for other markers and vital signs.

354

When we compared the patients according to SI, we found high risk patients to have significantly lower dIVCe and dIVCCT (Table 4). In fact, all US- and CT-derived measurements were lower in high-risk SI group; however, statistical significance was not reached for most of them (Table 4).

DISCUSSION In this study, we found that the correlation of dIVC, dAorta, IVC-CI, IVC-DI, and dIVC/dAorta index with any of the vital signs or laboratory values of hemorrhage and shock (Hg, Hct, Lactate, BE) were poor. In a recent study, Juhl-Olsen et al.[18] measured dIVCe, dIVCi, and IVC-CI before and after 480 mL of blood donation in 37 healthy volunteers, and they found no Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Çelik et al. Utility of IVC and aorta measurements in trauma

Table 2. Correlational analysis of US- and CT-derived measurements with initial vital signs and laboratory values

Hemoglobin

Hematocrite

SBP

DBP

MAP

Heart rate

Lactate

BE

Ultrasonography dIVCe

0.061

0.089

0.303 0.114 0.210

-0.071

0.057 -0.107

dIVCi

-0.036

0.008

0.278 0.112 0.204

-0.011

0.059 -0.096

dAorta

0.073

0.078

0.107 0.080 0.103

-0.106

-0.089 0.050

dIVC/dA

-0.018

0.006

0.261 0.073 0.169

-0.043

0.030 -0.046

dIVC-CI

0.134

0.091

-0.123 -0.047 -0.087

0.006

-0.015 0.035

dIVC-DI

0.134

0.091

-0.123 -0.047 -0.087

0.006

-0.015 0.035

Computed tomography dIVC

0.115

0.144

0.280 0.160 0.226

-0.035

0.152 -0.028

dAorta

0.178

0.183

0.184 0.238 0.256

-0.099

-0.038 -0.025

dIVC/dA

-0.014

0.011

0.121 0.008 0.048

0

0.139 -0.021

Spearman’s rank correlation test was performed. Bold values indicate statistically significant correlations, p<0.05. SBP: Systolic blood pressure; DBP: Diastolic blood pressure; MAP: Mean arterial pressure; BE: Base excess; dIVC: Inferior vena cava diameter; dIVCe: Inferior vena cava diameter during expiration; dIVCi: Inferior vena cava diameter during inspiration; dAorta: Aortic diameter; CI: Collapsibility; DI: Distensibility.

Table 3. Correlational analysis of US- and CT-derived measurements

dIVCe-Ultrasonography

dIVC-Computed tomography

Correlation coefficient

p

0.714

<0.0001

dIVCe-Ultrasonography dAorta-Ultrasonography

0.355 <0.0001

dIVCe-Ultrasonography

dAorta-Computed tomography

0.359

<0.0001

dIVC-Computed tomography

dAorta-Computed tomography

0.271

0.0012

dAorta-Ultrasonography

dAorta-Computed tomography

0.732

<0.0001

dIVCe/dAorta (Ultrasonography)

dIVC/dAorta (Computed tomography)

0.583

<0.0001

Spearman’s rank correlation test was performed. dIVCe: Inferior vena cava diameter during expiration; dIVC: Inferior vena cava diameter; dAorta: Aortic diameter; US: Ultrasonography; CT: Computed tomography.

correlation between dIVCe, dIVCi, IVC-CI and cardiac output (CO) measurements. They claimed that IVC-CI and dIVCe did not correlate with the hemodynamic response generated by early hemorrhage. Sabaghian et al.[23] studied the correlation between US dIVC, IVC-CI, and IVC-DI measurements and total (TBW) and extracellular (ECW) water content measured by bio-impedence analysis in patients with chronic HD before and after HD. They found the highest correlation coefficient to be 0.27, which was also poor and almost similar to our findings. In another study, IVC-CI, IVC-DI, and dIVC/ dAorta index failed to reliably predict fluid responsiveness in cardiac surgery patients.[19] Considering these studies and our findings, one may think rather than a single and baseline measurement of an dIVC or any parameter derived from it, the change in serial measurements may be a better estimate.

Indeed, Lyon et al.[11] observed a 5-mm decrease in dIVC after 450 cc of blood loss in a similar healthy blood donor cohort of 31 volunteers and claimed dIVC as a reliable indicator of blood loss. On the contrary, in a study performed on healthy blood donors, Resnick et al.[17] failed to demonstrate a clinUlus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

ically significant change in dIVCe, dIVCi, and IVC-CI after blood donation. Dipti et al.[24] performed a meta-analysis of studies comparing dIVCe between shock vs. non-shock states and reported a mean difference of 6.26 mm, which was significant. The value of defining a single standard range as normal for everyone was questioned as well. In a study of adult hemodialysis patients, Cheriex et al.[5] proposed the optimal values of IVC diameter relative to BSA (8 to 11.5 mm/m2), which is hard to accurately and practically obtain. To overcome this problem, Kosiak et al.[15] introduced dIVC/dAorta index as a promising relative measurement parameter. Several other studies showed a significant relationship between dIVC/dAorta index and CVP; unfortunately, the value of CVP as a good surrogate marker of fluid status was recently questioned.[25,26] In more recent studies, dIVC/dAorta index was shown to have a low predictive value and more susceptible to patient characteristics than IVC.[19,27–29] In this study, we classified patients according to their SI at admission as low and high risk, and we found the differences in dIVCe and dIVCCT to be statistically significant, and dAorta-US and CT at 355

Ă&#x2021;elik et al. Utility of IVC and aorta measurements in trauma

Table 4. Demographic and clinical characteristics of the study population according to shock index

Shock index

Demographics

Age (years), median (IQR)

Shock index â&#x2030;¤0.9 (n=123)

Shock index >0.9 (n=17)

p*

38

38

0.6368

Male, n (%) Vital signs, median (IQR)

Systolic blood pressure (mmHg)

129

104

<0.0001

Diastolic blood pressure (mmHg)

80

70

<0.0001

Mean arterial pressure (mmHg)

96

81

<0.0001

Heart rate (bpm)

87

106

<0.0001

Temperature (C)

36.7

36.6

0.2788

Respiratory rate (/min)

16

16

0.2344

98

99

0.2443

0.69

0.98

<0.0001

pSO2 (%)

Shock index

Laboratory values

Hemoglobin (g/dL), mean (SD)

13.9

12.8

0.0884

Hematocrit (%/mm3), mean (SD)

42.0

39.2

0.0720

Lactate (mmol/L), median (IQR) (n=69)

2.2

2.6

0.2101

Base excess (mEq/L), median (IQR) (n=68)

0.65

-1.00

0.3542

Ultrasonography measurements and indexes, median (IQR)

dIVCe (mm)

16

15

0.0386

dIVCi (mm)

8

7

0.2607

dAorta (mm)

16

15

0.0568

IVC-CI (%)

47.4

45.0

0.8782

IVC-DI (%)

90.0

81.8

0.8782

1.00

0.89

0.0964

dIVCe/dAorta

CT measurements and Indexes, median (IQR)

dIVC-CT (mm)

17

15

0.0080

dAorta-CT (mm)

17

16

0.0611

dIVC/dAorta-CT

1.00

0.89

0.1280

*Mann-Whitney U test. IVC: Inferior vena cava; IQR: Interquartile ranges; dIVCe: Inferior vena cava diameter during expiration; dIVCi: Inferior vena cava diameter during inspiration; dAorta: Aortic diameter; IVC-CI: Inferior vena cava-collapsibility index; IVC-DI: Inferior vena cava-distensibility index; CT: Computed tomography; pSO2: Peripheral oxygen saturation; SD: Standard deviation.

significance margin. However, the correlation between these parameters and biomarkers of hemorrhage and shock was low. It seems from the literature and our findings that there is a slight relationship between dIVC, dAorta, and shock state.

However, we still do not have clearly defined reference values of dIVC, dAorta, or relative parameters for pediatric and adult patients, and the predictive value of a single measurement at admission is low. Despite the significant difference, the difference in dIVCe was just 1 mm when patients were grouped according to SI; therefore, this difference cannot be regarded as clinically important.

We found that diameters measured by US and CT were highly correlated. Knaut el al.[30] compared dAorta by US and CT in 356

a double-blinded, prospective study of 104 patients and concluded that the measurements were highly correlated, similar to our findings. Therefore, the change in relative parameters such as dIVC/dAorta index theoretically may have more value in predicting hemorrhage or shock state. However, we were unable to show a significant difference in patients according to SI. Further studies are needed to investigate the value of this parameter relative to a more objective standard, such as stroke volume or CO.

Limitations As in all studies involving human measurements, there was a slight chance of measurement error. However, to minimize Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Çelik et al. Utility of IVC and aorta measurements in trauma

this, all measurements were performed thrice and the mean of those measurements was used for the final analysis. In this study, unstable patients were excluded. This may have hampered to identify significant differences in diameters according to shock state.

Conclusion dIVC and dAorta measured at the time of ED admission by US or CT and the parameters derived from them were not correlated with blood pressure, heart rate, hemoglobin, and hematocrit, lactate or base excess levels in nonintubated, undifferentiated, adult trauma patients. Therefore, the value of an initial and single measurement of those parameters in the evaluation of trauma patients should be questioned. However, the change in the relative parameters may still be of value and should be investigated in further studies.

Conflict of interest: None declared.

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27. Modi P, Glavis-Bloom J, Nasrin S, Guy A, Chowa EP, Dvor N, et al. Accuracy of Inferior Vena Cava Ultrasound for Predicting Dehydration in Children with Acute Diarrhea in Resource-Limited Settings. PLoS One 2016;11:e0146859.

28. Gui J, Guo J, Nong F, Jiang D, Xu A, Yang F, et al. Impact of individual characteristics on sonographic IVC diameter and the IVC diameter/ aorta diameter index. Am J Emerg Med 2015;33:1602–5.

29. Ng L, Khine H, Taragin BH, Avner JR, Ushay M, Nunez D. Does bedside sonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in children? Pediatr Emerg Care 2013;29:337–41.

30. Knaut AL, Kendall JL, Patten R, Ray C. Ultrasonographic measurement of aortic diameter by emergency physicians approximates results obtained by computed tomography. J Emerg Med 2005;28:119–26.

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Çelik et al. Utility of IVC and aorta measurements in trauma

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Ultrason ve bilgisayarlı tomografi ile travma hastalarının başvurusu esnasında ölçülen inferiyor vena kava ve aort çap parametreleri yaşamsal bulgular, kanama ve şok belirteçleri ile korele değildir Dr. Ömer Faruk Çelik,1 Dr. Haldun Akoğlu,2 Dr. Ali Çelik,2 Dr. Ruslan Asadov,3 Dr. Özge Ecmel Onur,2 Dr. Arzu Denizbaşı2 1 2 3

Cizre Devlet Hastanesi, Acil Tıp Kliniği, Şırnak Marmara Üniversitesi Pendik Eğitim ve Araştırma Hastanesi, Acil Tıp Anabilim Dalı, İstanbul Marmara Üniversitesi Pendik Eğitim ve Araştırma Hastanesi, Radyoloji Anabilim Dalı, İstanbul

AMAÇ: Ultrason (US) invaziv olmayan, kolaylıkla erişilebilir ve ucuz bir yöntemdir. İnferiyor vena kava (IVC) çapı ve solunumsal değişkenliği hemodinamik durumun iyi bir göstergesi olarak bildirilmiştir. Ancak, IVC temelli parametrelerin sıvı ve kanama durumunu belirleme gücü yönünden son çalışmalar birbiriyle tutarsızdır.

GEREÇ VE YÖNTEM: Bu acil servise başvuran hastalarda gerçekleştirilen gözlemsel bir çalışmadır. IVC ve aorta çapları hastaların ilk başvurusunda US ve bilgisayarlı tomografi (BT) ile ölçülmüştür. Bu ölçümlerin ve bu ölçümlerden köken alan parametrelerin ilk yaşamsal bulgular ile kanama ve şokun laboratuvar belirteçleriyle korelasyonu değerlendirilmiştir. Ayrıca US ve BT ölçümlerinin tutarlılığı Bland-Altman analiziyle incelenmiştir.

BULGULAR: Çalışmanın son örneklemi 140 hasta olup, ortalama yaş 38 yıl, erkek oranı %79.3’dür. İnferiyor vena kava ve aorta çapları yaşamsal bulgular ile kanama ve şok belirteçleri ile, US ya da BT ile ölçülmesinden bağımsız şekilde klinik olarak anlamlı bir korelasyonu tespit edilmemiştir.

Ultrason ve BT ile ölçülen IVC çaplarının birbiri ike tutarlılığı ve korelasyonu yüksektir.

TARTIŞMA: Travma hastalarının değerlendirmesinde tek sefer ve ilk başvuruda ölçülen IVC ve aort parametrelerinin değeri sorgulanmalıdır. Ancak, takip esnasında bu parametrelerdeki değişimin değeri yapılacak ilerki çalışmalarda yeniden değerlendirilmelidir.

Anahtar sözcükler: Aort; inferiyor vena kava; şok; travma.

Ulus Travma Acil Cerrahi Derg 2018;24(4):351-358

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doi: 10.5505/tjtes.2017.72365

Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

ORIGIN A L A R T IC L E

Comparison of the functional results of radial head resection and prosthesis for irreparable mason type-III fracture Mehmet Can Ünlü, M.D.,1 Mehmet Fatih Güven, M.D.,1 Lercan Arslan, M.D.,1 Önder Aydıngöz, M.D.,1 Mustafa Gökhan Bilgili, M.D.,2 Alkan Bayrak, M.D.,2 Muharrem Babacan, M.D.,1 Gökhan Kaynak, M.D.,1 Hüseyin Botanlıoğlu, M.D.1 1

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

2

Department of Orthopaedics and Traumatology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: The radial head is essential for the rotational stability of the forearm and resistance to valgus stress. Radial head fractures are the most common elbow fracture in adults. Various treatment options are available, depending on the fracture severity.

However, the treatment of Type-III fractures is controversial. The aim of this study was to evaluate functional results in patients with irreparable Mason Type-III radial head fractures treated with radial head resection or prosthesis.

METHODS: Fourteen irreparable Mason Type-III radial head fracture patients treated with radial head resection (n=7) or radial head prosthesis (n=7) were evaluated in this multicenter, retrospective study. Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Elbow and Wrist scores were used to determine clinical outcomes. A hydraulic hand dynamometer was used to measure grip strength on the operated and unoperated sides to avoid potential bias. Measurements were made three times for each extremity, and the mean value was recorded. Grip strength was calculated as a percentage of the strength of the unoperated side.

RESULTS: Functional outcomes for resection and prosthesis patients were the following: mean DASH scores, 25.8 and 17.2; mean Mayo Elbow scores, 74 and 84.1; mean Mayo Wrist scores, 84 and 92.5; and maximum grip strengths, 48.8% and 77.8%, respectively. The range of motion of the respective resection and prosthesis groups were as follows: flexion, 112.14° and 104.29°; extension, −10.00° and −25.00°; pronation, 70.00° and 47.86°; and supination, 70.00° and 52.14°.

CONCLUSION: Although range of motion was restricted in the radial head resection group, functional results and grip strength were superior in patients treated with a radial head prosthesis. These results support the radial head prosthesis as a superior treatment modality for patients with irreparable Mason Type-III radial head fractures with respect to patient satisfaction and functional outcomes.

Keywords: Arthroplasty; fracture; prosthesis; radial head; resection.

INTRODUCTION Radial head fracture is the most frequently diagnosed fracture of the elbow in adults.[1,2] The radial head is crucial for elbow biomechanics and, in particular, resistance to valgus stress and the rotational stability of the forearm.[3,4] Therefore, restoration of elbow biomechanics is essential for acceptable func-

tional results in radial head fractures. Various treatment options are available, depending on fracture severity.[5,6] Although biological treatment modalities, such as conservative methods and open reduction and internal fixation, are first-choice treatments,[7] especially for Mason Type-III fractures, the optimum treatment method remains controversial.[5,6] Results of radial head resection (RHR)[8,9] and radial head prosthesis

Cite this article as: Ünlü MC, Botanlıoğlu H, Güven MF, Arslan L, Aydıngöz Ö, Bilgili MG, et al. Comparison of the functional results of radial head resection and prosthesis for irreparable mason type-III fracture. Ulus Travma Acil Cerrahi Derg 2018;24:359-363.

Address for correspondence: Hüseyin Botanlıoğlu, M.D. İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Turkey Tel: +90 212 - 414 30 00 E-mail: huseyinbotanlioglu@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(4):359-363 DOI: 10.5505/tjtes.2017.97682 Submitted: 08.08.2017 Accepted: 21.09.2017 Online: 23.10.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Ünlü et al. Comparison of the functional results of radial head resection and prosthesis for irreparable mason type-III fracture

(RHP)[10–12] for radial head fractures have been presented in the literature, but relevant data remain limited. The main objective of this study was to compare these two treatment modalities in terms of the clinical outcomes and grip strength of patients with irreparable Mason Type-III radial head fractures.

MATERIALS AND METHODS In this retrospective comparative study, patients with an isolated radial head fracture who were surgically treated with either RHR or RHP in two different clinics and by two different surgeons between 2008 and 2013 were evaluated. Patients with RHR and RHP were evaluated clinically and radiographically. Fractures were classified according to the Mason classification system,[13] and only Type-III fractures were included (Fig. 1). Patients with additional bone damage, neurological deficit, or instability at the time of diagnosis or with prior upper-extremity trauma anamnesis were excluded. Fourteen patients matched the criteria and were divided into two groups: those in Group I were treated with RHR, and those in Group II were treated with RHP. Interposition arthroplasty was not performed on patients in Group I. Each group consisted of seven (five males and two females in Group I, four males and three females in Group II) patients. In Group I, the mean age at the time of the operation was 42.5 years. Two patients were left hand dominant and five were left hand dominant. The right elbow was affected in two patients, and the left elbow was affected in five patients, with the dominant limb being affected in two patients. The mean follow-up duration was 31.1 months.

In Group II, the mean age at the time of the operation was 49 years. One patient was left hand dominant and six were left hand dominant. The right elbow was affected in three patients, and the left elbow was affected in four patients, with the dominant limb being affected in three patients. The mean follow-up duration was 28.2 months. All patients were initially immobilized in a long-arm splint at 90° of elbow flexion with neutral rotation during the postoperative period. In all cases, motion was initiated within 7–10 days.

All surgical procedures were performed by two different surgeons, and all patients were evaluated clinically and ra-

(a)

(b)

Figure 1. Anteroposterior (a) and lateral (b) X-ray images of a patient with Mason Type-III radial head fracture.

360

diographically at the end of the follow-up period. The range of motion of the elbow and forearm were measured using a goniometer, and the values were compared with those of the uninjured side. The Disabilities of the Arm, Shoulder and Hand (DASH),[14] Mayo Wrist,[15] and Oxford Elbow[16] scoring systems were used to evaluate the functional status. The maximum grip strength of each patient was assessed with the Jamar hydraulic hand dynamometer (JAMAR® Plus+ Digital Hand Dynamometer; Patterson Medical/Sammons Preston, Bolingbrook, IL, USA), which is recommended by the American Hand Therapist Society.[17] For measurements, the patients were in a comfortable sitting position with the arm at abduction and neutral rotation, the elbow flexed at 90°, and the wrist in a neutral position. Grip strength was measured with the forearm in supination, pronation, and a neutral position; three measurements were taken for each position (Fig. 2). The mean value was determined, which was measured in pounds (lbf).[18] Assessment was also performed on the unaffected side using the same method. An adjustment was made for right-handed patients in terms of their dominant hand.

The difference between the dominant and nondominant sides was considered to be 10% for right-handed patients; for lefthanded patients, the difference in hand dominance was ignored.[19,20] Anteroposterior and lateral X-rays were used for radiological assessment at the end of the follow-up period.

Congruency of the elbow joint surface, proximal medial shift of the radius, and degenerative changes (subchondral sclerosis, joint space narrowing, etc.) were evaluated.

Statistical analysis was performed by the NCSS 2007 statistical software (Number Cruncher Statistical System, UT, USA).

The Mann–Whitney U-Test, Fisher’s exact test, and the Wilcoxon test were used for comparing groups, evaluating qualitative data, and comparing affected and unaffected sides as well as for descriptive statistics, including means and standard deviations. A p-value of <0.05 was considered to indicate statistical significance.

RESULTS In Group I, the mean DASH, Oxford Elbow, and Mayo Wrist

(a)

(b)

(c)

Figure 2. Hand grip strength of patients was measured with a hydraulic hand dynamometer (JAMAR® Plus+) in pronation (a), supination (b), and a neutral position (c). Patients were placed in a relaxed sitting position with 90° of elbow flexion.

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Ünlü et al. Comparison of the functional results of radial head resection and prosthesis for irreparable mason type-III fracture

(a)

(b)

Table 1. Demographic characteristics and functional results of our study including statistical analysis

Age (years)

RA group

RHP group

p

42.5

49

0.125

Gender Male

5

4

Female

2

3

0.557

Side

(c)

(d)

Left

5

4

Right

2

3

Follow-up (months)

0.557

31

28

0.222

25.8

19.9

0.798

Oxford Elbow score

32

40

0.334

Mayo Wrist score

84

94

0.209

DASH score

RA: Resection arthroplasty; RHP: Radial head prosthesis; p: P-value <0.05. No statistically significant difference between two groups in terms of functional results.

Figure 3. Postoperative X-ray images of patients treated with radial head resection (a, b) and radial head prosthesis (c, d). In patients treated with radial head resection, medial radial shift was observed in anteroposterior X-ray images.

scores were 25.84, 32.43, and 84.29, respectively (Table 1). At the final examination, the mean values for flexion, extension, pronation, and supination were 112.14, −10.00, 70.00, and 70.00, respectively, on the affected sides of patients treated with RHR (Table 2). In Group II, the mean DASH, Oxford Elbow, and Mayo Wrist scores were 19.91, 40.29, and 94.29, respectively. At the end of the follow-up period, the mean values for flexion, extension, pronation, and supination were 104.29, −25.00, 47.86, and 52.14, respectively, on the affected sides of patients treated with RHP. No instability was detected on the last physical examination of each group.

Table 2. Range of motion and hand grip strength results of our study including statistical analysis. Extension is significantly restricted in Group II. The difference between two groups in terms of grip strength is not statistically significant

RA (Group 1)

RHP (Group 2)

p

ROM flexion AS

112.14±10.75 104.29±5.35 0.054

NAS

127.86±6.99

127.86±6.99

0.041

0.016

P

1

ROM extansion -10±8.66

-25±9.57

0.014

Considering radiological assessment, proximal medial radial shift was observed in all patients treated with RHR (Figure 3). No sign of heterotopic ossification was observed in either group, and no signs of implant loosening were recorded in Group II. Subchondral sclerosis and joint space narrowing were identified in one patient in each group.

NAS

0±.0

0±.0

1

p

0.042

0.018

Comparing the two groups, the difference in terms of flexion and grip strength did not reach significance, but extension was restricted in Group II (p=0.014). In addition, there were no significant differences between the unaffected sides of each group with respect to flexion and extension. Analysis between affected and unaffected sides showed that flexion and extension were negatively affected in both the groups (p<0.05). Moreover, in Group I, grip strength was negatively affected in all positions; however, grip strength was decreased in only the neutral position in Group II (Table 2).

GS-pronation

No wound infection, sepsis, or neurovascular compromise was observed in the study patients. Moreover, no postoperUlus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

AS

GS-neutral AS

41.89±27.58

58.19±16.72 0.225

NAS

75.16±9.28

70.66±15.31 0.225

p

0.018

0.028

AS

41.09±21.76

52.36±13.77 0.180

NAS

62.36±8.15

62.14±17.33 0.565

p

0.018

0.091

AS

44.41±24.87

54.4±15.76

0.277

NAS

70.49±6.41

64.06±4.89

0.064

0.018

0.176

GS-supination

p

RA: Resection arthroplasty, RHP: Radial head prosthesis; ROM: Range of motion; GS: Grip strength; AS: Affected side; NAS: Nonaffected side; p: p-value <0.05.

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Ünlü et al. Comparison of the functional results of radial head resection and prosthesis for irreparable mason type-III fracture

ative ligamentous instability or posterior interosseous nerve injury was observed.

DISCUSSION Biological methods are first-choice treatments for isolated Mason Type-III fractures but are considered controversial in the treatment of fractures with ≥3 fragments.[21] A meta-analysis of the treatment of Mason Type-III fractures favored the outcomes of RHP over those of osteosynthesis.[22] RHR and RHP are the preferred treatment choices for irreparable Mason Type-III fractures.[7,23] However, conflicting results have been reported in the literature regarding both treatment modalities. Moreover, studies comparing the outcomes of RHR and RHP are limited.

In our study, loss of grip strength and motion were observed in patients treated with RHR, which was compatible with the literature. However, we did not encounter complications such as elbow instability, neuropathy, and proximal radioulnar synostosis because fractures with associated injuries were specifically excluded from our study. Our results are supported by a study conducted by Karlsson et al.[8] that evaluated isolated comminuted radial head fractures; this study found that the mean range of motion deficit in the elbow was 5°–10°. In addition, good to excellent results according to the Mayo Elbow Performance Index were reported by Antuña et al.[9] in a review of 26 patients treated with primary radial head excision who were followed up for a minimum of 15 years. However, Swanson et al.[24] presented a clear sequence of events when a loss of radiocapitellar contact resulted in lateral elbow instability, arthritis, loss of strength and motion, and ulnar nerve symptoms. In terms of RHR, it has been reported that 55% patients encountered restrictions in their daily life, and 36% experienced limitations at work.[25] Herbertsson et al.[26] suggested that, if the initial attempt to save the radial head caused unfavorable results, a delayed excision may be performed.

Radial head arthroplasty is indicated for the management of comminuted displaced radial head fractures when stable internal fixation is unachievable or in cases of instability following radial head excision, malunion, and nonunion. In our study, satisfactory functional and clinical results were achieved in patients treated with RHP with no signs of implant loosening or instability. These outcomes were supported by Harrington et al.,[11] who presented the results of the long-term followup of 20 patients treated with RHP; use of a prosthesis was advocated when the radial head could not be reconstructed to restore the stability of the elbow and forearm. Moreover, Zunkiewicz et al.[12] reported the results of 29 patients with a mean follow-up period of 34 months. Satisfactory functional scores, with a Mayo Elbow Performance Index score of 92 and an acceptable level of complications, were noted. The outcomes of patients with acute traumatic elbow instability treated with RHP were presented in a study that included 27 patients. In that study, 22 patients had good or excellent 362

results according to the Mayo Elbow Performance Index.

Unlike our evaluation, complications including stem loosening, component failure, instability, infection, dislocation, and arthritis were reported.[27] Another complication difference was reported by Flinkkilä et al.,[28] who reviewed the results of press-fit RHP in 37 patients with a mean follow-up of 50 months. One-third of their patients had early symptomatic loosening, which necessitated implant removal in nine patients. In addition, Lópiz et al.[10] reported the mid-term follow-up of RHR and RHP patients. Their functional results were better for RHP; however, with a higher complication rate, a greater number of patients required revision surgeries, thus lowering their mean functional status. The longer followup duration and older patient age compared to our study may be one reason for the revision surgeries and may have contributed to the lower functional scores.

Hand grip strength is crucial for performing the activities of daily life and for good functional results.[29] Research comparing the functional and grip strength results of RHP and RHR in the treatment of Mason Type-III radial head fractures is limited. In our study, the mean functional score and grip strength results were superior in patients treated with RHP, but this difference did not reach significance, which may be attributable to our small number of patients. Analysis showed that extension was significantly restricted in the RHP group.

Most importantly, in Group I, decreased grip strength was observed in all positions of the forearm. However, this decrease was limited to only the neutral position in Group II. The limitations of our study are its retrospective design, including patients treated at two different clinics by two different surgeons, and its small sample size. Studies with more patients and a longer follow-up period are necessary for more conclusive results.

Conclusion Patients with irreparable Mason Type-III radial head fractures who require excellent hand grip strength are excellent candidates for RHP. However, RHR is easy to perform and is a good treatment choice for patients with isolated Mason Type-III radial head fractures who wish to reclaim their ability to perform the activities of daily life at the cost of grip strength.

Conflict of interest: None declared.

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8. Karlsson MK, Herbertsson P, Nordqvist A, Hasserius R, Besjakov J, Josefsson PO. Long-term outcome of displaced radial neck fractures in adulthood: 16-21 year follow-up of 5 patients treated with radial head excision. Acta Orthop 2009;80:368–70.

9. Antuña SA, Sánchez-Márquez JM, Barco R. Long-term results of radial head resection following isolated radial head fractures in patients younger than forty years old. J Bone Joint Surg Am 2010;92:558–66.

10. Lópiz Y, González A, García-Fernández C, García-Coiradas J, Marco F. Comminuted fractures of the radial head: resection or prosthesis? Injury 2016 Sep;47 Suppl 3:S29–34.

11. Harrington IJ, Sekyi-Otu A, Barrington TW, Evans DC, Tuli V. The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review. J Trauma 2001;50:46–52.

12. Zunkiewicz MR, Clemente JS, Miller MC, Baratz ME, Wysocki RW, Cohen MS. Radial head replacement with a bipolar system: a minimum 2-year follow-up. J Shoulder Elbow Surg 2012;21:98–104.

13. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg 1954;42:123–32.

14. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29:602–8.

15. MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient rating of wrist pain and disability: a reliable and valid measurement tool.

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16. The B, Reininga IH, El Moumni M, Eygendaal D. Elbow-specific clinical rating systems: extent of established validity, reliability, and responsive-

ness. J Shoulder Elbow Surg 2013;22:1380–94.

17. Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of grip and pinch strength evaluations. J Hand Surg Am 1984;9:222–6.

18. Haidar SG, Kumar D, Bassi RS, Deshmukh SC. Average versus maximum grip strength: which is more consistent? J Hand Surg Br 2004;29:82–4.

19. Petersen P, Petrick M, Connor H, Conklin D. Grip strength and hand dominance: challenging the 10% rule. Am J Occup Ther. 1989;43:444–7.

20. Armstrong CA, Oldham JA. A comparison of dominant and non-dominant hand strengths. J Hand Surg Br 1999;24:421–5.

21. Ring D. Displaced, unstable fractures of the radial head: fixation vs. replacement--what is the evidence? Injury 2008;39:1329–37.

22. Dou Q, Yin Z, Sun L, Feng X. Prosthesis replacement in Mason III radial head fractures: A meta-analysis. Orthop Traumatol Surg Res 2015;101:729–34.

23. Iftimie PP, Calmet Garcia J, de Loyola Garcia Forcada I, Gonzalez Pedrouzo JE,Giné Gomà J. Resection arthroplasty for radial head fractures: Long-term follow-up. J Shoulder Elbow Surg. 2011;20:45–50.

24. Swanson AB, Jaeger SH, La Rochelle D. Comminuted fractures of the radial head. The role of silicone-implant replacement arthroplasty. J Bone Joint Surg Am 1981;63:1039–49.

25. Fuchs S, Chylarecki C. Do functional deficits result from radial head resection? J Shoulder Elbow Surg 1999;8:247–51.

26. Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F, Karlsson MK. Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg Am 2004;86–A:1925–30.

27. Doornberg JN, Parisien R, van Duijn PJ, Ring D. Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg Am 2007;89:1075–80.

28. Flinkkilä T, Kaisto T, Sirniö K, Hyvönen P, Leppilahti J. Short- to midterm results of metallic press-fit radial head arthroplasty in unstable injuries of the elbow. J Bone Joint Surg Br 2012;94:805–10.

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2005;35:605–18.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Mason tip III parçalı radius başı kırıklarında rezeksiyon ve protez uygulamalarının fonksiyonel sonuçlarının karşılaştırılması Dr. Mehmet Can Ünlü,1 Dr. Mehmet Fatih Güven,1 Dr. Lercan Arslan,1 Dr. Önder Aydıngöz,1 Dr. Mustafa Gökhan Bilgili,2 Dr. Alkan Bayrak,2 Dr. Muharrem Babacan,1 Dr. Gökhan Kaynak,1 Dr. Hüseyin Botanlıoğlu1 1 2

İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Ortopedi ve Tavmatoloji Anabilim Dalı, İstanbul Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul

AMAÇ: Radius başı ön kol rotasyonel stabilitesi ve dirsek valgus stresine dayanma açısından önemlidir. Radius başı erişkinlerdeki en sık dirsek kırığıdır. Kırığın derecesine göre farklı tedavi yöntemleri tanımlanmıştır. Bununla birlikte, tip III kırıkların tedavisi tartışmalıdır. Bu çalışmanın amacı ileri derecede parçalı Mason tip III radius başı kırıklarının baş rezeksiyonu veya protez ile tedavi sonuçlarının araştırılmasıdır.

GEREÇ VE YÖNTEM: Radius başı rezeksiyonu (n=7) veya radius başı protezi (n=7) ile tedavi edilmiş parçalı Mason tip III kırığı çok merkezli ve geriye dönük olarak değerlendirildi. Klinik sonuçları değerlendirmede DASH (Disabilities of the Arm, Shoulder and Hand) ve Mayo dirsek-el bileği skorları kullanıldı. Kavrama kuvvetini değerlendirmede hidrolik el dinomometresi kullanıldı; kavrama kuvveti her iki taraf ekstremite için üçer kez tekrarlanıp ortalaması alındı. Kavrama kuvveti sağlam tarafa göre yüzde olarak hesaplandı.

BULGULAR: Rezeksiyon ve protez yapılan hastalarda ortalama fonksiyonel sonuçlar sırası ile DASH skoru için 25.8 ve 17.2; Mayo dirsek skoru için 74 ve 84.1; Mayo el bileği skoru için 84 ve 92.5 bulundu. Maksimum kavrama kuvvetleri ise rezeksiyon grubu için %48.8, protez grubu için ise %77.8 oldu. Ortalama eklem hareket açıklığı rezeksiyon ve protez yapılan gruplarda sırası ile fleksiyon, 112.14° ve 104.29°; ekstansiyon -10.00° ve -25.00°; pronasyon, 70.00° ve 47.86°; supinasyon, 70.00° ve 52.14° bulundu.

TARTIŞMA: Radius başı rezeksiyonu yapılan hastalarda eklem hareket açıklığı kısıtlanmış bununla beraber fonksiyonel sonuçlar ve kavrama kuvveti radius protezi ile tedavi edilen hastalarda daha iyi olmuştur. Bu sonuçlar ileri derecede parçalı Mason tip III radius başı kırıklarının tedavisinde radius başı protezi uygulamasının hasta memnuniyeti ve fonksiyonel sonuçlar açısından rezeksiyona göre daha iyi olduğunu desteklemektedir.

Anahtar sözcükler: Artroplasti; kırık; protez; radius başı; rezeksiyon.

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CA S E SERI ES

Reconstruction of extensive scalp defects with anterolateral thigh flap Altuğ Altınkaya, M.D.,1

Şükrü Yazar, M.D.,1

İbrahim Sağlam, M.D.,2

Kaan Gideroğlu, M.D.3

Department of Plastic, Reconstructive and Aesthetic Surgery, Acıbadem Mehmet Ali Aydınlar University, Acıbadem Maslak Hospital, İstanbul-Turkey

1

2

Department of Plastic, Reconstructive and Aesthetic Surgery, Harran University, Training and Research Hospital, Şanlıurfa-Turkey

3

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

ABSTRACT BACKGROUND: Extensive scalp defects caused by various etiologies often require free-tissue transfer. We aimed to review our experience in the reconstruction of extensive scalp defects with free anterolateral flaps.

METHODS: A retrospective analysis was performed on all patients with extensive scalp defects that were reconstructed with free anterolateral thigh flaps from November 2007 to April 2015. Eleven patients with a mean age of 44 years were included in this study.

RESULTS: Eleven free-tissue transfers were used to reconstruct the extensive scalp defects. The flaps were 7–14 cm in width and 10–34 cm in length.

CONCLUSION: Microvascular free-tissue transfer is the mainstay for the treatment of extensive scalp defects. We recommend anterolateral thigh free flap use for challenging and complex cases, given the method’s numerous advantages, including reliability and safety.

Keywords: Anterolateral thigh flap; free flap; scalp.

INTRODUCTION Scalp defects can occur secondary to traumatic injuries, infections, irradiation, or oncological resections.[1] However, there are many options for scalp reconstruction. For small defects, primary closure is the recommended approach. When primary closure is not attainable, skin grafting, tissue expansion, and the use of local or regional tissue flaps can be used as alternative methods.

The use of free flaps is the only treatment option for large scalp defects with associated impaired viability of the surrounding tissue such as heavy trauma, osteoradionecrosis, osteomyelitis, and previous local flap failure.[2] Numerous free flap sources have been described in the literature for scalp re-

construction, including the latissimus dorsi, rectus abdominis, serratus anterior, omentum, radial forearm, and anterolateral free flaps.[3] Each of these sources has advantages and disadvantages.

Omentum was the first free flap described in scalp reconstruction.[4] Its large surface area provides an advantage in the reconstruction of wide scalp defects. However, the laparotomy requirements for harvesting and secondary complications thereafter, such as adhesions, ileus, and ventral hernia, limit its usage.[5] The latissimus dorsi muscle can serve as a musculocutaneous or muscular flap in scalp reconstruction, given its large surface area and long vascular pedicle.[6,7] However, it has certain

Cite this article as: Altınkaya A, Yazar Ş, Sağlam İ, Gideroğlu K. Reconstruction of extensive scalp defects with anterolateral thigh flap. Ulus Travma Acil Cerrahi Derg 2018;24:364-368.

Address for correspondence: Altuğ Altınkaya, M.D. Acıbadem Maslak Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 304 21 43 E-mail: altugaltinkaya@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(4):364-368 DOI: 10.5505/tjtes.2018.94684 Submitted: 25.09.2017 Accepted: 16.04.2018 Online: 20.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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disadvantages that include the requirement of repositioning the patient intraoperatively to harvest the flap, an unnatural appearance of a skin island in the scalp, difficulty in clinical flap monitoring particularly for the muscle-only flaps, a lack of durability in split-thickness grafts, potential complications such as seroma and wound dehiscence in the donor area, and, finally, sacrification of a functional muscle.[8] The serratus anterior flap is another option for scalp reconstruction. The main limitation of this flap is its size. The combined use of the latissimus dorsi and serratus anterior flap has been reported for larger defects.[9–11] It is possible to transfer vascularized ribs with serratus anterior muscle as a composite flap, which is a useful option in the simultaneous reconstruction of soft tissue and cranium.[11] The rectus abdominis muscle or musculocutaneous flap can be used in medium-sized scalp defects. The musculocutaneous flap has a very thick skin island, and abdominal skin does not have adequate color harmony with scalp skin.[12,13] Complications such as weakness or a hernia in the abdominal wall have been reported with the use of this flap.[14] The radial forearm flap has thin, pliable skin and usually is a suitable option for scalp reconstruction. The major concerns regarding this flap involve sacrificing a major artery as well as donor area morbidity and size limitations.[15] The most suitable option for the reconstruction of extensive scalp defects is the anterolateral thigh free flap. The tissue can be harvested in large sizes, provides durable soft tissue, and allows single-stage reconstruction of the defect. Further, the donor area is in an aesthetically desirable region that can be easily hidden with clothing.[16,17]

This case series outlines our experiences using anterolateral thigh free flaps in extremely large or near-total scalp defects and discusses the advantages and disadvantages of this surgical approach.

MATERIALS AND METHODS We included 11 patients, and informed consent was obtained from all. All procedures performed in this study were in accordance with the ethical standards of the institutional national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Acıbadem Mehmet Ali Aydınlar University institutional review board approved this study protocol. The study period ranged from November 2007 to April 2015. All patients were treated with anterolateral thigh flaps for scalp reconstruction; patient data are summarized in Table 1. The patients’ ages ranged from 23 to 65 years; six patients were male and five were female. Malignant tumors (nine of 11), radionecrosis (one of 11), and an unstable scar (one of 11) comprised the defect etiologies of our study. The histologic diagnoses of the malignant tumors were malignant melanoma (four patients), malignant proliferating trichilemmal tumor (two patients), squamous cell carcinoma (two patients), and dermatofibrosarcoma protuberans (one patient).

The sizes of the flaps were 10–34 cm in length and 7–17 cm in width. In five patients, the flap vessels were anastomosed to the superior thyroid artery and a branch of the internal jugular vein; superficial temporal vessels were used in four patients and facial vessels in two.

RESULTS Eleven anterolateral thigh flaps were harvested. The donor

Table 1. A summary of patients’ data, including etiology, defect size, recipient vessel, and complications Patıent Gender Age Etiology No.

Defect Recipient Donor site size vessel repair

Complication

Follow up

1

Male

23

Squamous cell carcinoma

7x13

STA

Primary closure

None

Unremarkable

2

Female

51

Malignant melanoma

8x14

FA

Primary closure

None

Unremarkable

3

Female

56

Malignant proliferating

12x18

SThA

Skin graft

None

Unremarkable

trichilemmal tumor

4

Male

47

Squamous cell carcinoma

12x18

SThA

Skin graft

None

Unremarkable

5

Female

62

Malignant melanoma

12x23

STA

Primary closure

None

Unremarkable

6

Male

39

Radionecrosis

6x16

STA

Primary closure

Hematoma

Unremarkable

7

Male

37

Malignant melanoma

6x12

SThA

Primary closure

None

Unremarkable

8

Male

45

Dermatofibrosarcoma

9x13

STA

Primary closure

None

Unremarkable

protuberans 9

Female

24

Malignant melanoma

5x13

SThA

Primary closure

None

Unremarkable

10

Male

65

Malignant poliferating

15x32

SThA

Skin graft

None

Ex

8x10

FA

Primary closure

Haematoma

Ex

11

Female

39

trichilemmal tumor Unstable Scar

STA: Superficial temporal artery; FA: Facial artery; SThA: Superior thyroid artery.

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site was closed primarily in eight patients, whereas splitthickness skin grafting was necessary for three patients. Two patients had donor site hematomas on the second day; the hematomas were evacuated, and donor sites were closed primarily in the operating room. All flaps remained viable without complication. The mean follow-up was 36 months.

During the study period, one patient died because of local recurrence of a malignant proliferating trichilemmal tumor, and another patient died due to myocardial infarction in the early follow-up period. Table 1 summarizes the surgical and follow-up data.

Case 1 A 65-year-old male patient was referred to our clinic. He presented with a rapidly growing ulcerated mass in the scalp.

An excision with 2-cm intact skin margins was performed, and the defect was closed with skin graft. The pathological finding was malignant proliferating trichilemmal tumor. In 3 weeks, he had local recurrence (Fig. 1a), and radical resection of the tumor and bilateral neck dissection were performed.

The resultant scalp defect was 15 × 32 cm (Fig. 1b). An anterolateral thigh flap of 17 × 34 cm was harvested from the left thigh (Fig. 1c). The flap vessels were anastomosed to the

(a)

(b)

superior thyroidal artery and vein in an end-to-end manner.

The donor site was closed with a split-thickness graft. This patient had the most extensive scalp defect among our cases, and almost half of the thigh was harvested as an anterolateral thigh flap without any problems in flap circulation. During the follow-up period, healing progressed without complication (Fig. 1d). During the 4th month postoperatively, the patient died of local recurrence and distant metastasis.

Case 2 A 56-year-old female patient was admitted to our clinic with a nonhealing ulcerated mass in her occipital area (Fig. 2a).

On incisional biopsy, the mass was definitively identified as a malignant proliferating trichilemmal tumor. The lesion was excised with wide skin margins peripherally and deep margins down to and including the periosteum. The resultant defect was 12×18 cm (Fig. 2b). An anterolateral thigh flap of 14×20 cm was harvested from the right thigh. The superior thyroidal artery and vein were used for anastomosis. The donor site was closed with a split-thickness skin graft. The healing process was uneventful (Fig. 2c). The patient was followed-up for 1 year, and no evidence of local or regional recurrence was observed.

(d)

(c)

Figure 1. (a) Preoperative view of the scalp. (b) Scalp defect after excision. (c) Marking of the anterolateral thigh flap. (d) Final result at 15-day follow-up.

(a)

(b)

(c)

Figure 2. (a) Preoperative occipital view of a patient with an ulcerated mass on her scalp. (b) Defect after excision. (c) Postoperative view at 3-week follow-up showing the anterolateral thigh flap covering the entire defect.

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DISCUSSION In scalp reconstruction, primary closure is the preferred treatment approach for small scalp defects, and secondary healing is less frequently preferred. For larger defects wherein primary closure is not an option, skin grafting is a reliable method for closing the wound if sufficient vascularized tissue is present. However, this approach has certain disadvantages for patients such as skin color variation, contour irregularities, and alopecia.[18] Tissue expansion is a suitable option to avoid these disadvantages and reconstruct the scalp defect with hair-bearing tissue. Defects involving up to 50% of the total surface area of the scalp can be closed with this technique.[19] However, tissue expansion is an elective process, and it requires stable calvarial coverage, patient compliance, and an adequate amount of scalp tissue.[20] For patients who are not suitable candidates for tissue expansion, but need prompt wound closure, local flaps are a reliable option. These flaps are versatile and can be easily transposed, rotated, or advanced. Due to the inelastic property of the scalp tissue, only small- to moderate-sized uncomplicated scalp defects can be closed with local flaps. When the scalp tissue is not suitable for use as a local flap, regional flaps are the next option. The primary regional flaps used in scalp reconstruction are the latissimus dorsi, pectoralis major, trapezius, temporalis, and temporoparietal flaps. The major problem associated with the use of regional flaps is their limited arc of rotation; thus, regional flaps are only suitable for the closure of peripheral scalp defects.

Free-tissue transfer is the only surgical option if the defect size is too large and cannot be closed with locoregional flaps or if defects become complicated due to previous radiotherapy or unsuccessful surgical attempts.

The anterolateral thigh flap was first described in 1984 and was gradually popularized thereafter.[21] In this study, we used the anterolateral thigh free flap in all cases. The anterolateral thigh flap has a wide variability in size. It has been harvested as large as 33 cm × 14 cm and is suitable for the reconstruction of extremely large or near-total scalp defects in one stage.[22] Primary closure of the donor area can be utilized for up to 10-cm wide flaps; grafting is required for larger flaps.

The pedicle length is approximately 10–12 cm if the descendent branch is dissected where it emerges from the lateral circumflex artery and is sufficient to reach the ipsilateral neck for anastomosis without a vein graft.[23] We used neck vessels in five patients, and anastomoses were performed without the need for a vein graft. The anterolateral thigh flap is useful due to the pliable nature of the anterolateral thigh skin. In overweight or obese patients, the subcutaneous tissue of the flap can be thinned with special attention to perforator localization.[24] When harvested as a fasciocutaneous flap, none of the major arteries or muscles in the body is sacrificed. The vascularized vastus lateralis muscle or fascia lata can be simulUlus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

taneously harvested with the anterolateral thigh flap in cases of infection or dural defects to accelerate healing and prevent cerebrospinal fluid leakage.[25]

Conclusion For extensive scalp defects, free-tissue transfer is the only option. The surgical aim for these types of scalp defects is closing the defect with reliable and durable soft tissue in one step. The anterolateral thigh flap is the only tissue flap that meets these criteria because of its variability in size and suitability for the reconstruction of major defects, malleability, long and reliable vascular pedicle, two-team approach to operation, and low donor site morbidity.

Conflict of interest: None declared.

REFERENCES 1. Lutz BS, Wei FC, Chen HC, Lin CH, Wei CY. Reconstruction of scalp defects with free flaps in 30 cases. Br J Plast Surg 1998;51:186–90.

2. Beasley NJ, Gilbert RW, Gullane PJ, Brown DH, Irish JC, Neligan PC. Scalp and forehead reconstruction using free revascularized tissue transfer. Arch Facial Plast Surg 2004;6:16–20.

3. Lin PY, Miguel R, Chew KY, Kuo YR, Yang JC. The role of the anterolateral thigh flap in complex defects of the scalp and cranium. Microsurgery 2014;34:14–9.

4. McLean DH, Buncke HJ Jr. Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg 1972;49:268–74.

5. Hultman CS, Carlson GW, Losken A, Jones G, Culbertson J, Mackay G, et al. Utility of the omentum in the reconstruction of complex extraperitoneal wounds and defects: donor-site complications in 135 patients from 1975 to 2000. Ann Surg 2002;235:782–95.

6. Furnas H, Lineaweaver WC, Alpert BS, Buncke HJ. Scalp reconstruction by microvascular free tissue transfer. Ann Plast Surg 1990;24:431–44.

7. Herrera F, Buntic R, Brooks D, Buncke G, Antony AK. Microvascular approach to scalp replantation and reconstruction: a thirty-six year experience. Microsurgery 2012;32:591–7.

8. McCombe D, Donato R, Hofer SO, Morrison W. Free flaps in the treatment of locally advanced malignancy of the scalp and forehead. Ann Plast Surg 2002;48:600–6.

9. Harii K, Yamada A, Ishihara K, Miki Y, Itoh M, May JW Jr. A free transfer of both latissimus dorsi and serratus anterior flaps with thoracodorsal vessel anastomoses. Plast Reconstr Surg 1982;70:620–9.

10. Trignano E, Fallico N, Nitto A, Chen HC. The treatment of composite defect of bone and soft tissues with a combined latissimus dorsi and serratus anterior and rib free flap. Microsurgery 2013;33:173–183.

11. Serra MP, Longhi P, Carminati M, Righi B, Robotti E. Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myo-osseous flap and latissimus dorsi myocutaneous flap. J Plast Reconstr Aesthet Surg 2007;60:1158–61.

12. Mehrara BJ, Disa JJ, Pusic A. Scalp reconstruction. J Surg Oncol 2006;94:504–8.

13. Oh SJ, Lee J, Cha J, Jeon MK, Koh SH, Chung CH. Free-flap reconstruction of the scalp: donor selection and outcome. J Craniofac Surg 2011;22:974–7.

14. Dulin WA, Avila RA, Verheyden CN, Grossman L. Evaluation of abdominal wall strength after TRAM flap surgery. Plast Reconstr Surg 2004:113:1662–7.

15. Kobienia BJ, Migliori M, Schubert W. Preexpanded radial forearm free flap to the scalp. Ann Plast Surg 1996;37:629–32.

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Altınkaya et al. Reconstruction of extensive scalp defects with anterolateral thigh flap 16. Bo B, Qun Y, Zheming P, Haitao X, Tianyi L. Reconstruction scalp defects after malignant tumor resection with anterolateral thigh flaps. J Craniofac Surg 2011;22:2208–11.

17. Fowler NM, Futran ND. Achievements in scalp reconstruction. Curr Opin Otolaryngol Head Neck Surg 2014;22:127–30.

18. Tutela JP, Banta JC, Boyd TG, Kelishadi SS, Chowdhry S, Little JA. Scalp reconstruction: a review of the literature and a unique case of total craniectomy in an adult with osteomyelitis of the skull. Eplasty 2014;14: e27.

19. Manders EK, Schenden MJ, Furrey JA, Hetzler PT, Davis TS, Graham WP 3rd. Soft-tissue expansion: concepts and complications. Plast Reconstr Surg 1984;74:493–507.

20. Lin SJ, Hanasono MM, Skoracki RJ. Scalp and calvarial reconstruction.

Semin Plast Surg 2008;22:281–93.

21. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept

based on the septocutaneous artery. Br J Plast Surg 1984;37:149–59.

22. Kuo YR, Seng-Feng J, Kuo FM, Liu YT, Lai PW. Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 cases. Ann Plast Surg 2002;48:161–6.

23. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109:2219–26.

24. Cigna E, Minni A, Barbaro M, Attanasio G, Sorvillo V, Malzone G, et al.

An experience on primary thinning and secondary debulking of anterolateral thigh flap in head and neck reconstruction. Eur Rev Med Pharmacol Sci 2012;16:1095–101.

25. Heller F, Hsu CM, Chuang CC, Wei KC, Wei FC. Anterolateral thigh fasciocutaneous flap for simultaneous reconstruction of refractory scalp and dural defects. Report of two cases. J Neurosurg 2004;100:1094–7.

OLGU SERİSİ - ÖZET

Geniş saçlı deri defektlerinin serbest anterolateral uyluk flebi ile onarımı Dr. Altuğ Altınkaya,1 Dr. Şükrü Yazar,1 Dr. İbrahim Sağlam,2 Dr. Kaan Gideroğlu3 1 2 3

Acıbadem Maslak Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İstanbul Harran Üniversitesi, Araştırma ve Uygulama Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Şanlıurfa Kartal Dr. Lütfi Kırdar Eğitim ve Araştırma Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Kliniği, İstanbul

AMAÇ: Farklı nedenlerle meydana gelen geniş saçlı deri defektlerinin onarımında çoğunlukla serbest doku nakilleri gerekmektedir. Bu çalışmanın amacı serbest anterolateral uyluk flebi ile onarım uygulanmış geniş saçlı deri defekti olan olgulardaki deneyimlerimizi gözden geçirmek ve paylaşmaktır.

GEREÇ VE YÖNTEM: 2007 ile 2015 yılları arasında geniş saçlı deri defekti olan, defekt onarımında anterolateral serbest uyluk flebi kullanılan olguların tıbbi kayıtları geriye dönük olarak tarandı. Ortalama yaşı 44 olan on bir hasta bu çalışmaya dahil edildi.

BULGULAR: Saçlı derideki geniş defekti onarmak için; genişliği 7 ile 14 cm, uzunluğu ise 10 ile 34 cm arasında değişen on bir serbest anterolateral uyluk flebi kullanıldı. Hiçbir hastada flep kaybı gözlenmedi.

TARTIŞMA: Saçlı deri onarımında kullanılabilecek pek çok serbest flep seçeneği bulunmaktadır. Serbest anterolateral uyluk flebi diğer serbest flep seçeneklerine olan üstünlüğü, güvenilirliği ve avantajları nedeniyle geniş saçlı deri defekti olan olgularda ilk seçenek olarak değerlendirilebilir.

Anahtar sözcükler: Anterolateral uyluk flebi; mikrocerrahi; saçlı deri; serbest flep.

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CA S E SERI ES

Three-dimensional printing-assisted surgical technique with limited operative exposure for both-column acetabular fractures Hyun-Chul Shon, M.D.,

Seungmyung Choi, M.D.,

Jae-Young Yang, M.D.

Department of Orthopedic Surgery, College of Medicine, Chungbuk National University, Cheongju-Korea

ABSTRACT BACKGROUND: It is often difficult to achieve satisfactory reduction and fixation of both-column acetabular fractures owing to the complexity of the regional anatomy of the pelvis and the fracture configuration, which is commonly associated with a high degree of comminution. Herein, we describe the use of a three-dimensional (3D) patient-specific printed model of the pelvis to facilitate preoperative planning, simulate the fracture reduction procedure, and pre-contour the fixation plates for treating both-column acetabular fractures.

METHODS: The 3D-printed model was constructed using a fused deposition modeling method with computed tomography images as inputs. Operative and clinical outcomes were evaluated for 5 patients with both-column acetabular fractures (mean age: 41.4 years).

The status of fracture reduction was classified using the Matta criteria, and the functional outcome was assessed using the modified Merle d’Aubigne score.

RESULTS: Reduction was classified as excellent in 4 patients and good in 1 patient, and good functional outcomes were achieved in all patients at the final follow-up. The average incision length was 6.9 cm with an average operative time of 124 min.

CONCLUSION: We successfully applied 3D printing for the surgical management of both-column acetabular fractures, thereby improving surgical outcomes while achieving good-to-excellent reduction and good medium-term functional outcomes.

Keywords: Acetabulum; both-column fracture; limited exposure; preoperative planning; three-dimensional printing.

INTRODUCTION It is essential to achieve anatomical reduction and hip joint congruency, including secondary surgical congruency, of both-column acetabular fractures for rapid postoperative recovery and early rehabilitation as well as maintaining longterm hip joint function.[1–7] The treatment of both-column acetabular fractures is technically challenging owing to the complex regional anatomy of the pelvis and the complicated fracture configurations. Moreover, these injuries are located deep within the pelvis and are anatomically surrounded by major organs and neurovascular structures; thus, securing an

adequate surgical field of view is generally difficult. A wide operative exposure approach can improve the field of view but can increase the risk of major complications, including infection and impaired wound healing. It can also prolong the operative time and increase the volume of blood loss and the extent of soft tissue injury during the surgical procedure.[8–11] The severity of the injury itself and associated injures further influence the risk of mortality and postoperative complications.[12] Therefore, limiting the surgical field as much as possible can lower the risk of postoperative morbidities, particularly in patients with comminuted acetabular fractures or multiple associated injuries.

Cite this article as: Shon HC, Choi S, Yang JY. Three-dimensional printing-assisted surgical technique with limited operative exposure for both-column acetabular fractures. Ulus Travma Acil Cerrahi Derg 2018;24:369-375.

Address for correspondence: Seungmyung Choi, M.D. 1sunhwanro 776 (Gaesindong) Cheongju - South Korea Tel: 82-43-269-6077 E-mail: davidchoi1530@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(4):369-375 DOI: 10.5505/tjtes.2018.47690 Submitted: 18.07.2017 Accepted: 16.04.2018 Online: 25.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Ongoing developments in three-dimensional (3D) printing technology have extended the application of this technology to surgical planning of orthopedic trauma cases. Three-dimensional printed models offer several advantages over radiography and computed tomography imaging for surgical planning, the most important of these being an enhanced understanding of the 3D complexity of a fracture and providing necessary measurements for increasing the accuracy of intraoperative procedures.[6,7,11,13â&#x20AC;&#x201C;18] To date, the application of 3D printing technology for assessing and surgically treating bothcolumn acetabular fractures has not been comprehensively investigated. Therefore, in the present technical report, we describe our novel 3D-printing-assisted technique for preoperative planning and guidance of surgical procedures for managing both-column acetabular fractures with an aim of limiting operative exposure and saving operative time. We hypothesized that our 3D- printing-assisted surgical technique with limited operative exposure can achieve satisfactory reduction and fixation of both-column acetabular fractures, decrease the operative time and blood loss, and prevent postoperative complications. To evaluate the clinical feasibility of our technique, the clinical outcomes were analyzed over a mean follow-up period of 33.5 months in 5 patients with comminuted both-column acetabular fractures treated using our system.

MATERIALS AND METHODS Patient-specific computed tomography (CT) images of the pelvis were obtained using a slice thickness of 1 mm and saved in the Digital Imaging and Communications in Medicine (DICOM) format. A volume rendering technique was used to visualize the fracture fragments and remove surrounding tis-

(a)

(b)

sues. From the rendered volume, a 3D graphic model of the fracture was created and stored in the Standard Triangulation Language file format for use as an input to the 3D-printing machine file. The final files were printed using a commercially available printer, the EDISON 3D PRINTERTM (Rocket Co., Ltd., Seoul, Korea). The model was constructed using a degradable plastic. From the CT image inputs, the model was constructed within 3 h at an approximate cost of $30. The 3D printer used a fused deposition modeling (FDM) method that relies on a layer-by-layer process to construct 3D objects.

Once the full-size pelvis model was fabricated, the fracture lines were marked using an oil-based paint marker. After cutting along the marked fracture lines, each fracture fragment was separated using a craft knife, with the free fragments used to simulate the surgical procedure for fragment reduction and fixation in vitro. After achieving satisfactory reduction, temporary fixation of the fracture was performed using glue (Fig. 1a-f). The appropriate positioning of the fixation plate was then selected, including the location of the holes to use in the plate. The reconstruction osteosynthesis plating system (Synthes, Solothurn, Switzerland) was then precontoured and assembled to fit the real-size patient-specific pelvic model (Fig. 2). The pre-contoured plate was sterilized and stored until intraoperative application. Both-column acetabular fractures were managed by open reduction and internal fixation using a modified Stoppa limited approach. The patient was positioned supine, and hip flexion was performed to relax the iliopsoas muscle, the external iliac and femoral neurovascular bundle, and the abdominal muscles. A transverse incision was made 3 cm above the pubic symphysis.

(c)

(d)

(e)

(f)

Figure 1. (a) Three-dimensional reconstructed computed tomography scans showing a both-column fracture of the left acetabulum (a, b).

The fracture lines are marked (c, d), and temporary fixation of the fracture is performed using glue (e, f).

(a)

(b)

(c)

(d)

Figure 2. (a-d) Clinical photographs showing the sequential templating and plate pre-contouring technique.

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ical outcomes were evaluated intraoperatively, immediately postoperatively, and subsequently over a mean postoperative follow-up of 33.5 months.

Table 1. Demographic data and selected clinical

characteristics of patients Patient Age Sex Mechanism

(years) of injury

Concomitant injuries

1

Sacral fracture

23

Female

Fall

The study was approved by the institutional review board of Chungbuk National University. Patients provided informed consent for the surgical procedure, use of their data in the analysis of outcomes, and publication of the results.

Hemoperitonium

2

45

Male

Spinal fracture

Fall

RESULTS

Distal radius fracture

Hemoperitonium 3

49

Male

MVA

Patients’ Demographics and Outcomes

Spinal fracture

Tibiofibular fracture

Calcaneal fracture

The study cohort included 2 women and 3 men with a mean age of 41.4 years and a mean postoperative follow-up of 33.5 months. The mechanism of injury was a motor vehicle crash in 3 cases and fall from a height in 2 cases. Concomitant injuries included intra-abdominal injuries in 4 cases, urethral injury in 2 cases, a distal radius fracture in 2 cases, spinal fractures in 3 cases, a sacral fracture in 1 case, femoral fracture in 2 cases, tibiofibular fracture in 2 cases, and calcaneal fracture in 2 cases (Table 1).

Hemoperitonium 4

39 Female

MVA

Hemoperitonium

Urethral injury

Spinal fracture

Distal radius fracture

Femoral fracture

5

51

Male

MVA

Urethral injury

Femoral fracture

Tibiofibular fracture

Calcaneal fracture

MVA: Motor vehicle accident.

The incision was deepened to the rectus abdominis, passing the abdominal fascia to approach the internal aspect of the pelvis. On approaching, the corona mortis was identified and ligated, and sub-periosteal dissection was performed to expose the fracture fragments. If necessary, a lateral window of 4 cm along the iliac crest was made to approach the fracture extending to the iliac crest or posterior column fracture.

Between October 2012 and January 2014, 12 consecutive patients with both-column acetabular fractures were surgically managed. To evaluate the clinical feasibility of our 3D printing approach, only patients who had comminuted both-column acetabular fractures with multiple associated injuries were included in the study. A total of 5 patients with a follow-up of more than 2 years were analyzed. Clinical and radiolog-

All patients underwent internal fracture fixation using a modified Stoppa limited approach with an average incision length of 6.6 cm. The average operative time was 125 min, with an average estimated volume of blood loss of 282 mL. According to the Matta criteria,[1] fracture reduction was judged to be excellent in 4 patients and good in 1 patient. With regard to functional outcomes assessed using the modified Merle D’aubigne score,[19] all patients reported a good functional recovery. No instances of delayed incision healing, infection, or nonunion were identified (Table 2).

Case A 23-year old woman (patient 1) fell from a height and was admitted to our emergency department with a chief complaint of pain in her right pelvis. Radiographs and CT scans revealed a comminuted both-column fracture of the right acetabulum with a non-displaced sacral fracture. Other identified injuries included a hemoperitoneum and a fracture of the body of the second lumbar vertebra. Owing to the complex configuration of fracture fragments and multiple associated injuries, conventional surgical techniques for fracture reduction and

Table 2. Clinical outcomes of patients following the surgical procedure Patient

Incision length (cm)

Operation time (min)

Estimated volume of Matta’s criteria blood loss (mL)

Modified Merle d’Aubigne score

1 7 119 245 Good Good 2

5

109

215

Excellent Good

3

8

154

350

Excellent Good

4

6

124

324

Excellent Good

5

7

121

276

Excellent Good

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fixation would have required a wide operative exposure to obtain a satisfactory surgical view; this would have increased the risk for postoperative complications, particularly wound infection. Therefore, the decision was made to perform 3D printing-assisted preoperative planning and surgical procedure with a limited operative exposure.

Preoperatively, a 3D printed patient-specific pelvic model was constructed from the CT images obtained upon admission (Fig. 3a-c). The procedure for fracture reduction was simulated, followed by pre-contouring of 3.5-mm reconstruction plates (14 holes per plate for the anterior column). Data regarding the optimal points of entry and the position, direction, and length of the screw for fixation of the iliac crest fracture were also obtained from the model. The model provided an enhanced understanding of the association between the quadrilateral plate and the fracture fragments of the poste-

(a)

(b)

rior column. Based on this data, it was decided that a limited Stoppa approach would be sufficient to perform fracture reduction and fixation.

Two separate skin incisions were made: a transverse incision, 3 cm above the pubic symphysis, and a lateral window of 4 cm along the iliac crest. Reduction of the anterior column was achieved using reduction clamps, followed by insertion of a cancellous screw to stabilize the iliac crest fracture. The pre-contoured 14-hole plate was then introduced without requiring further adjustment of the fracture fragments as the location and depth of fixation screws used to stabilize the posterior column fragment were determined during the preoperative planning phase. The status of reduction was confirmed by fluoroscopy. Postoperative radiographs and CT scans were obtained to confirm that an appropriate reduction had been achieved, with no evidence of intra-articular screw

(c)

Figure 3. Image summary of the preoperative assessment of the both-column fracture of the right pelvis, showing the obturator oblique plain radiograph (a), computed tomography scans of the same view (b), and the three-dimensional printed model of the whole pelvis (c).

(a)

(b)

(c)

(d)

(e)

Figure 4. The status of fracture reduction and fixation verified through immediate postoperative plain radiographs (a-c) and computed tomography scans (d, e).

(a)

(b)

(c)

Figure 5. (a-c) A plain radiograph showing well maintained fixation and consolidation at 18 months postoperatively.

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penetration (Fig. 4a-e). Partial weight bearing was permitted 3 days postoperatively. The internal fixation was well maintained, as shown in plain radiographs obtained at 18 months postoperatively (Fig. 5).

In terms of operative data, the estimated incision length was 7 cm with an operation time of 119 min and blood loss of 245 mL. The status of reduction was classified as good based on the Matta criteria, with a good functional outcome reported by the patient using the modified Merle dâ&#x20AC;&#x2122;Aubigne score. The incision healed well without evidence of infection, and postoperative union of the fracture fragments was confirmed.

DISCUSSION Hurson et al.[6] reported that a rapid prototyping process with selective laser sintering facilitated rapid manufacturing of accurate 3D physical models of the bony pelvis for use in preoperative assessment and classification of acetabular fractures and for treatment planning. However, their model was not integrated into surgical management, unlike our system in which the 3D model was applied to identify the best reduction technique, select and pre-contour the fixation plate, and identify the optimal location and depth of the fixation screws as well as optimal entry points. In the present technical report, we provide evidence of the feasibility of our technique to achieve satisfactory reduction and fixation of both-column acetabular fractures. In addition to facilitating preoperative planning to achieve a good-to-excellent reduction of the fracture, our model-based planned approach decreased the operative time and volume of blood loss, reduced the required length of the incision, and prevented postoperative complications. As a qualitative comparison of the operative effectiveness of our approach, our outcomes were compared with those of Sagi et al.[9] who reported an average operative time of 263 min with a volume of blood loss of 750 mL using an anterior approach for the reduction and fixation of acetabular fractures. Therefore, although statistical analysis of our results was not feasible owing to the small sample size, we have provided preliminary evidence of the superiority of our model-based approach compared to conventional techniques in reducing the operative time and volume of blood loss.

Previous studies have reported operative outcomes using 3D printing for the planning of surgical procedures to treat unstable pelvic fractures. Zeng et al.[11] reported an average operative time of 110 min with an average volume of blood loss of 320 mL. For 2 patients with acetabular fractures, Wu et al.[10] reported an average operative time of 146 min with an average volume of blood loss of 450 mL. Using the modified Stoppa approach for acetabular fractures, Kim et al.[20] required an incision length â&#x2030;Ľ12 cm and reported a postoperative complication rate of 14%. Matta et al.[21] reported a postoperative complication rate of 13% with the use of an ilioinguinal approach. In their case series evaluating the use of 3D printing for treating acetabular fractures, Zeng et al.[11] Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4

identified a postoperative complication in only 1 of their 38 patients. These low rates of postoperative complications are consistent with our results.

As several authors have demonstrated, 3D printing techniques are particularly useful for managing comminuted fractures, which require an enhanced understanding of the complex configuration of fracture fragments[14,15,22,23] or fractures with associated injuries known to be important prognostic factors of clinical outcome.[10,24,25] Moreover, the limited surgical field required when using a model-based approach for surgical planning may minimize soft tissue trauma and prevent injury to essential structures, such as the inguinal canal, thereby lowering the overall risk for postoperative complications in comparison to a wide operative exposure.[10,11,13] However, future studies with larger populations followed-up over a longer period are required to clarify the effectiveness of our 3D printed model-based technique for treating comminuted both-column acetabular fractures and confirm its advantages over conventional operative procedures.

One of the disadvantages of this limited approach is that the visualization of fractures and subsequent contouring of the plate and fixation are restricted. In our study, the plate was pre-contoured to the 3D-printed model, and appropriate positioning of the plate, including the screw trajectory, was determined preoperatively. The advantages of pre-contouring the plate with limited operative exposure include a decrease in soft tissue injuries during the surgical procedure owing to soft tissue handling as least as possible. In addition, this limited approach can reduce operation time, blood loss, and risk of postoperative infection. Radiation exposure by fluoroscopic imaging is also decreased as no further contouring of the plate or adjustment of the screw trajectory is required.

The high cost and time required to fabricate printed models have been described as drawbacks of 3D printing techniques.

We circumvented these issues by using the FDM technique, which is widely available and is being used for rapid manufacturing of physical products. Although the FDM technique may be considered inadequate in terms of accuracy and quality of completion of the model, the technique has the distinct advantage of providing a relatively rapid manufacturing time for the model at a low cost (i.e., 3 h of manufacturing time at a cost of $30 in our study). Wang et al.[7] reported that the geometry of the 3D printed model of the pelvis created using the FDM technique was not statistically different from that of the original pelvis. Therefore, the 3D printed model of the pelvis is deemed to have sufficient specifications for clinical practice.

A limitation of the 3D printing technique used in our study was that the model could only be fabricated in one connected form. Therefore, a displaced fracture or a gap between fracture fragments was expressed as a connected entity that was cut out and separated after the model was fabricated. This 373

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approach might distort the configuration of fractures with severe comminution. Additionally, as our aim was to minimize fabrication time and cost, attention was placed on developing a real-size model with the accuracy of the gross shape of the pelvis maintained during the volume rendering process but not necessarily of its fine structural details. High detail can be achieved by capturing the image of each fragment from the DICOM data and separately fabricating each fracture fragment. However, this would take considerable time and added cost. With ongoing development of 3D printing techniques, the process is becoming faster and less expensive; therefore, current limitations in the model details will eventually be resolved. Hurson et al.[6] reported only fair interobserver agreement between the classification of fractures derived from the model and those from plain radiographs.

This agreement in fracture classification is lower than that expected and likely reflects current limitations of 3D models in capturing undisplaced fractures that are otherwise visible on conventional imaging. Varga et al.[26] also demonstrated that inappropriate image processing can introduce errors in the manufactured model. Therefore, a careful review of plain radiographs and CT images in combination with an evaluation of the 3D model is recommended to obtain a complete description of the configuration of acetabular fractures and prevent misdiagnosis of a hidden lesion. The accuracy of 3D printed models of the pelvis can be enhanced by using contrast CT images as inputs to the 3D printer.[27] The use of contrast CT images warrants further evaluation with the advancements in CT image resolution as well as technical capabilities of 3D printers that are expected to yield a higher model accuracy in the future.

To date, the advantages of 3D printing technology have not been fully investigated. In addition to preoperative planning and guidance of surgical procedures, custom-made plates and implants are personalized to the patients’ anatomy. Moreover, 3D bio-printing for designing biological constructs offers further advantages and leads to better outcomes. Therefore, additional research may be required not only to investigate further possible applications of this new technology but also to develop technologies for its safety profile, supposing these 3D printed materials are applied in vivo.

Conclusions Our 3D printing-assisted preoperative planning and surgical procedure with limited operative exposure for treating both-column acetabular fractures provided satisfactory fracture reduction and fixation, decreased operative time and volume of blood loss, and reduced the risk of postoperative complications. Future research is planned to further compare our technique with conventional surgical techniques in an effort to identify the optimal treatment and assess the cost-effectiveness of 3D printing techniques for orthopedic surgery.

Based on our current experience, we believe that the 3D printing technique may have huge potential benefits in clinical practice.

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Ethical Approval All procedures performed in studies involving human participants were approved by the institutional review board of Chungbuk National University and were in compliance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent Informed consent was obtained from all individual participants included in the study.

Conflict of interest: None declared.

REFERENCES 1. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am 1996;78:1632–45.

2. Letournel E. The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat Res 1993;292:62–76.

3. Gänsslen A, Frink M, Hildebrand F, Krettek C. Both column fractures of the acetabulum: epidemiology, operative management and long-termresults. Acta Chir Orthop Traumatol Cech 2012;79:107–13.

4. Lee KJ, Min BW, Son ES, Seo HJ, Park JH. Comparative results of acetabular both column fracture according to the fixation method. J Korean Hip Soc 2011;23:131–6.

5. Bhat NA, Kangoo KA, Wani IH, Wali GR, Muzaffar N, Dar RA. Operative management of displaced acetabular fractures: an institutional experience with a midterm follow-up. Orthop Traumatol Rehabil 2014;16:245–52.

6. Hurson C, Tansey A, O’Donnchadha B, Nicholson P, Rice J, McElwain J. Rapid prototyping in the assessment, classification and preoperative planning of acetabular fractures. Injury 2007;38:1158–62.

7. Wu XB, Wang JQ, Zhao CP, Sun X, Shi Y, Zhang ZA, at al. Printed three-dimensional anatomic templates for virtual preoperative planning before reconstruction of old pelvic injuries: Initial results. Chin Med J 2015;128:477–82.

8. Cole JD, Bolhofner BR. Acetabular fracture fixation via a modified Stoppa limited intrapelvic approach. Description of operative technique and preliminary treatment results. Clin Orthop Relat Res 1994;305:112–23.

9. Sagi HC, Afsari A, Dziadosz D. The anterior intra-pelvic (modified Rives-Stoppa) approach for fixation of acetabular fractures. J Orthop Trauma 2010;24:263–70.

10. Yu AW, Duncan JM, Daurka JS, Lewis A, Cobb J. A feasibility study into the use of three-dimensional printer modelling in acetabular fracture surgery. Adv Orthop 2015;2015:617046.

11. Zeng C, Xiao J, Wu Z, Huang W. Evaluation of three-dimensional printing for internal fixation of unstable pelvic fracture from minimal invasive para-rectus abdominis approach: a preliminary report. Int J Clin Exp Med 2015;8:13039–44.

12. Lieffers JR, Bathe OF, Fassbender K, Winget M, Baracos VE. Sarcopenia is associated with postoperative infection and delayed recovery from colorectal cancer resection surgery. Br J Cancer 2012;107:931–6.

13. Kim HN, Liu XN, Noh KC. Use of a real-size 3D-printed model as a preoperative and intraoperative tool for minimally invasive plating of comminuted midshaft clavicle fractures. J Orthop Surg Res 2015;10:91.

14. Chung KJ, Huang B, Choi CH, Park YW, Kim HN. Utility of 3D Printing for Complex Distal Tibial Fractures and Malleolar Avulsion Fractures: Technical Tip. Foot Ankle Int 2015;36:1504–10.

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Shon et al. 3D printing-assisted surgical technique with limited operative exposure for both-column acetabular fractures 15. Chung KJ, Kim YT, Yang I, Park YW, Kim HN. Preshaping plates for minimally invasive fixation of calcaneal fractures using a real-size 3Dprinted model as a preoperative and intraoperative tool. Foot Ankle Int 2014;35:1231–6.

16. Jeong HS, Park KJ, Kil KM, Chong S, Eun HJ, Lee TS. Minimally invasive plate osteosynthesis using 3D Printing for shaft fractures of clavicles: technical note. Arch Orthop Trauma Surg 2014;134:1551–5.

17. Brown GA, Firoozbakhsh K, DeCoster TA, Reyna JR, Moneim M. Rapid prototyping: the future of trauma surgery? J Bone Joint Surg Am 2003;85 Suppl 4:49–55.

18. Bagaria V, Deshpande S, Rasalkar DD, Kuthe A, Paunipagar BK. Use of rapid prototyping and three-dimensional reconstruction modeling in the management of complex fractures. Eur J Radiol 2011;80:814–20.

19. D’aubigne RM, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am 1954;36:451–75.

20. Kim HY, Yang DS, Park CK, Choy WS. Modified Stoppa approach for surgical treatment of acetabular fracture. Clin Orthop Surg 2015;7:29–38.

21. Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach. A 10-year perspective. Clin Orthop Relat Res

1994;305:10–9.

22. Liang W, Ye W, Ye D, Zhou Z, Chen Z, Li A, et al. Construction and biomechanical properties of polyaxial self-locking anatomical plate based on the geometry of distal tibia. BioMed Res Int 2014;2014:436325.

23. Song HK, Noh JW, Lee JH, Yang KH. Avoiding rotational mismatch of locking distal tibia plates depends on proper plate position. J Orthop Trauma 2013;27:e147–51.

24. Giannoudis PV, Grotz MRW, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br 2005;87:2–9.

25. Garrett J, Halvorson J, Carroll E, Webb LX. Value of 3-D CT in classifying acetabular fractures during orthopedic residency training. Orthopedics 2012;35:e615–20.

26. Varga Jr. E, Hammer B, Hardy BM, Kamer L. The accuracy of three-dimensional model generation. What makes it accurate to be used for surgical planning? Int J Oral Maxillofac Surg 2013;42:1159–66.

27. Bizzotto N, Sandri A, Regis D, Romani D, Tami I, Magnan B. Threedimensional printing of bone fractures: A new tangible realistic way for preoperative planning and education. Surg Innov 2015;22:548–51.

OLGU SERİSİ - ÖZET

Asetabulumun her iki kolon kırığına kısıtlı cerrahi ekspozür sağlayan üç boyutlu yazıcı yardımlı cerrahi teknik Dr. Hyun-Chul Shon, Dr. Seungmyung Choi, Dr. Jae-Young Yang Chungbuk Ulusal Üniversitesi Tıp Fakültesi, Ortopedi Cerrahisi Bölümü, Cheongju-Güney Kore

AMAÇ: Pelvisin bölgesel anatomisi ve genellikle yüksek derecede parçalı kırığın eşlik ettiği kırık konfigürasyonunun karmaşıklığı nedeniyle asetabulumun her iki kolonun kırıklarında tatminkâr bir redüksiyon ve fiksasyon elde etmek sıklıkla zordur. Bu yazıda, ameliyat öncesi planlamayı kolaylaştırmak, kırık redüksiyon işlemini simüle etmek ve asetabulumun her iki kolonunun kırıkları için tespit plaklarını önceden biçimlendirmek amacıyla üç boyutlu (3D) hastaya özgü pelvisin bilgisayarda oluşturulmuş bir modelinin kullanımı sunuldu.

GEREÇ VE YÖNTEM: Bilgisayarlı tomografi görüntülerini girdi olarak kullanıp oluşturulan birleştirmeli yığma modellemesi ile yazıcıda 3 boyutlu kalıp gerçekleştirildi. Asetabulumun her iki kolonunda kırıkları olan ortalama 41.4 yaşındaki beş hastanın cerrahi ve klinik sonuçları değerlendirildi.

Malta kriterleri kullanılarak kırık redüksiyonunun durumu sınıflandırılmış, modifiye edilmiş Merle d’Aubigne skoru kullanarak fonksiyonel sonuç değerlendirildi.

BULGULAR: Redüksiyon dört hastada mükemmel ve bir hastada iyi olarak sınıflandırılmış ve son izlemde hastaların hepsinde iyi fonksiyonel sonuçlar gerçekleştirilmiştir. Ortalama insizyon uzunluğu 6.9 cm ve ortalama cerrahi süresi 124 dakika idi.

TARTIŞMA: Asetabulumun her iki kolon kırığının cerrahi tedavisinde yazıcıyla 3 boyutlu sanal modellemeyi başarıyla uygulayarak cerrahi sonuçları iyileştirdik, iyi-mükemmel redüksiyon ve orta vadede iyi fonksiyonel sonuçlar elde ettik.

Anahtar sözcükler: Ameliyat öncesi planlama; asetabulum; her iki kolon kırığı; kısıtlı ekspozür; üç boyutlu modelleme.

Ulus Travma Acil Cerrahi Derg 2018;24(4):369-375

doi: 10.5505/tjtes.2018.47690

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CA S E R EP O RT

Strangulated Morgagni hernia in an adult: Synchronous prolapse of the liver and transverse colon Seok Youn Lee, M.D.,1

Jung Nam Kwon, M.D.,1

Yong Sung Kim, M.D.,2

Keun Young Kim, M.D.3

1

Department of Surgery, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo-Korea

2

Department of Internal Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo-Korea

3

Department of Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan-Korea

ABSTRACT Morgagni hernia (MH) is a very rare congenital defect found in the anterior aspect of the diaphragm between the costal and sternal portions of the muscle. The most common defect is congenital diaphragmatic hernia, 90% of which are Bochdalek type. MHs account for approximately 3% of all diaphragmatic hernias. Most MHs are found and repaired in children, but 5% are found in adults. Here, we present the case of an incarcerated and strangulated MH with synchronous prolapse of the liver and transverse colon in a 77-year-old man who was admitted to our hospital for abdominal pain and symptoms of intestinal obstruction.

Keywords: Adult; Morgagni hernia; synchronous.

INTRODUCTION MH was first described in 1769 by the Italian anatomist and pathologist Giovanni Battista Morgagni as an anterior diaphragmatic hernia originating from the costosternal trigones, a triangular space located between the muscle fibers originating from the xiphisternum and the costal margin of the diaphragm, and protruding into the central tendon.[1] The most common contents of the hernia sac include the omentum, followed by the colon, small bowel, stomach, and portions of the liver.[2] To our knowledge, the present case is a rare case of an adult with MH presenting with abdominal pain and synchronous prolapse of the liver and transverse colon.

CASE REPORT A 77-year-old man was admitted to the emergency room of our hospital complaining of respiratory distress, upper abdominal pain, nausea, and intermittent vomiting for two days. His medical history included interstitial lung disease, for which he

did not receive treatment. He had no history of past trauma or surgery. Physical examination revealed a soft abdomen with some tenderness in the epigastrium. Cardiopulmonary auscultation revealed decreased air entry in the right lung base but no other unusual findings. He was apyrexial and hemodynamically stable. Initial chest radiography revealed a soft-tissue mass and air-filled heterogeneous areas in the lower area of the right hemithorax (Fig. 1a). Computed tomography (CT) of the abdomen showed an intrathoracic transverse colon and liver at the right cardiodiaphragmatic angle (Fig. 1b). High-resolution computed tomography (HRCT) of the chest showed honeycombing consisting of multilayered thick-walled cysts in the basal and subpleural region (Fig. 1c). The patient was suspected to have MH with interstitial lung disease (usual interstital pneumonia pattern). Because he was considered not to have acute intestinal obstruction or strangulation, elective surgery was planned. However, 18 h after admission, the patient demonstrated progressive tachycardia and complained of increasing abdominal pain. CT of the abdomen revealed evidence of strangulated herniation of the transverse colon (Fig. 2).

Cite this article as: Lee SY, Kwon JN, Kim YS, Kim KY. Strangulated Morgagni hernia in an adult: Synchronous prolapse of the liver and transverse colon. Ulus Travma Acil Cerrahi Derg 2018;24:376-378.

Address for correspondence: Seok Youn Lee, M.D. Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, 321, Sanbon-ro, Gunpo-si, Gyeonggi-do, 15865, Korea, Gunpo-si-South Korea.

Tel: +82-31-390-2218 E-mail: sylee314@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(4):376-378 DOI: 10.5505/tjtes.2017.99045 Submitted: 14.01.2017 Accepted: 21.12.2017 Online: 19.06.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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(a)

(b)

(c)

Figure 1. (a) Plain radiogram of the chest showing a soft tissue mass with air-fluid levels at the right cardiophrenic angle (white arrows); (b) Axial computed tomographic image of the abdomen, showing a right intrathoracic transverse colon and liver with cardiac deviation. A small pleural effusion also can be seen (white arrows = liver); (c) High-resolution computed tomographic image of the chest showing honeycombing comprising reticular densities caused by thick walls of cysts as well as architectural distortion with traction bronchiectasis because of fibrosis.

Emergency laparotomy was performed, with the herniated liver and transverse colon reduced into the abdomen. The transverse colon and omentum demonstrated necrotic changes (Fig. 3a and b). Resection of 20 cm of the transverse colon and partial omentectomy were performed with endto-end hand-sewn anastomosis. Copious laparoscopic-guided lavage of the right hemithorax also was performed using 0.9% normal saline (Fig. 3c and d). The diaphragmatic defect was closed using 2-0 prolene with interrupted vertical mattress sutures. Prior to closure, a 32-F chest drain was inserted into the right intercostal space in the axillary line. The patient had uneventful postoperative recovery and remains well.

DISCUSSION

Figure 2. Axial computed tomographic image, showing a Morgagni hernia with strangulation of the transverse colon and liver; Fluid accumulation is noted at the superior aspect of the hernia with collapse of the underlying lung.

(a)

(b)

MH is a relatively rare pathologic condition. It arises from a defect of the septum transversum caused by the failure of closure of the pars sternalis with the seventh costochondral arch.[3] MHs are far more common on the right side despite protection from the liver. The rare incidence of a left-sided diaphragmatic hernia can be explained by the formation of a

(c)

(d)

Figure 3. (a) Operative view of the herniated left liver lobe (medial superior area) (black arrowheads); (b) Operative findings included a small and covered perforation with necrosis at the antimesenteric site of the transverse colon; (c) Laparoscopic view of a right-sided Morgagni defect; A 5 Ă&#x2014; 6-cm size defect was found after the liver and colon were pulled out into the abdomen; (d) Laparoscopic view of the right lower portion of the pleural cavity through the hernia sac, revealing strangulated colon-induced purulent fluid with pus.

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Lee et al. Strangulated Morgagni hernia in an adult: Synchronous prolapse of the liver and transverse colon

barrier of the pericardial sac on the sternocostal trigon. MHs usually constitute only the omentum in infants and children, but with time, the defect enlarges until the abdominal organs herniate through. Pregnancy, trauma, obesity, chronic constipation, and chronic cough are common predisposing conditions contributing to the development of MH. Exercise and other types of exertion may also result in symptoms.[4] Symptomatic patients frequently complain of abdominal or chest pain and respiratory distress. Acute abdominal symptoms because of intestinal obstruction and strangulation are rarely observed, as seen in our patient. In cases of MH, the great omentum and transverse colon are likely to herniate into the thoracic space. However, the stomach, small bowel, and liver also may be found within the hernia sac. Because the herniated organs are usually covered with the hernia sac (the parietal peritoneum), patients usually do not exhibit any symptoms. A strangulated MH with synchronous prolapse of the liver and transverse colon has been rarely reported in the literature.

Diagnosis of MH can be confirmed radiographically. Generally, on lateral radiography, a mass containing solid areas or fluid levels is observed at the cardiophrenic angle in the retrosternal space. However, diagnosis can be particularly challenging when the only radiographic finding is an anterior cardiophrenic angle abnormality with no evidence of bowel gas patterns in the chest. Contrast enema examination may also be useful, but CT is the best imaging method for demonstrating omental fatty tissue and intestinal air out of their localization. Magnetic resonance imaging is also considered to be a useful noninvasive modality for evaluating lower anterior mediastinal masses demonstrating fat density on CT.[5] Surgery provides definitive management for patients with an MH. However, because the prevalence of MH has not been reported, it is impossible to compare operative and nonoperative management outcomes. Hence, the actual benefit of surgery remains unknown. However, several authors have opined that surgery is the most common treatment for both symptomatic and asymptomatic cases to prevent possible enlargement of the hernia sac and complications of strangulation.[6] Primary repair can be performed via several methods

and approaches, including thoracoscopic, laparoscopic, both thoracoscopic and laparoscopic, open transthoracic and abdominal. The primary advantage of the thoracic approach is that it provides easier dissection of the hernia sac off the mediastinal and pleural structures. The abdominal approach facilitates easier reduction of the hernia contents, evaluation of the contralateral diaphragm for additional defects, and concomitant evaluation and repair of other intra-abdominal pathology. Laparotomy is appropriate for management of symptomatic adult patients with a MH, particularly those with findings of intestinal strangulation.

In conclusion, when confronted with assessing patients with respiratory distress and with symptoms suggestive of gastrointestinal obstruction, MH should be included in the differential diagnosis. Post-surgical recurrence rate of MH is very low and results area excellent. Thus, it should be borne in mind that surgical repair will prevent complications even in asymptomatic cases.

Acknowledgements: This paper was supported by Wonkwang University in 2018.

Conflict of interest: None declared.

REFERENCES 1. Bhasin DK, Nagi B, Gupta NM, Singh K. Chronic intermittent gastric volvulus within the foramen of Morgagni. Am J Gastroenterol 1989;84:1106–8.

2. Horton JD, Hofmann LJ, Hetz SP. Presentation and management of Morgagni hernias in adults: a review of 298 cases. Surg Endosc 2008;22:1413–20.

3. Collie DA, Turnbull CM, Shaw TRD, Price WH. Case report: MRI appearances of left sided Morgagni hernia containing liver. Br J Radiol 1996;69:278–80.

4. Lev-Chelouche D, Ravid A, Michowitz M, Klausner JM, Kluger Y. Morgagni hernia: unique presentations in elderly patients. J Clin Gastroenterol 1999;28:81–2.

5. Kamiya N, Yokoi K, Miyazawa N, Hishinuma S, Ogata Y, Katayama N. Morgagni hernia diagnosed by MRI. Surg Today 1996;26:446–8.

6. Meredith K, Allen J, Richardson JD, Bergamini TM. Foramen of Morgagni hernia: surgical consideration. J Ky Med Assoc 2000;98:286–8.

OLGU SUNUMU - ÖZET

Bir yetişkinde strangüle Morgagni hernisi: Karaciğer ve enine kolonun eş zamanlı prolapsusu Dr. Seok Youn Lee,1 Dr. Jung Nam Kwon,1 Dr. Yong Sung Kim,2 Dr. Keun Young Kim3 Wonkwang Üniversitesi Sanbon Hastanesi, Wonkwang Üniversitesi Tıp Fakültesi, Cerrahi Bölümü, Gunpo-Kore Tongkwang Üniversitesi Sanbon Hastanesi, Wonkwang Üniversitesi Tıp Fakültesi, İç Hastalıkları Anabilim Dalı, Gunpo-Kore 3 Wonkwang Üniversitesi Hastanesi, Wonkwang Üniversitesi Tıp Fakültesi, Cerrahi Bölümü, Iksan-Kore 1 2

Morgagni hernisi (MH) kasın kostal ve sternal bölümleri arasında diyafragmanın ön yüzünde çok seyrek saptanan doğuştan bir defekttir. En sık görülen defekt doğuştan diyafragma hernisi %90 oranında Bochdalek tipidir. MH’leri tüm diyafragmatik hernilerin aşağı yukarı %90’ını oluşturur. MH’lerin çoğu çocuklarda bulunur ve onarılır, ancak %5’i erişkinlerdedir. Burada, enkansere ve strangüle MH ile eş zamanlı karaciğer ve enine kolon düşüklüğü olan ve karın ağrısı ve intestinal obstrüksiyon semptomlarıyla hastanemize kabul edilmiş 77 yaşındaki bir erkek hastayı sunuyoruz.

Anahtar sözcükler: Eş zamanlı; Morgagni hernisi; yetişkin.

Ulus Travma Acil Cerrahi Derg 2018;24(4):376-378

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doi: 10.5505/tjtes.2017.99045

Ulus Travma Acil Cerrahi Derg, July 2018, Vol. 24, No. 4