TJTES 2018-6

ISSN 1306 - 696X

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

Volume 24 | Number 6 | November 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): November (Kasım) 2018 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)

KARE P U B L I S H I N G

www.tjtes.org

INFORMATION FOR THE AUTHORS The Turkish Journal of Trauma and Emergency Surgery (TJTES) is an official publication of the Turkish Association of Trauma and Emergency Surgery. It is a peer-reviewed periodical that considers for publication clinical and experimental studies, case reports, technical contributions, and letters to the editor. Six issues are published annually.

tion, called “Upload Your Files”.

As from 2001, the journal is indexed in Index Medicus and Medline, as from 2005 in Excerpta Medica and EMBASE, as from 2007 in Science Citation Index Expanded (SCI-E) and Journal Citation Reports / Science Edition, and as from 2014 in EBSCOhost. Our impact factor in SCI-E indexed journals is 0.473 (JCR 2016). It is cited as ‘Ulus Travma Acil Cerrahi Derg’ in PubMed.

Figures, illustrations and tables: All figures and tables should be numbered in the order of appearance in the text. The desired position of figures and tables should be indicated in the text. Legends should be included in the relevant part of the main text and those for photomicrographs and slide preparations should indicate the magnification and the stain used. Color pictures and figures will be published if they are definitely required and with the understanding that the authors are prepared to bear the costs. Line drawings should be professionally prepared. For recognizable photographs, signed releases of the patient or of his/her legal representatives should be enclosed; otherwise, patient names or eyes must be blocked out to prevent identification.

Submission of a manuscript by electronic means implies: that the work has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis); that it is not under consideration for publication elsewhere; and that its publication in the Turkish Journal of Trauma and Emergency Surgery is approved by all co-authors. The author(s) transfer(s) the copyright to the Turkish Association of Trauma and Emergency Surgery to be effective if and when the manuscript is accepted for publication. The author(s) guarantee(s) that the manuscript will not be published elsewhere in any other language without the consent of the Association. If the manuscript has been presented at a meeting, this should be stated together with the name of the meeting, date, and the place.

Manuscripts must be submitted in English. All submissions are initially reviewed by the editor, and then are sent to reviewers. All manuscripts are subject to editing and, if necessary, will be returned to the authors for answered responses to outstanding questions or for addition of any missing information to be added. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication. Final galley proofs are sent to the authors for approval.

Unless specifically indicated otherwise at the time of submission, rejected manuscripts will not be returned to the authors, including accompanying materials.

TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medical Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for reviews and case reports.

Open Access Policy: Full text access is free. There is no charge for publication or downloading the full text of printed material.

Manuscript submission: TJTES accepts only on-line submission via the official web site (please click, www.travma.org.tr/en) and refuses printed manuscript submissions by mail. All submissions are made by the on-line submission system called Journal Agent, by clicking the icon “Online manuscript submission” at the above mentioned web site homepage. The system includes directions at each step but for further information you may visit the web site (http://www.travma.org/en/ journal/).

Manuscript preparation: Manuscripts should have double-line spacing, leaving sufficient margin on both sides. The font size (12 points) and style (Times New Roman) of the main text should be uniformly taken into account. All pages of the main text should be numbered consecutively. Cover letter, manuscript title, author names and institutions and correspondence address, abstract in Turkish (for Turkish authors only), and title and abstract in English are uploaded to the Journal Agent system in the relevant steps. The main text includes Introduction, Materials and Methods, Results, Discussion, Acknowledgments, References, Tables and Figure Legends.

The cover letter must contain a brief statement that the manuscript has been read and approved by all authors, that it has not been submitted to, or is not under consideration for publication in, another journal.

It should contain the names and signatures of all authors. The cover letter is uploaded at the 10th step of the “Submit New Manuscript” sec-

Abstract: The abstract should be structured and serve as an informative guide for the methods and results sections of the study. It must be prepared with the following subtitles: Background, Methods, Results and Conclusions. Abstracts should not exceed 200 words.

References: All references should be numbered in the order of mention in the text. All reference figures in the text should be given in brackets without changing the font size. References should only include articles that have been published or accepted for publication. Reference format should conform to the “Uniform requirements for manuscripts submitted to biomedical journals” (http://www.icmje.org) and its updated versions (February 2006). Journal titles should be abbreviated according to Index Medicus. Journal references should provide inclusive page numbers. All authors, if six or fewer, should be listed; otherwise the first six should be listed, followed by “et al.” should be written. The style and punctuation of the references should follow the formats below: Journal article: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5.

Chapter in book: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62.

Our journal has succeeded in being included in several indexes, in this context, we have included a search engine in our web site (www. travma.org.tr) so that you can access full-text articles of the previous issues and cite the published articles in your studies.

Review articles: Only reviews written by distinguished authors based on the editor’s invitation will be considered and evaluated. Review articles must include the title, summary, text, and references sections.

Any accompanying tables, graphics, and figures should be prepared as mentioned above.

Case reports: A limited number of case reports are published in each issue of the journal. The presented case(s) should be educative and of interest to the readers, and should reflect an exclusive rarity. Case reports should contain the title, summary, and the case, discussion, and references sections. These reports may consist of maximum five authors.

Letters to the Editor: “Letters to the Editor” are only published electronically and they do not appear in the printed version of TJTES and PUBMED. The editors do not issue an acceptance document as an original article for the ‘’letters to the editor. The letters should not exceed 500 words. The letter must clearly list the title, authors, publication date, issue number, and inclusive page numbers of the publication for which opinions are released.

Informed consent - Ethics: Manuscripts reporting the results of experimental studies on human subjects must include a statement that informed consent was obtained after the nature of the procedure(s) had been fully explained. Manuscripts describing investigations in animals must clearly indicate the steps taken to eliminate pain and suffering. Authors are advised to comply with internationally accepted guidelines, stating such compliance in their manuscripts and to include the approval by the local institutional human research committee.

YAZARLARA BİLGİ Ulusal Travma ve Acil Cerrahi Dergisi, Ulusal Travma ve Acil Cerrahi Derneği’nin yayın organıdır. Travma ve acil cerrahi hastalıklar konularında bilimsel birikime katkısı olan klinik ve deneysel çalışmaları, editöryel yazıları, klinik olgu sunumlarını ve bu konulardaki teknik katkılar ile son gelişmeleri yayınlar. Dergi iki ayda bir yayınlanır.

Ulusal Travma ve Acil Cerrahi Dergisi TÜBİTAK TR Dizinde taranmaktadır, ayrıca uluslararası indekslerde, 2001 yılından itibaren Index Medicus, PubMed’de, 2005 yılından itibaren EMBASE’de, 2007 yılından itibaren Web of Science, Science Citation Index-Expanded’de (SCI-E), 2014 yılından itibaren de EBSCOhost indeksinde dizinlenmektedir. 2016 Journal Citation Report IF puanımız 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 6 November - Kasım 2018

Contents - İçindekiler Deneysel Çalışma - Experimental Experimental Studies - DeneyselStudy Çalışma 501-506 Synthetic mesh placement in the presence of abdominal infection: An experimental study of feasibility Karın içi enfeksiyon varlığında sentetik yama kullanımı: Deneysel bir uygulanabilirlik çalışması Çiftçi AB, Gündoğdu RH, Bozkırlı BO, Yazıcıoğlu MÖ, Gümüşkaya Öcal B, Özdem B 507-513 Predicting critical duration and reversibility of damage in acute mesenteric ischemia: An experimental study Akut mezenterik iskemi hasarının kritik zaman tahmini ve reversibilitesi Aköz A, Türkdoğan KA, Kahraman Çetin N, Kum S, Duman A, Türe M, Demirkıran AE

Original Articles - Orijinal Çalışma 514-520 Impact of ureteral access sheath force of insertion on ureteral trauma: In vivo preliminary study with 7 patients Üreter erişim kılıfı yerleştirme sırasında sarfedilen gücün üreter travmasına etkisi: Yedi hastayla in vivo ön çalışma Tefik T, Buttice S, Somani B, Erdem S, Oktar T, Özcan F, Koçak T, Nane İ, Traxer O 521-527 A pathology not be overlooked in blunt chest trauma: Analysis of 181 patients with bilateral pneumothorax Künt göğüs travmasında gözden kaçırılmaması gereken bir patoloji: Bilateral pnömotoraks saptanan 181 olgunun analizi Özdil A, Kavurmacı Ö, Akçam Tİ, Ergönül AG, Uz İ, Şahutoğlu C, Yüzkan S, Çakan A, Çağırıcı U 528-531 Significance of red blood cell distribution width and C-reactive protein/albumin levels in predicting prognosis of acute pancreatitis Akut pankreatitin prognozunu ön görmede eritrosit dağılım hacmi ve CRP/albümin değerlerinin önemi Yılmaz EM, Kandemir A 532-538 Factors predicting the early mortality of trauma patients Travma hastalarında erken mortaliteyi öngören faktörler Jin WYY, Jeong JH, Kim DH, Kim TY, Kang C, Lee SH, Lee SB, Kim SC, Park YJ, Lim D 539-544 The diagnostic value of irisin in patients with acute abdominal pain: A preliminary study Akut karın ağrılı hastalarda İrisin’in tanısal değeri: Bir ön çalışma Yeniocak S, Karcıoğlu Ö, Kalkan A, Saraç F, Akgül Karadana G, Keklikkıran ZZ, Gümüş A, Koldaş M, Korkut S 545-551 The Karaman score: A new diagnostic score for acute appendicitis Karaman skoru: Akut apandisit tanısında yeni bir skorlama sistemi Karaman K, Ercan M, Demir H, Yalkın Ö, Uzunoğlu Y, Gündoğdu K, Zengin İ, Aksoy YE, Bostancı EB 552-556 Laparoscopic versus open appendectomy in pregnancy: A single center experience Gebelikte laparoskopik ve açık apendektominin karşılaştırılması: Tek merkez deneyimi Gök AFK, Soytaş Y, Bayraktar A, Emirikçi S, İlhan M, Koltka AK, Günay MK 557-562 Can Alvarado and Appendicitis Inflammatory Response scores evaluate the severity of acute appendicitis?

Alvarado ve Apandisit İnflamatuvar Yanıt skorlamaları akut apandisitin şiddetini değerlendirebilir mi?

Yeşiltaş M, Karakaş DÖ, Gökçek B, Hot S, Eğin S

Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

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

Number - Sayı 6 November - Kasım 2018

Contents - İçindekiler 563-568 Wound dehiscence after penetrating keratoplasty Penetran keratoplasti sonrası travmatik yara yeri ayrılması Şingar Özdemir E, Burcu A, Yalnız Akkaya Z, Oral B, Örnek F 569-574 The effectiveness of non-operative treatment in high-grade liver and spleen injury in children Yüksek dereceli karaciğer ve dalak hasarında nonoperatif tedavinin etkinliği Karadeniz Cerit K, Ergelen R, Abdullayev T, Tuğtepe H, Dağlı TE, Kıyan G 575-580 Is tranexamic acid safe and reliable during tibial intramedullary nailing?

Tibia kırıklarının intramedüller çivileme ile tedavisinde traneksamik asit kullanımı güvenli ve güvenilir mi?

Batıbay SG, Türkmen İ, Duman S, Çamur S, Sağlam N, Batıbay S 581-586 Can double fluoroscopy in the oblique position reduce surgical time and radiation exposure during intertrochanteric femur fracture nailing? İntertrokanterik femur kırıklarında oblik pozisyonda uygulanan femur intramedüller çivilemesi sırasında çift skopi kullanımı cerrahi süre ve skopi süresini azaltabilir mi? Çelik H, Kara A, Sağlam Y, Türkmen İ, Aykut S, Erdil M 587-593 Distribution characteristics of combat-related shrapnel and relationship to weapon type and conflict location: Experience of an operational field hospital Çatışmaya bağlı şarapnellerin dağılım karakteristikleri ile bu dağılımın silah tipi ve çatışma bölgesi ile ilişkisi: Operasyon bölgesi hastanesindeki deneyimler Akay S, Aşık MB, Eksert S

Case Reports - Olgu Sunumu 594-596 Duodenal intramural hematoma due to early postoperative anticoagulant treatment after a renal transplant: A case report Böbrek nakli sonrası erken dönemde antikoagülan kullanımına bağlı gelişen duodenum intramural hamatomu: Olgu sunumu Bayraktar A, Ercan LD, Bakkaloğlu H, Gök AFK, İlhan M, Aydın AE 597-600 The importance of clinical approach in aggravated sexual abuse: Case report Nitelikli cinsel istismarda klinik yaklaşımın önemi: Olgu sunumu Karabağ G, Tanrıverdi Hİ, Yavuz MS, Genç A, Akın U, Saraç S 601-603 Treatment with vacuum-assisted closure system: A case of anastomotic leak after upper gastrointestinal surgery Vakum yardımlı kapama sistemi ile tedavi: Üst gastrointestinal cerrahiden sonra anastomoz kaçağı olan bir olgu Eğin S, Alemdar A, Sağlam F, Güney B, Güven H

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EXPERIMENTAL STUDY

Synthetic mesh placement in the presence of abdominal infection: An experimental study of feasibility Ahmet Burak Çiftci, M.D.,1 Rıza Haldun Gündoğdu, M.D.,2 Bahadır Osman Bozkırlı, M.D.,3 Mustafa Ömer Yazıcıoğlu, M.D.,2 Berrak Gümüşkaya Öcal, M.D.,4 Birsen Özdem, M.D.5 1

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

2

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

3

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

4

Department of Pathology, Ankara Atatürk Training and Research Hospital, Ankara-Turkey

5

Department of Microbiology, Ankara Atatürk Training and Research Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: There are varying opinions on the feasibility of the placement of synthetic materials in contaminated surgical fields. The aim of this study was to investigate the outcomes of the use of a commercially available composite mesh in the presence of abdominal infection.

METHODS: Twenty-four hours after the induction of experimental peritonitis, 20 rats were randomized into 2 groups of 10 subjects. After abdominal cleansing with a second laparotomy, the abdomen was closed with running sutures in the control group and the composite mesh was applied in the experimental group before closure. The rats were followed up for findings of sepsis, mortality, and wound infection. On the 28th day, the rats were sacrificed and evaluated for abdominal infection, abdominal adhesions, and bacterial growth in the mesh and tissue cultures.

RESULTS: The mortality rate was 0% and 30% in the control and mesh groups, respectively (p=0.21), and the wound infection rate was 20% and 57.1% (p=0.162). In the mesh group, the adhesions were significantly more intense (p=0.018) and significantly more microorganisms proliferated in the tissue cultures (p=0.003).

CONCLUSION: The significant increase in the intensity of adhesions and bacterial proliferation, as well as the higher rate of mortality and wound infection in the mesh group indicated that this composite mesh cannot be used safely in the repair of abdominal defects in the presence of abdominal infection.

Keywords: Adhesion; composite mesh; infected field; mesh infection; peritonitis.

INTRODUCTION The widespread use of prosthetic materials in the repair of ventral-incisional hernias has dramatically reduced the hernia recurrence rate, and the use of prosthetic mesh has practically become the standard protocol for treatment in this field.

[1] In some situations, however, mesh infections and the formation of adhesions make the use of these prosthetic materials controversial.[2] Especially in the presence of contamination, prosthetic mesh application is avoided by most general

surgeons for fear of complications such as mesh infection, adhesion formation, enterocutaneous fistula, and intestinal obstruction. This drawback makes the management of large, contaminated facia defects caused by emergency situations a challenge.

In some published studies, the use of synthetic mesh in the presence of abdominal infection or contamination is acknowledged to be contraindicated and biologic mesh placement is recommended in these situations.[3–5] However, probably due

Cite this article as: Çiftçi AB, Gündoğdu RH, Bozkırlı BO, Yazıcıoğlu MÖ, Gümüşkaya Öcal B, Özdem B. Synthetic mesh placement in the presence of abdominal infection: An experimental study of feasibility. Ulus Travma Acil Cerrahi Derg 2018;24:501-506.

Address for correspondence: Bahadır Osman Bozkırlı, M.D. Ankara Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, 06340 Ankara, Turkey Tel: +90 312 - 595 34 37 E-mail: bbozkirli@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):501-506 DOI: 10.5505/tjtes.2018.59263 Submitted: 21.12.2016 Accepted: 11.03.2018 Online: 30.10.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Çiftci et al. Synthetic mesh for infected abdominal defects: Is it feasible?

to collagenase activity, biologic mesh loses its surface area and biomechanical characteristics in time and it may also have poor incorporation and integration, which may result in recurrence.[3,6] Furthermore, the high cost of these biologic materials is another disadvantage of these meshes when compared with synthetic materials.[3,7] Recent studies have reported some synthetic meshes to be as resistant to infection as the biologic meshes.[8–10] In emergency situations, which may result in very large, contaminated, abdominal defects, there are different opinions on the feasibility of the use of prosthetic materials for the repair of these defects. This controversy in the literature makes the placement of synthetic materials in contaminated fields a subject that remains worthy of investigation. The aim of this study was to investigate the feasibility of the use of a commercially available synthetic composite mesh (Ventralight ST; Davol Inc, subsidiary of C. R. Bard, Inc., Warwick, RI, USA), composed of an absorbable anti-adhesive barrier and a light polypropylene component, for intraperitoneal placement in the presence of experimental peritonitis.

MATERIALS AND METHODS After receiving the approval of the ethics committee for laboratory animals of Ankara Training and Research Hospital, this study was performed in the experimental research laboratory of Ankara Training and Research Hospital. Twenty male Wistar Albino rats, weighing between 250 and 300g were used for this study. The rats were kept in cages at 23ºC, with 12-hour light and dark cycles and free access to standard rat food and tap water.

After the induction of anesthesia with an injection of 80 mg/ kg of ketamine (Ketalar; Pfizer, Inc., NY, NY, USA) and 5 mg/ kg xylazine (Rompun; Bayer AG, Leverkusen, Germany), the abdominal hair of the rats was shaved. Under sterile conditions, the abdominal cavity was entered via a 3-cm, vertical, midline incision. Peritonitis was induced using the cecal ligation and puncture model.[11] The cecum was ligated distally to the ileocecal valve with a 3/0 polyglactin suture (Vycril; Ethicon, Inc., Somerville, NJ, USA) and the ligated cecum was perforated distally to the ligation with the tip of an 18-G needle. After the intestinal content was observed from the perforation site, the cecum was replaced in the abdomen and the abdomen was closed with a 4/0 polypropylene running suture (Prolene; Ethicon, Inc., Somerville, NJ, USA). The rats were then returned to their cages with free access to rat chow and water and were followed for 24 hours. At the end of the 24th hour, the subjects were randomized to 2 groups with 10 rats in each group. After the induction of general anesthesia using the aforementioned method and the application of a single intramuscular 6 mg/kg dose of gentamicin (Gensif; Avicenna Farma, Istanbul, Turkey), the rats were re-operated on under sterile conditions. To confirm peritonitis, swab cultures were taken from every quadrant of the abdomen. Necrotic cecal 502

tissue was found and resected, and the abdomen was rinsed with 20 cc of warm saline. The abdomen was then closed with a running 4/0 polypropylene suture in the first group. In the mesh group, a 4x2-cm, rectangular Ventralight ST mesh was placed intraperitoneally and fixed to the abdominal wall with 3 transmuscular 4/0 polypropylene sutures on each side.

The abdominal wall was then closed with a 4/0 polypropylene suture. The skin was closed with a 4/0 Vycril suture in both groups.

Throughout the rest of the study (28 days), the rats were observed for findings of sepsis (apathy, piloerection, diarrhea, ocular bleeding, etc.), death, and findings of wound infection.

At the end of the 28th day, the rats were sacrificed with a high-dose ketamine injection. After shearing the hair and performing skin disinfection, the abdominal cavity was entered through a wide U-shaped incision encompassing the entire previous midline incision and the mesh, if present. This flap of the abdominal wall was excised after examination of the abdomen and the abdominal wall for adhesions using the macroscopic Zühlke score by 2 blinded researchers.[12] The scoring system for the macroscopic classification of adhesions was as follows: No adhesions scored 0, filmy adhesions that were easy to separate by blunt dissection scored 1, stronger adhesions with the beginning of vascularization that partly required sharp dissection scored 2, strong adhesions only separable by sharp dissection with clear vascularization scored 3, and very strong adhesions, including abdominal organs with high risk of organ damage by dissection scored 4. Swab cultures were taken following the examination of the abdominal cavity for the presence of abdominal abscesses. The resected abdominal wall was examined for the presence of abscess formation, mesh infection, and intestinal fistula. Then, under sterile conditions, every resected tissue was divided into 2 samples for tissue culture and histological examination. The samples taken for histological examination were first fixed in 10% formalin and then stained with hematoxylin and eosin after sectioning. The sections were then examined by a blinded histologist using a light microscope at 4-40x magnification for fibrosis, inflammatory cells (lymphocyte infiltration) and angiogenesis. The scale for grading of these parameters was as follows: 0, none; 1, little/few; 2, moderate; 3, abundant. Adhesions were evaluated and scored according to the Zühlke microscopic scoring system.[12] Microscopic scoring of adhesions was as follows. Loose connective tissue, an abundance of cells, old and new fibrin, and fine reticular fibers scored 1. Connective tissue with cells, capillaries, and rare collagen fibers scored 2. Thicker connective tissue, few cells, more vessels, and few elastic and smooth muscle fibers scored 3.

Old and firm granulation tissue, few cells, and hardly distinguishable serosal layers scored 4.

Statistical Analysis Ten rats were designated to each group for a sample size that would maintain 80% power and a confidence interval of Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

Çiftci et al. Synthetic mesh for infected abdominal defects: Is it feasible?

95%. Statistical analysis was performed using SPSS for Windows, Version 11.5 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were presented as mean values±SD for continuous numerical variables, and ordinal and nominal variables were presented as numbers and percentages. The significance of the difference between the groups in terms of the intensity of adhesions was assessed using the Mann-Whitney U test.

Fisher’s exact test was used to examine the difference between nominal variables. Since the number of proliferating microorganisms in the cultures was not normally distributed, a logarithmic conversion was performed. After the logarithmic conversion, the significance of the difference between the 2 groups in terms of the number of microorganisms was examined using Student’s t-test. A p value <0.05 was accepted as statistically significant.

A diagnosis of macroscopic infection was made if 1 of the following was visualized: purulent discharge, subcutaneous abscess, enterocutaneous fistula, or mesh protrusion from the surgical wound. Although there were more macroscopic wound infections in the mesh group when compared with the control group (57.1% and 20%, respectively), this difference was not statistically significant (p=0.162). None of Table 2. Infection in the groups

Control Mesh p group group (n=10) (n=7)

n % n %

WI (SA or MA)

2

20.0

4

57.1

0.162

RESULTS

Abdominal abscess – – – – –

An abundant growth of Gram-positive (Enterococci and Staphylococci) and Gram-negative (E. coli and Proteus) bacteria in the swab cultures taken from the abdominal cavity at the end of the 24th hour after the induction of peritonitis proved the presence of bacterial contamination in both groups. All of the rats had findings of sepsis, such as apathy, piloerection, diarrhea, and ocular bleeding.

cultures after sacrifice 2 20.0 3 42.9 0.593

Proliferation in swab

MA: Mesh abscess; SA: Subcutaneous abscess; WI: Wound infection.

Table 3. Bacterial growth in the control and mesh groups

A

B*

Control group

Mortality In the first 48 hours after the second operation, 3 of the 20 subjects (15%) died. All of the rats that died were in the mesh group. However, there was no statistically significant difference between the 2 groups in terms of mortality (p=0.210).

Rat 1

None

54 cfu/mL

Rat 2

None

1.000 cfu/mL

Rat 3

None

1.433 cfu/mL

Rat 4

None

8.0581 cfu/mL

Rat 5

8 colonies of E. coli

3.827 cfu/mL

Macroscopic Adhesion Score

Rat 6

None

78 cfu/mL

The abdominal adhesions in the mesh group were significantly more intense when compared with the control group (p=0.018) (Table 1, Fig. 1).

Rat 7

None

69.629 cfu/mL

Rat 8

2 colonies of E. coli

652 cfu/mL

Rat 9

None

18.615 cfu/mL

Macroscopic Infection and Microbiological Findings

Rat 10

None

31.333 cfu/mL

Mesh group

Wound infection was macroscopically observed in 2 rats from the control group and 4 rats from the mesh group.

Rat 1

None

1.612.500 cfu/mL

Rat 2

None

1.208.727 cfu/mL

Rat 3

>100 colonies of E. coli +

11.835.333 cfu/mL

Table 1. Macroscopic Zühlke scores Intensity of adhesions

Control group Mesh group (n=10) (n=7)

Rat 4

None

1.619.470 cfu/mL

Rat 5

None

201.000.000 cfu/mL

Rat 6

>100 colonies of E. coli +

3.210.454 cfu/mL

n % n %

Grade 0

4 40.0 – –

4 40.0 – –

Grade 1 Grade 2

– – 1 14.2

Grade 3

– – 3 42.9

Grade 4

2 20.0 3 42.9

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Bacillus species

Rat 7

Bacillus species >100 colonies of E.coli + 25.782.857 cfu/mL Bacillus species

A: Bacterial growth in abdominal swab cultures taken on the day of sacrifice; B: Bacterial growth in mesh/tissue cultures. *The growth in the mesh/tissue cultures consisted of E. coli in the control group and E. coli, Enterococci, and Bacteriodes species in the mesh group. cfu: Colony forming unit.

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Figure 1. Macroscopic view of Grade 4 adhesions in the mesh group with a focus of mesh abscess near the tip of the surgical instrument

Figure 3. A section from the mesh group. Neutrophils and lymphoplasmocyte infiltration accompanied by histiocytes beneath them can be seen on the abscess wall. Hematoxylin and eosin x20 magnification.

There was bacterial growth in all of the tissue and mesh/tissue samples taken from both groups. The mean number of proliferating bacteria in the mesh/tissue cultures was 7.99±5.49 in the control group and 15.72±1.88 in the mesh group (after logarithmic conversion) (p=0.003) (Table 3).

Histopathological Findings The scores for inflammatory cell infiltration, fibrosis, and neovascularization, as well as the microscopic Zühlke scores were significantly higher in the mesh group when compared with the control group (p=0.003, p=0.005, p=0.002, and p<0.001, respectively) (Figs. 2 and 3; Table 4).

DISCUSSION Figure 2. Grade 0 adhesion in the control group (Adipocytes can be seen in the subcutaneous tissue. There are no inflammatory cells or fibrosis) Hematoxylin and eosin x4 magnification.

the rats in either of the groups demonstrated evidence of abdominal abscesses. There was also no significant difference between the groups with regard to bacterial growth in the swab cultures that were taken on the day of sacrifice (p=0.593) (Table 2).

Mesh infection after ventral hernia surgery is a substantial problem, causing a high risk of hernia recurrence and increasing the incidence of reoperation, the length of hospital stay, and the financial burden on the healthcare system.[13,14] Especially in cases with contamination (i.e., fascia defects caused by gunshot wounds, necrotizing fasciitis, cases of hernia with strangulation or intestinal perforation, parastomal hernia, etc.), there is an increased incidence of mesh infections.[8] It is asserted that among synthetic meshes, lightweight, mi-

Table 4. Histopathology scores Variables

Mesh (n=7)

p

Zühlke microscopic adhesion score

1 (0–2)

2 (2–3)

<0.001

Inflammatory cell infiltration score

1 (0–2)

2 (2–3)

0.003

Neovascularisation score

1 (0–2)

2 (2–3)

0.002

Fibrosis score

1 (0–2)

2 (1–3)

0.005

4.5 (0–7)

9 (8–11)

<0.001

Total score

504

Control (n=10)

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Çiftci et al. Synthetic mesh for infected abdominal defects: Is it feasible?

croporous, polypropylene materials have a greater tendency to be resistant to infection. Recent technological advances have enabled these lightweight polypropylene meshes to be produced without the disadvantage of decreased mechanical resistance, thereby minimizing the foreign body reaction polypropylene triggers in the body and decreasing the likelihood of infection and increasing patient comfort due to less fibrosis and rigidity.[15,16] Ventralight ST, which was used in this study, is a composite mesh with a lightweight polypropylene component and an absorbable adhesion barrier that is composed of chemically modified sodium hyaluronate, carboxymethylcellulose, and polyethylene glycol-coated polyglycolic acid fibers.[17] In this study, the feasibility of intraperitoneal synthetic mesh application in the presence of abdominal infection was investigated. The cecal ligation and perforation model was used to create bacterial peritonitis in rats and the outcomes of a control group with no mesh and a mesh group were compared.

Although there was no significant difference between the 2 groups in the macroscopic findings of infection, there was an apparent tendency for macroscopic infection in the mesh group. In studies that argue for the safety of synthetic mesh application in contaminated fields, which inspired this experimental study, the rate of mesh infection was reported to be around 20%.[8–10] Although the reasons for this marked difference between these reported results and those of the present study (57.1% macroscopic infection in the mesh group in the present study versus 20% in previous studies) may be more complicated, the authors believe that 1 possible reason may be the severity of the experimental septic peritonitis in this study.

One of the parameters that were evaluated in this experimental trial was the severity of adhesions, as adhesions are a feared complication of surgical operations performed in the presence of abdominal infections, causing significant rates of morbidity and mortality. In the present study, there were significantly more adhesions in the mesh group. This finding demonstrates that the use of synthetic materials distinctly increases adhesions in the presence of infection, and the intraperitoneal application of these materials in infected surgical fields cannot be considered sufficiently safe even with an adhesion barrier. What is more, the scores for inflammatory cell infiltration, neovascularization, and fibrosis were significantly higher in the mesh group, indicating an increased inflammatory response in the hosts with prosthetic meshes applied in the presence of infection. Although a Cochrane meta-analysis has reported the benefit of hyaluronate/carboxymethylcellulose membrane in decreasing abdominal adhesions,[18] in the present trial, it may be speculated that inflammatory reaction eliminated this anti-adhesive effect, causing increased adhesions in the mesh group.

The most interesting finding of the current study was the death of 3 rats in the mesh group (30% mortality), whereas no Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

mortality was encountered in the control group. The authors comment that this may indicate a heavier septic burden in the mesh group and that the rats in this group may have had a weaker immune defense against bacterial infection. Also, the significantly higher bacterial count in the tissue-mesh cultures in the mesh group demonstrated that the synthetic material in this group may be a suitable environment for easier bacterial growth. This was speculated to be the explanation for the higher mortality rate in the mesh group.

This study has several limitations that deserve mentioning.

First of all, there is significant difference between rats and humans with regard to the proportion of the size of the mesh and the mesh pores to the size of the abdominal wall. Also, the mesh used in this experiment was fixated with 6 sutures.

In humans, the number of fixation points in proportion to the mesh size would be much higher. These limitations mean that the findings of the present study are difficult to adapt to humans. Secondly, the completion of this study on the 28th day, and the absence of biomechanical parameters like mesh tension strength, prevent offering any opinions regarding late complications. Finally, the body concentration of the antiadhesives in the adhesion barrier and their systemic effects during breakdown in this model might be different in humans.

In conclusion, the findings of this study demonstrate that the use of this synthetic composite mesh, composed of lightweight polypropylene, hyaluronate, carboxymethylcellulose, polyethylene glycol, and polyglycolic acid, in the infected abdomen is not favorable and it is still imperative to be very selective and cautious regarding the use of synthetic materials in the presence of severe abdominal contamination. There is still a need for more experimental research with stronger statistical power that will further contribute to this subject.

Conflict of interest: None declared.

REFERENCES 1. Den Hartoq D, Dur AH, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev 2008;16:CD006438.

2. Choi JJ, Palaniappa NC, Dallas KB, Rudich TB, Colon MJ, Divino C. Use of mesh during ventral hernia repair in clean-contaminated and contaminated cases: outcomes of 33,832 cases. Ann Surg 2012;255:176–80.

3. Shankaran V, Weber DJ, Reed L, Luchette FA. A review of available prosthetics for ventral hernia repair. Ann Surg 2011;253:16–26.

4. Hiles M, Record Ritchie RD, Altizer AM. Are biologic grafts effective for hernia repair?: a systematic review of the literature. Surg Innov 2009;16:26–37.

5. Catena F, Ansaloni L, Gazzotti F, Gagliardi S, Di Saverio S, D’Alessandro L, et al. Use of porcine dermal collagen graft (Permacol) for hernia repair in contaminated fields. Hernia 2007;11:57–60.

6. Bellows CF, Shadduck PP, Helton WS, Fitzgibbons RJ. The design of an industry-sponsored randomized controlled trial to compare synthetic mesh versus biologic mesh for inguinal hernia repair. Hernia 2011;15:325–32.

7. Smart NJ, Marshall M, Daniels IR. Biological meshes: a review of their use in abdominal wall hernia repairs. Surgeon 2012;10:159–71.

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8. Carbonell AM, Cobb WS. Safety of prosthetic mesh hernia repair in contaminated fields. Surg Clin North Am 2013;93:1227–39.

9. Carbonell AM, Criss CN, Cobb WS, Novitsky YW, Rosen MJ. Outcomes of synthetic mesh in contaminated ventral hernia repairs. J Am Coll Surg 2013;217:991–8.

10. Deerenberg EB, Mulder IM, Grotenhuis N, Ditzel M, Jeekel J, Lange JF. Experimental study on synthetic and biological mesh implantation in a contaminated environment. Br J Surg 2012; 99:1734–41.

11. Hubbard J, Choudry M, Schwacha MG, Kerby JD, Rue LW 3rd, Bland KI, et al. Cecal ligation and puncture. Shock 2005;24:52–7.

12. Sortini D, Feo CV, Maravegias K, Carcoforo P, Pozza E, Liboni A, et al.

Role of Peritoneal Lavage in Adhesion Formation and Survival Rate in Rats: An Experimental Study. J Invest Surg 2006;19:291–7.

13. Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998;133:378–82.

14. Sadava EE, Krpata DM, Gao Y, Novitsky YW, Rosen MJ. Does presoaking synthetic mesh in antibiotic solution reduce mesh infections? An experimental study. J Gastrointest Surg 2013;17:562–8.

15. Li J, Ji Z, Zhang W, Li L. The comparison of lightweight mesh and standard mesh in incisional hernia repair with the open sublay technique: the results of a meta-analysis. Surg Laparosc Endosc Percutan Tech 2015;25:238–44.

16. Díaz-Godoy A, García-Ureña MA, López-Monclús J, Vega Ruíz V, Melero Montes D, Erquinigo Agurto N. Searching for the best polypropylene mesh to be used in bowel contamination. Hernia 2011;15:173–9.

17. Deeken CR, Matthews BD. Ventralight ST and Sorbafix versus Physiomesh and securestrap in a porcine model. JSLS 2013;17:549–59.

18. Kumar S, Woung PF, Leaper DJ. Intra-peritoneal prophylactic agents for preventing adhesions and adhesive intestinal obstruction after nongynaecological abdominal surgery. The Cochrane Database Syst Rev 2009;21:CD005080.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Karın içi enfeksiyon varlığında sentetik yama kullanımı: Deneysel bir uygulanabilirlik çalışması Dr. Ahmet Burak Çiftci,1 Dr. Rıza Haldun Gündoğdu,2 Dr. Bahadır Osman Bozkırlı,3 Dr. Mustafa Ömer Yazıcıoğlu,2 Dr. Berrak Gümüşkaya Öcal,4 Dr. Birsen Özdem5 Bingöl Devlet Hastanesi, Genel Cerrahi Kliniği, Bingöl Ankara Atatürk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Ankara Ankara Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Ankara 4 Ankara Atatürk Eğitim ve Araştırma Hastanesi, Patoloji Kliniği, Ankara 5 Ankara Atatürk Eğitim ve Araştırma Hastanesi, Mikrobiyoloji Kliniği, Ankara 1 2 3

AMAÇ: Sentetik malzemelerin kontamine alanlarda kullanımı ile ilgili farklı görüşler mevcuttur. Bu çalışma, ticari olarak erişilebilen kompozit yamalardan birinin karın içi enfeksiyon varlığında kullanılabilirliğini araştırmayı amaçlamaktadır.

GEREÇ VE YÖNTEM: Yirmi adet sıçanda deneysel peritonit oluşturulmasından 24 saat sonra, denekler iki adet onarlı gruba randomize edildi. İkinci bir laparotomi ile karın içinin temizlenmesini takiben karın kontrol grubunda sürekli sütürlerle, deney grubundaysa kompozit yama kullanılarak kapatıldı. Bundan sonra sıçanlar sepsis bulguları, ölüm ve yara yeri enfeksiyonu açısından takip edildi. Yirmi sekizinci günde sıçanlar sakrifiye edilerek karın içi enfeksiyon, karın içi yapışıklıklar açısından ve alınan yama ve doku örnekleri de kültür üremeleri açısından değerlendirildi.

BULGULAR: Mortalite oranları kontrol ve yama gruplarında sırasıyla %0 ve %30 (p=0.21) ve yara yeri enfeksiyonu oranları ise sırasıyla %20 ve %57.1’di (p=0.162). Yama grubunda yapışıklıklar istatistiksel olarak önemli biçimde daha yoğundu (p=0.018) ve doku kültürlerinde önemli ölçüde daha fazla mikroorganizma üremişti (p=0.003).

TARTIŞMA: Yama grubunda karın içi yapışıklıkların yoğunluğunun ve bakteri üremesinin önemli ölçüde daha fazla olması ve aynı zamanda mortalite ve yara yeri enfeksiyonu oranlarındaki artış eğilimi, bu kompozit yamanın, karın içi enfeksiyon varlığında karın defektlerinin onarımı için güvenle kullanılamayacağını göstermektedir.

Anahtar sözcükler: Enfekte alan; karın içi yapışıklık; peritonit; yama enfeksiyonu.

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doi: 10.5505/tjtes.2018.59263

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EXPERIMENTAL STUDY

Predicting critical duration and reversibility of damage in acute mesenteric ischemia: An experimental study Ayhan Aköz, M.D.,1 Kenan Ahmet Türkdoğan, M.D.,1 Nesibe Kahraman Çetin, M.D.,2 Selen Kum, M.D.,3 Ali Duman, M.D.,1 Mevlüt Türe, M.D.,4 Ahmet Ender Demirkıran, M.D.5 1

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

2

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

3

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

4

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

5

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

ABSTRACT BACKGROUND: The objective of the current study was to investigate the value of the ischemic biomarkers endothelial cell-specific molecule-1 (endocan) and signal peptide-CUB-EGF domain-containing protein-1 (SCUBE-1) in the diagnosis and assessment of earlystage and irreversible damage in acute mesenteric ischemia.

METHODS: An experimental mesenteric ischemia reperfusion model was designed using 54 rats. Nine groups were created: Three sham groups [Groups I (30th minute), IV (2nd hour), and VII (6th hour)], in which only blood and tissue specimens were sampled; 3 ischemia groups [Groups II (30th minute), V (2nd hour), and VIII (6th hour)], in which blood and tissue specimens were sampled after ligation of the superior mesenteric artery (SMA); and 3 reperfusion groups [Groups III (30th minute), VI (2nd hour), and IX (6th hour)], in which blood and tissue specimens were sampled after declamping the SMA and reperfusion for 1 hour. SCUBE-1 and endocan samples obtained from blood and tissue were examined histopathologically.

RESULTS: The SCUBE-1 level was higher in the ischemia groups when compared with the sham groups (p<0.05), and the endocan level was markedly different in the late ischemia (6th hour) group. When these 2 markers were used together to assess irreversible mesenteric damage in the histopathological examination, the sensitivity in distinguishing between reversible or irreversible damage was 94.1% with a specificity of 73.7%.

CONCLUSION: The elevation of SCUBE-1 alone seems to be significant for predicting early mesenteric ischemia in laboratory rats.

The combination of SCUBE-1 and endocan may be useful to detect irreversible intestinal damage.

Keywords: Acute mesenteric ischemia; endocan; irreversibility; signal peptide-CUB-EGF domain-containing protein-1.

INTRODUCTION Signal peptide-CUB-EGF domain-containing protein-1 (SCUBE-1) is a novel cell surface protein that contains some molecules found in alpha-granules.[1] It is translocated to the platelet surface after thrombin activation. The accumulation of SCUBE-1 has been detected in advanced atherosclerotic lesions in humans. It is considered a new platelet endothelial adhesion molecule. In acute ischemic stroke and acute coro-

nary syndrome, the mechanisms responsible for ischemic complications are platelet activation and aggregation. Dai et al.[2] demonstrated that the SCUBE-1 protein can be a good marker for acute thrombotic diseases. It is detectable within 6 hours of the onset of ischemic symptoms. Endothelial cell– specific molecule 1 (endocan) is a new biomarker of endothelial dysfunction.[3] It is a soluble dermatan sulfate proteoglycan which is primarily secreted by vascular endothelial cells.[4] Endocan plays a key role in the pathophysiology of endothelial

Cite this article as: Aköz A, Türkdoğan KA, Kahraman Çetin N, Kum S, Duman A, Türe M, et al. Predicting critical duration and reversibility of damage in acute mesenteric ischemia: An experimental study. Ulus Travma Acil Cerrahi Derg 2018;24:507-513.

Address for correspondence: Ayhan Aköz, M.D. Adnan Menderes Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, 09100 Aydın, Turkey Tel: +90 256 - 212 18 50 E-mail: akozayhan@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):507-513 DOI: 10.5505/tjtes.2018.69710 Submitted: 06.10.2017 Accepted: 21.06.2018 Online: 08.11.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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dysfunction through its role in regulating physiological and pathological disorders.[5,6] Although not common, acute mesenteric ischemia (AMI) is a lethal vascular emergency. If it is not treated effectively and promptly, it may cause ischemia, or even infarction. In the past decade, several large clinical series have reported high mortality rates of 30% to 65%.[7,8] However, the optimal surgical management is still debated and deserves a clear recommendation based on a higher level of evidence.[9] The ability to catch patients in the reversible period could increase the chances of success, and decrease mortality and morbidity.

The objective of the current study was to investigate the role of SCUBE-1 and endocan, which can help make a diagnosis of ischemic events at different times, and to determine their power in distinguishing cases in which the damage is still reversible.

MATERIALS AND METHODS Animals A total of 54 female Wistar albino rats weighing between 220 and 250 g were used in the study. The research was conducted after receiving the approval of the animal ethics committee (64583101/2016/006). The rats were housed at room temperature (20±2°C) in a 12-hour daylight/dark environment, fed with standard food pellets, and allowed free access to water in individual cages.

Experimental Protocol In all, 54 rats were used to design an experimental mesenteric ischemia reperfusion model. There were a total of 9 groups in the study. Three of these groups were sham groups [Groups I (30th minute), IV (2nd hour), and VII (6th hour)], from which only blood and tissue specimens were sampled. There were 3 ischemia groups [Groups II (30th minute), V (2nd hour), and VIII (6th hour)], in which blood and tissue specimens were sampled after ligation of the superior mesenteric artery (SMA). The remaining 3 groups were reperfusion groups [Groups III (30th minute), VI (2nd hour), and IX (6th hour)], in which blood and tissue specimens were sampled after the SMA was declamped and reperfusion was induced for 1 hour.

SCUBE-1 and endocan retrieved from the blood samples and tissue samples were examined histopathologically.

Blood taken from the rats was centrifuged at 3500 rpm for 10 minutes. The serum was collected and stored at –80°C until further analysis.

SCUBE-1 An enzyme-linked immunosorbent assay (ELISA) kit (Sunlong Biotech Co., Ltd., Hangzhou, Zhejiang, China) designed for rats was used to determine the SCUBE-1 level in the serum samples. The test results were calculated using a bio-ELISA 508

reader (DARx800; Calabasas, USA) using a standard curve of 450 nm. The limit to detect SCUBE-1 was 0.01 ng/mL, and the assay range was 0.1-7 ng/mL. All of the procedures were performed according to the manufacturer’s instructions.

Endocan A commercial Sunlong Biotechrat ELISA kit, (Sunlong Biotech Co., Ltd., Hangzhou, Zhejiang, China) was used to determine the endocan ESM-1 level in the serum samples. The test results were calculated using a bio-ELISA reader (DARx800; Calabasas, USA) using a standard curve of 450 nm and a limit of 0.01 ng/mL. The assay range was 0.1-8 ng/mL for endocan ESM-1. All of the procedures were performed according to the manufacturer’s instructions.

Histopathological Evaluation For the histopathological examination, small intestine tissues were collected from all of the groups. They were fixed in 10% formaldehyde for 48 hours. Following fixation, ileum specimens were dehydrated in an ascending alcohol series (70, 90, 96, 100%), clarified with xylene and embedded in paraffin wax. Using a fully automatic microtome, 4-um sections were taken from the paraffin blocks and stained with hematoxylin and eosin. An experienced pathologist who was blind to the study groups used a light microscope for the histological examination of the preparates. All of the ileum tissue slides were examined at high magnification. Five different areas of the preparates from each group were evaluated at a magnification of x100. Mucosal injury was rated according to the classification systems described by Chiu et al.:[10] Grade 0: Normal mucosa.

Grade 1: Subepithelial spaces at villus top due to capillary congestion Grade 2: Expansion of subepithelial space with moderate lifting of epithelial layer Grade 3: Massive epithelial detachment with occasional hemorrhage Grade 4: Denuded villi with dilated capillaries Grade 5: Disintegration of lamina propria, ulceration, and hemorrhage.

Statistical Evaluation Descriptive statistics of the categorical variables were demonstrated in numbers (%) and chi-square tests were used for the comparison of groups. The Kolmogorov-Smirnov test was used to test whether continuous variables were normally distributed. Since endocan and SCUBE-1 were normally distributed, descriptive statistics were shown as the average±SD, and one-way analysis of variance (ANOVA) and independent samples t-tests were used to compare groups and time. The Bonferroni correction was used as a multiple comparison test. Descriptive statistics of i-scores not normally distributed were presented as the median (25%–75%), and the Mann-Whitney U-test and Kruskal-Wallis ANOVA tests were used to compare groups and time.

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Table 1. Table of average endocan and SCUBE-1 level of the study groups in terms of time

Time

Sham (Group I, IV, VII)

Ischemia (Group II, V, VIII)

Reperfusion (Group III, VI, IX)

2.12±0.19

1.96±0.19

2.15±0.20

30th minute

Endocan (Mean±SD)

2 hour 1.99±0.18 2.17±0.27 2.24±0.17 nd

6th hour

2.01±0.04

2.49±0.33

2.36±0.24

SCUBE 1 (Mean±SD)

1.37±0.20

1.17±0.09

1.49±0.23

30 minute th

2nd hour 1.25±0.16 1.44±0.21 1.71±0.40 6th hour

1.16±0.16

1.62±0.16

1.69±0.28

Endocan: Endothelial cell-specific molecule-1; SCUBE-1: Signal peptide-CUB-EGF domain-containing protein 1; SD: Standard deviation.

Receiver operating characteristic (ROC) analysis and a classification and regression tree (CART) analysis were performed for SCUBE-1 and endocan to be able to distinguish between normal-ischemia and reversibility-irreversibility. The sensitivity and specificity values were calculated according to the section points obtained.

minute 30 (p=0.206); however, SCUBE-1 was statistically significant (p=0.028). This difference occurred between ischemia and reperfusion groups. While endocan levels at the second hour were not found to be significant (p=0.131), SCUBE-1 was significantly different (p=0.036). This difference was seen between sham and reperfusion groups. Both endocan and SCUBE-1 were found to be significantly different in groups at the 6th hour (p=0.034, p=0.001, respectively). While the significant difference in endocan was seen between sham and ischemia groups, the significance in SCUBE-1 was observed between both sham-ischemia and sham-reperfusion groups.

The association between groups, ischemia-reperfusion data, and time variables were analyzed using multiple correspondence analysis. Pearson correlation analysis was conducted to determine the association between continuous variables.

The preparates were given ischemia scores between 0 and 5 histopathologically and grouped as normal or ischemic.

Endocan and SCUBE-1 levels were used to determine these groups. Both endocan and SCUBE-1 were statistically significantly distinguishable between normal and ischemic preparates (p=0.015, p=0.002, respectively). ROC analysis

RESULTS Endocan and SCUBE-1 levels were compared between the sham (Group 1), ischemia (Group 2), and reperfusion (Group 3) groups at 30 minutes, 2 hours, and 6 hours (Table 1 and Fig. 1). Endocan was not found to be statistically significant at

Variable Groups Endocan 1 Endocan 2 Endocan 3 Scube 1 1 Scube 1 2 Scube 1 3

3.0

Levels of Marker

2.5

2.0

1.5

ur s

3

6

ho

in

ur s

m

ho

2

30

Sc

ub e

1

2

6

ho

ur s

ur s

in m

ho

2

30

ur s

ur s 1

6

ho

in m

2

30

ho

ur s

ur s 3

6

ho

in m

ho

30

2

En

do c

an

2

6

ho

ur s

ur s

in m

ho

30

2

1

m

2

30

Groups

ho

in

Time

ur s 6 ho ur s

1.0

Figure 1. Average endocan and SCUBE-1 level of the study groups in terms of time. Endocan: Endothelial cell-specific molecule-1; SCUBE-1: Signal peptide-CUB-EGF domain-containing protein 1.

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Table 2. The average ischemia score of the ischemia and reperfusion groups at the 30th minute, 2nd hour,

and 6th hour Time

Ischemia Reperfusion

30th minute

2 (1–2.25)

2 (1–3)

2 hour

3.5 (3–4.25)

3.5 (3–5)

6th hour

5 (4–5)

5 (4–5)

nd

Reperfusion

30 min

6 hr

0.5

Dimension 2

Sham

0.0

Reversible

Irreversible

-0.5

2 hr

-1.0

Ischemia Groups Reversible/Irreversible Time

-1.0

-0.5

0.0 0.5 Dimension 1

1.0

(b)

When all of the preparates from the 30th minute, 2nd hour, and 6th hour, which were given ischemia scores between 0 and 5 histopathologically, were compared in terms of ischemia and reperfusion groups, no statistically significant difference was found. When the ischemia scores of the ischemia group were compared in terms of time, there were significant differences between the 30th minute and 2nd hour, and the 30th minute and 6th hour (p=0.002). When the ischemia scores of the reperfusion group were compared in terms of time, there were significant differences between the 30th minute and 2nd hour, and the 30th minute and 6th hour (p=0.002) (Table 2).

According to multiple correspondence analysis results, there was a tendency to sham and reversible at 30th minute, ischemia at the second hour, and reperfusion and irreversible ischemia at the sixth hour (Fig. 2).

Both ROC and CART analyses were conducted to find out the power of endocan and SCUBE-1 in determining preparates grouped as reversible (Figs. 3a-c and 4a) and irreversible (Fig. 4b and c) according to ischemia score.

1.5

Figure 2. The distribution of preparates according to the results of multiple correspondence analysis.

(a)

results indicated that an endocan cut-off value of 2.09 had a sensitivity of 75.7% and a specificity 75%. A SCUBE-1 cut-off value of 1.46 had a sensitivity of 64.9% and a specificity of 87.5%. The positive likelihood ratio (+LR) and negative likelihood ratio (–LR) values of endocan and SCUBE-1 were 3.28 and 0.32, and 5.20 and 0.40, respectively.

According to ROC analysis results (Fig. 5), the cutoff value of endocan was 2.18 with an area under the curve (AUC) of 0.870 (p<0.0005), while the cutoff value of SCUBE-1 was

(c)

Figure 3. (a) Normal intestinal mucosa in the sham group: Grade 0 (1st Group, 30th minute) (H&E; x100). (b) Almost normal intestinal mucosa, subepithelial spaces at the top of villi (blue arrows): Grade 1 (4th Group ischemia, 30th minute) (H&E; x100). (c) Subepithelial elevation (red arrow): Grade 2 (7th Group reperfusion, 30th minute) (H&E; x100).

(a)

(b)

(c)

Figure 4. (a) Massive epithelial detachment (green arrow) and a few damaged villi (yellow arrow): Grade 3 (8th Group reperfusion, 2nd hour) (H&E; x100). (b) Damaged villi with dilated capillaries (black arrow): Grade 4 (6th Group ischemia, 5th hour) (H&E; x100). (c) Disintegration of lamina propria, ulceration, and hemorrhage (blue arrows): Grade 5 (6th Group ischemia, 6th hour) (H&E; x100).

510

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1.48 with an AUC of 0.882 (p<0.0005). The sensitivity and specificity of endocan and SCUBE-1 grouped according to cutoff value to distinguish reversible-irreversible were 76.5% and 94.7%, and 79.4% and 89.5%, respectively. The +LR and –LR values of endocan and SCUBE-1 were 14.43 and 0.24 and 7.56 and 0.22, respectively.

1.0

Sensitivity

0.8

In CART analysis, the cutoff values of SCUBE-1 and endocan were determined to be 1.61 and 2.18, respectively, using a Gini index. With this analysis, all 19 preparates could be determined (Fig. 6). When these 2 markers were used together, the sensitivity in distinguishing between reversible and irreversible damage was 94.1%, and the specificity was 73.7%.

0.6

0.4

0.2

DISCUSSION

Endocan Scube 1 0.0 0.0

0.2

0.4 0.6 1 - Specificity

0.8

1.0

Figure 5. Receiver operating characteristic analysis conducted to find out the power of endocan and SCUBE-1 to determine preparates grouped as reversible and irreversible according to ischemia score. Endocan: Endothelial cell-specific molecule-1; SCUBE-1: Signal peptide-CUB-EGF domain-containing protein 1.

Groups Node 0 % n Category Reversible 64.2 34 Irreversible 35.8 19 Total 100.0 53

Reversible Irreversible

SCUBE 1 Improvement=0.231

>1.610

<=1.610 Node 1 Category Reversible Irreversible Total

% n 86.5 32 13.5 5 69.8 37

Node 2 Category % n Reversible 12.5 2 Irreversible 87.5 14 Total 30.2 16

ENDOCAN Improvement=0.053

<=2.180 Node 3 Category %

>2.180

n

Reversible 100.0 25 Irreversible 0.0 0 Total 47.2 25

Node 4 Category % Reversible Irreversible Total

n

58.3 7 41.7 5 22.6 12

Figure 6. Classification and regression tree analysis of SCUBE-1 and endocan according to Gini index. Endocan: Endothelial cellspecific molecule-1; SCUBE-1: Signal peptide-CUB-EGF domaincontaining protein 1.

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Generally, 2 questions occur to a clinician who comes across a case that is thought to be AMI. First, how can I find the correct diagnosis? Second, is it too late for successful therapy? In the literature, different biochemical markers, such as D-lactate, D-dimer, and intestinal fatty acid-binding protein (I-FABP) have been studied to diagnose AMI.[11–13] However, there is still no test that has provided completely satisfying results. SCUBE-1 was researched in 1 study as a predictor in the diagnosis of AMI, but to our knowledge, endocan has not been studied for this purpose.[14] This is the first study to evaluate both markers together and to attempt to determine histopathologically whether they might indicate if the damage that has occurred as a result of AMI is reversible or irreversible. We found that a low level of endocan and elevated SCUBE-1 seem to be significant for predicting early mesenteric ischemia and that irreversible intestinal damage can be detected using a combination of SCUBE-1 and endocan.

Platelet activation and endothelial damage play a critical role in different stages of AMI. SCUBE-1 has been identified in previous studies as a new platelet-endothelial secreted protein, the level of which rises with platelet activation.[1,2] The role of SCUBE-1 has been investigated in some ischemic diseases (e.g., acute coronary syndrome, acute ischemic stroke). Dai et al.[2] reported that in acute ischemic stroke and acute coronary syndrome plasma, SCUBE-1 concentration was significantly elevated. In addition, Dai et al.[2] found that while the plasma SCUBE-1 level may not be a sensitive marker for acute stroke and coronary syndrome, it might be a good marker of platelet activation in acute thrombotic disease. Turkmen et al.[14] reported that the SCUBE-1 level may be used in the early diagnosis of AMI; however, they noted that further studies are required. They found both histopathological differences at the 30th minute and differences in an ischemia group compared with a sham group in terms of SCUBE-1, but they did not present sensitivity or specificity data. In our study, there were histopathological differences 511

Aköz et al. Predicting critical duration and reversibility of damage in acute mesenteric ischemia

at the 30th minute in sham, ischemia, and reperfusion groups; however, there were no differences in SCUBE-1 and endocan when compared with the sham group (p<0.05). Differences were present at the second hour in the sham-reperfusion SCUBE-1 group, at the sixth hour in the sham-ischemia and sham-reperfusion SCUBE-1 groups, and in the sham-ischemia endocan group. Histopathological differences could be observed as early as the 30th minute and significantly measured at the sixth hour. The results of our study are consistent with the results described by Türkmen et al. We also believe that SCUBE-1 has the potential to be used as a predictor to demonstrate ischemic harm in AMI at the 30th minute; however, we cannot say that it is completely sufficient to make an early and definitive diagnosis.

In AMI diagnosis studies conducted with d-dimer, lactate, and I-FABP, many sensitivity and specificity values have been found.[15] Various cutoff levels for these markers have been reported. Recognized cutoff levels are needed for markers that may be of use for AMI, such as those already established for other diseases, such as the troponin level in acute myocardial infarction.[16,17] Lactate, the concentration of which can lead to metabolic acidosis, has been investigated as a predictive marker in the diagnosis of ischemia. A study showed that in AMI, lactate was 100% sensitive and 42% specific.[18] In another experimental study, when compared with the sham group, there was a significant increase in plasma lactate in the SMA of the mesenteric ischemia group.[18,19] However, Acosta et al.[20] examined patients who were exposed to ischemia for different periods and at different degrees in terms of lactate level and found no statistically significant difference, concluding that lactate levels could not be used as an early diagnostic marker.

Our purpose in adding endocan to SCUBE-1, which is activated by platelet aggregation, was to estimate the condition in the endothelial area. Qui et al.[21] showed that in patients with acute myocardial infarction, endocan may be used to evaluate endothelial dysfunction. Detecting the endocan level early may be useful in identifying individuals at high risk and thus allowing for early intervention to reduce the prevalence of AMI. Su et al.[22] found that endocan production was significantly increased in the 6-72-hour period. In our study, endocan was significantly elevated in the ischemia group when compared with the sham group at the sixth hour. This demonstrates that, while like SCUBE-1, endocan has the potential to be used as a predictor in determining damage in AMI, because the results take longer to appear than SCUBE-1, it cannot be said to be a completely sufficient marker for an early and definitive diagnosis.

Before starting treatment in AMI patients, knowledge about whether the damage is reversible or irreversible in cases considered for surgical treatment can be a useful guide for the clinician. In our study, the endocan and SCUBE-1 +LR and–LR 512

values were 14.43 and 0.24, and 7.56 and 0.22, respectively, in the classification of reversible-irreversible groups based on histopathological grading. The correlation coefficient of endocan and SCUBE-1 was 0.62 (p=0.0005). When these 2 markers were evaluated with CART analysis, the +LR and– LR values were 3.16 and 0.08, respectively. According to this analysis, these markers strongly excluded irreversible cases.

All 25 reversible cases of the 53 preparates were identified when an endocan <2.18 cutoff was used with SCUBE-1 <1.61 (Fig. 6).

The primary limitation of this study is the exclusion of other significant markers. The second limitation is the fact that it was research based on an animal model. Thirdly, hydration, particularly at the sixth hour, may have influenced marker levels.

In conclusion, although we cannot state definitively that they can be used in early diagnosis, the SCUBE-1 level appears to have the potential to be an early-stage damage marker in AMI. When SCUBE-1 and endocan are studied together according to cutoff values, a reversible-irreversible distinction can be made. However, more extensive studies are needed to fully see the potential practical applications.

Conflict of interest: None declared.

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2. Dai DF, Thajeb P, Tu CF, Chiang FT, Chen CH, Yang RB, et al. Plasma concentration of SCUBE1, a novel platelet protein, is elevated in patients with acute coronary syndrome and ischemic stroke. J Am Coll Cardiol 2008;51:2173–80.

3. Balta S, Mikhailidis DP, Demirkol S, Ozturk C, Kurtoglu E, Demir M, et al. Endocan-a novel inflammatory indicator in newly diagnosed patients with hypertension: a pilot study. Angiology 2014;65:773–7.

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Aköz et al. Predicting critical duration and reversibility of damage in acute mesenteric ischemia 11. Assadian A, Assadian O, Senekowitsch C, Rotter R, Bahrami S, Fürst W, et al. Plasma D-lactate as a potential early marker for colon ischaemia after open aortic reconstruction. Eur J Vasc Endovasc Surg 2006;31:470–4 12. Acosta S, Nilsson TK, Björck M. D-dimer testing in patients with suspected acute thromboembolic occlusion of the superior mesenteric artery.

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DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut mezenterik iskemi hasarının kritik zaman tahmini ve reversibilitesi Dr. Ayhan Aköz,1 Dr. Kenan Ahmet Türkdoğan,1 Dr. Nesibe Kahraman Çetin,2 Dr. Selen Kum,3 Dr. Ali Duman,1 Dr. Mevlüt Türe,4 Dr. Ahmet Ender Demirkıran5 Adnan Menderes Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Aydın Adnan Menderes Üniversitesi Tıp Fakültesi, Patoloji Anabilim Dalı, Aydın 3 Adnan Menderes Üniversitesi Tıp Fakültesi, Histoloji Anabilim Dalı, Aydın 4 Adnan Menderes Üniversitesi Tıp Fakültesi, Biyoistatistik Anabilim Dalı, Aydın 5 Adnan Menderes Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Aydın 1 2

AMAÇ: Bu çalışmada akut mezenterik iskemide yeni iskemik biyobelirteçler olan endocan ve SCUBE-1’in erken evre hasar, tanı ve irreversibıl hasar değerlerini araştırmayı amaçladık.

GEREÇ VE YÖNTEM: Elli dört sıçan ile deneysel bir mezenterik iskemi reperfüzyon modeli tasarlandı. Dokuz grup oluşturuldu: Kan ve doku örneklerinin sadece örneklendiği üç sahte grup [Grup I (30. dakika), IV (2. saat) ve VII (6. saat)]; superior mezenterik arter (SMA) bağlandıktan sonra kan ve doku numuneleri örneklenen üç iskemi grubu [Grup II (30. dakika), V (2. saat) ve VIII (6. saat)]; ve SMA dekompresyonundan sonra kan ve doku numuneleri örneklendirilen ve reperfüzyon bir saat süreyle indüklenen üç reperfüzyon grubu [Grup III (30. dakika), VI (2. saat) ve IX (6. saat)].

SCUBE-1 ve endocan için kan örnekleri alındı ve histopatolojik olarak doku örnekleri incelendi.

BULGULAR: SCUBE-1 düzeyleri iskemi grubunda sahte gruba göre daha yüksek iken (p<0.05), geç iskemi (6. saat) grubunda endocan düzeyleri belirgin olarak farklıydı. Bu iki belirteç, histopatolojik incelemeye göre irreversıble mezenterik hasar için birlikte kullanıldığında, reversible-irrreversible hasar ayırımını %94.1 sensitivite, %73.7 spesifite ile belirledi.

TARTIŞMA: SCUBE-1’in tek başına yükselmesi laboratuvar sıçanlarında erken mezenterik iskemiyi öngörmede önemli olarak gözükmektedir. Bununla birlikte, SCUBE-1 ve endocan eş zamanlı kullanımı irreversible bağırsak hasarının tespitinde daha kullanılışlı olabilir.

Anahtar sözcükler: Akut mezenter iskemi; endocan; irreversibilite; SCUBE 1.

Ulus Travma Acil Cerrahi Derg 2018;24(6):507-513

doi: 10.5505/tjtes.2018.69710

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ORIG I N A L A R T IC L E

Impact of ureteral access sheath force of insertion on ureteral trauma: In vivo preliminary study with 7 patients Tzevat Tefik, M.D.,1,5 Salvatore Buttice,2,5 M.D., Bhaskar Somani, M.D.,3,5 Selçuk Erdem, M.D.,1 Tayfun Oktar, M.D.,1 Faruk Özcan, M.D.,1 Taner Koçak, M.D.,1 İsmet Nane, M.D.,1 Olivier Traxer, M.D.4,5 1

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

2

Department of Urology, San Giovanni di Dio Hospital, Contrada Consolida, Agrigento-Italy

3

University Hospital Southampton NHS Trust, University of Southampton, Southampton-UK

4

Sorbonne Université, GRC n°20 LITHIASE RENALE, AP-HP, Hôpital Tenon, Paris-France

5

PetraUroGroup, Paris-France

ABSTRACT BACKGROUND: Ureteral access sheaths (UASs) are commonly used in retrograde intra-renal surgery (RIRS). Despite their advantages, there is a risk of ureteral trauma during their placement and subsequent stricture following surgery. The aim of this study was to evaluate the UAS force of insertion (FOI) during placement and its impact on ureteral trauma.

METHODS: Seven female patients who underwent RIRS for kidney stones were included in the study. A digital force gauge (Chatillon DFX II; Ametek Test and Calibration Instruments, Largo, Florida, USA) was connected to the distal end of the UAS and the UAS FOI was continuously measured during insertion. UASs of different sizes were used and ureteral injury was evaluated under direct vision with the Post-Ureteroscopic Lesion Scale (PULS) score.

RESULTS: Five pre-stented patients and 2 non-stented patients were included in the study. The size of the UASs used in non-stented patients was 9.5/11.5-F and 10/12-F, whereas one 11/13-F and four 12/14-F sheaths were used in the pre-stented patients. The highest maximal UAS FOI observed was 5.9 Newton (N) in a pre-stented patient with a 12/14-F UAS, where a second attempt was performed after initial failure. The lowest maximal UAS FOI was 0.91 N in a non-stented patient using a 9.5/11.5-F UAS. A semirigid ureteroscopy with a 7.8-F sheath was performed in this patient prior UAS placement. The PULS score was 1 in the 2 non-stented patients and 0 in all of the pre-stented patients.

CONCLUSION: In this small cohort, a preoperative JJ stent seemed to protect the ureter, even with larger diameter UASs of 12/14F. Non-stented RIRS with a UAS is possible, but may cause low-grade ureteral trauma.

Keywords: Force of insertion; retrograde intra-renal surgery; ureteral access sheath.

INTRODUCTION Since their first introduction in 1974, ureteral access sheaths (UASs) have commonly been used to facilitate entry of ureteroscopes into the ureter.[1] Technological advancement led to a hydrophilic coating for UASs that decreased the

shear force and made the passage smoother.[2] This increase in safety resulted in wide use of UASs, especially during retrograde intra-renal surgery (RIRS) to treat kidney stones and upper tract urothelial carcinoma. UASs are now primarily used because they facilitate multiple passes of the ureteroscope into the renal collecting system and reduce intra-renal

Cite this article as: Tefik T, Buttice S, Somani B, Erdem S, Oktar T, Özcan F, et al. Impact of ureteral access sheath force of insertion on ureteral trauma: In vivo preliminary study with 7 patients. Ulus Travma Acil Cerrahi Derg 2018;24:514-520.

Address for correspondence: Professor Olivier P Traxer, M.D. Sorbonne Université, GRC n°20 Lithiase renale, AP-HP, Hôpital Tenon, F-75020 Paris, France.

Hôpital Tenon, 4 rue de la Chine 75020 Paris, France Tel: 01.56.01.61.53 E-mail: olivier.traxer@aphp.fr Ulus Travma Acil Cerrahi Derg 2018;24(6):514-520 DOI: 10.5505/tjtes.2018.15263 Submitted: 19.10.2018 Accepted: 24.10.2018 Online: 30.10.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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pressure by improving irrigation.[3,4] Some authors have reported protection of endoscopes and others have claimed improvements in visibility with UAS use.[5,6] Moreover it has been said to protect the ureter when extracting multiple stone fragments.[7] Even though improvements in stone-free rates have been reported, there seems to be a lack of consensus on the topic.[8–10] Despite their advantages, there are some important drawbacks to UAS use. They may decrease ureteral blood flow and induce long-term ureteral stricture formation.[11,12] UAS usage also increases the overall cost of the procedure.[13] As it is not positioned under direct vision, it may by-pass small stone fragments or tumors.[14] Furthermore, UASs have the potential to damage the flexible scope if a small fragment becomes entrapped between the shaft of the scope and the inner wall of the UAS.[15] Injury of the ureteral wall and severe ureteral trauma have been associated with excessive UAS insertion force.[16,17] The aim of this preliminary study was to report the force of insertion (FOI) during placement of UAS and its impact on ureteral injury.

(Chatillon DFX II; Ametek Test and Calibration Instruments, Largo, FL, USA) with the capability for readability from 0.01 to 50 Newton (N) at a millisecond frequency during placement (Fig. 1). Specifically, one end of the load cell was fixed with 30° to 35° to the UAS proximal shaft. The other end of the load cell was held by the surgeon, where they would apply the necessary force for UAS placement to the load cell (Fig. 2). The load cell transmitted the pressure to the force gauge, continuously measuring and recording the FOI. All insertions were performed by a single surgeon (TT).

Surgical Procedure All of the patients were placed in the lithotomy position under general anesthesia and the FOI was recorded by a single technician (ST). Each procedure began with the placement of two 0.035-inch polytetrafluoroethylene-coated wires using a semi-rigid ureteroscope, 1 safety guidewire and 1 working guidewire in the renal pelvis. The orifice was marked using

MATERIALS AND METHODS Patients A total of 7 patients who were to undergo therapeutic RIRS for kidney stones were recruited for this prospective cohort study. All of the patients were female and more than 18 years of age. Female patients were recruited for the cohort in order to avoid male urethral resistance in the UAS FOI measurements. The exclusion criteria were male gender, ureteral stricture disease, and use of medications for ureteral relaxation or anticoagulant treatment. All of the patients provided informed consent to undergo a RIRS procedure as per the principles of the Declaration of Helsinki consent process.

Measurement of Ureteral Access Sheath Force of Insertion The distal part of the UAS was fixed to a load cell and the FOI was continuously recorded with a digital force gauge

Figure 4. Digital force gauge (Chatillon DFX II; Ametek Test and Calibration Instruments, Largo, Florida, USA) used to measure force of insertion during placement.

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Figure 2. Insertion of a ureteral access sheath (UAS). One end of the load cell is fixed at a 30-35° angle to the proximal shaft of the UAS. The surgeon holds the instrument on the other end of the load cell. The force of insertion from the surgeon’s hand is applied directly to the load cell. The surgeon does not touch the UAS.

Figure 3. X-ray images during ureteral access sheath force of insertion measurement taken from the ureteral orifice until reaching the proximal ureter as confirmed with fluoroscopy.

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fluoroscopy. Then the tip of the inner dilator of the UAS was placed just at the ureteral orifice through the guidewire and confirmed with fluoroscopy. Subsequently, the load cell was fixed to the UAS. Recording was initiated at the ureteral orifice and continued until the placement of the UAS at the proximal ureter (Fig. 3). UASs of various sizes were used.

Following the surgery, the ureter was examined ureteroscopically after removing the UAS under direct vision. Ureteral injury was evaluated by the surgeon using Post-Ureteroscopic Lesion Scale (PULS) scoring.18 A PULS grade 0 included mucosal contusions with minimal hematoma, grade 1 was a superficial tear of the mucosa, grade 2 was a deep tear of the mucosal and submucosal layers without contrast media extravasation, grade 3 was a localized perforation with contrast media extravasation, grade 4 was more than 50% transection of the ureter, and grade 5 was complete ureteric avulsion.[18] JJ stents were placed in all patients and removed after 1 to 3 weeks. All of the patients underwent renal ultrasonography (kidneys, ureters, and bladder) to determine the presence of any residual fragments or hydronephrosis.

RESULTS All of the RIRS operations were performed for kidney stones and were completed successfully. The median age of the patients was 46 years (interquartile range: 34–65 years). The stone location was in the lower calyx (n=3), pelviureteric junction (n=3), and the mid calyx (n=1), with a mean stone size of 11.7±1.8 mm. The median American Society of Anesthesiologists score was II. The patients’ demographic data and stone characteristics are shown in Table 1. Rocamed Bi-Flex (Rocamed, Monaco), Boston Scientific Navigator HD (Boston Scientific Corp., Marlborough, MA, USA), Cook Flexor (Cook Medical, Inc., Bloomington, IN, USA), and Olympus UroPass (Olympus Corp., Tokyo, Japan) were the 4 brands of UAS used. The UASs took an average of 9.9±2.6 seconds to place with an average maximum FOI and load of 2.4±1.7 N and 1.2±0.6 N, respectively. The UAS FOI and PULS scores are given in Table 2.

Of the patients listed in Table 1, patient (Pt) 1 and Pt 7 had no preoperative JJ stent (Table 1). The maximum and aver-

Table 1. Demographic data of patients and stone characteristics Patients

Age

Gender

Stone location

Stone size (mm)

Laterality

Body mass index

ASA score

1

65

Female

Ureteropelvic junction

11

Left

35.9

4

2

41

Female

Middle calyx

24

Right

28.9

1

3

34

Female

Upper calyx

31

Left

23.4

1

4

51

Female

Lower calyx

12

Left

36.3

3

5

29

Female

Lower calyx

13

Left

29

1

6 78 Female Ureteropelvic junction 10 Right 32 4 7

46

Female

Lower calyx

11

Right

31.2

2

ASA: American Society of Anesthesiologists.

Table 2. Ureteral access sheath and force of insertion data of patients and ureteral lesion scores Patients UAS brand UAS size Preop Preop Success Insertion Max Average PULS Stone

(F) JJ URS time load load score free

(sec) (N) (N) 1 Rocamed® Bi-Flex™

10/12

No

No

1. attempt

15

1.9

1.88

1

Yes

2

Boston Scientific

11/13

Yes

No

1. attempt

9

1.78

0.75

0

No

Navigator™ HD

3

Cook Flexor®

12/14

Yes

No

1. attempt

8.5

0.98

0.69

0

No

4

Cook Flexor

12/14

Yes

No

1. attempt

11.5

2.11

0.75

0

Yes

5

Olympus UroPass®

12/14

Yes

No

1. attempt

10

3.02

1.56

0

Yes

®

6

Cook Flexor

12/14

Yes

No

1. attempt

–

3.48

1.71

0

Yes

6

Cook Flexor®

12/14

Yes

No

2. attempt

7

5.9

1.85

0

Yes

7

Cook Flexor

9.5/11.5

No

7.8 F

1. attempt

8.5

0.91

0.57

1

No

®

®

PULS: Post-Ureteric Lesion Scale; UAS: Ureteral access sheath; UVJ: Ureterovesical junction. Rocamed (Rocamed, Monaco), Boston Scientific Navigator HD (Boston Scientific Corp., Marlborough, MA, USA), Cook Flexor (Cook Medical, Inc., Bloomington, IN, USA), and Olympus UroPass (Olympus Corp., Tokyo, Japan).

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age FOI with 10/12-F UAS for Pt 1 was 1.9 N and 1.88 N, respectively. Patient 7 had a narrow ureteric orifice and a rigid ureteroscopy with a 7.8-F ureteroscope was performed before inserting the UAS, thus passively dilating the ureter.

After the ureteroscopy, the maximum and average FOI with 9.5/11.5-F UAS for Pt 7 was 0.91 N and 0.57 N. respectively, (Fig. 4). A PULS score of 1 was observed in Pt 7.

The remaining 5 patients had JJ stents preoperatively. The gauge recorded no force after the ureterovesical junction (UVJ) until the beginning of the proximal ureter in Pt 2. Patient 3 had the lowest FOI among the pre-stented patients. with a maximum and average load of 0.98 and 0.69 N, respectively. Patient 4â&#x20AC;&#x2122;s FOI graphic had demonstrative peaks at the ureteral narrow points (Fig. 5).

Pt 6, who was pre-stented, had 2 UAS insertion attempts.

The first attempt was not successful, despite attempts at 3

(a)

Load (N)

6.0

consecutive force levels being applied in 3 seconds (Fig. 6a).

The inner dilator of the UAS was in the distal ureter, but the sheath could not be inserted through the orifice. The UAS was pulled back and ultimately insertion was successful with a more forceful attempt. The FOI applied was doubled and there was a resistance of approximately 6 N, which was relieved after passing through the orifice entrance. Figure 6b demonstrates the pattern of peaks, a lower FOI at the VUJ and proximal ureter, compared with the orifice. A superficial bleeding tear at the intramural ureteral orifice was observed under direct vision at the close of the procedure.

DISCUSSION Surgical management of kidney stones has changed dramatically in the last few decades. The wide use of RIRS has followed technological advancements in ureteroscopes, equipment, and flexible ureteroscopy techniques.[19] Despite being controversial and a lack of overwhelming support, UAS is widely used in RIRS.[20] The guidelines of the European Association of Urology have no clear recommendations for UAS usage, whereas the American Urological Association guidelines recommend the use of a UAS when performing RIRS for complex, high-volume renal stones.[21,22] The natural ureteral

5.0

(a) Load (N) 4.0 Tip of the inner dilator at the orifice

UAS insertion at the orifice

UVJ

Proximal ureter

6.0

3.0

5.0

2.0

4.0

0

(b)

5 Time (Seconds)

10

Load (N)

UAS insertion at the orifice

3.0

Tip of dilator at the orifice

Proximal ureter UVJ

2.0

6.0 5 Time (Seconds)

5.0 4.0 3.0 2.0

(b)

UAS insertion at the orifice Tip of dilator at the orifice

Load (N)

3.0 UVJ

Proximal ureter

2.0

10

UAS insertion at the orifice Tip of dilator at the orifice

Proximal ureter UVJ

1.0 1.0

-0.0 0

5 Time (Seconds)

10

Figure 4. Force of insertion (FOI) graphs of patients without a preoperative JJ stent. (a) FOI of the 10/12-F Rocamed Bi-Flex (Rocamend, Monaco) ureteral access sheath (UAS) in Patient 1.

The graphic demonstrates peaks at the entry of ureteral orifice, ureterovesical junction, and proximal ureter. (b) FOI of the 9.5/11.5F Cook Flexor UAS (Cook Medical, Inc., Bloomington, IN, USA) in Patient 7, who had undergone ureteroscopy prior to UAS insertion. Graphic without demonstrative peaks at the 3 ureteral narrow points. UAS: Ureteral access sheath; UVJ: Ureterovesical junction.

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-0.0 -0

5 Time (Seconds)

10

Figure 5. Force of insertion (FOI) graphs of patients with a preoperative JJ stent. (a) FOI of the 11/13-F Boston Scientific Navigator HD (Boston Scientific Corp., Marlborough, MA, USA) used in Patient 2. No force was recorded from the ureterovesical junction level to the beginning of the proximal ureter. (b) FOI of the 12/14 FCook Flexor sheath (Cook Medical, Inc., Bloomington, IN, USA) in Patient 4. FOI graph peaks are seen at the ureteral narrow points.

UAS: Ureteral access sheath; UVJ: Ureterovesical junction.

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(a) Load (N) 3.0

severe ureteral injury. Severe smooth muscle layer lesions were described in lower rates (2.9%) when using 9.5/11.5-F and 12/14 F-UASs.24 Moreover, a 14/16-F UAS had a higher rate (17.6%) of deeper mucosal lesion with a reported rate of 4.7% circumferential perforation.[25] Even though grade 3 ureteral injuries and full thickness separation of the ureter to the level of the periureteral fat have been described,[26] in this preliminary report, we observed only superficial ureteral injuries in 2 patients with PULS scores of grade 1.

UAS insertion attempts at the orifice

Tip of dilator at the orifice

2.0

1.0

-0.0 -0

5 Time (Seconds)

10

(b) Load (N) 6.0

Tip of dilator at the orifice

UAS insertion at the orifice

UVJ

Proximal ureter

5.0 4.0 3.0 2.0 1.0 -0.0 -0

5 Time (Seconds)

10

Figure 6. Force of insertion (FOI) graph for Patient 6 with 2 attempts made to achieve ureteral access sheath (UAS) insertion. (a) The unsuccessful first attempt to insert a 12/14-F Cook Flexor UAS (Cook Medical, Inc., Bloomington, IN, USA). The 3 peaks demonstrate the force applied 3 times at the ureteral orifice level without achieving passage of the UAS. (b) A different pattern of peaks of the same 12/14-F Cook Flexor UAS with less FOI at the ureterovesical junction and proximal ureter compared with the ureteral orifice site. Note that nearly double the force was applied on the second attempt in order to enter the ureteral orifice. UAS: Ureteral access sheath; UVJ: Ureterovesical junction.

lumen is 9-F, narrower than any UAS on the market.[23] Insertion of a UAS dilates the ureteral wall, and thus has the risk of producing mucosal and submucosal edema, hematoma, and lesions. Applying disproportionate force may produce partial or even complete transection. The incidence of ureteral injury may be up to 46.5% when using a 12/14-F UAS.[16] Larger diameter UASs have a significant risk of causing mucosal ureteral injury, and this may not necessarily decrease with a smaller diameter sheath. Nevertheless, a smaller diameter appears to have a lower rate of causing deeper mucosal and smooth muscle lesions.[24,25] Ureteral injury due to UAS placement does occur; however, there is no recommendation to abandon their use, due to the clear benefits they offer during RIRS. Traxer and Thomas[16] reported a rate of 13% severe ureteral injuries with 12/14-F UAS. Male gender and older patients had a greater risk for 518

There are controversial reports regarding whether UAS increases the risk of ureteral stricture. Barbour and Raman[27] reported a rate of 0.9% stricture following ureteroscopy with a UAS use rate of 22% in 234 patients. BaĹ&#x; et al.[28] stated that they observed 2 strictures among 1571 patients in their series.

Another study found a 1.4% stricture rate following RIRS with the use of various sizes of UAS. Neither study concluded that UAS was a contributing factor to ureteral stricture. Similar conclusions were stated by Traxer et al,[10] reporting no statistical significance regarding the use of UAS. We observed no ureteral stricture in this small cohort of patients.

A reduced ureteral blood flow with UAS placement does not seem to impact the ureter in the long-term. Lallas et al.[11] demonstrated a decrease in blood flow in a swine model when UASs were used. The authors reported that the decrease in blood flow was more pronounced with a larger UAS and took longer to restore the ureteral blood flow; however, they concluded that it remains safe to use a UAS due to compensatory mechanisms of ureteral wall blood flow restoration to near-baseline rates, which preserved urothelial integrity. Since the 2002 report of Lallas et al., no study has clearly demonstrated a long-term impact of decreased blood flow in humans due to a UAS. It seems that, rather than transient ureteral ischemia, a direct mechanical injury has more impact on the ureter. In our study, we evaluated direct mechanical injury with the PULS scoring system.

Preoperative insertion of a JJ stent is a method used to facilitate UAS placement and to protect the ureter from UAS trauma. Passive dilatation was first reported by Jones et al.[29] Shields et al.[30] found significantly higher successful UAS insertion rates in pre-stented patients. Traxer and Thomas[16] reported a 7-fold decrease in the risk of severe injury in prestented patients vs non-stented patients. Whereas, Doizi et al.[31] found no difference in the success rate of UAS placement in pre-stented patients using new and innovative UAS. Koo et al.[32] evaluated UAS FOI and found lower FOI values in pre-stented patients. In our study, we found lower UAS FOI values in pre-stented patients. We also noticed a PULS score of zero in all pre-stented patients and a PULS score of 1 in the non-stented patients.

Ureteral injury due to UAS seems not to be related simply to UAS diameter, but more to a mismatch in UAS and ureteral tone. One may assume that this tone could be felt by the Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

Tefik et al. Impact of ureteral access sheath force of insertion on ureteral trauma

surgeon as UAS FOI, and a higher FOI would mean a higher risk of ureteral injury. Koo et al. evaluated the UAS FOI in patients with an alpha-blockade, pre-stented patients, and controls. They found significantly lower and comparable UAS FOI values in the pre-stented and alpha-blockade patient groups.

Additionally, they noticed higher UAS FOI values in males and patients less than 70 years of age.[32] We did not administer an alpha-blockade to any of our patients and all of the patients in this study were female. Only Pt 6 was over 70 years of age and needed 2 attempts to achieve UAS placement. Even though pre-stented, Pt 6 had a higher UAS FOI compared to younger pre-stented patients. Progressive expansion in ureteral diameter and loss of the surrounding muscle mass with aging are believed to protect the ureter from UAS injury.

[32] Notwithstanding, no ureteral injury was recorded in the pre-stented Pt 6 with a maximal UAS FOI of 5.9 N. Koo et al. also noted that ureteral injury (grade 2 injury, including mucosa and smooth muscle with adventitial preservation) did not occur in cases in which the UAS FOI was <600 G (600 G=5.88 N). Kaler et al.[33] presented their study of a porcine model and reported no ureteral injury at UAS FOI ≤4 N. They encountered ureteral injury (splitting of porcine ureter) at 8 N. We had a PULS score of 0 in pre-stented patients with a maximum UAS FOI ranging from 0.98 N to 5.9 N. There was a PULS score of 1 in non-stented patients with a maximum UAS FOI of 1.9 N and 0.91 N. It seems that even with a higher UAS FOI, the risk of ureteral injury is lower in pre-stented ureters. Conversely, even less UAS FOI may cause injury in non-stented patients. In Pt 7, a semirigid ureteroscopy was performed just before the UAS insertion. This facilitated the UAS placement and the insertion was done with a low force of max 0.91 N and a steady graph without a feeling of resistance at the ureteral orifice. In this case, the semi-rigid ureteroscopy may have caused the PULS score 1, so it may be misleading to comment on ureteral injury at a FOI of 0.91 N. This study has some drawbacks that merit mentioning. It is a small cohort study with only female patients, making it difficult to draw overall conclusions. However, this patient group helped to gauge only ureteral resistance, and excluded male urethral resistance. Male patients are associated with a greater risk of ureteral injury, mainly as a result of the difference in sex hormones and the surrounding muscle mass exerting higher tonic effect.[32,33] Moreover, the size of the UASs used in this study were different, a factor making UAS FOI difficult to interpret. Lastly, the anesthetic drugs used were not taken into consideration. This may have influenced the results, as some anesthetics may have an effect on ureteral contractility and tone.

Conclusion In this small cohort, pre-stenting patients before RIRS seemed to protect them from ureteral injury. A higher UAS FOI of Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

<6N in pre-stented compared to non-stented patients did not cause ureteral injury. A larger diameter UAS of 12-14-F was safely used in pre-stented patients. Semi-rigid ureteroscopy before RIRS appeared to facilitate UAS placement. Using force gauge to measure UAS FOI may help future studies to better investigate successful and safe UAS placement.

Conflict of interest: None declared.

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7. De Coninck V, Keller EX, Rodríguez-Monsalve M, Audouin M, Doizi S, Traxer O. Systematic review of ureteral access sheaths: facts and myths.

BJU Int 2018 May [Epub ahead of print], 11 doi: 10.1111/bju.14389.

8. L’esperance JO, Ekeruo WO, Scales CD Jr, Marguet CG, Springhart WP, Maloney ME, et al. Effect of ureteral access sheath on stone-free rates in patientsundergoing ureteroscopic management of renal calculi. Urology 2005;66:252–5.

9. Portis AJ, Rygwall R, Holtz C, Pshon N, Laliberte M. Ureteroscopic laser lithotripsy for upper urinary tract calculi with active fragment extraction and computerized tomography followup. J Urol 2006;175:2129-33.

10. Traxer O, Wendt-Nordahl G, Sodha H, Rassweiler J, Meretyk S, Tefekli A, et al. Differences in renal stone treatment and outcomes for patientstreated either with or without the support of a ureteral access sheath: The Clinical Research Office of the Endourological SocietyUreteroscopy Global Study. World J Urol 2015;33:2137–44.

11. Lallas CD, Auge BK, Raj GV, Santa-Cruz R, Madden JF, Preminger GM. Laser Doppler flowmetric determination of ureteral blood flow afterureteral access sheath placement. J Endourol 2002;16:583–90.

12. Delvecchio FC, Auge BK, Brizuela RM, Weizer AZ, Silverstein AD, Lallas CD, et al. Assessment of stricture formation with the ureteral access sheath. Urology 2003;61:518–22.

13. Gurbuz C, Atış G, Arikan O, Efilioglu O, Yıldırım A, Danacıoglu O, et al. The cost analysis of flexible ureteroscopic lithotripsy in 302 cases.

Urolithiasis 2014;42:155–8.

14. Abrahams HM, Stoller ML. The argument against the routine use of ureteral access sheaths. Urol Clin North Am 2004;31:83–7.

15. Kaplan AG, Lipkin ME, Scales CD Jr, Preminger GM. Use of ureteral access sheaths in ureteroscopy. Nat Rev Urol 2016;13:135–40.

16. Traxer O, Thomas A. Prospective evaluation and classification of ureteral wall injuriesresulting from insertion of a ureteral access sheath during retrogradeintrarenal surgery. J Urol 2013;189:580–4.

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Tefik et al. Impact of ureteral access sheath force of insertion on ureteral trauma 17. Lildal SK, Sørensen FB, Andreassen KH, Christiansen FE, Jung H, Pedersen MR, et al. Histopathological correlations to ureteral lesions visualized during ureteroscopy. World J Urol 2017;35:1489–96.

18. Schoenthaler M, Buchholz N, Farin E, Ather H, Bach C, Bach T, et al.

The Post-Ureteroscopic Lesion Scale (PULS): a multicenter video-based evaluation of inter-rater reliability. World J Urol 2014;32:1033–40.

19. Doizi S, Traxer O. Flexible ureteroscopy: technique, tips and tricks.

Urolithiasis 2018;46:47–58.

20. Huang J, Zhao Z, AlSmadi JK, Liang X, Zhong F, Zeng T, et al. Use of the ureteral access sheath during ureteroscopy: A systematic review and meta-analysis. PLoS One 2018;13:e0193600.

21. Assimos D, Krambeck A, Miller NL, Monga M, Murad MH, Nelson CP, et al. Surgical Management of Stones: American Urological Association/ Endourological Society Guideline, PART I. J Urol 2016;196:1153–60.

22. Türk C, Petřík A, Sarica K, Seitz C, Skolarikos A, Straub M, et al.

EAU Guidelines on Interventional Treatment for Urolithiasis. Eur Urol 2016;69:475–82.

23. Zelenko N, Coll D, Rosenfeld AT, Smith RC. Normal ureter size on unenhanced helical CT. AJR Am J Roentgenol 2004;182:1039–41.

24. Guzelburc V, Guven S, Boz MY, Erkurt B, Soytas M, Altay B, et al. Intraoperative Evaluation of Ureteral Access Sheath-Related InjuriesUsing Post-Ureteroscopic Lesion Scale. J Laparoendosc Adv Surg Tech A 2016;26:23–6.

25. Miernik A, Wilhelm K, Ardelt PU, Adams F, Kuehhas FE, Schoenthaler M. Standardized flexible ureteroscopic technique to improve stone-freerates. Urology 2012;80:1198-202.

26. Patel RM, Okhunov Z, Kaler K, Clayman RV. Aftermath of Grade 3

Ureteral Injury from Passage of a UreteralAccess Sheath: Disaster or Deliverance? J Endourol Case Rep 2016;2:169–71.

27. Barbour ML, Raman JD. Incidence and Predictors for Ipsilateral Hydronephrosis FollowingUreteroscopic Lithotripsy. Urology 2015;86:465–71.

28. Baş O, Tuygun C, Dede O, Sarı S, Çakıcı MÇ, Öztürk U, et al. Factors affecting complication rates of retrograde flexible ureterorenoscopy: analysis of 1571 procedures-a single-center experience. World J Urol 2017;35:819–26.

29. Jones BJ, Ryan PC, Lyons O, Grainger R, McDermott TE, Butler MR. Use of the double pigtail stent in stone retrieval followingunsuccessful ureteroscopy. Br J Urol 1990;66:254-6.

30. Shields JM, Tunuguntla HS, Bhalani VK, Ayyathurai R, Bird VG. Construction-related differences seen in ureteral access sheaths: comparison of reinforced versus nonreinforced ureteral accesssheaths. Urology 2009;73:241–4.

31. Doizi S, Knoll T, Scoffone CM, Breda A, Brehmer M, Liatsikos E, et al. First clinical evaluation of a new innovative ureteral access sheath(ReTrace™): a European study. World J Urol 2014;32:143–7.

32. Koo KC, Yoon JH, Park NC, Lee HS, Ahn HK, Lee KS, et al. The Impact of Preoperative α-Adrenergic Antagonists on UreteralAccess Sheath Insertion Force and the Upper Limit of Force Required to Avoid Ureteral Mucosal Injury: A Randomized Controlled Study. J Urol 2018;199:1622–30.

33. Kaler K, O’Leary M, Valley Z, Cooper V, Yoon R, Patel R, et al. MP– 4.10: Initial clinical testing of ureteral access sheath force sensor to prevent ureteral injuries. Can Urol Assoc J 2018;12:S87.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Üreter erişim kılıfı yerleştirme sırasında sarfedilen gücün üreter travmasına etkisi: Yedi hastayla in vivo ön çalışma Dr. Tzevat Tefik,1,5 Dr. Salvatore Buttice,2,5 Dr. Bhaskar Somani,3,5 Dr. Selçuk Erdem,1 Dr. Tayfun Oktar,1 Dr. Faruk Özcan,1 Dr. Taner Koçak,1 Dr. İsmet Nane,1 Dr. Olivier Traxer4,5 İstanbul Üniversitesi İstanbul Tıp Fakültesi, Üroloji Anabilim Dalı, İstanbul San Giovanni di Dio Hastanesi, Üroloji Bölümü, Contrada Consolida, Agrigento-İtalya Southampton Üniversitesi, Southampton NHS Trust Üniversite Hastanesi, Southampton-İngiltere 4 Sorbonne Université, GRC n°20 lıthıase renale, AP-HP, Hôpital Tenon, Paris-Fransa 5 PetraUroGroup, Paris-Fransa 1 2 3

AMAÇ: Erişim kılıfları (EK) genellikle retrograt intrarenal cerrahide (RİRC) kullanılmaktadır. Avantajlarına rağmen yerleştirilmeleri sırasında üreter yaralanması ve cerrahi sonrasında darlık riski bulunmaktadır. Bu çalışmanın amacı sarf edilen itme gücünü ve üreter travmasına etkisini değerlendirmektir.

GEREÇ VE YÖNTEM: Böbrek taşları için RİRC uygulanmış yedi kadın hasta çalışmaya alındı. Bir dijital güç ölçüm cihazı (Chatillon DFX II; Ametek Test and Calibration Instruments, Largo, Florida, ABD) EK’ların ucuna monte edildi ve EK ile sarf edilen itme gücü, kılıfın yerleştirilmesi sırasında sürekli ölçüldü. Değişik boyutlarda EK’lar kullanıldı ve Postüreteroskopik Lezyon Ölçeği (PULS) skoru ile doğrudan görüş altında üreter yaralanması değerlendirildi.

BULGULAR: Daha önce stent konmuş beş ve konmamış iki hasta çalışmaya dahil edildi. EK’ların çapları daha önce stent konmamış hastalarda 9.5/11.5-F ve 10/12-F, daha önce stent konmuş hastaların birinde 11/13-F ve dördünde 12/14-F idi. Daha önce stent konulmuş hastada 12/14 F EK yerleştirmek için maksimal 9 Newton’luk (N) itme gücü sarf edildiği gözlendi. Bu hastada ilk başarısız denemeden sonra ikinci kez deneme yapıldı. Bir stent konmamış hastada 9.5/11.5-F EK’ları yerleştirmek için en düşük maksimal EK itme gücü (0.91 N) sarf edildi. EK’yı yerleştirmeden önce bu hastaya 7.8-F semirijit üreteroskopi uygulanmıştı. İki stent konmamış hastada da PULS skoru 1 ve önceden stent takılmış hastaların tümünde 0 idi.

TARTIŞMA: Bu küçük çaplı kohort çalışmasında ameliyat öncesi JJ yerleştirilmesinin, üreteri 12/14F gibi geniş çaplı EK’ların travmasından koruduğu görülmüştür. Önceden stentsiz olan hastalarda RİRC uygulamasında EK yerleştirilmesi mümkün ise de bu durum düşük dereceli üreter travmasına neden olabilir.

Anahtar sözcükler: İtme gücü; retrograt intrarenal cerrahi; üreter erişim kılıfı.

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doi: 10.5505/tjtes.2018.15263

Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

ORIG I N A L A R T IC L E

A pathology not be overlooked in blunt chest trauma: Analysis of 181 patients with bilateral pneumothorax Ali Özdil, M.D.,1 Önder Kavurmacı, M.D.,1 Tevfik İlker Akçam, M.D.,1 Ayşe Gül Ergönül, M.D.,1 İlhan Uz, M.D.,2 Cengiz Şahutoğlu, M.D.,3 Sabahattin Yüzkan, M.D.,4 Alpaslan Çakan, M.D.,1 Ufuk Çağırıcı, M.D.1 1

Department of Thoracic Surgery, Ege University Faculty of Medicine, İzmir-Turkey

2

Department of Emergency Medicine, Ege University Faculty of Medicine, İzmir-Turkey

3

Department of Anesthesiology and Reanimation, Ege University Faculty of Medicine, İzmir-Turkey

4

Department of Radiology, Ege University Faculty of Medicine, İzmir-Turkey

ABSTRACT BACKGROUND: Bilateral pneumothorax (BPTx) can become tension PTx and a cause of mortality, especially in severe multi-trauma patients. The purpose of this study was to analyze the incidence, morbidity, mortality, and associated factors of BPTx in multi-trauma patients in order to highlight the importance of the management of these cases, as well as complications, morbidity, and mortality.

METHODS: The data of 181 patients with BPTx, from a total of 3782 trauma patients, were reviewed retrospectively. The details recorded were age, gender, mechanism of trauma, radiological findings, co-existing thoracic and extra-thoracic injuries, incidence of intubation, mortality, and injury severity score (ISS). The association between laterality of rib fracture, hemothorax, subcutaneous emphysema, and BPTx, and the effect of age and gender on these injuries, mortality, and ISS were analyzed.

RESULTS: The patient group included 144 males, and the mean age was 36.07±15.77 years. The primary cause of trauma was a motor vehicle accident, seen in 67 (37.0%) patients. Bilateral rib fractures were detected in 75 (41.4%) patients. Hemothorax accompanied PTx in 41 (22.6%) patients bilaterally. The laterality of the rib fracture and hemothorax demonstrated a significant difference in the patient group over 60 years of age (p=0.017, p=0.005). Co-existing bilateral thoracic injuries were detected more often in this group. Twelve (17.6%) patients with only blunt chest trauma and 56 (82.4%) patients with multi-trauma were intubated. The difference between the 2 groups was not significant (p=0.532). The overall mortality rate was 18.2%. A comparison of ISS and mortality between the groups revealed no significant difference (p=0.22).

CONCLUSION: The incidence of BPTx after multi-trauma is approximately 5%, so it must be taken into consideration, especially in severe multi-trauma patients, to reduce mortality. Older age and the number of rib fractures were determined to be risk factors for morbidity and mortality in trauma with BPTx. Keywords: Bilateral pneumothorax; injury severity score; intubation; mortality; trauma.

INTRODUCTION Chest trauma accounts for 10% to 15% of all traumas and is the leading cause of trauma death after brain injury, with a mortality rate up to 25%. Blunt chest trauma (BCT) comprises 75% of chest trauma and the remainder is penetrating trauma.[1,2]

Pneumothorax (PTx) is a common and crucial consequence of BCT. It is a primary cause of mortality, so the diagnosis and management of PTx before fatal complications, such as tension PTx, can occur are important.[3] In addition, bilateral PTX (BPTx), which is often misdiagnosed, especially in severe multi-trauma patients who have vital signs sufficiently stable to undergo radiological examination with a chest X-ray or

Cite this article as: Özdil A, Kavurmacı Ö, Akçam Tİ, Ergönül AG, Uz İ, Şahutoğlu C, et al. A pathology not be overlooked in blunt chest trauma: Analysis of 181 patients with bilateral pneumothorax. Ulus Travma Acil Cerrahi Derg 2018;24:521-527.

Address for correspondence: Ali Özdil, M.D. Ege Üniversitesi Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, Bornova, İzmir, Turkey Tel: +90 232 - 390 49 19 E-mail: ali.ozdil@ege.edu.tr Ulus Travma Acil Cerrahi Derg 2018;24(6):521-527 DOI: 10.5505/tjtes.2018.76435 Submitted: 09.07.2018 Accepted: 08.10.2018 Online: 25.10.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Özdil et al. Bilateral pneumothorax due to blunt chest trauma

a thorax computed tomography (CT) in the early period of admission to emergency room, is a cause of mortality, just like tension PTx.

The present study was approved by the institutional ethics review panel. Patient consent for data collection was not required.

Rib fracture is the main cause of PTx and hemothorax in BCT, but it is not a requirement for the development of these complications. The incidence of PTx and hemothorax is approximately 35% in trauma patients with rib fractures.[1]

RESULTS

The aim of this study was to review the results of the clinical course of multi-trauma patients with BPTx first managed in the emergency room and followed up until discharge from the hospital in order to analyze the incidence, morbidity, and mortality of BPTx in multi-trauma patients with BCT in order to point out the importance of the management, prevention of complications, morbidity, and mortality. To the best of our knowledge, this study is one of the largest series in the English-language medical literature evaluating traumatic BPTx.

MATERIALS AND METHODS The data of 3782 multi-trauma patients admitted to the emergency room between January 2010 and December 2017 were retrospectively reviewed, and the records of 181 (4.78%) patients with BPTx were analyzed. The patient data were evaluated according to gender, age, mechanism of trauma, radiological findings, co-existing extra-thoracic injuries, treatment methods, length of hospital stay, mortality, and injury severity score (ISS).

All of the patients were first evaluated in the emergency room and initial treatment was performed there. The diagnosis of BPTx was performed with CT in patients with stable vital signs, which is routinely used for all multi-trauma patients as a part of the traumatic patient assessment algorithm. Bilateral thoracentesis was performed in unstable patients who were suspicious for BPTx as a result of physical examination findings, such as the absence of breath sounds or a finding of bilateral subcutaneous emphysema. All of the patients underwent a thorax CT after normalization of vital signs. Patients without any extrathoracic injury were hospitalized in the thoracic surgery department. Other patients with extrathoracic injury or an intubation requirement were followed up in the emergency room and the intensive care unit (ICU).

A total of 181 patients with a mean age of 36.07±15.77 years (range: 16–84 years) were included. Of the group, 144 were male. The main cause of trauma was a motor vehicle accident, observed in 67 (37.0%) patients, followed by a fall (22.1%), and a motorcycle accident (18.8%) (Fig. 1). Descriptive data of the patient demographics are provided in Table 1. Subcutaneous emphysema was the most common physical examination finding, observed bilaterally in 42 (23.2%) patients. Rib fractures were detected in 127 (70.1%) patients on thorax CT and 75 (41.4%) of these were bilateral; no rib fractures were detected in 54 (29.8%) patients. PTx was accompanied by hemothorax in 71 (39.2%) patients and 41 (22.6%) of these were bilateral (Fig. 2). Pneumomediastinum and sternum fracture were observed in 43 (23.8%) and 19 (10.5%) patients, respectively. A tube thoracostomy under local anesthesia was the most common invasive procedure performed for treatment. Twenty-seven (14.9%) patients underwent tube thoracostomy bilaterally, whereas 103 (56.9%) patients were kept under observation without any invasive procedures. The duration of the tube thoracostomy ranged from 5 to 16 days in patients with a bilateral drain.

Two groups of patients were formed, divided according to age of ≤60 and >60 years, and the groups displayed a significant difference in terms of the laterality of rib fracture, the number of rib fractures, and the laterality of hemothorax, with p values of 0.017, 0.017, and 0.005, respectively. These co-existing thoracic pathologies were seen bilaterally more frequently in the group of patients over 60 years of age. The mortality was also significantly higher in this patient group (p=0.013; Table 2). There was no significant difference between males and females according to the co-existing thoracic pathologies, ISS, intubation, need for mechanical ventilation (MV), or mortality (Table 3).

The analysis of the association between the number of rib fractures and co-existing thoracic pathologies revealed a sig-

522

Number of patients (%)

70

Data management and analysis of the study data was performed using IBM SPSS Statistics for Windows, Version 23.0.

(IBM Corp., Armonk, NY, USA). The Kolmogorov-Smirnov test was used to assess data distribution. Continuous variables were summarized as mean±SD. Categorical data were presented as percentages and compared using the Fisher exact test for 2 groups and the Pearson chi-squared test for >2 groups. Student’s t-test and the Mann-Whitney U-test were performed for data with normal and abnormal distribution, respectively. The statistical level of significance used was p<0.05.

67 (37.0%)

Motor vehicle accident Falls Motorcycle accidents Pedestrian accidents Crush

60 50 40

40 (22.1%) 34 (18.8%)

34 (18.8%)

30 20 10 0

6 (3.3%)

Trauma mechanism

Figure 1. Distribution of patients based on trauma mechanism.

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Özdil et al. Bilateral pneumothorax due to blunt chest trauma

Table 1. Distribution of patient demographics, radiological findings, and results of clinical course

n (%)

Age (years)

36.07±15.77

Gender

Female

37 (20.4)

Male

144 (79.6)

Table 2. The association between age, co-existing thoracic pathologies, tube thoracostomy insertion, injury severity score, intubation, and mechanical

ventilation, and mortality

≤60 years

>60 years

n (%)

n (%)

Subcutaneous emphysema

Trauma

Unilateral

23 (12.7)

1 (0.6)

(Isolated Blunt chest trauma

None

100 (55.2)

15 (8.3)

Bilateral

33 (18.2)

9 (5.0)

/ Multi-trauma)

28 (15.5)/153 (84.5)

0.137

Rib fracture

Radiological findings Subcutaneous emphysema

Unilateral

45 (24.9)

7 (3.9)

(None/Unilateral/Bilateral)

None

52 (28.7)

2 (1.1)

Rib fracture

Bilateral

59 (32.6)

16 (8.8)

(None/Unilateral/Bilateral)

54 (29.8)/52 (28.7)/75 (41.5)

No. of rib fractures

Hemothorax

110 (60.8)/30 (16.6)/41 (22.7)

≤6

97 (53.6)

9 (5.0)

>6

59 (32.6)

16 (8.8) 6 (3.3)

p

115 (63.5)/24 (13.3)/42 (23.2)

Pneumomediastinum

43 (23.8)

Sternum fracture

19 (10.5)

Hemothorax

Unilateral

24 (13.2)

103 (56.9)/51 (28.2)/27 (14.9)

None

102 (56.4)

8 (4.4)

Hospital stay (days)

12.93±15.04

Bilateral

30 (16.6)

11 (6.1)

Injury severity score

26.69±6.11

Tube thoracostomy

Tube thoracostomy (None/Unilateral/Bilateral)

Mortality 18.2%

nificant difference in the laterality of hemothorax when the patients were assessed in groups defined as having ≤6 or >6 rib fractures (Table 3). Patients with more than 6 rib fractures had a higher incidence of bilateral hemothorax (p<0.001) (Table 4).

Abdominal injuries, detected in 96 (53.0%) patients, were the most common extrathoracic injury accompanying BCT, followed by vertebral injuries in 83 (45.9%) patients and ex-

Unilateral

47 (26.0)

4 (2.2)

None

87 (48.1)

16 (8.8)

Bilateral

22 (12.2)

5 (2.8)

0.017

0.017

0.005

0.319

Injury severity score

≤18

23 (12.7)

5 (2.8)

>18

133 (73.5)

20 (11)

0.500

Intubation and mechanical ventilation

Yes

58 (32.0)

10 (5.5)

No

98 (54.2)

15 (8.3)

0.787

Mortality

12 Subcutaneous Emphysema

10 Rib Fracture

36

15 14

5 Hemothorax

7

Alive

132 (72.9)

16 (8.8)

Exitus

24 (13.3)

9 (5.0)

0.013

tremity fractures in 79 (43.6%) patients (Fig. 3). Seventy-eight (43.1%) patients were treated and managed in the emergency room and 35 (19.3%) patients were hospitalized in the thoracic surgery clinic. Patients requiring intubation and MV were referred to the ICU and followed up there. A total of 68 (37.6%) patients were intubated and monitored in the ICU. Twelve (17.6%) of these patients had only BCT and 56 (82.4%) had multi-trauma. There was no significant difference between the 2 groups in terms of intubation and MV (p=0.532).

Figure 2. Distribution of bilateral co-existing thoracic injuries.

The overall mortality rate was 18.2% (33 patients), 97.0% (32 patients) of which was observed in the group of patients

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Özdil et al. Bilateral pneumothorax due to blunt chest trauma

Table 3. The association between gender, co-existing thoracic injuries, tube thoracostomy insertion, ISS, intubation, and mechanical ventilation, and mortality

Table 4. The association between the number of rib fractures, co-existing thoracic injuries, and tube thoracostomy insertion

Male

n (%)

n (%)

Female

p

≤6

>6

n (%)

n (%)

4 (2.2)

p

Subcutaneous emphysema

Subcutaneous emphysema

Unilateral

20 (11.0)

19 (10.5)

None

69 (38.1)

46 (25.4)

13 (7.2)

Bilateral

17 (9.4)

25 (13.8)

Unilateral

19 (10.5)

5 (2.8)

None

96 (53.0)

Bilateral

29 (16.0)

0.139

0.139

Hemothorax

Rib fracture

Unilateral

19 (10.5)

11 (6.1)

10 (5.5)

None

75 (41.4)

35 (19.3)

17 (9.4)

Bilateral

12 (6.6)

29 (16.0)

Unilateral

42 (23.2)

10 (5.5)

None

44 (24.3)

Bilateral

58 (32.0)

0.820

<0.001

Tube thoracostomy

No. of rib fractures

≤6

86 (47.5)

20 (11.0)

>6

58 (32.0)

17 (9.4)

0.577

Hemothorax

Unilateral

25 (13.8)

5 (2.8)

None

86 (47.5)

24 (13.3)

Bilateral

33 (18.2)

8 (4.4)

Unilateral

42 (23.2)

9 (5.0)

None

80 (44.2)

23 (12.7)

Bilateral

22 (12.2)

5 (2.8)

0.766

Injury severity score

≤18

22 (12.2)

6 (3.3)

>18

122 (67.4)

31 (17.1)

1.000

Intubation and mechanical ventilation

Yes

50 (27.6)

18 (9.9)

No

94 (51.9)

19 (10.5)

Unilateral

27 (14.9)

24 (13.3)

None

67 (37.0)

36 (19.9)

Bilateral

12 (6.6)

15 (8.3)

0.097

0.814

Tube thoracostomy

0.131

mined between ISS and intubation and MV (p=0.275): the median ISS score was 27.5 (min-max: 21–34) and 26 (min-max: 21–29) for intubated and non-intubated patients, respectively.

The patients were also divided into 2 groups according to an ISS of ≤18 or >18. No difference was seen between the groups according to intubation and mortality (p=0.532 and p=0.299).

DISCUSSION BCT is a frequent cause of morbidity and mortality, especially in developing countries. The primary cause of BCT is motor vehicle and other traffic accidents, with an incidence rate reported in various studies that has ranged from 47.5%

Mortality

Alive

117 (64.6)

31 (17.1)

Exitus

27 (14.9)

6 (3.3)

0.815

96 (53.0)

Intra-abdominal injury

83 (45.9)

Vertebral fracture

who were intubated. The remaining 148 (81.8%) patients were discharged from the hospital with a mean hospital stay of 12.93±15.04 days (range: 1–120 days). There was no significant difference between the isolated thorax trauma patients and the multi-trauma patients in terms of mortality (p=0.331).The survival analysis also revealed no significant difference between these 2 groups (p=0.299).

The mean ISS was found to be 26.69±6.11 (range: 18–41). A comparison between ISS and mortality yielded no significant difference (p=0.22). The median ISS score was 26 (min-max: 21–29) in the patients who died and 26 (min-max: 21–33) in the discharged patients. No significant association was deter524

57 (31.5)

Upper extremity fracture

52 (28.7)

Cranial injury

Facial injury

47 (26.0)

Pelvic fracture

46 (25.4) 40 (22.1)

Lower extremity fracture

0

20

40 60 80 Number of patients (%)

100

120

Figure 3. Co-existing extra-thoracic injuries of patients with multitrauma.

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Ă&#x2013;zdil et al. Bilateral pneumothorax due to blunt chest trauma

to 70.9%.[2,4â&#x20AC;&#x201C;6] The incidence of motor vehicle accidents was 37.0% in our study, but with the addition of motorcycle and pedestrian accidents, the total was 74.6%, which is consistent with that seen in the literature.

Rib fracture may be both the result of BCT and the cause of thoracic pathologies like pain, contusion, PTx, and hemothorax. Cases of multiple rib fractures accompanying multitrauma have particularly been determined to be a prognostic factor of morbidity and mortality.[7] The incidence of rib fracture in all trauma cases varies in the range of 10% to 40%.

[1,4] Chrysou et al.[8] reported that rib fractures comprised the largest group of thoracic injuries, with a rate of 86.4%.

The incidence of bilateral rib fractures has been reported to be 22.7%. Sirmali et al.[2] reported that PTx, hemothorax, or hemopneumothorax had been noted in 72.3% of the cases with rib fractures. Liman et al.[6] stated an incidence rate of 52% hemo-/pneumothorax in patients with rib fractures. These 2 studies did not report the incidence rate of BPTx. In our study, the incidence of rib fractures was 70.1%, and 41.4% of these were bilateral. On the other hand, we did not detect rib fractures in 29.8% of the patients. This result was an important indicator of whether the major reason for PTx, especially BPTx, is related to rib fractures. Rib fractures may not be present in approximately one-third of patients; therefore, patients must be evaluated and followed up very closely after an initial intervention, even when there are no rib fractures or evident PTx. Lu et al.[9] reported the late onset of PTx during the first 2 days of admission with an incidence rate of 5.42% in trauma patients with minor rib fractures. Furthermore, Shorr et al.[4] found 44 (34.6%) cases of hemopneumothorax in 127 patients without bony thoracic injury.

Pneumothorax is a serious potential consequence of BCT that is life-threatening and requires immediate diagnosis and treatment. While a chest X-ray is usually sufficient to detect PTx, a thorax CT is usually needed in multi-trauma patients who cannot be positioned adequately for posteroanterior chest X-ray imaging. The frequency of PTx in BCT patients is approximately 15% to 20%.[4,10,11] Bilateral PTx is a more serious and complicated scenario that can be overlooked in BCT patients with multi-trauma. Shorr et al.[4] reported 15 instances of BPTx in 515 BCT patients, a rate of 2.9%. Freixinet et al.[12] conducted a study that included 1772 patients with chest trauma, and the incidence rate of BPTx was reported as 1.3%. Sunam et al.[13] described 40 patients with BPTx and mentioned that 25 cases were due to BCT. Halat et al.[14] reported that the incidence rate of BPTx in their study of 110 blunt chest trauma patients was 17.3%. In our study, the incidence rate of BPTx was 4.78% (181 patients among 3782). There are few studies specifying the incidence rate of BPTx in the literature and the incidence rate was a bit higher in our research results compared with most of the previously-mentioned studies. This difference may be associated with the method of initial imaging. All of our patients underwent thorax CT for the evaluation of thoracic injuries, which might Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

have yielded a determination of minor PTx that could not be seen on a chest X-ray or had not led to clinical symptoms and findings.

Age is a risk factor for the severity and complication of trauma. In elderly patients, multiple and bilateral rib fractures are seen more frequently, even in a moderate trauma, due to the osteoporosis and fragility of the bones. Therefore, the incidence of complications, like BPTx and hemothorax, as well as mortality, is higher in elderly trauma patients.[2,15,16] Sirmali et al.[2] reported that the highest morbidity and mortality rates were found in patients over the age of 60 years and mentioned that elderly patients with 6 or more rib fractures must be followed up in the ICU. Bulger et al.[15] stated that elderly patients had twice the rate of mortality and morbidity of younger patients with injuries of similar severity. In our study, co-existing thoracic pathologies and mortality were higher in the patient group that was over 60 years of age.

This finding indicates that elderly patients must be evaluated and followed up more intensively, independent of the severity of the trauma.

Extra-thoracic injuries frequently accompany BCT in multitrauma patients. Common associated injuries include spine injuries, extremity fractures, abdominal injuries, and head trauma.[17] In the study conducted by Chrysou et al.,[8] the most common co-existing extra-thoracic injuries were extremity fractures, spine injuries, and head trauma, with an incidence rate of 76.4%, 53.6%, and 37.3%, respectively.

Freixinet et al.[12] reported a rate of 19.1% for extra-thoracic trauma, and mentioned that limb fracture was the most common pathology, with an incidence of 28.7%. Hildebrand et al.[18] stated that injuries to the extremities were the most frequently associated injuries, independent of the severity of the thoracic injury. In their study composed of 1621 thoracic trauma patients, Lin et al.[19] also reported that extremity fractures were the most common (26.7%) associated injury accompanying traumatic rib fractures. The incidence rate of extra-thoracic injuries was 84.5% in our study. Abdominal injuries, including liver, spleen, and kidney pathologies, were the most common injuries at 53%, followed by vertebral fractures (45.9%). In contrast to the literature, extremity fractures were the third most frequently observed extra-thoracic injury in our research, with an incidence rate of 43.6%.

We think that this divergence was related to the inclusion of trauma patients who were sent from other hospitals due to the severity of the trauma, as our hospital has the biggest and most experienced trauma center in the region.

Intubation and MV are indicators of a poor prognosis in trauma patients. In multi-trauma patients, especially those with head and bilateral chest injuries, the incidence rate of intubation and MV is higher. The length of stay in the ICU is also typically longer in these patients. The incidence rate of intubation and MV was reported as 6.9% in 1772 trauma cases by Freixinet et al.[12] and was stated to be a poor prog525

Özdil et al. Bilateral pneumothorax due to blunt chest trauma

nostic factor for multiple injury and cardiorespiratory repercussions. Virgós Señor et al.[20] noted that MV was a significant factor for death in BCT patients and reported an incidence rate of 81.5% in 108 multi-trauma patients. The authors did not report any significant differences in terms of multiple trauma, head/brain injury, or PTx between the patients who did and did not require MV. They also indicated that PTx was a significant factor for survival in patients with MV. Charbit et al.[3] reported that 47.0% of patients with PTx after BCT were intubated and followed up with MV. Chrysou et al.[8] reported that intubation and MV had been necessary for 29.1% (32 in 110 patients) of polytrauma patients with BCT. In our study, the incidence rate of intubation and MV was 37.6%. While this rate is in the range of the 4 studies mentioned above, it was higher than that of 3 of the mentioned studies. This may be due to the fact that all of the patients in our study had BPTx. Virgós Señor et al.[20] reported a higher incidence rate than that of our study, which may have been because their study included trauma patients in an ICU. Furthermore, there was not a significant difference between the isolated BCT and the multi-trauma patients groups in our study, but the mortality rate was significantly higher in the intubated patient group, which is also consistent with the literature.

The overall mortality in polytrauma patients with BCT varies between 2.4% and 33.3%.[2,4–8,11,12,18–21] The factors associated with survival include the severity of the BCT and co-existing injuries, especially neurotrauma.[8,21] Di Bartolomeo et al.[11] reported an overall mortality rate of 23.3% in their study comprising 446 major trauma patients. They reported a mortality rate that increased to 30.4% in patients with PTx. Virgós Señor et al.[20] mentioned that mortality had occurred all in patients in need of MV and reported that they had not seen a higher mortality rate among polytrauma patients in their studies, even those with head and brain injury. Chrysou et al.[8] reported an overall mortality rate of 5.5% (6 in 110 patients) and stated that there was a significant association between mortality rate and ISS, as all 6 deaths were in the group with an ISS >24. Liman et al.[6] and Hasbahçeci et al.[17] also noted that mortality increased with an increasing ISS. Segers et al.[21] reported an overall mortality rate of 16.6% and an average ISS of 27.8 in their study that included 187 cases of thoracic trauma. They found a significant relationship between ISS and mortality, and reported that ISS was a valuable score for assessing the severity of trauma and predicting the outcome. In our study, the overall mortality rate was 18.2%, and 97% of those patients were in the intubated patient group. The difference between the isolated thorax trauma patients and multi-trauma patients was not significant in terms of mortality, a finding similar to the result obtained in the study of Virgós Señor et al.[20] We found that the mortality rate increased when the hospital stay was shorter. This difference may be related to the fact that most of the deaths occurred in the early period of admission due to fatal pathologies such as brain injury. There were no significant relationships between ISS and mortality in our study, 526

contrary to the studies cited. We think that this was likely due to the fact that there was a minimum ISS score of 18 in the BPTx patients.

Limitations There are some limitations to this study that should be kept in mind. This is a retrospective and single-center study, which results in a certain weakness of methodology and limited ability to generalize the result to other centers or circumstances.

Also, because of the retrospective design of the study and missing data, it was not possible to specify the exact cause of mortality, especially in multi-trauma patients. As a result of this shortcoming, detailed survival analysis with respect to BPTx could not be performed.

Conclusion In conclusion, pneumothorax is a life-threatening complication of BCT and it can be more complicated when it is bilateral. The rate of mortality caused by PTx in BCT is not clear in the literature. The available data are very limited, especially regarding BPTx after BCT. The mortality rate of 18.2% and the intubation incidence rate of 37.6% in our study point to the importance of diagnosis, management, and treatment of BPTx in BCT patients and the need for further studies about PTx and BPTx in multi-trauma patients. In addition, age must be kept in mind as a risk factor for morbidity and mortality independent of the severity of the trauma.

Funding: No funding was received for this work.

Conflict of interest: None declared.

REFERENCES 1. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures.

J Trauma 1994;37:975–9.

2. Sirmali M, Türüt H, Topçu S, Gülhan E, Yazici U, Kaya S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg 2003;24:133–8.

3. Charbit J, Millet I, Maury C, Conte B, Roustan JP, Taourel P, et al. Prevalence of large and occult pneumothoraces in patients with severe blunt trauma upon hospital admission: experience of 526 cases in a French level 1 trauma center. Am J Emerg Med 2015;33:796–801.

4. Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A. Blunt thoracic trauma: analysis of 515 patients. Ann Surg 1987;206:200–5.

5. Demirhan R, Onan B, Oz K, Halezeroglu S. Comprehensive analysis of 4205 patients with chest trauma: a 10-year experience. Interact Cardiovasc Thorac Surg 2009;9:450–3.

6. Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg 2003;23:374–8.

7. Esme H, Solak O, Yürümez Y, Yavuz Y. The factors affecting the morbidity and mortality in chest trauma. Ulus Travma Acil Cerrahi Derg 2006;12:305–10.

8. Chrysou K, Halat G, Hoksch B, Schmid RA, Kocher GJ. Lessons from a large trauma center: impact of blunt chest trauma in polytrauma patientsstill a relevant problem? Scand J Trauma Resusc Emerg Med 2017;25:42.

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Özdil et al. Bilateral pneumothorax due to blunt chest trauma 9. Lu MS, Huang YK, Liu YH, Liu HP, Kao CL.Delayed pneumothorax complicating minor rib fracture after chest trauma. Am J Emerg Med 2008;26:551–4.

10. Weissberg D, Refaely Y. Pneumothorax: experience with 1,199 patients.

Chest 2000;117:1279–85.

11. Di Bartolomeo S, Sanson G, Nardi G, Scian F, Michelutto V, Lattuada L. A population-based study on pneumothorax in severely traumatized patients. J Trauma 2001;51:677–82.

12. Freixinet J, Beltrán J, Rodríguez PM, Juliá G, Hussein M, Gil R, et al.

Indicators of severity in chest trauma. [Article in Spanish]. Arch Bronconeumol 2008;44:257–62.

13. Sunam G, Gök M, Ceran S, Solak H. Bilateral pneumothorax: a retrospective analysis of 40 patients. Surg Today 2004;34:817–21.

14. Halat G, Negrin LL, Chrysou K, Hoksch B, Schmid RA, Kocher GJ. Treatment of air leak in polytrauma patients with blunt chest injury. Injury 2017;48:1895–9.

15. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma 2000;48:1040–6.

16. Akköse Aydin S, Bulut M, Fedakar R, Ozgürer A, Ozdemir F. Trauma in the elderly patients in Bursa. Ulus Travma Acil Cerrahi Derg 2006;12:230–4.

17. Hasbahçeci M, Ozpek A, Başak F, Calışkan M, Ener BK, Alimoğlu O. Factors affecting mortality in blunt thoracic trauma. Ulus Travma Acil Cerrahi Derg 2013;19:127–32.

18. Hildebrand F, Giannoudis PV, Griensven Mv, Zelle B, Ulmer B, Krettek C, et al. Management of polytraumatized patients with associated blunt chest trauma: a comparison of two European countries. Injury 2005;36:293–302.

19. Lin FC, Li RY, Tung YW, Jeng KC, Tsai SC. Morbidity, mortality, associated injuries, and management of traumatic rib fractures. J Chin Med Assoc 2016;79:329–34.

20. Virgós Señor B, Nebra Puertas AC, Sánchez Polo C, Broto Civera A, Suárez Pinilla MA. Predictors of outcome in blunt chest trauma. [Article in Spanish]. Arch Bronconeumol 2004;40:489–94.

21. Segers P, Van Schil P, Jorens P, Van Den Brande F. Thoracic trauma: an analysis of 187 patients. Acta Chir Belg 2001;101:277–82.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Künt göğüs travmasında gözden kaçırılmaması gereken bir patoloji: Bilateral pnömotoraks saptanan 181 olgunun analizi Dr. Ali Özdil, Dr. Önder Kavurmacı, Dr. Tevfik İlker Akçam, Dr. Ayşe Gül Ergönül, Dr. İlhan Uz, Dr. Cengiz Şahutoğlu, Dr. Sabahattin Yüzkan, Dr. Alpaslan Çakan, Dr. Ufuk Çağırıcı Ege Üniversitesi Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, İzmir Ege Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İzmir Ege Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, İzmir 4 Ege Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, İzmir 1 2 3

AMAÇ: Bilateral pnömotoraks (BPTx), özellikle şiddetli multi-travma hastalarında tansiyon PTx gibi mortalitenin önemli bir nedeni olabilir. Bu çalışmada, BPTx tedavisi ve buna bağlı komplikasyon, morbidite ve mortalitenin önemini belirtmek amacıyla multi-travma sonrası BPTx insidansı, morbidite, mortalite oranları ve bunlarla ilişkili faktörlerin analiz edilmesi amaçlandı.

GEREÇ VE YÖNTEM: Travma sonrası başvuran 3782 hastadan BPTx saptanan 181 hastanın verileri yaş, cinsiyet, travma çeşidi, radyolojik bulgular, eşlik eden torasik ve ekstra-torasik yaralanmalar, entübasyon insidansı, mortalite ve travma şiddet skoru (TŞS) açısından geriye dönük olarak analiz edildi. Kot kırığının tarafı, hemotoraks, ciltaltı amfizemi ve BPTx arasındaki ilişki ile yaş ve cinsiyetin bu yaralanma, mortalite ve TŞS’ye etkisi araştırıldı.

BULGULAR: Yüz kırk dördünü erkeklerin oluşturduğu hastaların yaş ortalaması 36.07±15.77 idi. Travmanın başlıca nedeni 67 (%37.0) hastada bildirilen araç-içi trafik kazasıydı. Yetmiş beş (%41.4) hastada iki taraflı kot kırığı izlendi. Hastaların 41’inde (%22.6) BPTx’a iki taraflı hemotoraks eşlik ettiği belirlendi. Özellikle 60 yaş üstü hasta grubunda kot kırığı ve hemotoraksın tarafı açısından anlamlı fark saptandı (p=0.017, p=0.005). Bu hasta grubunda eşlik eden torasik yaralanmaların daha sık olarak iki taraflı olduğu belirlendi. İzole toraks travması olan 12 (%17.6) ve multi-travması olan 56 (%82.4) hasta entübe edildi. İki grup arasında entübasyon açısından anlamlı fark bulunmadı (p=0.532). Toplam mortalite oranı %18.2 idi. Travma şiddet skoru ile mortalite arasında anlamlı bir ilişki saptanmadı (p=0.22).

TARTIŞMA: Travma sonrasında BPTx insidansı yaklaşık olarak %5 oranındadır; bu nedenle özellikle şiddetli travma sonrasında mortalite oranını azaltmak amacıyla BPTx akılda bulundurulması gereken bir patolojidir. Yaş ve kot kırığı sayısı BPTx saptanan multi-travma hastalarında morbidite ve mortalite için risk faktörleridir.

Anahtar sözcükler: Entübasyon; iki taraflı pnömotoraks; mortalite; travma; travma şiddet skoru.

Ulus Travma Acil Cerrahi Derg 2018;24(6):521-527

doi: 10.5505/tjtes.2018.76435

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ORIG I N A L A R T IC L E

Significance of red blood cell distribution width and C-reactive protein/albumin levels in predicting prognosis of acute pancreatitis Eyüp Murat Yılmaz, M.D.,1

Altay Kandemir, M.D.2

1

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

2

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

ABSTRACT BACKGROUND: Acute pancreatitis (AP) is one of the major pathologies among gastrointestinal system diseases. The aim of this study was to determine the relationship between the red cell distribution width (RDW) value and the C-reactive protein (CRP)/ albumin ratio in patients with AP. METHODS: In this retrospective study, AP cases were enrolled and divided into 2 groups according to the Ranson criteria as moderate or severe pancreatitis. The RDW and CRP/albumin values, length of hospitalization and stay in the intensive care unit (ICU), and the complications experienced were compared between these 2 groups.

RESULTS: A total of 264 patients were included in the study. Moderate pancreatitis was detected in 204 patients (77.2%) while severe pancreatitis was seen in 60 patients (22.8%) (p=0.081). There was no statistically significant difference in the RDW value between the groups (p=0.193). The CRP/albumin values were significantly higher in the severe pancreatitis group compared with the moderate group (p<0.001). The severe AP group also had a longer period of hospital care, both overall and in the ICU (p=0.001, p=0.047).

CONCLUSION: RDW was not a specific marker for predicting prognosis in AP, but the CRP/albumin ratio is an easy-to-apply, inexpensive, and reliable marker.

Keywords: Acute pancreatitis; C-reactive protein/albumin; erythrocyte distribution width; prognosis.

INTRODUCTION Acute pancreatitis (AP) is one of the most common causes of hospitalization due to pathologies originating from the gastrointestinal tract, with an annual incidence of approximately 13 to 45/100,000.[1] The clinical picture may range from moderate to severe, or even mortal, in some cases. Although the mortality rate is around 1%, it increases with age. The rate of complications is in the range of 7% to 42%.[2] AP is quite an important clinical picture, and various biochemical tests and imaging methods, such as computerized tomography (CT), as well as some scoring systems, are routinely used in order to determine the intensive care need and prognosis of the patient.[3] There is no consensus on markers established for di-

agnosis, prognosis, and response to treatment, although markers such as C-reactive protein (CRP), amylase, lipase, trypsin, phospholipase 2, interleukin (IL)-8, and procalcitonin are currently used to diagnose and predict the severity of the disease.

Early diagnosis is highly important in terms of mortality and complications, and there are some scoring systems available that can be helpful in making an early diagnosis and predicting prognosis. The Ranson criteria, the Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II, and the Balthazar score are some of those that are most widely used.

[4,5] Ranson scoring is widely used in general surgery and gastroenterology clinics to predict prognosis.[4,6] It is an easyto-use scoring system with a sensitivity of 40% to 80% in

Cite this article as: Yılmaz EM, Kandemir A. Significance of red blood cell distribution width and C-reactive protein/albumin levels in predicting prognosis of acute pancreatitis. Ulus Travma Acil Cerrahi Derg 2018;24:528-531.

Address for correspondence: Eyüp Murat Yılmaz, M.D. Adnan Menderes Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, 09100 Aydın, Turkey Tel: +90 256 - 212 18 50 E-mail: drmyilmaz80@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):528-531 DOI: 10.5505/tjtes.2018.98583 Submitted: 24.11.2017 Accepted: 22.03.2018 Online: 30.10.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Yılmaz et al. Significance of red blood cell distribution width and CRP/albumin levels in predicting prognosis of acute pancreatitis

predicting the severity of the disease.[7,8] In addition, many clinical studies have reported that easily accessible markers, such as the neutrophil/lymphocyte ratio, the platelet/lymphocyte ratio, the red cell distribution width (RDW), and the level of procalcitonin can be helpful in predicting severity and prognosis of pancreatitis to different degrees. There are also a few studies in the literature reporting that the CRP/albumin ratio can be used in this respect.[9,10] The objective of this study was to evaluate the efficacy of RDW and CRP/albumin values, both of which are inexpensive, easy-to-access, and reproducible markers available from routine blood tests, in predicting the prognosis of the patients hospitalized due to AP.

MATERIALS AND METHODS Patients and Study Design Patients admitted to the Aydın Adnan Menderes University gastroenterology department with a diagnosis of AP between January 2014 and November 2017 were included in this study.

Approval was obtained from the Non-Interventional Clinical Research Ethics Board of Aydın Adnan Menderes University.

The Ranson scores were calculated for all patients at the time of admission, and 2 groups were created: moderate (Ranson score between 0-2) and severe (Ranson score ≥3).[11] The RDW and CRP/albumin values at admission were recorded. For routine imaging, CT was performed for all of the patients at the time of diagnosis, and was repeated for patients suspected of having a complication. Details of the complications observed were also recorded.

Statistical analysis was performed using the demographic data, the length of hospital stay, length of stay in ICU, and any complications experienced.

Statistical Analysis The statistical package IBM SPSS Statistics for Windows, Version 20.0. (IBM Corp., Armonk, NY, USA) was used to evaluate the data. Mean±SD, median (maximum-minimum), percentage, and frequency values were used as variables.

Levene’s test was used to assess the homogeneity of variances, a prerequisite for parametric tests. The Shapiro-Wilk test was used to test the assumption of normality. If the parametric test prerequisites were met, Student’s t-test was used to compare differences between 2 groups, and if not, the Mann-Whitney U test was applied. The relationship between 2 continuous variables was assessed using the Pearson correlation coefficient, or the Spearman correlation coefficient, in cases where the parametric test prerequisites were not met.

P values of <0.05 and <0.01 were considered statistically significant. Test performance can be described by a test’s ability to correctly diagnose or to accurately differentiate cases into subgroups (healthy/patient, etc.). The final Ranson scores (0–2; >3) were evaluated using receiver operating characterUlus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

istic (ROC) curve analysis. The area under the curve (AUC), sensitivity, and selectivity values were calculated.

RESULTS A total of 264 patients were included in the study, of whom 159 (60.2%) were female and 105 (39.8%) were male. Among these, 131 (49.6%) patients were identified as nonbiliary and 133 (50.4%) as biliary AP patients. The mean age was 59.97 years (range: 21–95 years). Complications occurred in 22 patients (8.3%), and there was no instance of mortality observed in the group. The mean length of stay in the hospital was 6.43 days (range: 0–34 days), and the mean length of stay in the ICU was 1.04 days (range: 0–34 days). The mean RDW value was determined to be 15.21% (range: 11.3–18%), and the mean CRP/albumin value was 19.16 mg/L (range: 0.05– 114.94 mg/L) (Table 1).

When we divided the patients into 2 groups according to the Ranson score, moderate pancreatitis was determined in 204 (77.2%) patients and severe pancreatitis in 60 (22.8%) patients (p=0.081). There was no statistically significant difference between the groups in the RDW value (p=0.193). However, the CRP/albumin value was significantly higher in the severe AP group than in the moderate AP group (p<0.001).

The mean length of stay in the hospital and in the ICU was longer in the severe AP group than in the moderate group (p=0.001, p=0.047) (Table 2).

Table 1. Descriptive statistics

n

Min.

Max.

Mean±SD

Age

264 21.0 95.0 59.97±17.47

Ranson

264 0.0 6.0 2.06±1.04

RDW

264 11.3 187.0 15.21±10.86

ICU (day)

264

0.0

34.0

1.04±3.43

Total hospital (day)

264

0.0

34.0

6.43±4.47

CRP/albümin

263 .05 144.94 19.16±26.09

CRP: C-reactive protein; ICU: Intensive care unit; RDW: Red cell distribution width; Min.: Minimum; Max.: Maximum; SD: Standard deviation.

Table 2. Data of moderate and severe acute pancreatitis Ranson

0–2 >3 p (n=204) (n=60)

Age

58.95±17.54 63.43±16.88 0.081

RDW

14.34±1.94 18.15±22.39 0.193

ICU (day)

0.77±3.1

1.97±4.28

0.047*

Total hospital (day)

5.66±3.01

9.03±7.01

0.001*

CRP/albümin

9.29±12.04 52.58±32.49 0.001*

CRP: C-reactive protein; ICU: Intensive care unit; RDW: Red cell distribution width. *: p<0.05.

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Yılmaz et al. Significance of red blood cell distribution width and CRP/albumin levels in predicting prognosis of acute pancreatitis

conducted with 322 AP patients, Gülen et al.[18] considered RDW values to be significant for early prediction of prognosis in nontraumatic AP cases. Cetinkaya et al.[19] studied 102 patients diagnosed with AP and noted a significant correlation between RDW and mortality values, and indicated that RDW was an important and easy-to-use marker in prognosis. In our study, however, no statistically significant difference was determined, although RDW values were higher in the severe AP group than in the moderate AP group. Though RDW is an easy-to-use test that is inexpensive and readily accessible, the contrast between our results and those in the literature raises questions and would suggest that further studies with larger study groups are needed, especially when our rather large sample size is considered.

ROC Curve

1.0

Sensitivity

0.8

0.6

0.4

0.2

0.0

0.0

0.2

0.4

0.6

0.8

1.0

1 - Specificity Diagonal segments are produced by ties

Figure 1. C-reactive protein/albumin ratio cutoff curve according to Ranson value. ROC: Receiver operating characteristic.

ROC curve analysis with a Ranson score cut-off point revealed that it was statistically significant to determine limit values for a CRP/albumin parameter (p<0.01). According to the Rankin scale cut-off point, the CRP/albumin limit value parameter of 8.5102 had a specificity of 66% and sensitivity of 90% (Fig. 1).

DISCUSSION Despite improvements in diagnostic algorithms and intensive care conditions, as well as new approaches in treatment modalities, the mortality rate is reported to be 10% to 20% in severe AP cases that develop multiple organ failure.[12] Multiple organ failure and infectious necrosis are recognized as the most common factors increasing mortality, and thus they have been used as markers for predicting prognosis in such cases.[13–15] Biochemical markers, such as IL-6, IL-8, CRP, and IL-10, in addition to scoring systems, such as the Ranson criteria, the Baltazar score, and the APACHE II score have been used to estimate prognosis.[16] The present study was designed to use biochemical tests that are easily accessible and inexpensive to physicians regardless of location in order to predict the severity and prognosis of AP. RDW is a low-cost and reliable whole blood analyzer parameter showing the distribution of erythrocyte volume and can be measured easily and simply. It is a valuable measurement in many pathological diseases, ranging from sepsis to cancer, and from kidney dysfunction to cardiovascular disease, and it has also been shown in the literature to be an important inflammatory marker.[10] It has been identified as an important marker in determining the mortality rate and length of hospital stay in patients in many clinical trials.[17] In a study 530

The CRP/albumin ratio, currently a popular marker, was the second marker to be examined as part of this study’s objective.

CRP/albumin is becoming a commonly used marker for various diseases, ranging from inflammatory processes, such as sepsis and ulcerative colitis, to prognosis in cases of malignancies, such as hepatocellular carcinoma and pancreatic cancer.[20–22] Although it is recognized as an inflammatory marker, studies investigating CRP/albumin in AP patients are currently very limited in the literature. In their study of 192 patients with AP, Kaplan et al.[9] analyzed the Ranson and Atlanta scores, as well as the effects of CRP/albumin values, on prognosis and severity.

They observed an increase in severity and poor prognosis with increased CRP/albumin values. They reported better prognosis in the patients with a CRP/albumin ratio <16.28 and poor prognosis when it was >16.28. In our study too, the prognosis became worse and the disease severity increased as the CRP/ albumin ratio increased. The length of stay in the hospital and in the ICU, an important predictor of prognosis, increased as the CRP/albumin ratio increased. We found the sensitivity of CRP/albumin to AP to be 90% with a cut-off value of 8.51.

While the available research on CRP/albumin in AP is still very limited, it is a very promising, easily measurable, reproducible, noninvasive, and inexpensive test for AP. In conclusion, AP is a clinical entity with high mortality in severe cases, and therefore a marker for prognosis must be simple, easily accessible, inexpensive, and reliable for physicians.

Although many studies have reported that RDW may be such a simple, reliable, inexpensive, and easily accessible test to predict mortality,[23] our results did not indicate that RDW was very significant in predicting prognosis. We would like to highlight the CRP/albumin ratio, already a popular marker for inflammation, as a promising potential marker for use in determining a prognosis in AP cases, though we recommend further studies on this topic.

The authors declare that there is no conflict of interest regarding publication of this article. No financial support was obtained.

Conflict of interest: None declared.

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Yılmaz et al. Significance of red blood cell distribution width and CRP/albumin levels in predicting prognosis of acute pancreatitis

REFERENCES 1. Goyal H, Awad H, Hu ZD. Prognostic value of admission red blood cell distribution width in acute pancreatitis: a systematic review. Ann Transl Med 2017;5:342.

2. Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology 2013;144:1252–61.

3. Bülbüller N, Doğru O, Ayten R, Akbulut H, Ilhan YS, Cetinkaya Z. Procalcitonin is a predictive marker for severe acute pancreatitis. Ulus Travma Acil Cerrahi Derg 2006;12:115–20.

4. İlhan M, İlhan G, Gök AF, Bademler S, Verit Atmaca F, Ertekin C. Evaluation of neutrophil-lymphocyte ratio, platelet-lymphocyte ratio and red blood cell distribution width-platelet ratio as early predictor of acute pancreatitis in pregnancy. J Matern Fetal Neonatal Med 2016;29:1476–80.

5. Balthazar EJ. CT diagnosis and staging of acute pancreatitis. Radiol Clin North Am 1989;27:19–37.

6. Lerch MM, Adler G. Experimental animal models of acute pancreatitis.

Int J Pancreatol 1994;15:159–70.

7. Kılıç MÖ, Çelik C, Yüksel C, Yıldız BD, Tez M. Correlation between Ranson score and red cell distribution width in acute pancreatitis. Ulus Travma Acil Cerrahi Derg 2017;23:112–6.

8. Khanna AK, Meher S, Prakash S, Tiwary SK, Singh U, Srivastava A, et al. Comparison of Ranson, Glasgow, MOSS, SIRS, BISAP, APACHEII, CTSI Scores, IL-6, CRP, and Procalcitonin in Predicting Severity, Organ Failure, Pancreatic Necrosis, and Mortality in Acute Pancreatitis.

HPB Surg 2013;2013:367581.

9. Kaplan M, Ates I, Akpinar MY, Yuksel M, Kuzu UB, Kacar S, et al. Predictive value of C-reactive protein/albumin ratio in acute pancreatitis.

Hepatobiliary Pancreat Dis Int 2017;16:424–30.

10. Goyal H, Lippi G, Gjymishka A, John B, Chhabra R, May E. Prognostic significance of red blood cell distribution width in gastrointestinal disorders. World J Gastroenterol 2017;23:4879–91.

11. Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch Surg 1993;128:586–90.

12. Güldoğan CE, Kılıç MÖ, Balamir İ, Tez M, Turhan T. Correlation between ischemia-modified albumin and Ranson score in acute pancreatitis.

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13. Li Y, Zhao Y, Feng L, Guo R. Comparison of the prognostic values of inflammation markers in patients with acute pancreatitis: a retrospective cohort study. BMJ Open 2017;7:e013206.

14. Bezmarevic M, Mirkovic D, Soldatovic I, Stamenkovic D, Mitrovic N, Perisic N, et al. Correlation between procalcitonin and intra-abdominal pressure and their role in prediction of the severity of acute pancreatitis.

Pancreatology 2012;12:337–43.

15. Mounzer R, Langmead CJ, Wu BU, Evans AC, Bishehsari F, Muddana V, et al. Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis. Gastroenterology 2012;142:1476–82.

16. Rao SA, Kunte AR. Interleukin-6: An Early Predictive Marker for Severity of Acute Pancreatitis. Indian J Crit Care Med 2017;21:424–8.

17. Lippi G, Mattiuzzi C, Cervellin G. Learning more and spending less with neglected laboratory parameters: the paradigmatic case of red blood cell distribution width. Acta Biomed 2017;87:323–8.

18. Gülen B, Sonmez E, Yaylaci S, Serinken M, Eken C, Dur A, et al. Effect of harmless acute pancreatitis score, red cell distribution width and neutrophil/ lymphocyte ratio on the mortality of patients with nontraumatic acute pancreatitis at the emergency department. World J Emerg Med 2015;6:29–33.

19. Cetinkaya E, Senol K, Saylam B, Tez M. Red cell distribution width to platelet ratio: new and promising prognostic marker in acute pancreatitis.

World J Gastroenterol 2014;20:14450–4.

20. Arima K, Yamashita YI, Hashimoto D, Nakagawa S, Umezaki N, Yamao T, et al. Clinical usefulness of postoperative C-reactive protein/albumin ratio in pancreatic ductal adenocarcinoma. Am J Surg 2018;216:111–5.

21. Gibson DJ, Hartery K, Doherty J, Nolan J, Keegan D, Byrne K et al.

CRP/Albumin Ratio: An Early Predictor of Steroid Responsiveness in Acute Severe Ulcerative Colitis. J Clin Gastroenterol 2018;52:e48–52.

22. Llop-Talaveron J, Badia-Tahull MB, Leiva-Badosa E. An inflammationbased prognostic score, the C-reactive protein/albumin ratio predicts the morbidity and mortality of patients on parenteral nutrition. Clin Nutr 2017;pii:S0261–5614(17)30296–0.

23. Wang D, Yang J, Zhang J, Zhang S, Wang B, Wang R et al. Red cell distribution width predicts deaths in patients with acute pancreatitis. J Res Med Sci 2015;20:424–8.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut pankreatitin prognozunu ön görmede eritrosit dağılım hacmi ve CRP/albümin değerlerinin önemi Dr. Eyüp Murat Yılmaz,1 Dr. Altay Kandemir2 1 2

Adnan Menderes Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Aydın Adnan Menderes Üniversitesi Tıp Fakültesi, Gastroenteroloji Bilim Dalı, Aydın

AMAÇ: Akut pankreatit (AP) gastrointestinal patolojiler arasında önemli patolojilerden birisi olup çalışmadaki amacımız eritrosit dağılım hacmi (RDW) ve C-reaktif proten (CRP)/albümin ile prognoz ilişkisini belirleyebilmektir.

GEREÇ VE YÖNTEM: Çalışma geriye dönük olup akut pankreatit olguları alınmış ve Ranson skoruna göre ılımlı ve şiddetli grup olarak iki gruba bölünmüştür. Bu iki grup arasında RDW, CRP/albumin ve hastanede yatış ile yoğun bakımda yatış süreleri, komplikasyonları karşılaştırılmıştır.

BULGULAR: Toplam 264 hasta çalışmaya alındı. Hastaların 204’ünde (%77.2) ılımlı pankreatit saptanırken, 60 hastada (%22.8) şiddetli pankreatit saptandı (p=0.081). Bu iki grup arasındaki RDW değerlerine bakıldığında istatistiksel olarak anlamlı bir farklılık olmadığı gözlendi (p=0.193).

C-reaktif proten/albümin değerlerine bakıldığında şiddetli AP grubunda diğer gruba göre değerlerin oldukça yüksek olduğu saptandı (p<0.001).

Hastanede toplam yatış süreleri ve yoğun bakımda toplam yatış sürelerine bakıldığında ise şiddetli AP grubundaki hastaların diğer gruba göre daha fazla hastanede kaldıkları gözlendi (p=0.001, p=0.047).

TARTIŞMA: Akut pankreatit tablosunda RDW net olarak prognozu ön görmede spesifik bir markır değilken, CRP/albümin kolay uygulanabilen, ucuz ve güvenilir bir markırdır.

Anahtar sözcükler: Akut pankreatit; CRP/albümin; eritrosit dağılım hacmi; prognoz.

Ulus Travma Acil Cerrahi Derg 2018;24(6): 528-531

doi: 10.5505/tjtes.2018.98583

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ORIG I N A L A R T IC L E

Factors predicting the early mortality of trauma patients Won Young Yong Jin M.D.,1 Jin Hee Jeong, M.D.,1,2 Dong Hoon Kim M.D., PhD.,1 Tae Yun Kim M.D.,1 Changwoo Kang, M.D.,1 Soo Hoon Lee, M.D.,1 Sang Bong Lee, M.D.,1 Seong Chun Kim, M.D., PhD.,3 Yong Joo Park, M.D.,3 Daesung Lim, M.D.3 1

Department of Emergency Medicine,Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do-Republic of Korea

Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do-Republic of Korea

2 3

Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon

Hospital, Changwon, Gyeongsangnam-Republic of Korea

ABSTRACT BACKGROUND: The aim of this study was to identify factors predicting early mortality in trauma patients.

METHODS: This was a study of 6288 trauma patients admitted to the hospital between July 2011 and June 2016. Among the variables recorded for a prospective trauma registry, the following were selected for analysis: sex; age; a combination of the Glasgow Coma Scale score, age, and systolic blood pressure (SBP) (GAP); a combination of the mechanism of injury, the Glasgow Coma Scale score, age, and SBP (MGAP); SBP; respiratory rate; peripheral oxygen saturation (SpO2 value); the Glasgow Coma Scale score; laboratory variables; and presentation time. Logistic regression analysis was used to explore associations between these variables and early mortality.

RESULTS: In total, 296 (4.6%) patients died within 24 hours. Univariate regression analysis indicated that age, the GAP, the MGAP, SBP, SpO2, the Glasgow Coma Scale score, base excess, hemoglobin level, platelet count, INR, and presentation time predicted early mortality. Multivariate regression showed that the GAP, the MGAP, SpO2, base excess, platelet count, and INR were independently predictive. The areas under the receiver operator curve comparisons for the GAP and MGAP models revealed the superiority of the GAP-based model.

CONCLUSION: The GAP model, SpO2, base excess, platelet count, and INR predicted the early mortality of trauma patients.

Keywords: Acute traumatic coagulopathy; base excess; mortality; peripheral oxygen saturation; trauma; trauma scoring system.

INTRODUCTION Trauma is a serious global medical and economic issue, accounting for 10% of all mortality worldwide.[1,2] Many studies of trauma-related death have been performed, including the establishment of trauma scoring systems (TSSs) and the evaluation of coagulopathy associated with bleeding and nontrauma-related factors, such as the time of presentation to emergency departments (EDs).[3â&#x20AC;&#x201C;5] Over the past 40 years, TSSs have been developed to rate trauma severity and predict mortality. These include the In-

jury Severity Score (ISS); the Trauma-related Injury Severity Score (TRISS); the Revised Trauma Score (RTS); the Mechanism, Glasgow Coma Scale, Age, and Systolic Blood Pressure (MGAP) Score; and the Glasgow Coma Scale, Age, and Systolic Blood Pressure (GAP) Score. Of these, the MGAP and GAP systems are more recent additions. They are simple, rapid scoring systems that are more accurate than other TSSs in the prediction of trauma-associated mortality.[3,6â&#x20AC;&#x201C;9] Bleeding and coagulation disorders cause most preventable trauma-related mortality. Over the last 10 years, the number of studies of acute traumatic coagulopathy (ATC) has

Cite this article as: Jin WYY, Jeong JH, Kim DH, Kim TY, Kang C, Lee SH, et al. Factors predicting the early mortality of trauma patients. Ulus Travma Acil Cerrahi Derg 2018;24:532-538.

Address for correspondence: Jin Hee Jeong, M.D. 79, Gangnam-ro 52727 Jinju-si - South Korea Tel: 82-10-4846-9592 E-mail: pernoctans@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):532-538 DOI: 10.5505/tjtes.2018.29434 Submitted: 16.04.2018 Accepted: 16.07.2018 Online: 01.11.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Jin et al. Factors predicting the early mortality of trauma patients

increased significantly. ATC independently predicts mortality and is commonly encountered during the treatment of trauma patients.[4,10,11] Recently, ED presentation time, which is an indicator of treatment quality, has become a topic of interest.[12] A study has explored whether presentation time was associated with prognosis.[13] Several studies have explored whether traumaassociated in-hospital mortality differed in those admitted during business and non-business hours. Although the results varied somewhat, no remarkable difference was noted.[5,14] However, these studies related to TSSs, ATC, and ED presentation time evaluated only in-hospital or 30-day mortality, not early mortality. The major causes of early and late mortality caused by trauma are different. Most early mortality is caused by bleeding and brain injuries, whereas most late mortality is attributable to complications developing in the hospital, such as infection and multiple organ failure (MOF).

[15] The associated factors may differ. Predictive factors are needed, since most deaths from trauma are cases of early mortality.[16,17] These factors should be readily identifiable in the early phase of management. Indeed, if such factors could be promptly identified, trauma patients could receive more aggressive treatment. Thus, factors that could rapidly predict early mortality were the subject of this study.

MATERIALS AND METHODS Study Design Data in a prospectively recorded trauma registry were retrospectively reviewed to identify 24-hour mortality and early predictors thereof. Professional health information managers, closely supervised by emergency physicians, maintain the ED trauma registry of our 900-bed tertiary care university hospital. All ED patients are managed by board-certified emergency physicians. This study was approved by the Gyeongsang National University Hospital Institutional Review Board.

Patient Information Patients aged ≥16 years with blunt or penetrating trauma admitted to the ED of a single hospital between July 2011 and June 2016 were evaluated. The exclusion criteria were other forms of trauma, trauma of unknown type, and dead-on-arrival status (whether or not cardiopulmonary resuscitation was attempted). Patients who were discharged or transferred to another hospital within 24 hours of arrival were also excluded.

Variables Among the many possible variables, those that have usefully predicted trauma mortality in previous studies and could be quickly scored (within 30 minutes) were selected for analysis.

Variables exhibiting significant correlations (multicollinearity) were excluded. Sex, age, the GAP, the MGAP, systolic blood Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

pressure (SBP), respiratory rate (RR), peripheral oxygen saturation (SpO2) level, the Glasgow Coma Scale (GCS) score, base excess, hemoglobin (Hb) level, platelet count, international normalized ratio (INR), and presentation time were evaluated. The first measurement taken after ED presentation was used in this study. The GAP and MGAP reliably predict trauma-related mortality and can be readily calculated even in busy EDs (Table 1).[8,9] Presentation time was classified as a weekday or not a weekday. Weekdays were defined as Monday to Friday from 09:00 to 17:59. Early mortality was defined as mortality within 24 hours of presentation. The primary outcomes were early mortality and factors predicting such mortality.

Statistical Analysis Multivariate imputation by chained equation was used to impute missing values.[18] Sex, age, the GAP, the MGAP, SBP, RR, SpO2, the GCS, Hb level, platelet count, INR, and presentation time were subjected to univariate analysis, and factors identified as significant were then subjected to multivariate analysis (with the exceptions of age and SBP because both feature in the GAP and MGAP). Multivariate logistic regression was performed twice, including either the GAP or the MGAP and other variables identified as significant by the univariate analysis. The equation used to calculate predicted survival (Ps) was: Ps = 1/(1 + e-b), b = b0 + b1 x GAP + b2 x sex + b3 x INR… (thus including coefficients b0, b1, b2, b3…).

The coefficients were derived during multivariate regression analysis. The discriminatory ability of the final models was evaluated by drawing receiver operator characteristic curves and a comparison of the curves using the method of DeLong et al.[19] The ease of deriving the variables of the final model was also assessed. The cutoffs were the 3 GAP groups (mild, moderate, and severe), INR 1.5, platelet count <100,000/µL, base excess –6, and the 6 saturation groups (>91%, 90–81%, Table 1. GAP and MGAP scoring systems GAP GCS

Points MGAP 3–15

Age (years)

GCS

Points 3–15

Age (years)

<60

3 <60

5

>60

0 >60

0

SBP (mmHg)

SBP (mmHg)

>120

6 >120

5

60−120

4 60−120

3

<60

0 <60

0

Blunt trauma

4

GAP: Glasgow Coma Scale, Age, and Systolic Blood Pressure; GCS: Glasgow Coma Scale; MGAP; Mechanism, Glasgow Coma Scale, Age, and Systolic Blood Pressure.

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Jin et al. Factors predicting the early mortality of trauma patients

80–71%, 70–61%, 60–51%, <50%) derived in previous studies.[1,9,20–22] A p value <0.05 was considered statistically significant. MedCalc 17 (MedCalc BVBA, Ostend, Belgium) and Stata version 13 (StataCorp LP, College Station, TX, USA) software were used for the analysis.

RESULTS Baseline Characteristics In total, 45,589 trauma patients were admitted to the ED during the study period, and 26,202 patients ≥16 years of age with blunt/penetrating trauma were included. After excluding those who had experienced cardiac arrest prior to presentation and those discharged or transferred within 24 hours, a total of 6288 patients remained (Fig. 1). The mean patient age was 57.3±18.6 years, and 67.1% were male. Baseline data (and the percentages of missing data) are shown in Table 2.

Univariate and Multivariate Logistic Regression The 24-hour mortality rate of the study patients was 4.6%.

No significant between-group difference in sex was noted (males 67.0% vs. females 68.9%; p=0.49). However, a significant difference was observed in terms of age (56.90 vs. 64.56 years, p<0.001). Univariate logistic regression showed that age, the GAP, the MGAP, SBP, SpO2, the GCS, base excess, Hb level, platelet count, INR, and presentation time predicted 24-hour mortality (Table 3).

The results of the two multivariate logistic regression analyses are shown in Table 4. Both the GAP and the MGAP were significant, whereas neither Hb level nor presentation time was significant. Two GAP and MGAP models were created using SpO2, base excess, platelet count, and INR values. The GAP-based model afforded good discrimination [area under the receiver operator characteristic curve (AUROC): 0.962; p<0.001; 95% confidence interval (CI): 0.94–0.973].

The MGAP-based model also afforded good discrimination (AUROC 0.958; p<0.001; 95% CI: 0.946–0.970). AUROC comparisons revealed the superiority of the GAP-based 45.589 All trauma patients 10.679 Patients <15 years old 8.641 Trauma other than blunt or penetrating trauma 67 Trauma with unknown mechanism 26.202 Patients 311 Dead on arrival with or without attempt of CPR* 2.5891 Patients 19.603 Patients who were discharged or transferred

within 24 hours 6.288 Patients

5.992 Patients 24 hours-Survival

296 Patients 24 hours-Death

Figure 1. Study patients. CPR: Cardiopulmonary resuscitation.

534

model (p<0.001; 95% CI: 0.003–0.005; absolute difference: 0.00383).

A categorical model using the GAP was created because it is easy to apply (Table 5). GAP <19 points, INR >1.5, platelets count <100,000/µL, base excess <-6, and saturation <90% Table 2. Baseline characteristics and missing data percentages Variables

Total patients (n=6288)

Missing case n (%)

4217 (67.1)

0 (0)

Sex (male, %) Age (years)

57.26

0 (0)

GAP

20.76

22 (0.3)

MGAP

24.63

22 (0.3)

Systolic blood pressure(mmHg)

131.99

6 (0.1)

Respiratory rate (cpm)

19.90

0 (0)

SpO2 (%)

96.75

240 (3.8)

GCS

14.11

16 (0.3)

Base excess (mmol/L)

−2.24

680 (10.8)

Hemoglobin level (g/dL)

12.83

93 (1.5)

Platelet count (10³/mm3)

233.65

93 (1.5)

1.14

616 (9.8)

2662 (42.3)

0 (0)

International normalized ratio Presentation time (weekday, %)

GAP: Glasgow Coma Scale, Age, and Systolic Blood Pressure; GCS: Glasgow Coma Scale; INR: International normalized ratio; MGAP: Mechanism, Glasgow Coma Scale, Age, and Systolic Blood Pressure; SpO2: Peripheral oxygen saturation.

Table 3. Univariate analysis for factors associated with early mortality Variables

β

p

95% CI

Sex (male)

−0.089

0.487

−0.341-0.163

Age (years)

0.025

<0.001

0.018-0.032

GAP

−0.464

<0.001

−0.498-−0.430

MGAP

−0.446

<0.001

−0.479-−0.412

Presentation time

0.272

0.028

0.030-0.515

SBP (mmHg)

−0.022

<0.001

−0.026-−0.018

Respiratory rate (cpm)

0.005

0.808

−0.033-0.042

<0.001

−0.154-−0.117

SpO2 (%)

−0.135

GCS

−0.449 <0.001 −0.480-−0.418

Base excess (mmol/L)

−0.224

<0.001

−0.246-−0.201

Hemoglobin level (g/dL)

−0.323

<0.001

−0.371-−0.275

Platelet count (10³/mm ) −0.009 <0.001 −0.011-−0.007 3

INR

0.838 <0.001 0.669-1.006

CI: Confidence interval; GAP: Glasgow Coma Scale, Age, and Systolic Blood Pressure; GCS: Glasgow Coma Scale; INR: International normalized ratio; MGAP: Mechanism, Glasgow Coma Scale, Age, and Systolic Blood Pressure; SpO2: Peripheral oxygen saturation.

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Jin et al. Factors predicting the early mortality of trauma patients

Table 4. Multivariate analysis for factors associated with early mortality Variables

β

p

95% CI

Variables

p

β

95% CI

GAP

−0.415 <0.001 −0.452-−0.378 MGAP

−0.399 <0.001 −0.435-−0.362

Presentation time

0.222

0.215

−0.129-0.573

Presentation time

0.280

0.112

−0.065-0.625

SpO2 (%)

−0.034

0.004

−0.057-−0.011

SpO2

−0.039 <0.001 −0.061-−0.018

Base excess (mmol/L)

−0.091

<0.001

−0.124-−0.058

Base excess

−0.114

<0.001

−0.146-−0.082

Hemoglobin level (g/dL)

−0.056

0.180

−0.139-0.026

Hemoglobin level

−0.014

0.730

−0.096-0.067

Platelet count (10³/mm3) –0.005 <0.001 −0.007-−0.002 Platelet count

–0.005 <0.001 −0.007-−0.002

INR

0.313 <0.001 0.176-0.450

0.294 <0.001 0.158-0.430 INR

CI: Confidence interval; GAP: Glasgow Coma Scale, Age, and Systolic Blood Pressure; GCS: Glasgow Coma Scale; INR: International normalized ratio; MGAP: Mechanism, Glasgow Coma Scale, Age, and Systolic Blood Pressure; SpO2: Peripheral oxygen saturation.

Table 5. Categorical analysis using the GAP model Variables

Odd ratio

p

95% Confidence interval

Glasgow Coma scale Moderate (19&24 points)

36.201

<0.001

24.969–52.483

Severe (11–18 points)

340.151

<0.001

219.945–526.053

Saturation (%) 90–81

8.563

<0.001

6.128–11.966

80–71

30.669

<0.001

18.342–51.281

70–61

27.484

<0.001

10.701–70.592

60–51

61.325

<0.001

15.295–245.875

<50

10.310

0.042

1.083–98.142

International normalized ratio >1.5

18.737

<0.001

14.127–24.850

Platelet count <100 (10³/mm3)

4.351

<0.001

3.350–5.651

Base excess (mmol/L) <-6

11.190

<0.001

8.739–14.329

CI: Confidence interval; GAP: Glasgow Coma Scale, Age, and Systolic Blood Pressure.

showed a significant association for predicting early mortality.

The odds ratios became greater as the conditions measured indicated greater seriousness.

DISCUSSION The aim of this research was to identify factors that can rapidly predict early mortality in trauma patients. The GAP, the MGAP, SpO2, base excess, platelet count, and INR were determined to be useful in this context. Of the 2 models using these parameters, the GAP was better than the MGAP. Trauma-related mortality can be classified into 3 categories based on time; the causes of mortality differ between categories. The categories are immediate death (within minutes after injury), death within 24 hours, and in-hospital death after 24 hours. Most in-hospital mortality occurs during the second and third periods. Although factors directly related to trauma often cause mortality during the second period, the immediate effects of the accident decrease in the third Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

period, during which death is caused by complications, such as sepsis and MOF.[15] Thus, as early and late trauma mortality differ in their etiologies, only 24-hour mortality was assessed in this study.

Most trauma-related mortality occurs within the first 24 to 48 hours.[16,17] The survival of patients admitted to EDs is determined by the severity of the condition at the time of presentation and the promptness of treatment. Therefore, patients must be rapidly triaged, and the worst-affected treated quickly. Several studies have identified predictors of early mortality. However, these studies involved hospitalized patients or those with specific diseases, or employed tests that are not readily available.[17,23–25] One recent study proposed an early mortality prediction model for trauma patients based on clinical and laboratory values, as in the present study.[26] This model was simple and included some variables that were similar to those used in our study for trauma mortality prediction. However, that study evaluated the 28-day mortality, not 535

Jin et al. Factors predicting the early mortality of trauma patients

24-hour mortality. Furthermore, they used traumatic brain injury as a factor, which required image scan-taking times.

In contrast, we evaluated only variables that can be rapidly measured, in order to facilitate rapid triage and thereby aid in initial management. Based on the categorical model outcomes using the GAP, we identified that a GAP <19 points, INR >1.5, platelets count <100,000/µL, base excess <-6, and saturation <90% could be used as cutoff values for predicting early mortality. A previous study showed that these factors proved to be significant factors for in-hospital or 30-day mortality.[9,20–22] In addition, the results indicated that they can also be used as the factors for early mortality.

Of the various TSSs, the RTS has been widely used since 1989. Although the RTS is simple to use, its predictive power is less than that of other recent TSSs. The ISS (developed in 1974) and the TRISS (developed in 1987) have found widespread use. Although the TRISS is more accurate, patients must be examined, and the required measurements are usually available only after several hours, rendering the system unsuitable as a predictor of early mortality.[6] The ISS also requires that patients be examined.[3] The GAP and MGAP are recent systems that do not require examination.[8,9] Both systems are rapid and more predictive than the RTS.[9,27,28] Thus, we chose the GAP and MGAP to predict early mortality. Previous studies on TSSs focused principally on in-hospital mortality. The GAP was studied in this context and, although short-term mortality was mentioned, this did not meet our definition of early mortality, as it was defined in terms of mortality in the ED or the operating room rather than in terms of time.[9] One GAP validation study examined 24-hour mortality. However, the study included only patients with severe trauma; thus, not all trauma patients were included, and only 100 patients were evaluated.[27] We found that when the GAP was used to evaluate all trauma patients admitted to the ED, the GAP predicted 24-hour mortality.

Many trauma patients die as a result of bleeding. We found that the percentage of patients who died from uncontrolled bleeding after trauma accounted for 30% to 35% of mortality during the acute stage.[29] ATC develops during bleeding associated with tissue damage and resuscitation, and is caused by the consumption of coagulation factors and platelets, loss of red cells, blood dilution by fluid, hormonal and cytokineinduced changes, hypoxia, acidosis, hypothermia, and immune system activation.[4] Although trauma patients may die from direct bleeding, death is further accelerated by ATC caused by bleeding and other factors. Many studies have been published on ATC,[4,10,11] and have used various definitions of coagulopathy.[4] In the present study, we used INR and platelet count to reflect ATC because these parameters can be easily measured (within 30 minutes at our hospital). Both were risk factors for 24-hour mortality. Prothrombin time-based assays (e.g., INR) and activated partial thromboplastin time (aPTT) are standard laboratory tests for ATC.[4] However, both tests were developed to evaluate clotting factor deficiencies rather 536

than the acquired coagulopathy associated with trauma.

Therefore, these tests are inappropriate when measuring ATC. Some studies have used viscoelastic tests (thromboelastography and rotation thromboelastometry) in trauma settings.[30] However, no standard viscoelastic test for ATC is yet available and, unlike INR and aPTT tests, viscoelastic tests are not performed in all hospitals. INR is more sensitive than the aPTT test when used to detect traumatic coagulation disorders.[31] Other studies have also used INR to predict ATC.[32] Platelets are responsible for primary hemostasis. A low platelet count is a risk factor for mortality.[33] If ATC is promptly detected and treated, mortality can be reduced; active testing and treatment are needed. Previous research on the effect of ATC on early mortality has indicated that ATC increased such mortality,[20,25] but these studies did not explore whether ATC predicted mortality. We found that ATC predicted early mortality. To the best of our knowledge, this is the first study to use both ATC and TSSs to predict early trauma-related mortality.

The base deficit (BD) is a prognostic marker that has been widely used since the 1960s. Recent studies have confirmed that BD significantly predicts mortality in trauma patients, despite recent advances in such treatment.[21] A higher BD suggests severe traumatic injury[34,35] and is associated with complications, such as MOF, adult respiratory distress syndrome, acute lung injury, and renal failure coagulopathy.[36–38] We also found that BD significantly predicted 24-hour mortality. Automated blood gas analysis yields fast results, particularly on point-of-care testing in EDs, and is simple to perform.

Saturation was a useful predictor of trauma mortality in an earlier study.[22] The RTS (a TTS) used respiratory rate (RR) as a predictive variable.[5] In trauma patients, the RR often fails to reflect ventilation or oxygenation status, as it is greatly affected by pain or psychological stress. Also, the normal range of RR is wide (10–29/minutes), and therefore the RTS may not accurately reflect actual ventilation or oxygenation.

[39] In contrast, the objective SpO2 accurately reflects the ventilation/oxygenation status of trauma patients. We found that the RR did not predict 24-hour mortality, but saturation did.

Recent studies have evaluated trauma patient prognosis in terms of ED presentation time and found no difference in mortality between those admitted during business and nonbusiness hours[5,14,40] because the medical resources available in hospitals with highly developed trauma systems do not vary significantly by the time of day. Such resources include 24-hour in-house surgeons and anesthesiologists and 24-hour emergency surgery/intervention suites. Our hospital is a tertiary care center for trauma patients, and we have access to such medical resources 24 hours a day. We found that presentation time did not affect mortality. Presentation time can affect ED waiting time or the incidence of adverse events, but in well-run hospitals, presentation time has no significant effect on early mortality after trauma.

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Jin et al. Factors predicting the early mortality of trauma patients

In this study, the mortality rate was 4.7%, lower than that of other studies. This may be attributable to the exclusion of patients who were dead-on-arrival with or without attempted cardiopulmonary resuscitation. Also, we included those with mild trauma as well as those with serious trauma.

Our study had several limitations. First, the research was performed in a single center serving a Korean population only.

Thus, this study may have a different age distribution and sex ratio than previous studies, and our results may not be completely applicable to all settings. Multicenter studies with different populations are required. Second, we did not include all of the clinical variables that could possibly affect trauma mortality, such as medical history, pre-hospital transfer time, or pre- or intra-hospital interventions. Third, the study was retrospective in nature. Hence, some data were missing, and the results may thus be compromised, despite our use of multiple imputation. Fourth, we enrolled only adults >16 years of age. Pediatric patients were excluded because they have unique physiological characteristics. In future, early mortality in pediatric patients should be studied.

Conclusion The GAP, MGAP, SpO2, base excess, platelet count, and INR usefully predicted early mortality among trauma patients. The GAP model is simpler and more accurate than the MGAP model. We believe that our GAP-based model will be useful for early triage and appropriate initial management of trauma patients.

Acknowledgements The trauma registry was originally developed as a part of Emergency Department-based Injury In-depth Surveillance conducted by the Korea Centers for Disease Control and Prevention.

Conflict of interest: None declared.

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8. Sartorius D, Le Manach Y, David JS, Rancurel E, Smail N, Thicoïpé M, Mechanism, glasgow coma scale, age, and arterial pressure (MGAP): a new simple prehospital triage score to predict mortality in traumapatients. Crit Care Med 2010;38:831–7.

9. Kondo Y, Abe T, Kohshi K, Tokuda Y, Cook EF, Kukita I. Revised trauma scoring system to predict in-hospital mortality in the emergency department: Glasgow Coma Scale, Age, and Systolic Blood Pressure score. Crit Care 2011;15:R191.

10. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma 2003;54:1127–30.

11. Maegele M, Paffrath T, Bouillon B. Acute traumatic coagulopathy in severe injury: incidence, riskstratification, and treatment options. Dtsch Arztebl Int 2011;108:827–35.

12. Di Bartolomeo S. The ‘off-hour’ effect in trauma care: a possible quality indicator with appealing characteristics. Scand J Trauma Resusc Emerg Med 2011;19:33.

13. Jneid H, Fonarow GC, Cannon CP, Palacios IF, Kilic T, Moukarbel GV,et al. Impact of time of presentation on the care and outcomes of acute myocardial infarction. Circulation 2008;117:2502–9.

14. Laupland KB, Ball CG, Kirkpatrick AW. Hospital mortality among major trauma victims admitted on weekends and evenings: a cohort study. J Trauma Manag Outcomes 2009;3:8.

15. Sobrino J, Shafi S. Timing and causes of death after injuries. Proc (Bayl Univ Med Cent) 2013;26:120–3.

16. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, et al.

Epidemiology of trauma deaths: a reassessment. J Trauma 1995;38:185– 93.

17. Wang H, Robinson RD, Moore B, Kirk AJ, Phillips JL, Umejiego J, et al.

Predictors of early versus late mortality in pelvic trauma patients. Scand J Trauma Resusc Emerg Med 2016;24:27.

18. White IR, Royston P, Wood AM. Multiple imputation using chained equations: Issues and guidance for practice. Stat Med 2011;30:377–99.

19. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 1988;44:837–45.

20. Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T, et al. Early coagulopathy in multiple injury: an analysis from the GermanTrauma Registry on 8724 patients. Injury 2007;38:298–304.

21. Ibrahim I, Chor WP, Chue KM, Tan CS, Tan HL, Siddiqui FJ, et al. Is arterial base deficit still a useful prognostic marker in trauma? A systematic review. Am J Emerg Med 2016;34:626–35.

22. Huber-Wagner S, Stegmaier J, Mathonia P, Paffrath T, Euler E, Mutschler W, et al. The sequential trauma score - a new instrument for the sequential mortality prediction in major trauma. Eur J Med Res 2010;15:185–95.

23. Gerdin M, Roy N, Khajanchi M, Kumar V, Dharap S, Felländer-Tsai L, et al. Predicting early mortality in adult trauma patients admitted to three public university hospitals in urban India: a prospective multicentre cohort study. PLoS One 2014;9:e105606.

24. Hampton DA, Lee TH, Diggs BS, McCully SP, Schreiber MA. A predictive model of early mortality in trauma patients. Am J Surg 2014;207:642–7.

25. Mitra B, Cameron PA, Mori A, Fitzgerald M. Acute coagulopathy and early deaths post major trauma. Injury 2012;43:22–5.

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27. Ahun E, Köksal Ö, Sığırlı D, Torun G, Dönmez SS, Armağan E. Value of the Glasgow coma scale, age, and arterial blood pressure score for predicting the mortality of major trauma patients presenting to the emergency department. Ulus Travma Acil Cerrahi Derg 2014;20:241–7.

28. Baghi I, Shokrgozar L, Herfatkar MR, Nezhad Ehsan K, Mohtasham Amiri Z. Mechanism of Injury, Glasgow Coma Scale, Age, and Systolic Blood Pressure: A New Trauma Scoring System to Predict Mortality in Trauma Patients. Trauma Mon 2015;20:e24473.

29. Evans JA, van Wessem KJ, McDougall D, Lee KA, Lyons T, Balogh ZJ. Epidemiology of traumatic deaths: comprehensive population-based assessment. World J Surg 2010;34:158–63.

30. Johansson PI, Stissing T, Bochsen L, Ostrowski SR. Thrombelastography and tromboelastometry in assessing coagulopathy in trauma. Scand J Trauma Resusc Emerg Med 2009;17:45.

31. Yuan S, Ferrell C, Chandler WL. Comparing the prothrombin time INR versus the APTT to evaluate the coagulopathy of acute trauma. Thromb Res 2007;120:29–37.

32. Peltan ID, Vande Vusse LK, Maier RV, Watkins TR. An International Normalized Ratio-Based Definition of Acute Traumatic Coagulopathy Is Associated With Mortality, Venous Thromboembolism, and Multiple Organ Failure After Injury. Crit Care Med 2015;43:1429–38.

33. Stansbury LG, Hess AS, Thompson K, Kramer B, Scalea TM, Hess JR.

The clinical significance of platelet counts in the first 24 hours after severe injury. Transfusion 2013;53:783–9.

34. Sinert R, Zehtabchi S, Bloem C, Lucchesi M. Effect of normal saline infusion on the diagnostic utility of base deficit in identifying major injury in trauma patients. Acad Emerg Med 2006;13:1269–74.

35. Mofidi M, Hasani A, Kianmehr N. Determining the accuracy of base deficit in diagnosis of intra-abdominal injury in patients with blunt abdominal trauma. Am J Emerg Med 2010;28:933–6.

36. Sauaia A, Moore FA, Moore EE, Haenel JB, Read RA, Lezotte DC. Early predictors of postinjury multiple organ failure. Arch Surg 1994;129:39– 45.

37. Davis JW, Parks SN, Kaups KL, Gladen HE, O’Donnell-Nicol S. Admission base deficit predicts transfusion requirements and risk of complications. J Trauma 1996;41:769–74.

38. Eberhard LW, Morabito DJ, Matthay MA, Mackersie RC, Campbell AR, Marks JD, et al. Initial severity of metabolic acidosis predicts the development of acute lung injury in severely traumatized patients. Crit Care Med 2000;28:125–31.

39. Raux M, Thicoïpé M, Wiel E, Rancurel E, Savary D, David JS, et al.

Comparison of respiratory rate and peripheral oxygen saturation to assess severity in trauma patients. Intensive Care Med 2006;32:405–12.

40. Arbabi S, Jurkovich GJ, Wahl WL, Kim HM, Maier RV. Effect of patient load on trauma outcomes in a Level I trauma center. J Trauma 2005;59:815–8.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Travma hastalarında erken mortaliteyi öngören faktörler Dr. Won Young Yong Jin,1 Dr. Jin Hee Jeong,1,2 Dr. Dong Hoon Kim,1 Dr. Tae Yun Kim,1 Dr. Changwoo Kang,1 Dr. Soo Hoon Lee,1 Dr. Sang Bong Lee,1 Dr. Seong Chun Kim,3 Dr. Yong Joo Park,3 Dr. Daesung Lim3 Gyeongsang Ulusal Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Jinju-si, Gyeongsangnam-do-Kore Cumhuriyeti Gigeongsang Sağlık Bilimleri Enstitüsü, Gyeongsang Ulusal Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Jinju-si, Gyeongsangnam-do-Kore Cumhuriyeti 3 Gyeongsang Ulusal Üniversitesi Tıp Fakültesi ve Gyeongsang Ulusal Üniversitesi Changwon Hastanesi, Acil Tıp Anabilim Dalı, Changwon, GyeongsangnamKore Cumhuriyeti 1 2

AMAÇ: Bu çalışmanın amacı travma hastalarında mortaliteyi erkenden öngören faktörleri tanımlamaktır.

GEREÇ VE YÖNTEM: Bu çalışma 2011 Temmuz ile 2016 Temmuz arasında 6.288 travma hastasında gerçekleştirildi. Bir ileriye yönelik travma kayıt sisteminden alınan değişkenler arasında aşağıdakiler tek veya kombinasyon hali hastaların cinsiyeti, yaşı; Glasgow Koma Ölçeği Skoru, yaş ve sistolik kan basıncı (SKB) kombinasyonu (GYS); travmanın mekanizması, Glasgow Koma Skoru, yaş ve SKB kombinasyonu (MGYS); solunum hızı; periferik oksijen doygunluğu (SpO2 değeri); Glasgow Koma Ölçeği Skoru; laboratuvar değişkenleri ve başvuru zamanı. Bu değişkenler ile erken mortalite arasındaki ilişkileri araştırmak için lojistik regresyon analizi kullanıldı.

BULGULAR: Yirmi dört saat içinde toplam 296 (%4.6) hasta hayatını kaybetti. Tek değişkenli regresyon analizinde yaş, GYS, SKB, alkali fazlalığı, hemoglobin düzeyi, trombosit sayısı, INR ve başvuru zamanı erkenden mortaliteyi öngörmüştür. Çok değişkenli regresyon analizi de GYS, MGYS, SpO2, alkali fazlalığı, trombosit sayısı ve INR birbirlerinden bağımsız olarak mortaliteyi öngörmüştür. GYS ve MGYS modelleri için alıcı iletim eğrisi altındaki alanların karşılaştırmaları GYS modelinin üstünlüğünü ortaya koymuştur.

TARTIŞMA: GYS modeli, SpO2, alkali fazlalığı, trombosit sayısı ve INR travma hastalarında erkenden mortaliteyi öngörmüştür.

Anahtar sözcükler: Akut travmatik koagülopati; alkali fazlalığı; mortalite; periferik oksijen doygunluğu; travma; travma skorlama sistemi.

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doi: 10.5505/tjtes.2018.29434

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ORIG I N A L A R T IC L E

The diagnostic value of irisin in patients with acute abdominal pain: A preliminary study Selman Yeniocak, M.D.,1 Özgür Karcıoğlu, M.D.,2 Asım Kalkan, M.D.,1 Fatma Saraç, M.D.,3 Gökçe Akgül Karadana, M.D.,4 Zehra Zeynep Keklikkıran, M.D.,5 Alper Gümüş, M.D.,6 Macit Koldaş, M.D.,6 Semih Korkut, M.D.7 1

Department of Emergency, University of Health Sciences, Haseki Training and Research Hospital, İstanbul-Turkey

2

Department of Emergency, University of Health Sciences, İstanbul Training and Research Hospital, İstanbul-Turkey

3

Department of Pediatric Surgery, University of Health Sciences, Haseki Training and Research Hospital, İstanbul-Turkey

4Department of Emergency Medicine, Koç University Faculty of Medicine, İstanbul-Turkey 5

Department of General Surgery, University of Health Sciences, Haseki Training and Research Hospital, İstanbul-Turkey

6

Department of Clinical Chemistry, University of Health Sciences, Haseki Training and Research Hospital, İstanbul-Turkey

7

Department of Emergency, University of Health Sciences, İstanbul Kartal Dr. Lütfi Kırdar Training and Research Hospital İstanbul-Turkey

ABSTRACT BACKGROUND: The aim of this study was to investigate the prognostic value of irisin by examining the serum level of this smooth muscle protein in patients presenting at the emergency department (ED) with acute abdominal pain.

METHODS: This research was performed as a single-center, prospective, cross-sectional study. In all, 213 adult patients presenting at the ED with acute abdominal pain and 140 healthy controls were enrolled. The serum irisin level was correlated with the leukocyte, C-reactive protein, amylase, and creatine kinase values. The irisin level was compared between groups of those who were admitted or discharged, and those who received surgical or medical treatment.

RESULTS: The mean irisin level of the 213 patients and the 140 controls was 6.81±3.17 mcg/mL vs. 5.69±2.08 mcg/mL. The mean irisin value of the hospitalized patients (7.98±3.11 mcg/mL) was significantly higher than that of the discharged patient group (6.38±3.09 mcg/mL) and the controls (control vs. discharged: p=0.202; control vs. hospitalized: p<0.001; discharged vs. hospitalized: p=0.001). When compared with that of the control group, the irisin level was significantly higher in patients with gall bladder diseases, urolithiasis, and acute appendicitis (p=0.001, p=0.007, p=0.007).

CONCLUSION: The serum irisin level in patients with abdominal pain may serve as a guide in diagnostic decision-making and determining the prognosis for cases of acute abdominal pain involving luminal obstruction in tubular intra-abdominal organs.

Keywords: Acute abdominal pain; emergency department; irisin; outcome.

INTRODUCTION Patients with abdominal pain represent a group frequently seen in the emergency department (ED). A differential diagnosis of a patient with acute abdominal pain is the duty and responsibility of the emergency physician. Various markers are useful. Laboratory test results, in addition to the patient’s

history and physical examination results, significantly facilitate diagnosis. New markers are also regularly announced, and these can serve as guides in the diagnosis of abdominal pain.[1] Biochemical markers, such as D-dimer and C-reactive protein (CRP), have been studied in the differential diagnosis of patients with acute abdominal pain, particularly those requiring surgical intervention, and these parameters have been

Cite this article as: Yeniocak S, Karcıoğlu Ö, Kalkan A, Saraç F, Akgül Karadana G, Keklikkıran ZZ, et al. The diagnostic value of irisin in patients with acute abdominal pain: A preliminary study. Ulus Travma Acil Cerrahi Derg 2018;24:539-544.

Address for correspondence: Selman Yeniocak, M.D. Sağlık Bilimleri Üniversitesi, Haseki Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, İstanbul, Turkey.

Tel: +90 212 - 529 44 00 E-mail: selmanyeniocakacil@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):539-544 DOI: 10.5505/tjtes.2018.29235 Submitted: 12.01.2018 Accepted: 26.07.2018 Online: 28.11.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Yeniocak et al. The diagnostic value of irisin in patients with acute abdominal pain

reported to be potential markers of the need for surgery in patients with undiagnosed acute abdominal pain.[2] Irisin is recognized as an exercise hormone originating from skeletal muscle.[3] In addition to skeletal muscle, it is also produced in other sites, such as fat, the liver, the heart, and salivary gland tissues.[4–6] Irisin is a version of the fibronectin type III domain-containing 5 (FNDC5) protein, which regulates the release of irisin from muscle cells.[7] The irisin precursor FNDC5 mRNA has been reported to be released from tissues such as the ovaries, the adrenal gland, the vena cava, the kidney, the urethra, the bladder, the liver, and the small intestines.[4] Bakal et al. reported increased irisin levels in cases of acute appendicitis (AA). The purpose of the present study was to assess whether adding measurement of the blood irisin level to the routine blood work-up would be useful in establishing a diagnosis in patients presenting with acute abdominal pain.

[8]

MATERIALS AND METHODS Study Design and Setting This research was performed as a single-center, prospective, and cross-sectional study. Following receipt of ethics committee approval (Haseki Training and Research Hospital (2016/297), patients presenting at the ED with non-specific acute abdominal pain were reviewed for inclusion in the study. This hospital ED treats approximately 200,000 patients a year. Approximately 2% of these patients present with abdominal pain.

Participants Patients aged 18 years or more and presenting at the ED with acute abdominal pain ongoing for fewer than 7 days were included in a 3-month study. The only eligibility criteria were age and presentation with acute abdominal pain at the ED. The participants were enrolled by the emergency physician on duty based on the chief complaint. Pregnant patients, and those determined to have liver failure, anorexia nervosa, acute myocardial infarction (AMI) or ischemic heart disease, metabolic syndrome, or diabetes mellitus, which might affect blood irisin levels, and those under 18 years of age were excluded. A total of 140 healthy volunteers were also recruited as a control group for the study.

Sex, age, weight, height, length of time of pain until presentation at the ED, and blood leukocyte, CRP, amylase, and creatine kinase (CK) values of patients were recorded on patient forms. The blood irisin level was expressed as microgram/ milliliter (mcg/mL) and the level observed in the patient and control groups was compared. The patients were diagnosed on the basis of anamnesis, physical examination, biochemical blood tests, and radiological imaging, as well as operation specimens collected from patients undergoing surgery following the requisite consultations.

540

Blood Irisin Measurements Human irisin enzyme-linked immunosorbent assay kits (Catalog No. CK-E90905; Hangzhou Eastbiopharm Co., Ltd., Hangzhou, China) were used to determine irisin levels, according to the manufacturer’s instructions. Specimen absorbance was determined using a Biotek ELX800 microplate reader (Biotek Instruments, Inc., Winooski, VT, USA) at a wavelength of 450 nm. The results were expressed in µg/mL. The minimum detectable level was 0.05 µg/mL.

Statistical Analysis Statistical analysis was performed using SPSS for Windows, Version 15.0 (SPSS Inc., Chicago, IL, USA) software. Descriptive data were expressed as numbers and percentages for categorical variables, and as mean, SD, minimum, maximum, and median for numerical variables. Student’s t-test was used for comparisons between 2 groups of numerical variables when normal distribution conditions were established, and the Mann-Whitney U test was applied when normal distribution was not established. One-way analysis of variance and the Kruskal-Wallis test were used for comparisons between more than 2 groups. Subgroup analyses of comparisons of more than 2 groups were performed using the Mann-Whitney U test with a Bonferroni correction. Correlations between numerical variables were examined using Spearman correlation analysis since parametric test conditions were not established. P<0.05 was regarded as statistically significant.

The sample size was calculated to be of sufficient size to predict a small to medium-size effect in the difference of irisin levels in 2 independent groups with an alpha-error of 0.05 and 95% power.

RESULTS A total of 213 patients and a 140-member healthy control group were included in the study. In all, 185 patients were excluded for following reasons: pregnancy (n=16), liver failure (n=7), anorexia nervosa (n=3), ischemic heart disease (n=35), metabolic syndrome or diabetes mellitus (n=37), and those who declined to participate in the study (n=85).

The patient group consisted of 119 men (55.9%) and 94 women (44.1%), with a mean age of 42.9±19.1 years (median: 40 years, range: 18–87 years). The control group consisted of 74 men (52.9%) and 66 women (47.1%) with a mean age of 44.7±18.8 years (median: 42 years, range: 18–87 years).

The mean length of time between the onset of pain and presentation at the ED was 22.6±14.8 hours (median: 24 hours, range: 3-72 hours). The patients’ general characteristics and parameter values are shown in Table 1.

The mean leukocyte value in the patient group was 11.423.1±4978.6 mm3, the mean CRP level was 528.5±6179.1 mg/L, the mean amylase value was 117.6±275.8 U/L, and the Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

Yeniocak et al. The diagnostic value of irisin in patients with acute abdominal pain

Table 1. Patients’ general characteristics and laboratory values

n

%

Mean±SD

Range/Median

Gender Male

119

55.9

Female

94

44.1

Age (years)

42.9±19.1

18–87/40

Body mass index (kg/m ) 26.2±3.6 2

Pre-presentation pain duration (hours)

18.3–37.1/26.2

22.6±14.8

3–72/24

Leukocyte (mm ) 11.423.1±4978.6 3650–28.470/10.160 3

C-reactive protein (mg/L)

0.14–419.1/8.07

Amylase (U/L)

117.6±275.8

14.6-2411.1/63.1

Creatine kinase (U/L)

266.2±1569.4

11–22.767.6/96.9

Irisin (mcg/mL)

6.81±3.17

0.16–13.59/6.47

DISCUSSION The blood irisin level of patients presenting with acute abdominal pain was significantly higher compared with that of the healthy control group in this study. Analysis of the diagnostic subgroups revealed that the blood irisin level was higher in the patients with AA, biliary colic, and colic in the urinary tract than in the control group. Higher blood levels

16

14

14

12

4

4 Other

2 0 Patient Group

Control Group

Figure 1. Patients’ irisin values.

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Control

6

Acute gastroenteritis

6

Peptic ulcer

8

Ileus

8

10

Acute pancreatitis Ovarian disease

10

Nonspecific

Irisin-95% CI

12

Acute appendicitis

The mean irisin value in the patient group was 6.8±3.2 mcg/ mL (range: 0.2–13.6 mcg/mL), compared with 5.7±2.1 mcg/ mL (range: 0.2–10.5 mcg/mL) in the control group. The difference between the mean irisin level in the patient group and the control group was statistically significant (p=0.005). However, no statistically significant difference was determined

When the irisin level in the patient group was compared with that of the control group, the irisin level in the patient group was determined to be significantly higher in those with AA (Mean±SD: 8.59±3.61 mcg/mL, range: 6.67–10.51 mcg/ mL), urolithiasis (Mean±SD: 7.55±3.07, range: 6.38–8.72) and gallbladder subgroups (Mean±SD: 7.57±2.49, range: 6.51– 8.62) compared with the control group (p=0.007, p=0.007, p=0.001). Diagnoses in the ED demonstrating prevalence and irisin level are provided in Table 3 and Figure 2.

Urolithiasis

The patients’ mean body mass index (BMI) was 26.2±3.6 kg/ m2 (median: 26.2 kg/m2, range: 18.3–37.1 kg/m2). The mean BMI among members of the control group was 25.5±3.4 kg/ m2 (median: 25.6 kg/m2, range: 18.4–36.1 kg/m2). The difference between the mean BMI value of the patient and control groups was not statistically significant (p=0.074).

in the mean irisin level when analyzed according to gender (p=0.108) (Table 2, Fig. 1).

Gall bladder disease

mean CK value was 266.2±1569.4 U/L. The irisin level in the patient group was significantly positively correlated with the amylase value among the general characteristics and parameters (p=0.028). No statistically significant association was determined with the leukocyte, CRP, or CK level (p=0.788, p=0.200, and p=0.807, respectively).

Irisin

43.12±78.59

Figure 2. Irisin values by patient group.

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Yeniocak et al. The diagnostic value of irisin in patients with acute abdominal pain

Table 2. Distribution of patient and control group cases by gender and irisin level

Patients

Control group

p

n % Mean±SD Range/Median n % Mean±SD Range/Median

Gender

Male 119 55.9

74 52.9

Female

66 47.1

94

44.1

0.108

Irisin 6.81±3.17 0.16–13.59/6.47 5.69±2.08 0.18–10.54/5.78 0.005

Table 3. Diagnoses in the emergency department (in order of prevalence) and irisin level Irisin

N

%

Mean

SD

Median

5.69 2.08 5.78

95% CI

Range

Control

140

Diagnosis Nonspecific

68 31.92 5.42 3.02 5.09

4.69

Urolithiasis

29 13.62 7.55 3.07 7.12

6.38 8.72

Gall bladder disease

24

6.51

Peptic ulcer

17 7.98 7.95 3.25 7.51 6.28 9.62

11.27

7.57

2.49

7.31

5.34 6.04 6.15 8.62

Acute appendicitis

16 7.51 8.59 3.61 8.61 6.67 10.51

Acute gastroenteritis

13 6.10 6.52 2.75 5.99 4.86 8.18

Ovarian disease

10 4.69 7.08 3.18 7.14 4.81 9.36

Ileus

6 2.82 9.04 3.46 8.93 5.41 12.67

Acute pancreatitis

6 2.82 6.00 1.63 6.40 4.29 7.72

Other

24 11.27 6.79 3.13 7.17

Gastrointestinal mass *

Hernia*

5.47 8.11

4 1.88 6.57 1.79 7.24 4 1.88 5.09 4.53 4.83

Small bowel disease*

4 1.88 6.35 3.24 6.02

GI perforation*

3 1.41 6.54 2.29 7.59

Urinary infection*

3 1.41 5.73 1.76 5.80

Abdominal aortic aneurysm* 1 0.47 12.43 – 12.43

Abdominal abscess*

1 0.47 5.10 – 5.10

Splenic infarction*

1 0.47 7.91 – 7.91

Familial Mediterranean fever 1 0.47 12.18 – 12.18

Mesenteric ischemia*

Mesenteric lymphadenitis 1 0.47 5.01 – 5.01

*

1 0.47 11.42 – 11.42

*

*Included in the analysis as the “other” group. SD: Standard deviation; CI: Confidence interval.

in patients with diseases involving narrowing or obstruction of the tubular appendix vermiformis or the urinary or biliary tract suggested that irisin may be a potential marker in the diagnosis of these diseases. Bakal et al.[8] investigated the irisin level in blood, urine, and saliva in pediatric patients with AA. They also used immunohistochemical methods to determine the blood irisin level in diseased appendix vermiformis tissue.

Patients with AA had a higher irisin level compared with the control group. When they followed up with these patients 542

after surgery, they observed a dramatic drop in the irisin level. They suggested that irisin together with an increase in neutrophil level might be a good marker in cases of AA. The results reported by Bakal et al. support our own research.

The blood irisin level in patients diagnosed with AA in our study was higher than that of the control group.

Irisin level has thus far only been investigated in AA among patients with acute abdominal pain, and ours is the first study Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

Yeniocak et al. The diagnostic value of irisin in patients with acute abdominal pain

to investigate irisin level in all types of non-traumatic acute abdominal pain. The present study is valuable in terms of determining that there were high blood irisin levels in biliary colic and urolithiasis as well as AA. The determination of a high blood irisin level in the pathology of organs with a tubular structure can assist with the exclusion of other etiological causes of abdominal pain.

Blood irisin level has already been investigated in several diseases. Numerous studies have linked it to muscle mass and insulin resistance, leading to investigation of potential cardiovascular effects. The potential influence in chronic kidney failure, some cancers, metabolic disease, non-alcoholic liver disease, and osteoporosis have also been examined; however, irisin has been assessed more as a hormone than as a biochemical marker.[9] The present study indicates that irisin may be a biochemical marker in some specific groups of conditions featuring abdominal pain.

Aydın et al.[10] investigated the irisin level in serum and saliva in patients who experienced AMI. The serum and saliva levels of irisin measured at the time of presentation and after 72 hours were elevated, while the CK and CK-MB levels were decreased. They suggested that a low irisin level in the early period might be used as a biomarker to support a diagnosis of AMI. An interesting aspect of that study is that, using immunohistochemistry, they were able to demonstrate that not only the striated muscle of the salivary glands, but also the lumen, was able to secrete irisin. Their study is evidence that some proteins can be produced in the salivary glands and acinar cells.

The common feature of the structures of gastrointestinal, biliary, and urinary tract organs is that they are tubular organs with a smooth muscle structure.[11] The pathophysiology of this diagnostic group of diseases associated with a high irisin level included early luminal narrowing and obstruction in the late phase. Distension occurring due to increasing hydrostatic pressure in the proximal part following obstruction stimulates tubular organ peristalsis.[12–15] This smooth muscle mass with increasing peristalsis can be postulated to give rise to increased irisin production either itself, or through interaction with other autocrine and endocrine organs under the influence of inflammation caused by the obstruction.

Irisin was once thought to be released only by skeletal muscle, but has since been shown to be secreted by other organs as well.[3,6,16,17] Irisin release in tubular organ diseases may be confirmed with additional immunohistochemical studies. In the present study it was observed that the irisin level in cases of peptic ulcer, a disease of the stomach, which is a tubular organ and part of the gastrointestinal tract with a smooth muscle wall, did not increase compared with the level of the control group. This may have been a result of narrowing or obstruction of the lumen not related to the physiopathology of peptic ulcer.[11,18] Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

No single biomarker would be sufficient to distinguish the inflammatory condition of tubular organs (e.g., AA, renal colic) per se. Nonetheless, the present findings suggest that irisin may be useful in the differential diagnosis. Acar et al.[19] examined many variables, including serum leukocytes, lymphocytes, neutrophils, neutrophil-lymphocyte ratio, and mean platelet volume, in the diagnosis of tubular organ inflammation. They suggested that these biomarkers could be useful parameters to discriminate and diagnose these conditions, since the level was often higher in those with AA or renal colic than that seen in healthy controls. Similarly, the results of the present research also suggest that the irisin value may be useful in the specific diagnosis of patients with acute abdominal conditions.

Limitations The major limitation of this study is the small number of patients included in the sample. In addition, the group assessed was limited only to adults with acute abdominal pain who presented at the ED and was not further refined. Another weakness of this study is that irisin levels were not evaluated immunohistochemically. A further limitation is that the blood irisin level was not monitored after our patients were admitted to the ED. We think that future studies on the causes of acute abdominal pain occurring due to tubular organ obstruction will test our findings.

Conclusion In conclusion, the blood irisin level may be useful in the differential diagnosis of diseases involving narrowing or obstruction of tubular organs in patients presenting at the ED with acute abdominal pain.

Conflict of interest: None declared.

REFERENCES 1. Meisner M. Pathobiochemistry and clinical use of procalcitonin. Clin Chim Acta 2002;323:17–29.

2. Akyildiz H, Akcan A, Oztürk A, Sozuer E, Kucuk C, Yucel A. D-dimer as a predictor of the need for laparotomy in patients with unclear nontraumatic acute abdomen. A preliminary study. Scand J Clin Lab Invest 2008;68:612–7.

3. Boström P, Wu J, Jedrychowski MP, Korde A, Ye L, Lo JC, et al. A PGC1α-dependent myokine that drives brown-fat-like development of white fat and thermogenesis. Nature 2012;481:463–8.

4. Huh JY, Panagiotou G, Mougios V, Brinkoetter M, Vamvini MT, Schneider BE, et al. FNDC5 and irisin in humans: I. Predictors of circulating concentrationsin serum and plasma and II. mRNA expression and circulatingconcentrations in response to weight loss and exercise. Metabolism 2012;61:1725–38.

5. Kuloglu T, Aydin S, Eren MN, Yilmaz M, Sahin I, Kalayci M, et al.

Irisin: a potentially candidate marker for myocardial infarction. Peptides 2014;55:85–91.

6. Roca-Rivada A, Castelao C, Senin LL, Landrove MO, Baltar J, Belén Crujeiras A, et al. FNDC5/irisin is not only a myokine but also an

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Yeniocak et al. The diagnostic value of irisin in patients with acute abdominal pain adipokine. PLoS One 2013;8:e60563.

7. Spiegelman BM. Banting Lecture 2012: Regulation of adipogenesis: toward newtherapeutics for metabolic disease. Diabetes 2013;62:1774–82.

8. Bakal U, Aydin S, Sarac M, Kuloglu T, Kalayci M, Artas G, et al. Serum, Saliva, and Urine Irisin with and Without Acute Appendicitis and Abdominal Pain. Biochem Insights 2016;9:11–7.

9. Gouveia MC, Vella JP, Cafeo FR, Affonso Fonseca FL, Bacci MR. Association between irisin and major chronic diseases: a review. Eur Rev Med Pharmacol Sci 2016;20:4072–7.

10. Aydin S, Aydin S, Kobat MA, Kalayci M, Eren MN, Yilmaz M, et al.

Decreased saliva/serum irisin concentrations in the acute myocardialinfarction promising for being a new candidate biomarker for diagnosisof this pathology. Peptides 2014;56:141–5.

11. Junqueira LC, Carneiro In: J. Aytekin Y, Solakoğlu S, editors. Basic Histology. Nobel Tıp Kitapevleri; 2006. p. 207–13.

12. Freeman HJ. Spontaneous free perforation of the small intestine in Crohn’s disease. Can J Gastroenterol 2002;16:23–7.

13. Way LW, Doherty GM. Current Surgical Diagnosis Treatment. 11th ed.

New York C: Mcgrav-Hill Companies; 2003. p.595-624.

14. Lewis KS, Whipple JK, Michael KA, Quebbeman EJ. Effect of analgesic treatment on the physiological consequences of acute pain. Am J Hosp Pharm 1994;51:1539–54.

15. Smith DR. Urinary Stone Disease. In: Tanagho EA, McAninch JW editors. General Urology. 14th ed. New York: Appleton & Lange; 1994.

16. Albayrak S, Atci İB, Kalayci M, Yilmaz M, Kuloglu T, Aydin S, et al. Effect of carnosine, methylprednisolone and their combined applicationon irisin levels in the plasma and brain of rats with acute spinal cordinjury.

Neuropeptides 2015;52:47–54.

17. Aydin S, Kuloglu T, Aydin S, Kalayci M, Yilmaz M, Cakmak T, et al. A comprehensive immunohistochemical examination of the distribution of the fat-burning protein irisin in biological tissues. Peptides 2014;61:130– 6.

18. Sezer R. Sindirim Sistemi Hastalıkları. Büyüköztürk K, editör. İç Hastalıkları. Istanbul: Nobel Tıp Kitapevi; 1992. p.634–62.

19. Acar E, Özcan Ö, Deliktaş H, Beydilli H, Kırlı İ, Alataş ÖD, et al. Laboratory markers has many valuable parameters in the discriminationbetween acute appendicitis and renal colic. Ulus Travma Acil Cerrahi Derg 2016;22:17–22.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut karın ağrılı hastalarda İrisin’in tanısal değeri: Bir ön çalışma Dr. Selman Yeniocak,1 Dr. Özgür Karcıoğlu,2 Dr. Asım Kalkan,1 Dr. Fatma Saraç,3 Dr. Gökçe Akgül Karadana,4 Dr. Zehra Zeynep Keklikkıran,5 Dr. Alper Gümüş,6 Dr. Macit Koldaş,6 Dr. Semih Korkut7 Sağlık Bilimleri Üniversitesi Haseki Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, İstanbul Sağlık Bilimleri Üniversitesi İstanbul Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, İstanbul 3 Sağlık Bilimleri Üniversitesi Haseki Eğitim ve Araştırma Hastanesi, Çocuk Cerrahisi Kliniği, İstanbul 4 Koç Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İstanbul 5 Sağlık Bilimleri Üniversitesi Haseki Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul 6 Sağlık Bilimleri Üniversitesi Haseki Eğitim ve Araştırma Hastanesi, Biyokimya Anabilim Dalı, İstanbul 7 Sağlık Bilimleri Üniversitesi İstanbul Kartal Dr. Lütfi Kirdar Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, İstanbul 1 2

AMAÇ: Akut karın ağrısı şikayeti ile acil servise müracaat eden hastalarda düz kas proteini Irisin’in serum düzeyini ölçerek tanısal değerini araştırmak amacıyla bu çalışma yapıldı.

GEREÇ VE YÖNTEM: Bu araştırma, tek merkezli, ileriye yönelik ve kesitsel bir çalışma olarak yapıldı. Akut karın ağrısı şikayeti ile acil servise başvuran 213 erişkin hasta ve 140 kişilik sağlıklı kontrol grubu dahil edildi. Serum irisin düzeyleri, lökosit, C-reaktif protein, amilaz ve kreatin kinaz değerleri ile karşılaştırıldı. Serum İrisin düzeyleri, yatışı yapılan ile taburcu olan ve cerrahi ile tıbbi tedavi yapılan gruplar da karşılaştırıldı.

BULGULAR: Çalışmaya dahil edilen 213 hasta ve 140 kontrol grubu ortalama Irisin düzeyleri 6.81±3.17 mcg/mL ve 5.69±2.08 mcg/mL idi. Hastaneye yatırılan hastaların ortalama Irisin değerleri (7.98±3.11 mcg/mL), taburcu edilen hastaların (6.38±3.09 mcg/mL) ve kontrol grubu olguların Irisin değerlerinden (kontrol grubu – taburcu hasta grubu p=0.202) anlamlı derecede yüksekti (kontrol grubu - hastaneye yatırılan grup p<0.001, taburcu edilen grup - hastaneye yatırılan grup p=0.001). Kontrol grubu ile karşılaştırıldığında, safra kesesi hastalıkları, ürolitiyazis ve akut apandisitte irisin düzeyleri anlamlı olarak daha yüksekti (p=0.001, p=0.007, p=0.007).

TARTIŞMA: Serum İrisin seviyeleri, düz kas yapısı içeren karıniçi tübüler organların luminal obstrüksiyonu gelişmiş akut karın ağrılı hastalarda tanı ve prognoz belirlemede bir belirteç olarak kullanılabilir.

Anahtar sözcükler: Akut karın ağrısı; acil servis; Irisin; sonuç.

Ulus Travma Acil Cerrahi Derg 2018;24(6):539-544

544

doi: 10.5505/tjtes.2018.29235

Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

ORIG I N A L A R T IC L E

The Karaman score: A new diagnostic score for acute appendicitis Kerem Karaman, M.D.,1 Metin Ercan, M.D.,1 Hakan Demir, M.D.,1 Ömer Yalkın, M.D.,1 Yener Uzunoğlu, M.D.,1 Kemal Gündoğdu, M.D.,1 İsmail Zengin, M.D.,1 Yakup Ersel Aksoy, M.D.,2 Erdal Birol Bostancı, M.D.1 1

Department of General Surgery, Sakarya University Training and Research Hospital, Sakarya-Turkey

2

Department of Radiology, Sakarya University Training and Research Hospital, Sakarya-Turkey

ABSTRACT BACKGROUND: The Karaman score is a novel diagnostic scoring system consisting of 6 parameters. The aim of the present study was to assess the diagnostic performance of the Karaman score in comparison with the Alvarado score.

METHODS: A total of 200 patients who underwent an appendectomy were enrolled in the study (research registry number: 2290).

RESULTS: The cutoff threshold of the Karaman score in distinguishing acute appendicitis from negative appendectomy was ≥9 with 84.3% sensitivity, 64.7% specificity, 92.1% positive predictive value (PPV), and 45.8% negative predictive value (NPV). The cutoff threshold of the Alvarado score in distinguishing acute appendicitis from negative appendectomy was ≥8 with 72.9% sensitivity, 70.6% specificity, 92.4% PPV, and 34.8% NPV. In multivariate logistic regression analysis, an Alvarado ≥8 score (Odds ratio [OR]:6.644, 95% confidence interval [CI]: 2.854–15.466; p<0.001) and a Karaman ≥9 score (OR:10.374, 95% CI: 4.383–24.558; p<0.001) were each individually predictive in distinguishing acute appendicitis from negative appendectomy when correction was made according to age and gender. However, when both scores were evaluated together, the Alvarado score ≥8 lost its efficacy (OR:1.838, 95% CI: 0.517–6.530; p=0.347), whereas the Karaman score ≥9 retained its predictive power (OR:6.586, 95% CI: 1.893–22.917; p=0.003).

CONCLUSION: The Karaman score was more predictive than the Alvarado score in distinguishing acute appendicitis from a negative appendectomy.

Keywords: Acute appendicitis; Alvarado score; Karaman score; negative appendectomy; sensitivity; specificity.

INTRODUCTION Acute appendicitis is the most common abdominal emergency requiring surgery, and has an estimated life time prevalence of 7%.[1] Despite the development of new technologies in radio-diagnostics and the availability of many laboratory tests and scoring systems, diagnosis of appendicitis remains challenging.[2–4] The Alvarado score is the most well-known and best performing scoring system in validation studies.[5] The Karaman score is a novel diagnostic tool consisting of 6 parameters based on the patient’s symptoms and signs supported by laboratory tests, and is easy to perform.

The primary outcome of the present study was to determine the diagnostic performance of the Karaman score in acute appendicitis. The second outcome was to compare the results of the Karaman score with the Alvarado score. Finally, the third outcome was to determine the diagnostic compliance of the Karaman and Alvarado scores with ultrasound (US) and computerized tomography (CT) findings.

MATERIALS AND METHODS After receiving ethics committee approval, the study was conducted between May 2014 and December 2015 in the

Cite this article as: Karaman K, Ercan M, Demir H, Yalkın Ö, Uzunoğlu Y, Gündoğdu K, et al. The Karaman score: A new diagnostic score for acute appendicitis. Ulus Travma Acil Cerrahi Derg 2018;24:545-551.

Address for correspondence: Kerem Karaman, M.D. Köprübaşı Mah, Huzur Liva 3 Sitesi, No: 31, B Blok, Daire: 6, Serdivan, 54100 Adapazarı, Turkey Tel: +90 264 - 888 40 00 / 2209 E-mail: karaman_kerem@yahoo.com.tr Ulus Travma Acil Cerrahi Derg 2018;24(6):545-551 DOI: 10.5505/tjtes.2018.62436 Submitted: 11.08.2017 Accepted: 17.04.2018 Online: 16.11.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Karaman et al. The Karaman score: A new diagnostic score for acute appendicitis

general surgery department of Sakarya University Training and Research Hospital. Informed consent was obtained from all of the patients. Patients were included if they were ≥18 years of age. A total of 200 patients qualified for the study during the research period. All of the patients were scored using the Alvarado and Karaman scoring systems. The Alvarado score includes 8 parameters, whereas the Karama score uses 6 parameters.

The Karaman Scoring System The Karaman scoring system consists of 6 parameters. Of these, 2 symptomatic parameters are anorexia and migratory right iliac fossa pain. Rebound tenderness in the right iliac fossa and aggravation of peritoneal irritation in the right iliac fossa with heavy coughing are the 2 positive signs. Additionally, a leukocyte count of >10.000/mm3 and a left shift of neutrophils of >70% are the positive laboratory parameters.

Each positive parameter in the Karaman score generates 2 points, while 1 point is removed for each negative parameter.

The maximum number of points for diagnosis is 12 and the minimum is -6 points.

Table 1. The Karaman and Alvarado scoring systems Karaman score

Positive (+) Negative (–)

Symptoms Anorexia

+2

+2

Migratory right iliac fossa pain

-1

Signs

Rebound tenderness in right

iliac fossa

Peritoneal irritation in right iliac

fossa with heavy coughing

+2

-1

+2

-1

Laboratory findings

WBC >10.000/mm3

+2 -1

PMNL >70%

+2

-1

12

-6

Total points

Alvarado score Symptoms Anorexia

+1

+1

Migratory right iliac fossa pain

Study Design

Nausea/vomiting

A scoring chart with both the Karaman and the Alvarado score criteria was completed by the attending surgeon at the time of presentation prior to radiological examinations (US, CT) (Table 1). The appendectomy decision was based solely on the surgeon’s clinical judgment after taking into consideration all of the clinical, laboratory, and radiological findings. The Karaman and Alvarado scores were used only for research purposes.

Signs

Tenderness in right iliac fossa

Rebound tenderness in right

iliac fossa

Elevation of body temperature

(≥37.3Cº)

+1

+2 +1 +1

Laboratory findings

Patients were monitored following admission, surgery, and through discharge from the hospital. Daily follow-up included monitoring of vitals 3 times a day and systemic examination once a day. Postoperative histopathology findings were collected and correlated with the scoring systems. The study was terminated after 200 consecutive appendectomies.

The diagnostic performance of the Karaman and Alvarado scores was determined according to sensitivity, specificity, and the positive predictive value (PPV) and negative predictive value (NPV). The diagnostic compliance of the Karaman and Alvarado scores with US and CT findings was also analyzed.

Statistical Analysis Data analysis was performed using SPSS Statistics for Windows, Version 17.0 (SPSS, Inc., Chicago, IL, USA). Normal distribution of continuous variables was determined using the Kolmogorov-Smirnov test. Continuous variables were represented by the median (minimum-maximum), otherwise, the number of cases and percentages were used for categorical data. The Mann-Whitney U test was applied for comparisons of the non-normally distributed data. Categorical variables were analyzed using a chi-square or the McNemar test, as appropriate. The diagnostic performance of the Alvarado and 546

WBC >10.000/mm3

+1

PMNL >75%)

+1

Total points

10

0

PMNL: Polymorphonuclear leukocytes; WBC: White blood cell.

the Karaman scoring systems was evaluated using receiver operating characteristic (ROC) curve analysis. The optimal cutoff point of each scoring system was assumed to provide the maximum sum of sensitivity and specificity. The diagnostic performance of the scoring systems was evaluated, including sensitivity, specificity, PPV, and NPV. The agreement between the Alvarado and Karaman scores was evaluated by calculating the kappa coefficient. Analysis of the best scoring system for diagnosis was determined using multiple logistic regression analysis after adjustment for age and gender. An adjusted odds ratio (OR) and 95% confidence interval (CI) for each independent variable was also calculated. A p value less than 0.05 was considered statistically significant.

RESULTS A total of 200 patients underwent appendectomy and were included in the study. Of these, 118 patients were male (59%) Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

Karaman et al. The Karaman score: A new diagnostic score for acute appendicitis

Table 2. Patient demographic data and characteristics Variables n=200 Age (years), median (min-max)

32 (18–78)

Gender, n (%)

Table 3. Comparison of patient characteristics and

demographic data according to acute appendicitis and negative appendectomy results Acute appendicitis

Male

118 (59)

Age (years),

Female

82 (41)

median (min-max)

Histopathological signs, n (%)

Appendicitis

Acute appendicitis

Perforated appendicitis

Negative (n=34)

29 (18–46)

Positive (n=166)

p

32 (18–78)

0.102†

Gender, n (%) 166 (83)

Male

14 (41.2)

104 (62.7)

136 (68)

Female

20 (58.8)

62 (37.3)

0.020‡

18 (9)

US findings, n (%)

Phlegmonous appendicitis

12 (6)

No

10 (58.8)

18 (33.3)

Non-appendicitis

34 (17)

Yes

7 (41.2)

36 (66.7)

Lymphoid hyperplasia

20 (10)

CT findings, n (%)

Normal appendix

12 (6)

No

14 (51.9)

13 (9.0)

Meckel’s diverticulitis

1 (0.5)

Yes

13 (48.1)

132 (91.0)

Over cyst rupture

1 (0.5)

Alvarado score, 6.5 (2–10)

8 (3–10)

<0.001†

3 (-3–12)

10.5 (-3–12)

<0.001†

Localization, n (%)

median (min-max)

Retrocecal

146 (73)

Karaman score,

Subcecal

37 (18.5)

median (min-max)

Peri-ileal

9 (4.5)

Pelvic

4 (2)

Retroileal

4 (2)

Alvarado score, median (min-max)

8 (2–10)

Karaman score, median (min-max)

9 (-3–12)

and 82 patients were female (41%). The median age was 32 years (min-max: 18–72 years). In all, 166 patients (83%) had histopathologically confirmed acute appendicitis. Of these, 18 patients (9%) had perforated acute appendicitis, whereas 12 patients (6%) had phlegmonous appendicitis. Thirty-four patients (17%) had a negative appendectomy. In that group, 20 patients (10%) had lymphoid hyperplasia, 12 patients (6%) had a normal appendix, 1 patient (0.5%) had Meckel’s diverticulitis, and 1 patient (0.5%) had over cyst rupture. The most frequently observed localization of the appendix was retrocecal (146 patient, 73%) followed by subcecal (37 patients, 18.5%), peri-ilieal (9 patients, 4.5%), pelvic (4 patients, 2%), and retroileal (4 patients, 2%), respectively. The median Alvarado score among the patients was 8 (min-max: 2–10), whereas the median Karaman score was 9 (min-max: -3–12) (Table 2).

No significant difference was found according to median age between the patients with acute appendicitis and those with a negative appendectomy (p=0.102). However, the male /female ratio was significantly higher in patients with acute appendicitis and the negative appendectomy rate was significantly higher in females (p=0.02). US could not significantly differentiate acute appendicitis from negative appendectomy (p=0.061). On the other hand, the detection of acute appendicitis by CT was Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

0.061‡

<0.001‡

Mann-Whitney U test; ‡Pearson’s chi square test.

CT: Computerized tomography; US: Ultrasound (abdominal).

†

significantly higher (p=0.001). The median Alvarado score in patients with acute appendicitis was 8 (min-max: 3-10) and the median Alvarado score for negative appendectomy patients was 6.5 (min-max: 2–10). The median Alvarado score of 8 (min-max: 3–10) was significantly more frequently observed in patients histopathologically diagnosed as having acute appendicitis than in those with negative appendectomy (p=0.001).

The median Karaman score for acute appendicitis was 10.5 (min-max: -3–12), whereas the median Karaman score for negative appendectomy was 3 (min-max: -3–12). The median Karaman score of 10.5 (min-max: -3–12) was significantly more frequent in patients with acute appendicitis than in those with a negative appendectomy (p=0.001), (Table 3).

Receiver operating characteristic (ROC) analysis of the Karaman score revealed that the area under the curve (AUC) was significant in distinguishing acute appendicitis from negative appendectomy (AUC: 0.821, 95% CI: 0.732–0.910; p<0.001), (Fig. 1a). The cutoff threshold of the Karaman score in distinguishing acute appendicitis from negative exploration was ≥9, with 84.3% sensitivity, 64.7% specificity, 92.1% PPV, and 45.8% NPV. ROC analysis of the Alvarado score revealed that the AUC was significant in distinguishing acute appendicitis from negative appendectomy (AUC: 0.782, 95% CI: 0.690–0.874; p=0.001), (Fig. 1b). The cutoff threshold of the Alvarado score in distinguishing acute appendicitis from negative appendectomy was ≥8 with 72.9% sensitivity, 70.6% specificity, 92.4% PPV, and 34.8% NPV (Table 4).

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Karaman et al. The Karaman score: A new diagnostic score for acute appendicitis

0.8

0.8

0.6

0.6

Sensitivity

(b) 1.0

Sensitivity

(a) 1.0

0.4

0.2

0.4

0.2

0.0

0.0 0.0

0.2

0.4 0.6 1 - Specificity

0.8

1.0

0.0

0.2

0.4 0.6 1 - Specificity

0.8

1.0

Figure 1. Receiver operating characteristics curve demonstrating the predictive values of the (a) Karaman and (b) Alvarado scoring systems.

A positive correlation was found according to the distribution of the Alvarado (8</≥8) and Karaman scores (<9/≥9).

According to the histopathological findings, the frequency of a Karaman score of ≥9 was in 152 of 200 cases (76%), in 140 of 166 acute appendicitis specimens (84.3%), and in 12 of 34 non-appendicitis specimens (35%). On the other hand, the frequency of an Alvarado score of ≥8 was present in 131 of 200 cases (65.5%), 121 of 166 acute appendicitis specimens (72.9%), and in 10 of 34 non-appendicitis specimens (29.4%).

Overall, the frequency of a Karaman score of ≥9 was significantly higher than an Alvarado score of ≥8 (76% vs 65%; p=0.001). A comparison of the 2 scoring systems according to negative appendectomy revealed no significant difference (35.3% vs 29.4%; p=0.625). However, the frequency of a Karaman score of ≥9 was significantly higher in acute appendicitis than an Alvarado score of ≥8 (84.3% vs 72.9%; p=0.001).

Each parameter used in the present study was analyzed according to diagnostic sensitivity, specificity, PPV, NPV, positive and negative likelihood ratio, and accuracy. Right iliac fossa Table 4. Diagnostic performance of Alvarado and Karaman scores

The area under the ROC curve 95% confidence interval P value Cutoff point

Alvarado Karaman 0.782

0.821

0.690–0.874

0.732–0.910

<0.001

<0.001

≥8

≥9

Sensitivity

72.9% 84.3%

Specificity

70.6%

64.7%

Positive predictive value

92.4%

92.1%

Negative predictive value

34.8%

45.8%

ROC: Receiver operating characteristic.

548

tenderness had the highest sensitivity (100%), with 83% accuracy, followed by peritoneal irritation with heavy coughing (sensitivity: 90%, accuracy: 80.4%) and anorexia (sensitivity: 89.8%, accuracy: 80%).Fever (sensitivity: 29.5%, accuracy: 37%) and a neutrophil ratio of >75% (sensitivity: 62.7%, accuracy: 67%) had the lowest sensitivity and accuracy (Table 5).

In multivariate logistic regression analysis, both an Alvarado score of ≥8 (OR: 6.644, 95% CI: 2.854–15.466; p<0.001) and a Karaman score of ≥9 (OR: 10.374, 95% CI: 4.383–24.558; p<0.001) were predictive in distinguishing acute appendicitis from negative appendectomy when a correction was made for age and gender. However, when the 2 scores were compared, the Alvarado score lost its efficacy (OR:1.838, 95% CI: 0.517–6.530; p=0.347), whereas the Karaman scoring system maintained its predictive power (OR: 6.586, 95% CI: 1.893– 22.917; p=0.003), (Table 6).

DISCUSSION The Karaman score is a new, practical, cost-effective, and feasible scoring system developed on the basis of clinical symptoms, signs, and laboratory data. In contrast to the Alvarado and other scoring systems, fewer parameters are used. In addition, the validation of the parameters used in the Karaman score is well known from previous studies. Like the Alvarado score, the cutoff for the white blood cell (WBC) count in the Karaman score is >10.000/mm3, with the aim of improving the diagnosis of acute appendicitis. In a meta-analysis including 14 studies, a WBC of >10.000/mm3 had a sensitivity and specificity of 83% and 67%, respectively.[6] Similarly, in the study reported by Bates et al.,[7] a WBC count of <9000/mm3 reduced the negative appendectomy rate. In the present study, the sensitivity and specificity of a WBC of >10.000/mm3 was 85.5% and 55.9% with an accuracy of 80.5%. A polymorphonuclear leucocyte (PMNL) ratio of >75% has also been determined to be a discriminator of acute appendicitis, but had a limited Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

Karaman et al. The Karaman score: A new diagnostic score for acute appendicitis

Table 5. Diagnostic power of each parameter used in the study

Sensitivity Specificity PPV NPV +LR -LR Accuracy (%) (%) (%) (%) (%)

White blood cell >10.000/mm3

85.5

55.9

90.4 44.2 1.94 0.26 80.5

Polymorphonuclear leucocytes >%70

77.1

70.6

92.8 38.7 2.62 0.32 76.0

Polymorphonuclear leucocytes >%75

62.7

88.2

96.3 32.6 5.33 0.42 67.0

Fever >37.3º

29.5

73.5

84.5 17.6 1.12 0.96 37.0

Anorexia

89.8

32.4

86.6 39.3 1.33 0.32 80.0

Nausea and vomiting

75.8

24.2

83.3 16.7 1.00 1.00 67.1

Right quadrant tenderness

100.0

0.0 83.0 – 1.00 – 83.0

Peritoneal irritation with coughing

90.0

29.4

86.2

Ultrasound

66.7

58.8

83.7 35.7 1.62 0.57 64.8

Computerized tomography

91.0

51.8

91.0 51.9 1.89 0.17 84.8

40.0

1.29

0.31

80.4

+LR: Positive likelihood ratio; -LR: Negative likelihood ratio; NPV: Negative predictive value; PPV: Positive predictive value.

Table 6. Multivariate logistic regression analysis for

distinguishing acute appendicitis from negative appendectomy

Odds ratio

95% CI

p†

Model I Age

1.036

0.995–1.077

0.083

Male factor

2.935

1.285–6.704

0.011

Alvarado ≥8

6.644

2.854–15.466

<0.001

Model II Age

1.039

0.998–1.082

0.063

Male factor

2.988

1.255–7.114

0.013

Karaman ≥9

10.374

4.383–24.558

<0.001

Model III Age

1.037

0.996–1.080

0.077

Male factor

3.054

1.278–7.299

0.012

Alvarado ≥8

1.838

0.517–6.530

0.347

Karaman ≥9

6.586

1.893–22.917

0.003

†

Multivariate logistic regression analysis. CI: Confidence interval.

clinical significance, with a sensitivity ranging from 66% to 87%, and a specificity of 33% to 84%.[8,9] The cutoff value for the PMNL percentage in the Karaman score was >70% due to the high sensitivity reported by Andersson et al.[10] (sensitivity: 93% in 502 patients) and Fergusson et al.[11] (sensitivity: 87% in 1013 patients). Similarly, the sensitivity of a PMNL percentage of >70% in the present study was greater than a PMNL percentage of >75% (77.1% vs 62.7%) with an accuracy of 76%.

In contrast to the Alvarado score, fever is not used as a parameter in the Karaman score as a result of the limited diagnostic significance demonstrated in other studies.[12–14] The diagnostic sensitivity and accuracy of the presence of a fever Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

of 37.3 °C or more in the present study was 29.5% and 37%, respectively, which supported our hypothesis that fever is not a particularly valuable indicator for the diagnosis of acute appendicitis. Furthermore, the presence of nausea and vomiting is also not used in the Karaman score due to low sensitivity (75.8%) and specificity (24.2%), which has also previously been demonstrated in other studies (sensitivity: 40–72% and specificity: 45-69%).[15–17] In the present study, the cutoff threshold of the Karaman score in distinguishing acute appendicitis from negative appendectomy was ≥9, with an 84.3% sensitivity, 64.7% specificity, a 92.1% PPV, and a 45.8% NPV. A higher sensitivity (96.2%) and sensitivity (90.5%) were found in a study performed by Nanjundaiah et al.[18] with a Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score of >7.5. The sensitivity and specificity of an Alvarado score of >7 was 58.9% and 85.7% in that study. Similarly, Chong et al.[19] conducted a study that included 192 patients and determined that a RIPASA score of >7.5 and an Alvarado score of >7 had a diagnostic sensitivity of 98% and 68.32%, respectively. However, in contrast to the Karaman score, which uses only 6 parameters, the RIPASA score consists of 18 parameters, including urine analysis, which adds a financial burden. The diagnostic sensitivity of the Karaman score appears to be superior when compared with other scoring systems used in the study reported by Erdem et al.[20] Alvarado (cutoff: 6.5, sensitivity: 81.8%) Eskelinen (cutoff: 63.2, sensitivity: 80.5%), RIPASA (cutoff: 10.25, sensitivity: 83.1%), and Ohmann (cutoff: 13.75, sensitivity: 80.5%).

The most crucial element is to determine how a negative appendectomy can be prevented when facilities and equipment are limited. Diagnosis of acute appendicitis based on only 1 or 2 parameters is not reliable. While 1 positive parameter may support the possibility of acute appendicitis, a negative parameter raises doubts. Additional laboratory tests and radiological 549

Karaman et al. The Karaman score: A new diagnostic score for acute appendicitis

images, such as C-reactive protein (CRP), CT, or MRI may help to diagnose acute appendicitis, but increase the cost. One of the advantages of the Karaman scoring system is a greater ability to predict a negative appendectomy compared with the Alvarado score, which becomes very valuable in the absence of devices to perform CT or MRI or laboratory tests to assess calcitonin, CRP level, and other molecular markers.

In the present study, the accuracy of US in detecting acute appendicitis was low (sensitivity: 66.7%, specificity: 58.8%, accuracy: 64.8%). It is well established that interpretation of US images is operator-dependent. The night shift staff members performing US at our emergency clinic are often junior assistants, which may have affected these results. On the other hand, the diagnostic value of CT has been reported in the literature to be high, with a sensitivity of 91% and an accuracy of 84.8%.[21] In the present study, the negative appendectomy rate was higher in female patients than in males (24.9% vs 11.9%; of total study patients: 17%), which is comparable with the literature.[22] Lymphoid hyperplasia was the most common leading cause of a negative appendectomy. Both the Alvarado and the Karaman scores failed to distinguish lymphoid hyperplasia from acute appendicitis. CT and US may help in determining lymphoid hyperplasia and prevent false-positive misdiagnoses of appendicitis.[23] When there is doubt, while US is operatordependent, CT is much more helpful in reducing the negative appendectomy rate.

The present study has some limitations. First, the sample size was small. Secondly, a comparison was only made with the Alvarado score.

Conclusion Diagnosis of acute appendicitis is still mainly based on history, and clinical and laboratory data. The Karaman score is a costeffective and practical scoring system consisting of 6 parameters that is easy to perform. The Karaman score appears to be more predictive than the Alvarado score in distinguishing acute appendicitis from negative appendectomy.

Conflict of interest: None declared.

REFERENCES 1. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990;132:910–25.

2. Lee YJ, Kim B, Ko Y, Cho KE, Hong SS, Kim DH, et al. Low-Dose (2-mSv) CT in Adolescents and Young Adults With Suspected Appendicitis: Advantages of Additional Review of Thin Sections Using Multiplanar Sliding-Slab Averaging Technique. AJR Am J Roentgenol 2015;205:W485–91.

3. Duke E, Kalb B, Arif-Tiwari H, Daye ZJ, Gilbertson-Dahdal D, Keim SM, et al. A Systematic Review and Meta-Analysis of Diagnostic Per-

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formance of MRI for Evaluation of Acute Appendicitis. AJR Am J Roentgenol 2016;206:508–17.

4. Al-Abed YA, Alobaid N, Myint F. Diagnostic markers in acute appendicitis. Am J Surg 2015;209:1043–7.

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

Ann Emerg Med 1986;15:555–64.

6. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004;91:28–37.

7. Bates MF, Khander A, Steigman SA, Tracy TF Jr, Luks FI. Use of white blood cell count and negative appendectomy rate. Pediatrics 2014;133:e39–44.

8. Shogilev DJ, Duus N, Odom SR, Shapiro NI. Diagnosing appendicitis: evidence-based review of the diagnostic approach in 2014. West J Emerg Med 2014;15:859–71.

9. Yang HR, Wang YC, Chung PK, Chen WK, Jeng LB, Chen RJ. Laboratory tests in patients with acute appendicitis. ANZ J Surg 2006;76:71–4.

10. Andersson RE, Hugander AP, Ghazi SH, Ravn H, Offenbartl SK, Nyström PO, et al. Diagnostic value of disease history, clinical presentation, and inflammatory parameters of appendicitis. World J Surg 1999;23:133–40.

11. Fergusson JA, Hitos K, Simpson E. Utility of white cell count and ultrasound in the diagnosis of acute appendicitis. ANZ J Surg 2002;72:781– 5.

12. Cardall T, Glasser J, Guss DA. Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis. Acad Emerg Med 2004;11:1021–7.

13. Petroianu A. Diagnosis of acute appendicitis. Int J Surg 2012;10:115–9.

14. Andersson RE, Hugander A, Ravn H, Offenbartl K, Ghazi SH, Nyström PO, et al. Repeated clinical and laboratory examinations in patients with an equivocal diagnosis of appendicitis. World J Surg 2000;24:479–85.

15. Ebell MH. Diagnosis of appendicitis: part 1. History and physical examination. Am Fam Physician 2008;77:828–30.

16. Howell JM, Eddy OL, Lukens TW, Thiessen ME, Weingart SD, Decker WW; American College of Emergency Physicians. Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Med 2010;55:71–116.

17. Laurell H, Hansson LE, Gunnarsson U. Manifestations of acute appendicitis: a prospective study on acute abdominal pain. Dig Surg 2013;30:198–206.

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

19. Chong CF, Thien A, Mackie AJ, Tin AS, Tripathi S, Ahmad MA, et al.

Comparison of RIPASA and Alvarado scores for the diagnosis of acute appendicitis. Singapore Med J 2011;52:340–5.

20. Erdem H, Çetinkünar S, Daş K, Reyhan E, Değer C, Aziret M, et al.

Alvarado, Eskelinen, Ohhmann and Raja Isteri Pengiran Anak Saleha Appendicitis scores for diagnosis of acute appendicitis. World J Gastroenterol 2013;19:9057–62.

21. Karabulut N, Kiroglu Y, Herek D, Kocak TB, Erdur B. Feasibility of lowdose unenhanced multi-detector CT in patients with suspected acute appendicitis: comparison with sonography. Clin Imaging 2014;380:296– 301.

22. Chandrasegaram MD, Rothwell LA, An EI, Miller RJ. Pathologies of the appendix: a 10-year review of 4670 appendicectomy specimens. ANZ J Surg 2012;82:844–7.

23. Xu Y, Jeffrey RB, DiMaio MA, Olcott EW. Lymphoid Hyperplasia of the Appendix: A Potential Pitfall in the Sonographic Diagnosis of Appendicitis. AJR Am J Roentgenol 2016;206:189–94.

Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

Karaman et al. The Karaman score: A new diagnostic score for acute appendicitis

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Karaman skoru: Akut apandisit tanısında yeni bir skorlama sistemi Dr. Kerem Karaman,1 Dr. Metin Ercan,1 Dr. Hakan Demir,1 Dr. Ömer Yalkın,1 Dr. Yener Uzunoğlu,1 Dr. Kemal Gündoğdu,1 Dr. İsmail Zengin,1 Dr. Yakup Ersel Aksoy,2 Dr. Erdal Birol Bostancı1 1 2

Sakarya Üniversitesi Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Sakarya Sakarya Üniversitesi Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, Sakarya

AMAÇ: Karaman skorlama sistemi akut apandisit tanısında kullanılan ve 6 parametreden oluşan yeni bir tanısal skorlama sistemidir. Bu çalışmanın amacı Karaman skorunun akut apandisit tanı performansını Alvarado skoru ile karşılaştırmalı olarak ortaya koymaktır.

GEREÇ VE YÖNTEM: Akut apandisit tanısı ile apendektomi yapılan 200 hasta çalışmaya alındı.

BULGULAR: Karaman skorunun akut apandisiti negatif apandektomiden ayırmadaki kestirim değeri ≥9 olup, sensitivitesi %84.3, spesifitesi %64.7, pozitif prediktif değeri %92.1 ve negatif prediktif değeri %45.8 olarak saptandı. Alvarado skorunun akut apandisiti negatif apandektomiden ayırmadaki kestirim değeri ise ≥8 olup, sensitivitesi %72.9, spesifitesi %70.6, pozitif prediktif değeri %92.4 ve negatif prediktif değeri %34.8 olarak saptandı.

Multilojistik regreyon analizinde, yaş ve cinsiyete göre düzeltme yapıldığında; hem Alvarado ≥8 (OR=6.644, %95 CI: 2.854–15.466, p<0.001) hem de Karaman ≥9 skoru (OR=10.374, %95 CI: 4.383–24.558, p<0.001) akut apandisiti negatif apandektomiden ayırmada anlamlı olarak etkin saptandı. Ancak, her iki skor bir arada değerlendirildiğinde, Alvarado skoru ≥8 etkinliğini yitirirken (OR=1.838, %95 CI: 0.517–6.530 and p=0.347) Karaman skoru ≥9 prediktif etkinliğini göstermeye devam etmekteydi (OR=6.586, %95 CI: 1.893–22.917, p=0.003).

TARTIŞMA: Karaman skoru akut apandisiti negatif apandektomiden ayırt etmede daha etkin saptanmıştır.

Anahtar sözcükler: Akut apandisit; Alvarado skoru; negatif apandektomi; sensitivite; spesifite.

Ulus Travma Acil Cerrahi Derg 2018;24(6):545-551

doi: 10.5505/tjtes.2018.62436

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ORIG I N A L A R T IC L E

Laparoscopic versus open appendectomy in pregnancy: A single center experience Ali Fuat Kaan Gök, M.D.,1 Yiğit Soytaş, M.D.,1 Adem Bayraktar, M.D.,1 Selman Emirikçi, M.D.,1 Mehmet İlhan, M.D.,1 Ahmet Kemalettin Koltka, M.D.,2 Mustafa Kayıhan Günay, M.D.1 1

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

2

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

ABSTRACT BACKGROUND: The aim of this study was to compare the obstetric and surgical outcomes of laparoscopic appendectomy (LA) and open appendectomy (OA) performed for pregnant women at a single center. It was the hypothesis of this study that there would be no significant difference in the results.

METHODS: The medical records of 57 consecutive pregnant women who underwent an appendectomy between January 2009 and September 2018 were reviewed retrospectively. The patients were divided into 2 groups: OA and LA. The collected data included age, gestational age, diagnostic modalities used, duration of surgery, length of hospital stay, morbidity, and mortality.

RESULTS: Eighteen (31%) patients underwent LA and 39 (69%) patients underwent OA. There were no significant differences in the demographic data. The duration of surgery was significantly less in the laparoscopic group (37 vs 57 minutes; p=0.005). There were no statistically significant differences in the outcomes of deep or superficial surgical site infection, length of hospital stay, pre-term delivery, or loss of the fetus. There was no mortality in either group.

CONCLUSION: The results of this study suggest that LA can be a safe option for both the pregnant patient and the child. Further prospective, randomized studies with a larger group of pregnant patients with appendicitis are needed to fully determine the effects of laparoscopy in these circumstances.

Keywords: Appendectomy; laparoscopy; open appendectomy; pregnancy.

INTRODUCTION Acute appendicitis (AA) is the most common non-obstetric surgical emergency in pregnant women.[1] Owing to the physiological changes in pregnancy, such as mild leukocytosis and change in appendix location, diagnosis of appendicitis may be challenging. Surgical treatment is the standard of care in pregnant women with appendicitis. Nevertheless, Carstens et al.[2] reported that they have successfully treated a pregnant patient with appendicitis non-operatively in a remote area where there is no place for non-operative management of AA during pregnancy because of a higher rate of peritonitis,

fetal demise shock, and venous thromboembolism as compared with operative management.[3,4] The optimal surgical technique is still controversial in pregnant patients, but during recent years, laparoscopic appendectomy (LA) has become the preferred treatment for pregnant women with AA.[5,6] Appendectomy in pregnancy may have poor obstetric outcomes when a delay occurs in the diagnosis and/or treatment.

The aim of the present study was to compare obstetric and surgical outcomes of LA and open appendectomy (OA) during pregnancy in a single center. We hypothesized that there are no differences between LA and OA according to obstetric and surgical outcomes in pregnancy.

Cite this article as: Gök AFK, Soytaş Y, Bayraktar A, Emirikçi S, İlhan M, Koltka AK, et al. Laparoscopic versus open appendectomy in pregnancy: A single center experience. Ulus Travma Acil Cerrahi Derg 2018;24:552-556.

Address for correspondence: Ali Fuat Kaan Gök, M.D. İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 414 20 00 E-mail: afkgok@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):552-556 DOI: 10.5505/tjtes.2018.26357 Submitted: 17.11.2018 Accepted: 27.11.2018 Online: 30.11.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Gök et al. Laparoscopic versus open appendectomy in pregnancy

MATERIALS AND METHODS The medical records of 57 consecutive pregnant women who underwent appendectomy between January 2009 and September 2018 were reviewed retrospectively. The patients were divided into two groups as OA and LA. Data regarding age, gestational age, diagnostic modalities, duration of surgery, length of stay, pathological results, morbidity, and mortality were collected. The local ethics committee approved the study in accordance with the guidelines of the Declaration of Helsinki (second revision, 2008). Patient characteristics including age, gestational week, admission, white blood cell count, diagnostic modalities, surgical approach, and final pathology report were obtained from the medical records. The study population was divided into two groups according to the surgical approach. The 30-day postdischarge complications were compared between the two groups. Primary outcomes were the loss of the fetus and the preterm delivery. Secondary outcomes were the development of deep and superficial surgical site infections, hospital length of stay, duration of surgery, and readmission.

All patients were evaluated according to the İstanbul University Istanbul Faculty of Medicine, Trauma and Emergency Surgery Unit guideline (Fig. 1). The appendicitis diagnosis was based on the clinical, laboratory, and imaging findings. All patients underwent abdominal ultrasonography (US). Magnetic resonance imaging (MRI) was used to support the appen-

A pregnant woman with abdominal pain

Physical examination and laboratory tests (without ionizing radiation) and Gynecology consultation (to rule out obstetric pathology and to decide tocolysis)

Suspected appendicitis

Ultrasonography

Positive

Negative/inconclusive

Surgery (OA/LA)

Magnetic resonance imaging

Positive

Negative

Observation

Gynecology consultation (to evaluate fetal viability)

If needed

Recovery

Reevaluate

Discharge

Figure 1. Trauma and Emergency Surgery Unit guideline.

Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

dicitis diagnosis if the initial diagnosis could not be definitively diagnosed in the US. All patients were consulted by the Department of Obstetrics & Gynecology to evaluate fetal viability before and after the abdominal surgery. All of them received nifedipine and indomethacin for tocolytic purpose.

In addition, they received ampicillin–sulbactam (4 g/day) preoperatively and postoperatively for 24 h.

Standard or modified McBurney incision was preferred in open approach according to gestational age. Laparoscopic procedures were performed in all patients with three standard trocars (umbilicus 10 mm, left lower quadrant 10 mm, and suprapubic 5 mm) and HD systems (Karl Storz GmbH & Co. KG, Tuttlingen, Germany). Open incision technique was performed for entering the first trocar that was used for the camera. CO2 pressure was 14 mm Hg to maintain pneumoperitoneum. The specimens were extracted through the left lower quadrant trocar incision with a plastic bag.

All patients underwent operation with general anesthesia. Heart rate (three-channel electrocardiography), blood pressure, peripheral oxygen saturation, and end-tidal CO2 (Drager Infinity Vista XL Monitor) were monitored. For anesthesia induction, 2–3 μg/kg fentanyl, 2–2.5 mg/kg propofol (up to the loss of eyelash reflex), and 0.5 mg/kg rocuronium bromide were used. Patients were intubated with an appropriate endotracheal tube. The fresh gas flow was adjusted to 2–3 l/min (O2/air mix, 50%/50%) during surgery.

The tidal volume was adjusted to 6–8 ml/kg with a ventilatory frequency of 12 beats/min by volume-controlled mechanical ventilation (Drager Fabius GS). End-tidal CO2 was maintained at 30–40 mm Hg. During anesthesia maintenance, 50% O2/50% air mix, sevoflurane (0.5%–2%), and 0.05–0.45 μg/kg/min remifentanil were used. All patients received 1 g intravenous paracetamol and 1 mg/kg tramadol. For postoperative analgesia, a 500 mg/6 h intravenous paracetamol was used.

Statistical analysis was performed by using the Statistical Package for the Social Sciences software, version 23 for Windows (IBM Corp., Armonk, NY, USA). The chi-squared test or Fisher’s exact test was used to compare categorical variables. The Student’s t-test was used to analyze normally distributed variables, and the non-parametric Mann–Whitney U test was used to analyze non-normally distributed variables.

A p-value <0.05 was considered statistically significant.

RESULTS During the study period, 57 pregnant patients were admitted with a diagnosis of appendicitis and underwent appendectomy. Of the patients, 18 (31%) underwent LA, and 39 (69%) underwent OA. The overall median age of the patients was 28 (19–41) years. There were no statistically significant differences between the two groups according to age, pregnancy week, and laboratory and pathological findings (Table 1).

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Gök et al. Laparoscopic versus open appendectomy in pregnancy

Table 1. Demographic, laboratory, and pathological findings

Overall n=57 (100%)

Open appendectomy n=39 (69%)

Laparoscopic appendectomy n=18 (31%)

p

Age (years)

28 (19–41)

27 (19–41)

29 (21–41)

0.606

Gestational age (weeks)

16 (4–36)

17 (5–36)

15 (4–26)

0.078

Pregnancy trimester

1

18 (32.0%)

11 (28.2%)

7 (38.9%)

2

29 (51.0%)

19 (48.7%)

10 (55.6%)

3

10 (17.0%)

9 (23.1%)

1 (5.6%)

13106 (7600–23700)

12500 (7600–27300)

12550 (8800–19600)

0.491

(range: 2800–10000)

9800 (5270–22800)

9800 (5900–22800)

9810 (5270–17700)

0.712

CRP level (mg/L, range: 0–5)

21 (1–160)

21 (1–160)

22 (2–139)

0.711

0.258

Leukocyte count

(range: 4300–10300)

Neutrophil count

Pathology

Normal appendix

4 (7.0%)

3 (7.7%)

1 (5.6%)

Acute appendicitis

52 (91.0%)

36 (92.3%)

16 (88.8%)

Perforated appendicitis

1 (2.0%)

0 (0.0%)

1 (5.6%)

Overall n=57 (100%)

Open appendectomy n=39 (69%)

Laparoscopic appendectomy n=18 (31%)

0.323

Table 2. Outcomes

p

Primary outcomes

Preterm delivery

2 (5.0%)

2 (5.1%)

0 (0.0%)

1.000

Fetal loss

1 (2.5%)

1 (2.6%)

0 (0.0%)

1.000

Secondary outcomes

Readmission

3 (12.5%)

2 (5.1%)

1 (5.6%)

1.000

SSSI

2 (5.0%)

1 (2.6%)

1 (5.6%)

0.536

DSSI

2 (5.0%)

2 (5.1%)

0 (0.0%)

1.000

LoS (days)

1 (1–7)

1 (1–7)

1 (1–3)

0.243

DoS (min)

50 (25–110)

57 (25–110)

37 (23–95)

0.005

Mortality

0

SSSI: Superficial surgical site infection; DSSI: Deep surgical site infection; LoS: Length of stay (days); DoS: Duration of surgery (minutes).

All patients underwent abdominal US (n=57, 100%). MRI was obtained to clarify the diagnosis for 10 (17.5%) patients with an unclear diagnosis of appendicitis. Sensitivity and specificity of US were 84.9% and 50%, respectively. Sensitivity and specificity of MRI were 66.7% and 100%, respectively.

There were no statistically significant differences between the two groups according to preterm delivery, fetal loss, and other complications. The duration of surgery was significantly shorter in the LA group than in the OA group (Table 2).

554

DISCUSSION The aim of the present study was to compare obstetric and surgical outcomes of LA and OA in pregnant women in a single center. The findings from our study showed that there were no differences between LA and OA in pregnancy in terms of obstetric and surgical complications. There was no evidence of a statistically significant negative effect of laparoscopy on obstetric and surgical outcomes. On the other hand, the duration of surgery was significantly shorter in the LA group (57 vs. 37 min, p=0.005) (Table 2). There was a pronounced trend for OA in late gestational age, but there was no statistical significance.

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Gök et al. Laparoscopic versus open appendectomy in pregnancy

Somewhat surprisingly, the length of stay was not different in two groups. We were expecting that the length of stay of the LA group might be shorter than that of the OA group.

In a systematic review of 20 studies, Prodromidou et al.[7] reported that the length of stay of LA is 1 day shorter than that of OA.[7] We think that our result might be due to preoperative and postoperative consultations to assess the mother and fetus regardless of the surgical intervention. In addition, the diagnostic tools that we used to ensure the diagnosis of appendicitis, such as US and MRI, take some time. In the same study, they found that there is no difference in the incidence of intra-abdominal abscesses or wound infection among the two groups. This result is similar to our results according to surgical site infections, despite the surgical site infection rate would be expected to be lower in laparoscopic cases. We think that our result might be due to pre- and postoperative antibiotic treatments.

paroscopy may cause maternal hypercapnia and hypoxemia that affect the fetus.[21] Some studies suggested low pressure during laparoscopy to prevent fetal loss.[22,23] On the contrary, in our study, the pressure was maintained at 14 mm Hg as our standard laparoscopic pressure, and there were no statistically significant differences between the two groups according to preterm delivery and fetal loss. Safe abdominal access for laparoscopy can be accomplished using either an open or a closed technique when used appropriately. The concern for the use of closed access techniques, such as Veress needle or optical entry, has largely been based on the potentially higher risk for injury to the uterus or other intra-abdominal organs in pregnant patients.[24,25] In the present study, always open incision technique was performed for initial port placement to avoid the aforementioned complications. An increasing number of studies have suggested that laparoscopic surgeries are safe during pregnancy.[22,23,26,27]

The risk of preterm delivery is associated with perforated appendicitis. Some studies reported that the risk of preterm delivery is between 8% and 33%.[8,9] In our study, we observed that the perforated appendicitis rate was 2%, and the preterm delivery rate was 5% (Tables 1 and 2).

In our study, we tried to summarize our institution’s experience on pregnant women with appendicitis, but the study has some limitations. These limitations include small sample size, retrospective design, only 30-day outcomes, and not well documented physical examination findings.

In a large population-based study, the negative appendectomy rate is 17.4%.[10] Bhandari et al.[11] reported that the negative appendectomy rates are 21.4% and 21.3% (p=0.52) in their pregnant and non-pregnant cohorts, respectively. In our study, we observed the negative appendectomy rate in 4 (7%) patients. This could be explained by the accuracy of our diagnostic tools. Appropriate imaging in the diagnosis of appendicitis has resulted in a decreased negative appendectomy rate from as high as 25% to approximately 1% to 3%.[12] Some series reported that US was found to be 78% to 83% sensitive and 83% to 93% specific for the diagnosis of AA.[13,14] The use of MRI during the work-up of suspected appendicitis during pregnancy reduces the unnecessary operation rate by 50%.[15] Avcu et al.[16] reported that the sensitivity and specificity of MRI are 84.9% and 50%, respectively. In our study, the sensitivity and specificity of US were 84.9% and 50%, respectively, and the sensitivity and specificity of MRI were 66.7% and 100%, respectively.

Conclusion

LA was preferred in the first and second trimesters. Owing to the technical difficulties of LA, OA was preferred more often in the third trimester. Some studies showed that LA can be used in all trimesters, whereas Kirshtein et al. recognized the third trimester as a contraindication for LA.[17–19] A systematic review stated that there is no difference in fetal loss or preterm delivery for LA managed in the first and third trimesters.

[20] In our study, only one patient underwent LA in the third trimester, whereas nine patients underwent OA (Table 1).

Before this, laparoscopy was considered as a risk factor for fetal loss due to the pneumoperitoneum. Increased intraabdominal pressure and Trendelenburg position during laUlus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

Overall, the present study suggests that LA is safe for pregnant patients and their infants. It must be kept in mind that our study was only conducted on a small group of patients retrospectively. Further prospective randomized studies are needed to determine the effects of laparoscopy on a larger group of pregnant patients.

Conflict of interest: None declared.

REFERENCES 1. Andersen B, Nielsen TF. Appendicitis in pregnancy: diagnosis, management, and complications. Acta Obstet Gynecol Scand 1999;78:758–62.

2. Carstens AK, Fensby L, Penninga L. Nonoperative Treatment of Appendicitis during Pregnancy in a Remote Area. AJP Rep 2018;8:e37–8.

3. Cheng HT, Wang YC, Lo HC, Su LT, Soh KS, Tzeng CW, et al. Laparoscopic appendectomy versus open appendectomy in pregnancy: A population-based analysis of maternal outcome. Surg Endosc. 2015;29:1394– 9.

4. Abbasi N, Patenaude V, Abenhaim HA. Management and outcomes of acute appendicitis in pregnancy-population-based study of over 7000 cases. BJOG 2014;121:1509–14.

5. Korndorffer JR Jr, Fellinger E, Reed W. SAGES guideline for laparoscopic appendectomy. Surg Endosc 2010;24:757–61.

6. Cox TC, Huntington CR, Blair LJ, Prasad T, Lincourt AE, Augenstein VA, et al. Laparoscopic appendectomy and cholecystectomy versus open: a study in 1999 pregnant patients. Surg Endosc 2016;30:593–602.

7. Prodromidou A, Machairas N, Kostakis ID, Molmenti E, Spartalis E, Kakkos A, et al. Outcomes after open and laparoscopic appendectomy during pregnancy: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2018;225:40–50.

8. Kazim SF, Pal KM. Appendicitis in pregnancy: experience of thirty-eight

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Gök et al. Laparoscopic versus open appendectomy in pregnancy patients diagnosed and managed at a tertiary care hospital in Karachi. Int J Surg 2009;7:365–7.

9. Aggenbach L, Zeeman GG, Cantineau AE, Gordijn SJ, Hofker HS. Impact of appendicitis during pregnancy: no delay in accurate diagnosis and treatment. Int J Surg 2015;15:84–9.

10. Zingone F, Sultan AA, Humes DJ, West J. Risk of acute appendicitis in and around pregnancy: a population-based cohort study from England.

Ann Surg 2015;261:332–7.

11. Bhandari TR, Shahi S, Acharya S. Acute Appendicitis in Pregnancy and the Developing World. Int Sch Res Notices 2017;2017:2636759.

12. Garcia EM, Camacho MA, Karolyi DR, Kim DH, Cash BD, Chang KJ, et al; Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® Right Lower Quadrant Pain-Suspected Appendicitis. J Am Coll Radiol 2018;15:S373–87.

13. 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.

14. Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, et al. US or CT for Diagnosis of Appendicitis in Children and Adults?

A Meta-Analysis. Radiology 2006;241:83–94.

15. Rapp EJ, Naim F, Kadivar K, Davarpanah A, Cornfeld D. Integrating MR imaging into the clinical workup of pregnant patients suspected of having appendicitis is associated with a lower negative laparotomy rate: singleinstitution study. Radiology 2013;267:137–44.

16. Avcu S, Çetin FA, Arslan H, Kemik Ö, Dülger AC. The value of diffusion-weighted imaging and apparent diffusion coefficient quantification in the diagnosis of perforated and nonperforated appendicitis. Diagn Interv Radiol 2013;19:106–10.

17. Chung JC, Cho GS, Shin EJ, Kim HC, Song OP. Clinical outcomes com-

pared between laparoscopic and open appendectomy in pregnant women.

Can J Surg 2013;56:341–6.

18. Lyass S, Pikarsky A, Eisenberg VH, Elchalal U, Schenker JG, Reissman P. Is laparoscopic appendectomy safe in pregnant women? Surg Endosc 2001;15:377–9.

19. Kirshtein B, Perry ZH, Avinoach E, Mizrahi S, Lantsberg L. Safety of laparoscopic appendectomy during pregnancy. World J Surg 2009;33:475– 80.

20. Walsh CA, Tang T, Walsh SR. Laparoscopic versus open appendicectomy in pregnancy: a systematic review. Int J Surg 2008;6:339–44.

21. O’Rourke N, Kodali BS. Laparoscopic surgery during pregnancy. Curr Opin Anaesthesiol 2006;19:254–9.

22. Jeong JS, Ryu DH, Yun HY, Jeong EH, Choi JW, Jang LC. Laparoscopic appendectomy is a safe and beneficial procedure in pregnant women. Surg Laparosc Endosc Percutan Tech 2011;21:24–7.

23. Park SH, Park MI, Choi JS, Lee JH, Kim HO, Kim H. Laparoscopic appendectomy performed during pregnancy by gynecological laparoscopists. Eur J Obstet Gynecol Reprod Biol 2010;148:44–8.

24. Friedman JD, Ramsey PS, Ramin KD, Berry C. Pneumoamnion and pregnancy loss after second-trimester laparoscopic surgery. Obstet Gynecol 2002;99:512–3.

25. Halpern NB. Laparoscopic cholecystectomy in pregnancy: a review of published experiences and clinical considerations. Semin Laparosc Surg 1998;5:129–34.

26. Rollins MD, Chan KJ, Price RR. Laparoscopy for appendicitis and cholelithiasis during pregnancy: a new standard of care. Surg Endosc 2004;18:237–41.

27. İlhan M, İlhan G, Gök AFK, Günay K, Ertekin C. The course and outcomes of complicated gallstone disease in pregnancy: Experience of a tertiary center. Turk J Obstet Gynecol 2016;13:178–82.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Gebelikte laparoskopik ve açık apendektominin karşılaştırılması: Tek merkez deneyimi Dr. Ali Fuat Kaan Gök,1 Dr. Yiğit Soytaş,1 Dr. Adem Bayraktar,1 Dr. Selman Emirikçi,1 Dr. Mehmet İlhan,1 Dr. Ahmet Kemalettin Koltka,2 Dr. Mustafa Kayıhan Günay1 1 2

İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul İstanbul Üniversitesi İstanbul Tıp Fakültesi, Anestezi ve Reanimasyon Anabilim Dalı, İstanbul

AMAÇ: Bu çalışmanın amacı tek bir merkezde apandisit nedeniyle ameliyat edilen gebe kadınlarda laparoskopik ve açık apendektominin (OA) obstetrik ve cerrahi sonuçlarını karşılaştırmaktır. Bu çalışmadaki ana hipotezimiz bahsedilen sonuçlar açısından açık ya da laparoskopik apendektomi (LA) arasında fark olmadığıdır.

GEREÇ VE YÖNTEM: Ocak 2009 ile Eylül 2018 arasında apendektomi yapılan 57 ardışık gebe kadının tıbbi kayıtları geriye dönük olarak incelendi.

Hastalar açık ve laparoskopik apendektomi olmak üzere iki gruba ayrıldı. Toplanan veriler yaş, gebelik yaşı, tanı yöntemleri, ameliyat süresi, kalış süresi, morbidite ve mortaliteyi içermektedir.

BULGULAR: On sekiz (%31) hastaya LA ve 39 (%69) hastaya OA uygulandı. Demografik veriler arasında fark yoktu. Laparoskopik grupta cerrahinin süresi anlamlı olarak daha kısaydı (37 ve 57 dakika, p=0.005). Derin ve yüzeyel cerrahi alan enfeksiyonları, yatış süresi, erken doğum ve fetal kayıp gibi sonuçlarda istatistiksel olarak anlamlı bir fark bulunmadı. Her iki grupta da mortalite yoktu.

TARTIŞMA: Genel olarak, bu çalışma LA’nın gebe hasta ve fetüs için güvenli olduğunu düşündürmektedir. Apandisitli gebe hastalar üzerinde laparoskopinin etkilerini belirlemek için, daha geniş sayıda olguda ileriye yönelik randomize çalışmalara ihtiyaç vardır.

Anahtar sözcükler: Açık apendektomi; apendektomi; gebelik; laparoskopi.

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doi: 10.5505/tjtes.2018.26357

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ORIG I N A L A R T IC L E

Can Alvarado and Appendicitis Inflammatory Response scores evaluate the severity of acute appendicitis?

Metin Yeşiltaş, M.D., Dursun Özgür Karakaş, M.D., Semih Hot, M.D., Seracettin Eğin, M.D.,

Berk Gökçek, M.D.,

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

ABSTRACT BACKGROUND: The Alvarado score (AS) and the Appendicitis Inflammatory Response score (AIRS) were developed to diagnose acute appendicitis (AA). The aim of this study was to evaluate the severity of AA using the AS and the AIRS tools.

METHODS: Patients who presented between January 2016 and December 2017 and underwent surgery for AA and who had a preoperative AS and AIRS value were evaluated retrospectively. The details of age, sex, pathological severity, the presence of local peritonitis or fecaloid, drainage, appendix diameter, and operation type were evaluated according to the AS and the AIRS. RESULTS: A total of 578 patients were included in the study. Appendicitis was the most common pathological severity classification (44.4%). The most common appendix diameter group was 7–10 mm (59.2%). The difference observed in the AS and AIRS results for all of the pathological severity categories was statistically significant (p<0.05). The AIRS revealed a statistically significant difference (p<0.05) in the detection of uncomplicated and complicated appendicitis. The AIRS difference was statistically significant for appendix diameter (p<0.05). The AS and the AIRS results were both statistically significant for drainage (p<0.05). The AS was correlated with pathological severity, local peritonitis, and drainage, while the AIRS was correlated with pathological severity, uncomplicated/complicated determination, appendix diameter, and drainage (p<0.05).

CONCLUSION: Both the AS and the AIRS can evaluate pathological severity, but only the AIRS can evaluate complicated or uncomplicated appendicitis and the diameter of the appendix. These tools can be used to reduce the number of unnecessary radiological or surgical interventions.

Keywords: Acute appendicitis; Alvarado score; Appendicitis Inflammatory Response score; drainage; local peritonitis; pathology.

INTRODUCTION Acute abdominal pain is a common complaint of emergency admission, with ratio of 10%.[1] Of the cases of acute abdominal pain, a reported 1.9% are caused by acute appendicitis (AA).[2] The clinical presentation and symptoms of AA are frequently atypical and can be similar to other diseases, which makes diagnosis difficult. Delayed diagnosis, however, can lead to perforation of the appendix. Until recently, a 15% negative appendectomy rate was accepted in order to reduce the perforation rate.[3] Some 2% of claims in emergency departments are cases of appendicitis.[4] Today, in light of scientific

improvements as well as malpractice cases, the negative appendectomy must be very rare.

An anamnesis and physical examination are the initial methods for diagnosis, as in other diseases. The diagnostic accuracy of laboratory tests (especially leucocyte count, C-reactive protein [CRP], and neutrophil percentage) has been reported to be 82.5%.[5] Diagnosis sensitivity has been reported for ultrasonography (USG) as 83.1%, computed tomography (CT) as 89.9% and magnetic resonance imaging (MRI) as 89.9%, and the specificity has been reported as 90.9%, 93.6%, and 93.6%, respectively.[6] Scoring systems were developed to help diag-

Cite this article as: Yeşiltaş M, Karakaş DÖ, Gökçek B, Hot S, Eğin S. Can Alvarado and Appendicitis Inflammatory Response scores evaluate the severity of acute appendicitis? Ulus Travma Acil Cerrahi Derg 2018;24:557-562.

Address for correspondence: Dursun Özgür Karakaş, M.D. Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, 34100 İstanbul, Turkey Tel: +90 212 - 238 79 00 E-mail: drdok1978@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):557-562 DOI: 10.5505/tjtes.2018.72318 Submitted: 05.10.2018 Accepted: 14.11.2018 Online: 26.11.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Yeşiltaş et al. Can Alvarado and Appendicitis Inflammatory Response scores evaluate the severity of acute appendicitis?

nose AA. The diagnosis sensitivity of the Alvarado score (AS) has been reported as 78.41%, the Appendicitis Inflammatory Response score (AIRS) as 78.41%, and the Raja Isteri Pengiran Anak Saleha Appendicitis scoring system (RIPASA) as 93.18%, while the diagnosis specificity has been reported as 100%, 91.67%, and 91.67%, respectively.[7] The severity of AA is generally evaluated radiologically. The white blood cell (WBC), CRP, and total bilirubin values, the neutrophil-to-lymphocyte ratio, and the combination of radiology and laboratory scoring systems are used for severity evaluation.[8–12] The AS and the AIRS were designed to help diagnose AA. The aim of this study was to retrospectively assess use of the AS and the AIRS to evaluate severity of appendicitis.

MATERIALS AND METHODS

The AS consists of the symptoms of pain migration to the right iliac fossa (RIF), anorexia, nausea and vomiting, examination findings of RIF tenderness, rebound tenderness, and fever, as well as laboratory results indicating leukocytosis and a shift of the WBC to the left. The AIRS uses the symptoms of vomiting, pain in the RIF, signs of abdominal defense, and a temperature >38.8°C, in addition to laboratory values indicating Table 1. Alvarado scoring system for acute appendicitis Diagnosis Score Symptoms Pain migration to right iliac fossa

1

Anorexia

1

1

Nausea & vomiting

Signs

Right iliac fossa tenderness

2

Rebound tenderness

1

Fever

Diagnosis Score Vomiting 1 Pain in right iliac fossa

1

Abdominal defense Low

1

Medium

2

Severe

3

Temperature >38.8°C

1

Segmented neutrophils 70%–84%

1

≥85%

2

Leukocytes (x109/L)

After receiving institutional approval from the ethics committee of Okmeydanı Training and Research Hospital, patients from between January 2016 and December 2017 who were operated on for AA and who had preoperative AS and AIRS results were evaluated retrospectively. Age, sex, pathological details (severity, the presence of local peritonitis or a fecaloid, the diameter of the appendix), and surgical details (operation type and presence of drainage) were evaluated using the AS and the AIRS.

Table 2. Acute Inflammatory Response Score for acute appendicitis

10.0–14.9

1

≥15.0

2

C-reactive protein (g/L) 10–49

1

≥50

2

Total 12 Score: 0–4 low probability, 5–8 mild probability, 9–12 high probability.

segmented neutrophils, and leukocyte and CRP values.[7] The AS and the AIRS criteria are illustrated in Table 1 and Table 2.

Pathological severity was evaluated by the pathology department using the categories of lymphoid hyperplasia, appendicitis, phlegmonous/suppurative appendix, and perforation. Perforated appendicitis was considered complicated, while the remainders were classified as uncomplicated. The appendix diameter measurement was separated into 4 groups: <6 mm, 7–10 mm, 11–20 mm, and >21 mm. Appendectomies were performed laparoscopically or as open surgery.

The statistical analysis was performed using SPSS for Windows, Version 16.0 (SPSS Inc., Chicago, IL, USA). A single sample t-test was used for age (mean ±SD). The ratio of male to female patients, and the operation type were calculated as percentages. The Kruskal-Wallis and Mann-Whitney U tests were used to evaluate the AS and AIRS results. Pearson’s correlation test was used to evaluate the correlation between the scores and the findings.

1

RESULTS

Leukocytosis

2

1

A total of 578 patients were included in the study. The mean age was 30.2±12.9 years. In all, 34% of patients were female and 66% were male. A laparoscopic procedure was performed in 55.4% of the cases, while an open technique was used in 44.6%. Drainage was required in 11.6%. The pathological severity classification was lymphoid hyperplasia in 2.8%,

Laboratory Shift of the white blood cell count to the left

Total 10 Score: <4 unlikely probability, 4–7 suspected probability, >7 definite probability.

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Yeşiltaş et al. Can Alvarado and Appendicitis Inflammatory Response scores evaluate the severity of acute appendicitis?

appendicitis in 44.4%, phlegmonous/suppurative appendix in 41.9%, and perforation in 10.9%. The diameter of the appendix was <6 mm in 11.6% of the cases, 7–10 mm in 59.2%, 11–20 mm in 27.5%, and 1.7% of the appendices measured >21 mm. Local peritonitis was present in 62.3% of the patients and a fecaloid was present in 63% (Table 3).

The results of evaluation of pathological severity using the AS and the AIRS are shown in Table 4. Both the AS and the AIRS demonstrated statistically significant differences in determining all of the severity groups (both: p=0.0001). The differences in the determination of lymphoid hyperplasia with appendicitis, phlegmonous/suppurative classification, and perforation were also statistically significant (AS: p=0.008, p=0.0001,

Table 4. AS and AIRS evaluation according to pathological severity, appendix diameter, local peritonitis, and drainage Findings

AS AIRS Mean p Mean Rank Rank

Pathologic severity

Lymphoid hyperplasia

Appendicitis

160.56 0.0001 158.91 0.0001 270.00 245.51

Phlegmonous/suppurative 312.14 Perforation

Lymphoid hyperplasia

89.38

0.008

65.47

Lymphoid hyperplasia

0.0001 61.66

30.2±12.9

Sex

Lymphoid hyperplasia

22.72

197

34

Male

381

66

0.0001 16.34

Open

258

44.6

Laparoscopic

320

55.4

Drainage

46.01

Appendicitis

232.48 0.003 218.99 0.0001 282.93

Appendicitis

155.56 0.038 145.09 0.0001

Perforation

180.65 223.38

Perforation

153.78 185.60

Uncomplicated

286.40 0.17 277.08 0.0001

Complicated

314.82 390.99

Yes

67

11.6

Appendix diameter

511

88.4

Pathological severity 1

7–10 mm

281.95

279.48

11–20 mm

304.80

328.02 349.00

<6 mm

288.15

0.464 239.60

16

2.8

Appendicitis

257

44.4

>21 mm

311.30

Phlegmonous/suppurative

242

41.9

<6 mm

208.17

63

10.9

7–10 mm

203.78

<6 mm

109.37

11–20 mm

115.94

124.22

<6 mm

38.60

37.06

Lymphoid hyperplasia

Perforation

Pathological severity 2 Uncomplicated

515

89.1

Complicated

63

10.9

Diameter

<6 mm

67

11.6

7–10 mm

342

59.2

11–20 mm

159

27.5

>20 mm

10

1.7

Local peritonitis Yes

360

62.3

218

37.7

No

Fecaloid Yes

364

63

214

37

No

0.0001

44.39

Phlegmonous/suppurative 152.80 0.932 144.51 0.001

Operation

No

0.0001

133.99

Perforation

Phlegmonous/suppurative 268.61

Female

0.038

139.96 139.43

Age (years), Mean±SD

97.91

Appendicitis

Phlegmonous/suppurative 133.73

%

318.43

314.82 390.99

Table 3. Demographic data, surgical details, and pathological results of patients (n=578) n

p

SD: Standard deviation.

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0.764 180.95 0.460 0.665

>21 mm

41.65

7–10 mm

244.69

0.069

209.13 89.60

0.0001 0.044

52.00

0.125 237.59

11–20 mm

264.45

7–10 mm

175.48

>21 mm

193.65

218.25

11–20 mm

85.41

85.23

>21 mm

87.00

0.002

279.57

0.548 174.76 0.915

0.001

0.174 0.775

89.75

Other

Local peritonitis +

298.55

0.072 299.84

Local peritonitis –

274.56

Drainage +

282.17

Drainage –

345.43

0.052

272.42

0.002 271.32 0.0001 428.14

AS: Alvarado score; AIRS: Appendicitis Inflammatory Response score.

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Yeşiltaş et al. Can Alvarado and Appendicitis Inflammatory Response scores evaluate the severity of acute appendicitis?

The results of the AS and the AIRS evaluation of appendix diameter are also demonstrated in Table 4. The AS did not yield a statistically significant differences between diameter categories (p=0.464); however, the AIRS result was statistically significant (p=0.001). With the AIRS, differences between <6 mm and 11–20 mm, <6 mm and >21 mm, and 7–10 mm and 11–20 mm were statistically significant (p=0.0001, p=0.044 and 0.002, respectively). Other differences between diameters were not statistically significant (p>0.05).

The results of the AS and AIRS evaluation of other findings are also shown in Table 4. The presence of local peritonitis was not statistically significant for the AS or the AIRS (p=0.072, p=0.052 respectively). Drainage, however, was a statistically significant result for both the AS and the AIRS (p=0.002, p=0.0001, respectively) (Figs. 1 and 2).

The correlation between scores and findings is demonstrated in Table 5. The correlation with pathological severity was statistically significant for both scoring systems (both p=0.0001).

The AS result for distinguishing between uncomplicated/ complicated was not statistically significant (p=0.085) but the AIRS correlation was statistically significant (p=0.001).

Similarly, the AS correlation for appendix diameter was not statistically significant (p=0.307), but the AIRS result was staTable 5. Correlation of findings and scores Findings Scores Pearson correlation Pathological severity

AS

Diameter

Local peritonitis

Drainage

0.72 0.085

AIRS 0.221 0.0001 AS 0.043 0.307 AIRS 0.171 0.0001 AS

0.88

0.035

AIRS 0.76 0.066 AS 0.137 0.001 AIRS 0.298 0.0001

AS: Alvarado score; AIRS: Appendicitis Inflammatory Response score.

560

0.0001

AIRS 0.325 0.0001

Complicated/uncomplicated AS

0.196

p

Alvarado score

250

Lymphoid hyperplasia Appendicitis

N (number)

200

Phlegmenous/supurative Perforated

150

Local peritonitis + Drainage +

100

<6 mm diameter

50

7–10 mm diameter 11–20 mm diameter

0

1

2

3

4

5 6 7 Score

8

9

10

>21 mm diameter

Figure 1. Distribution of Alvarado score according to findings.

120

Appendicitis Inflammatory Response score Lymphoid hyperplasia Appendicitis

100 N (number)

p=0,0001, respectively; AIRS: p=0.038, p=0.0001, p=0.0001, respectively). In addition, differences between appendicitis with a phlegmonous/suppurative appendix and perforation were statistically significant (AS: p=0.003, p=0.038, respectively; AIRS: p=0.0001, p=0.0001, respectively). The difference between a phlegmonous/suppurative evaluation and perforation was not statistically significant for the AS (p=0.932), but was statistically significant for the AIRS (p=0.001). The difference between uncomplicated and complicated appendicitis results was not statistically significant for the AS (p=0.17), but was statistically significant for the AIRS (p=0.0001).

Phlegmenous/supurative

80

Perforated

60

Local peritonitis + Drainage +

40

<6 mm diameter

20 0

7–10 mm diameter 11–20 mm diameter

1

2

3

4

5

6 7 8 Score

9 10 11 12

>21 mm diameter

Figure 2. Distribution of Appendicitis Inflammatory Response score according to findings.

tistically significant (p=0.0001). The AS determination of local peritonitis was statistically significant (p=0.035), while the AIRS was not (p=0.066). The correlation for both the AS and the AIRS was statistically significant for the subsequent need for drainage (p=0.001, p=0.0001 respectively).

DISCUSSION Though imaging modalities facilitate the accurate diagnosis of severity in AA, it can still be difficult in geriatric, pediatric, and female patients, and pregnant patients, in particular. This can be a cause of delayed diagnosis. Some 28% to 29% of AA cases have been found to be complicated with a perforation or gangrene, and postoperative morbidity rates have increased to between 9% and 18%.[13] Therefore, many clinical, laboratory, and radiological studies have been performed to better determine the severity of AA. Both the AS and the AIRS systems consist of symptoms, signs, and laboratory results. Symptoms are more in the foreground in the AS, while the AIRS includes a CRP value. De Castro et al.[14] and Kollár et al.[15] reported that the AIRS had greater discriminative power than the AS in diagnosing AA as a result of the addition of the CRP component.

Kalliakmanis et al.[16] evaluated AA symptoms, and reported that pain migration to the right lower quadrant, loss of appetite, periumbilical pain, fever, rebound tenderness, and local rigidity were statistically correlated with histopathological severity (p<0.05).

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Yeşiltaş et al. Can Alvarado and Appendicitis Inflammatory Response scores evaluate the severity of acute appendicitis?

Andersson et al.[17] reviewed the clinical and laboratory diagnosis of appendicitis. They found that duration of right quadrant pain >24 hours; fever (>37.7 °C); pain migration; direct, indirect, and rebound tenderness; and guarding were significant clinical signs for AA (p<0.05). A WBC count of ≥10 (×109/L), granulocyte count ≥7 (×109/L), polymorphonuclear neutrophil proportion >75%, and CRP level >10 (mg/L) were significant laboratory results for AA (p<0.05); however, only WBC and CRP were significant for complicated appendicitis. Xharra et al.[18] reported that the diagnostic accuracy of CRP, WBC, and the percentile of neutrophils (PN) was 83.2%, 82.6%, and 77.5%, respectively. The combination of CRP+, WBC+, and PN increased the accuracy to 91.9%.[18] Sevinç et al.[19] reported that WBC >11.900 mm3, serum bilirubin >1.0 mg/dL, and a neutrophil-lymphocyte ratio (NLR) >3.0 were significantly associated with an AA diagnosis. In patients with AA, serum bilirubin >1.0 mg/dL or NLR >4.8 was significantly associated with the presence of perforation.

USG is the least expensive imaging modality, and it is easily applicable and harmless, but requires a radiologist. The sensitivity of a USG diagnosis of AA has been reported as 83.7%, with a specificity of 95.9%. USG is ineffective if the appendix is <6 mm in diameter. CT has been reported to have a 98.5% sensitivity and a 98% specificity in the diagnosis of AA. The sensitivity was 64.3%–96.4% and the specificity was 100% for the severity of AA. The negative appendectomy rate was 8.7% versus 16.7% based on a clinical evaluation. The most important disadvantage of CT is the exposure to radiation (not suitable for children or pregnant woman) and long-term risks of cancer.[3,7,20] We evaluated the pathological severity, appendix diameter, and the presence of local peritonitis and drainage in the assessment of the severity of AA. Pathological severity was evaluated as complicated/uncomplicated with a more detailed classification as appropriate.

[21] Our pathology department evaluated AA using the categories of lymphoid hyperplasia, appendicitis, phlegmonous/ suppurative appendix, and perforation. Transmural inflammation, ulceration, or thrombosis, with or without extramural suppuration, may appear in the pathology of uncomplicated appendicitis. Necrosis and perforation appear in complicated cases. Our study findings of 89.2% uncomplicated and 10.9% complicated was lower than reports in the literature.[13] Both the AS and the AIRS demonstrated statistically significant results in predicting the pathological severity of AA; however, only the AIRS could differentiate between uncomplicated and complicated cases.

The appendix diameter is an important sign for radiological diagnosis, and >6 mm is accepted as indicating AA. However the diameter may also be <6 mm in cases of AA and USG is ineffective for diagnosing an appendix <6 mm in diameter.

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In our group, 11.6% of the patients had an appendix diameter measured at <6 mm. The results of our study showed that the AS cannot predict appendix diameter, but the AIRS was successful, especially those <6 mm and >21 mm.

[7,22,23]

Local peritonitis is a pathological finding that is an indicator of the severity of AA. In this study, the results of local peritonitis rate were evaluated as 6.25% for lymphoid hyperplasia, 44% for appendicitis, 76.8% for phlegmonous/suppurative, and 95.2% for perforated; the local peritonitis percentage increased with the severity of AA and was statistically significant (p<0.005). The items included in both scores are not affected by local peritonitis, and while these 2 scoring systems cannot predict local peritonitis, the AS was significantly correlated with local peritonitis findings.

The use of drainage is an operative approach associated with perforation or infected periappendiceal fluid and is an indicator of the severity of AA. Drainage was performed in 7.5% of the uncomplicated cases and increased to 44.4% in complicated AA. Both scoring systems can predict the need for drainage.

In conclusion, complicated or perforated appendicitis is still the most important complication of delayed or misdiagnosed AA. The scoring systems used symptoms, signs, and laboratory results. They are easy and inexpensive to administer, harmless, and offer a 78.41% sensitivity and 91.67% specificity for the diagnosis of AA while also being useful for determining severity. The AIRS results were more significant for the prediction of complicated appendicitis and appendix diameter compared with the AS. CRP is the most important differential item for the AIRS. The use of the AIRS can decrease unnecessary radiological and surgical interventions. A prospective, randomized, controlled trial is needed for further evaluation of these scores and imaging modalities, such as USG, CT, or diagnostic laparoscopy.

Conflict of interest: None declared.

REFERENCES 1. Gans SL, Pols MA, Stoker J, Boermeester MA; expert steering group.

Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg 2015;32:23–31.

2. Viniol A, Keunecke C, Biroga T, Stadje R, Dornieden K, Bösner S, et al.

Studies of the symptom abdominal pain-- a systematic review and metaanalysis. Fam Pract 2014;31:517–29.

3. Shogilev DJ, Duus N, Odom SR, Shapiro NI. Diagnosing appendicitis: evidence-based review of the diagnostic approachin 2014. West J Emerg Med 2014;15:859–71.

4. Brown TW, McCarthy ML, Kelen GD, Levy F. An epidemiologic study of closed emergency department malpracticeclaims in a national database of physician malpractice insurers. Acad Emerg Med 2010;17:553–60.

5. Yang HR, Wang YC, Chung PK, Chen WK, Jeng LB, Chen RJ. Laboratory tests in patients with acute appendicitis. ANZ J Surg 2006;76:71–4.

6. Eng KA, Abadeh A, Ligocki C, Lee YK, Moineddin R, Adams-Webber T, et al. Acute Appendicitis: A Meta-Analysis of the Diagnostic Accuracy

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7. Karami MY, Niakan H, Zadebagheri N, Mardani P, Shayan Z, Deilami I. Which One is Better? Comparison of the Acute Inflammatory Response, Raja Isteri Pengiran Anak Saleha Appendicitis and Alvarado ScoringSystems. Ann Coloproctol 2017;33:227–31.

8. Göya C, Hamidi C, Okur MH, Içer M, Oğuz A, Hattapoğlu S, et al. The utility of acoustic radiation force impulse imaging in diagnosing acuteappendicitis and staging its severity. Diagn Interv Radiol 2014;20:453–8.

9. Kelly ME, Khan A, Riaz M, Bolger JC, Bennani F, Khan W, et al. The Utility of Neutrophil-to-Lymphocyte Ratio as a Severity Predictor of Acute Appendicitis, Length of Hospital Stay and Postoperative Complication Rates. Dig Surg 2015;32:459–63.

10. Nomura S, Watanabe M, Komine O, Shioya T, Toyoda T, Bou H, et al.

Serum total bilirubin elevation is a predictor of the clinicopathologicalseverity of acute appendicitis. Surg Today 2014;44:1104–8.

11. Garst GC, Moore EE, Banerjee MN, Leopold DK, Burlew CC, Bensard DD, et al. Acute appendicitis: a disease severity score for the acute care surgeon. J Trauma Acute Care Surg 2013;74:32–6.

12. Atema JJ, van Rossem CC, Leeuwenburgh MM, Stoker J, Boermeester MA. Scoring system to distinguish uncomplicated from complicated acuteappendicitis. Br J Surg 2015;102:979–90.

13. Li J, Xu R, Hu DM, Zhang Y, Gong TP, Wu XL. Effect of Delay to Operation on Outcomes in Patients with AcuteAppendicitis: a Systematic Review and Meta-analysis. J Gastrointest Surg 2018 Jul 6. doi: 10.1007/ s11605-018-3866-y. [Epub ahead of print].

14. de Castro SM, Ünlü C, Steller EP, van Wagensveld BA, Vrouenraets BC. Evaluation of the appendicitis inflammatory response score for pa-

tientswith acute appendicitis. World J Surg 2012;36:1540–5.

15. Kollár D, McCartan DP, Bourke M, Cross KS, Dowdall J. Predicting acute appendicitis? A comparison of the Alvarado score, the Appendicitis Inflammatory Response Score and clinical assessment. World J Surg 2015;39:104–9.

16. Kalliakmanis V, Pikoulis E, Karavokyros IG, Felekouras E, Morfaki P, Haralambopoulou G, et al. Acute appendicitis: the reliability of diagnosis by clinical assessment alone. Scand J Surg 2005;94:201–6.

17. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004;91:28–37.

18. Xharra S, Gashi-Luci L, Xharra K, Veselaj F, Bicaj B, Sada F, et al. Correlation of serum C-reactive protein, white blood count and neutrophilpercentage with histopathology findings in acute appendicitis. World J Emerg Surg 2012;7:27.

19. Sevinç MM, Kınacı E, Çakar E, Bayrak S, Özakay A, Aren A, et al. Diagnostic value of basic laboratory parameters for simple and perforatedacute appendicitis: an analysis of 3392 cases. Ulus Travma Acil Cerrahi Derg 2016;22:155–62.

20. Bixby SD, Lucey BC, Soto JA, Theysohn JM, Ozonoff A, Varghese JC. Perforated versus nonperforated acute appendicitis: accuracy of multidetector CT detection. Radiology 2006;241:780–6.

21. Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015;386:1278–87.

22. Park NH, Oh HE, Park HJ, Park JY. Ultrasonography of normal and abnormal appendix in children. World J Radiol 2011;3:85–91.

23. Willekens I, Peeters E, De Maeseneer M, de Mey J. The normal appendix on CT: does size matter? PLoS One 2014;9:e96476.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Alvarado ve Apandisit İnflamatuvar Yanıt skorlamaları akut apandisitin şiddetini değerlendirebilir mi?

Dr. Metin Yeşiltaş, Dr. Dursun Özgür Karakaş, Dr. Berk Gökçek, Dr. Semih Hot, Dr. Seracettin Eğin Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

AMAÇ: Alvarado (AS) ve apandisit inflamatuvar yanıt (AİYS) skorları akut apandisit (AA) tanısı için geliştirilmiş skorlardır. Bu çalışmanın amacı AA şiddetinin AS ve AIYS ile değerlendirmesidir.

GEREÇ VE YÖNTEM: Ocak 2016–Aralık 2017 tarihleri arasında AA nedeni ile ameliyat edilen ve ameliyat öncesi AS ve AİYS yapılan hastalar geriye dönük değerlendirildi. Yaş, cinsiyet, patolojik şiddet, lokal peritonit, fekaloid, drenaj, apendiks çapı ve operasyon şekli AS ve AİYS’ye göre değerlendirildi.

BULGULAR: Çalışmaya 578 hasta dâhil edildi. Apandisit %44.4 ile en sık görülen patolojiydi. En sık ölçülen apandiks çapı ise %59.2 ile 7-10 mm idi.

Bütün patolojiler arasındaki AS ve AİYS istatistiksel olarak anlamlı bulundu (p<0.05). Komplike ve komplike olmayan apandisitler arasındaki sadece AİYS istatistiksel olarak anlamlı bulundu (p<0.05). Apandiks çapları arasındaki sadece AİYS istatistiksel olarak anlamlı bulundu (p<0.05). Drenaj yapılan hastalarda AS ve AİYS istatistiksel olarak anlamlı farklılık saptandı (p<0.05). AS ile patolojik şiddet, lokal peritonit ve drenajın korelasyonu, AİYS ile patolojik şiddet, komplike/komplike olmayan, apandiks çapı ve drenajın korelasyonu istatistiksel olarak anlamlı bulundu (p<0.05).

TARTIŞMA: Alvarado skoru ve AİYS her ikisi de patolojik şiddeti değerlendirebilmekte iken sadece AİYS komplike ve komplike olmayan apandisitleri, apandiks çapının daha anlamlı değerlendirebilmektedir. Bu skorları kullanarak gereksiz radyolojik ve cerrahi girişimlerini azaltabilecektir.

Anahtar sözcükler: Akut apandisit; Alvarado skoru; apandisit inflamatuvar yanıt skoru; drenaj; lokal peritonit; patoloji.

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doi: 10.5505/tjtes.2018.72318

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ORIG I N A L A R T IC L E

Wound dehiscence after penetrating keratoplasty Evin Şingar Özdemir, M.D.,1 Ayşe Burcu, M.D.,1 Barış Oral, M.D.,2 Firdevs Örnek, M.D.1

Züleyha Yalnız Akkaya, M.D.,1

1

Department of Ophthalmology, Ankara Training and Research Hospital, Ankara-Turkey

2

Department of Ophthalmology, Ağrı State Hospital, Ağrı-Turkey

ABSTRACT BACKGROUND: The purpose of this study was to investigate factors affecting wound dehiscence due to blunt trauma following penetrating keratoplasty (PK) and the clinical outcomes.

METHODS: The medical records of patients who experienced blunt traumatic wound dehiscence after PK between 1995 and 2015 were analyzed retrospectively. The incidence and etiology of the trauma, the time interval between PK and globe rupture, final graft clarity, best-corrected visual acuity, complications, secondary surgeries, and factors potentially affecting wound dehiscence size were recorded.

RESULTS: This study included a total of 39 patients with a mean age of 42.66±16.66 years, of whom 23 patients were male and 16 patients were female. The incidence of wound dehiscence was 2.3%. The mean interval between the PK procedure and wound dehiscence was 25.91±47.24 months and the mean follow-up time was 34.43±51.02 months. The most common trauma mechanism was force with a blunt object (53.8%) and the most frequent site of wound dehiscence was the temporal quadrant (30.8%), the wound ranging from 30° to 270° in size. The patients were divided into 4 groups according to wound dehiscence size. As the size of the wound dehiscence size increased, the male ratio increased, wound dehiscence was more commonly located in the nasal and superior quadrants, lens injury and posterior segment complications were more frequent, and graft transparency was achieved at a lower rate.

CONCLUSION: Traumatic wound dehiscence after PK is rare, but may lead to serious, lifelong consequences, including eye loss.

Patients should be well informed about the risks and potential sequelae of wound dehiscence.

Keywords: Penetrating keratoplasty; trauma; wound dehiscence.

INTRODUCTION Wound dehiscence after penetrating keratoplasty (PK) is a rare but well-known complication, suggesting that the grafthost interface does not regain the tensile strength of primary corneal tissue.[1–3] This complication typically occurs in the early postoperative period, and the risk factors include premature suture removal, wound healing abnormalities, suddenly increased intraocular pressure, corneal edema, and trauma.[4–6] Delayed occurrence in the postoperative period is uncommon, and it typically occurs as a result of direct trauma or increased intraocular pressure due to glaucoma.[3–6]

Several studies have previously identified many risk factors for wound dehiscence (spontaneous or traumatic) after PK, such as age, preoperative indications, increased intraocular pressure, postoperative steroid use, and the timing of suture removal.[7–11] Intraocular tissues are more severely affected as the size of wound dehiscence increases.[2] This study is a description of the clinical features of corneal wound dehiscence due to blunt trauma after PK and factors that can affect wound dehiscence and the outcomes.

MATERIALS AND METHODS This retrospective, non-comparative study was approved by the human research ethics committee at Ankara Training

Cite this article as: Şingar Özdemir E, Burcu A, Yalnız Akkaya Z, Oral B, Örnek F. Wound dehiscence after penetrating keratoplasty. Ulus Travma Acil Cerrahi Derg 2018;24:563-568.

Address for correspondence: Evin Singar Özdemir, M.D. Sükriye Mah., Ulucanlara Cad., Ankara Eğitim ve Araştırma Hastanesi, Altındağ, 06340 Ankara, Turkey Tel: +90 312 - 595 34 91 E-mail: evinsingar@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(6):563-568 DOI: 10.5505/tjtes.2018.44450 Submitted: 19.03.2017 Accepted: 09.04.2018 Online: 10.04.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Singar Özdemir et al. Traumatic wound dehiscence after penetrating keratoplasty

and Research Hospital and it conformed to the principles of the Declaration of Helsinki (clinical trial number: 5308). The medical records of 1697 patients who underwent PK in the clinic between January 1, 1995 and December 31, 2015 were retrospectively screened. Patients who experienced wound dehiscence related to blunt ocular trauma after PK were included in this study. Patients who had wound dehiscence as a result of nontraumatic loosening or removal of sutures, penetrating injury, and those who did not experience wound dehiscence after trauma were excluded from the study.

Following the trauma, the wound was repaired under general anesthesia with interrupted or continuous 10/0 nylon sutures according to the state of the eye. Anterior vitrectomy, crystalline lens extraction, or iris repositioning was performed in the same or another session, as indicated.

Patients were assigned to 4 groups according to the size of the wound dehiscence: Group A comprised patients with a wound dehiscence ≤60°, Group B was made up of patients with a wound dehiscence of between 60° and 120°, Group C was composed of patients with a wound dehiscence between 120° and 180°, and patients with wound dehiscence >180° were included in Group D. Details of the patient’s age, sex, involved eye, reason for PK, suturing technique, type of trauma, the interval between keratoplasty and trauma, extent of the wound dehiscence, location of the dehiscence, presence of sutures and use of a topical steroid and cyclosporin A (CsA) at the time of trauma, repair surgery, resuturation or resuturation with other procedures), preoperative and postoperative best corrected visual acuity (BCVA), and graft clarity were recorded. Graft clarity was based on the transparency of the central part of the graft. The graft was also accepted as transparent if astigmatism secondary to the peripheral scar of the graft could be corrected with glasses or contact lenses and the scar did not progress to the pupillary area.

SPSS for Windows, Version 16.0. (SPSS Inc., Chicago, IL, USA) software was used to perform statistical analyses using frequency tables, descriptive tables, Pearson’s chi-squared, ttests and one-way analysis of variance. A value of p<0.05 was accepted as statistically significant.

RESULTS This study included 39 eyes of 39 patients who experienced blunt trauma after undergoing PK. The demographic features of the patients are shown in Table 1. The technique used was a running suture in 31 traumatized eyes (79.5%) and an interrupted PK suture in 8 eyes (20.5%). The sutures were still present in 24 (61.5%) cases, and in 19 of those patients the suture opened at the time of trauma. In all, 23 patients were using topical steroids (59%) and 14 were using a topical CsA (Restasis; Allergan, Inc., Irvine, CA, USA) (35.9%) at the 564

time of the trauma. Topical medication was in use to control increased intraocular pressure before the trauma in 2 cases (5.1%). The most frequent site of wound dehiscence was the temporal region, seen in 12 cases (30.8%), as illustrated in Table 2.

The factors affecting wound dehiscence size are shown in Table 2. The size of the wound dehiscence was not significantly correlated to age (p=0.89), PK indication (p=0.15), trauma etiology (p=0.11), time to trauma after PK (p=0.83), PK suture technique (p=0.83), increased intraocular pressure after PK (p=0.56), presence of sutures at the time of trauma (p=0.67), or the use of a topical steroid (p=0.63) or topical CsA (p=0.38). Wound dehiscence of less than 120° was more common in females, while wound dehiscence of more than 120° was significantly more common in male paTable 1. The demographic features of the patients Characteristics Gender (female/male) Age (years), Mean±SD (range)

Lateralization (right/left eye), n (%)

16/23 42.66±16.66 (14–75) 21/18

Indication for PK

Keratoconus

Corneal scar secondary to perforating

eye injury

6 (15.4)

Corneal scar due to herpetic keratitis

5 (12.8)

Nonspecific corneal leucoma

5 (12.8)

Bullous keratopathy

3 (7.7)

Corneal descemetocele

2 (5.1)

Corneal dystrophy

2 (5.1)

Corneal perforation (secondary to dry

eye and buphthalmos)

Time between PK and trauma (months), Mean±SD (range) Follow-up time after repair (months), Mean±SD, (range)

14 (35.9)

2 (5.1) 25.91±47.24 (0.30–240) 34.43±51.02 (12–244)

Trauma incidence according to time after PK

≤1 month

2 (5.1%)

1–6 months

8 (20.5%)

6–12 months

13 (33.3%)

12–24 months

8 (20.5%)

24–60 months

4 (10.3%)

>60 months

4 (10.3%)

The size of wound dehiscence (degrees), Mean±SD (range)

149.86±80.96° (30°–360°)

PK: Penetrating keratoplasty; SD: Standard deviation.

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Table 2. Factors affecting traumatic wound dehiscence after penetrating keratoplasty

Wound dehiscence size

p

<60° (n=6)

≥60°–<120° (n=13)

≥120°–<180° (n=11)

≤180°(n=9)

Mean age (years)

45.16±11.07

44.53±20.81

41.45±18.00

39.77±12.9

0.89

5/1

7/6

3/8

1/8

0.023

Gender (female/male)

Indication for PK Keratoconus

2

6

4

2

Other

4

7

7

7

Etiology of trauma

Manual blunt trauma

2

6

3

1

Blunt object

4

4

7

6

Fall

–

3

1

–

–

–

–

2

Traffic accident (in-vehicle)

Time interval between PK and trauma

≥12 months

5

7

6

5

<12 months

1

6

5

4

Wound dehiscence site Superior

–

1

1

1

Inferior

3

–

3

3

Nasal

–

1

2

3

Temporal

–

5

5

2

Inferotemporal

1

2

–

–

Superotemporal

1

–

–

–

Inferonasal

–

4

–

–

Superonasal

1

–

–

–

5/1

10/3

8/3

0.15

0.11

0.83

0.031

PK suture technique Continuous/interrupted

8/1

0.83

Increased intraocular pressure after PK

–

–

1

1

0.56

Presence of sutures at the time of trauma

5

8

6

5

0.67

Topical steroids use

5

7

6

5

0.63

Topical CsA use

2

5

2

5

0.38

PK: Penetrating keratoplasty; CsA: Cyclosporin A.

tients (p=0.023). There was a significant correlation between wound dehiscence size and the quadrant affected by trauma (p=0.031). Wound dehiscence of 60° or less was most common in the inferior quadrant, dehiscence of 60° to 180° was most common in the temporal quadrant, and wound dehiscence of more than 180° was most common in the inferior and nasal quadrants.

The complications occurring during and after surgery and graft survival are provided in Table 3. As the size of the wound dehiscence size increased, lens injury (p=0.028) and posterior segment injuries (p=0.017) became more common. Posterior segment complications did not occur at less than 120° and were more common in wounds that were 120° or greater. Repeat keratoplasty due to tissue loss was performed during the Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

repair for 2 patients. Evisceration was performed in 5 cases (3 as a primary treatment and due to endophthalmitis in 2).

Corneal clarity was established in 24 (61.5%) eyes at the last visit. Graft failure occurred due to irreversible graft rejection (n=4), endothelial cell loss (n=6), and traumatic endophthalmitis (n=2). Among all of the evaluated parameters, only wound size (p=0.04) and posterior segment injuries (p=0.008) significantly affected the rate of graft survival.

The mean logMAR BCVA was 2.08±0.82 before PK, 1.15± 0.83 at the last visit before the trauma, and 1.25±1.12 at the final visit after the trauma. In the current study, the mean BCVA at the last visit following the trauma was statistically better than the mean BCVA before keratoplasty 565

Singar Özdemir et al. Traumatic wound dehiscence after penetrating keratoplasty

Table 3. The size of trauma-induced wound dehiscence complications during and after surgery graft survival

Wound dehiscence size

<60° (n=6)

≥60°–<120° (n=13)

≥120°–<180° (n=11)

p ≤180°(n=9)

Anterior segment complications Hyphema

1

–

1

2

Iris prolapse

1

2

3

5

Lens damage and vitreous prolapse

1

2

6

7

Posterior segment complications

Vitreous hemorrhage

–

–

2

1

Choroidal detachment

–

–

1

–

Retinal detachment

–

–

–

2

Graft survival

Graft transparency

4

10

9

Graft failure

2

3

2* 6**

0.001

0.017

0.041

3

*The number of patients who underwent evisceration as primary treatment.

(p=0.003), but worse than the mean BCVA before the trauma (p=0.048).

DISCUSSION In this study, we examined factors that could affect the size of wound dehiscence and the clinical features and outcomes of 39 PK patients who had blunt trauma-related wound dehiscence. During the 20-year period, the incidence of traumatic wound dehiscence following PK was approximately 2.3% (39/1697), similar to the previously reported incidence rate of 0.6% to 5.8%.[2,10,12–15] Although it is unknown just when a wound site regains original strength after PK, it has been reported that the strength of a post-PK cornea reaches 50% of the strength of a normal intact cornea by the 100th day, and 70% by the 6th month.[12] Thus, the same trauma mechanism may lead to different consequences due to the time elapsed since the PK procedure and other factors affecting wound healing, such as advanced age, the indication for PK, the PK suture technique, premature suture removal, prolonged topical steroid use, topical CsA use, or the presence of glaucoma.[1–13,16–20] Proper wound apposition is most important for wound strength in the early period after PK; factors influencing wound healing and apposition become prominent at later stages. Although previous studies have reported that wound dehiscence at the graft site developed between 3 days and 33 years after PK surgery,[3,13] most traumatic wound ruptures occur within the first year, with the first 1 month and the interval after suture removal being the most risky periods.[13,15] In our study, most of the traumatic ruptures occurred during the first year (58.9%), especially between 6 and 12 months after PK (33.3%).

566

Our study demonstrated that in women, wound dehiscence of less than 120° was significantly more common, while a dehiscence of greater than 120° was more frequently seen in men (p=0.023). We attributed this finding to a quick return to daily activities (particularly outdoor activities) before complete wound healing due to rapid visual recovery, particularly in young male patients.

Long-term topical steroid use may delay wound healing.

[3,9,10,21] There are several studies in which topical CsA did not delay corneal wound healing.[19,22] In the present study, 59% of the patients had a history of topical steroid use and 35.9% had used topical CsA. Kartal et al.[23] did not find a correlation between traumatic wound dehiscence size and steroid use. Similarly, we found no such association for either topical steroids or CsA (p=0.63, p=0.38). We attributed the absence of this relationship to the presence of sutures at the wound site during the first year when the use of topical steroids is greatest.

It has been reported that corneal sutures are important for establishing the continuity of the graft-host junction, even years later.[13] Lam et al.[13] reported that a larger dehiscence and a graft without sutures in place at the time of trauma was more likely to fail, had more posterior segment damage, and a poorer visual outcome. The risk of traumatic corneal graft rupture is significant and is associated with a poor visual outcome. Kawashima et al.[18] reported that globe rupture occurred despite the presence of sutures (51.2%), and that no significant relationship was found between the presence or absence of sutures and the occurrence of wound dehiscence.

In our study, sutures were present in 61.5% of the patients and suture presence did not appear to influence wound dehiscence size (p=0.83).

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Singar Özdemir et al. Traumatic wound dehiscence after penetrating keratoplasty

Previous studies have demonstrated that wound dehiscence occurred most frequently at the graft-host junction.[23,24] It has been reported that wound dehiscence is more common in the inferior half of the cornea due to the lack of protection from the eyebrow, nose, and cheek.[3] In our study, all of the instances of traumatic wound dehiscence occurred at the graft-host junction, and the most commonly involved quadrants, in descending order of frequency, were the temporal, lower, nasal, and upper quadrants. Dehiscence observed at the quadrant of trauma was attributed to impaired endurance of the wound site following PK even years later. There was a significant correlation between dehiscence size and the trauma quadrant (p=0.03). As the size of the dehiscence increased, it was more commonly observed in the nasal and upper quadrants, where dehiscence is usually less visible due to the protective effect of the surrounding bony structures.

We attributed this finding to a lower mean age and a greater male-to-female ratio, as males are typically exposed to more serious episodes of trauma.

In our study, graft transparency was achieved in 24 of 39 patients (61.5%), and this ratio is consistent with the literature (range: 20%–100%).[1,8,9] In eyes exposed to trauma after PK, the degree of endothelial injury depends on the direct effects of the trauma, lens injury, vitreous loss, wound size, and timing of the repair.[11,13,25] It was determined that wound dehiscence size (p=0.04) and the development of posterior segment complications at the time of trauma (p=0.008) significantly affected graft transparency. Lam et al.[13] reported that graft transparency could not be achieved in any of the patients with a wound dehiscence of 180° or more. Tran et al.[16] demonstrated that extensive dehiscence was more prevalent in patients with injury to the lens and to the posterior segment. We found that with a greater dehiscence size and with posterior segment involvement, the achievement of graft transparency was reduced. We attributed this finding to a greater prevalence of lens and posterior segment complications with resultant cell loss as wound dehiscence size increased.

Trauma severity and graft survival, and posterior segment complications have been reported to be the major factors determining BCVA.[1,2,4,7,13,23] A significant difference was found in the BCVA values of the 4 groups after the trauma as lens injury (p=0.028) and posterior segment complications (p=0.028) became more prevalent and graft survival was reduced (p=0.04) with increasing wound dehiscence.

As there are many factors that may affect wound apposition, the time required for wound endurance to return to normal is different in every patient. Wound dehiscence size and outcomes vary. We found that most traumatic ruptures occurred during the first year after PK. We did not find a specific factor affecting the size of wound dehiscence except male sex. As the size of the wound dehiscence increased, it was more commonly seen in the nasal and upper quadUlus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

rants, the incidence of posterior segment complications was greater, and graft survival was reduced. Patients who will undergo PK should be warned about measures to prevent eye trauma, and protective surgeries (lamellar surgery) should be performed when possible in order to achieve better globe integrity.

Acknowledgement Financial support: The authors declare that they did not receive a specific grant from any funding agency in the public, commercial, or not-for-public sectors for this research.

Conflict of interest: None declared.

REFERENCES 1. Foroutan AR, Gheibi GH, Joshaghani M, Ahadian A, Foroutan P. Traumatic wound dehiscence and lens extrusion after penetrating keratoplasty. Cornea 2009;28:1097–9.

2. Murata N, Yokogawa H, Kobayashi A, Yamazaki N, Sugiyama K. Clinical features of single and repeated globe rupture after penetrating keratoplasty. Clin Ophthalmol 2013;7:461–5.

3. Das S, Whiting M, Taylor HR. Corneal wound dehiscence after penetrating keratoplasty. Cornea 2007;26:526–9.

4. Pettinelli DJ, Starr CE, Stark WJ. Late traumatic corneal wound dehiscence after penetrating keratoplasty. Arch Ophthalmol 2005;123:853–6.

5. Binder PS, Abel R Jr, Polack FM, Kaufman HE. Keratoplasty wound separations. Am J Ophthalmol 1975;80:109–15.

6. Friedman AH. Late traumatic wound rupture following successful partial penetrating keratoplasty. Am J Ophthalmol 1973;75:117–20.

7. Williams MA, Gawley SD, Jackson AJ, Frazer DG. Traumatic graft dehiscence after penetrating keratoplasty. Ophthalmology 2008;115:276– 8.

8. Rohrbach JM, Weidle EG, Steuhl KP, Meilinger S, Pleyer U. Traumatic wound dehiscence after penetrating keratoplasty. Acta Ophthalmol Scand 1996;74:501–5.

9. Topping TM, Stark WJ, Maumenee E, Kenyon KR. Traumatic wound dehiscence following penetrating keratoplasty. Br J Ophthalmol 1982;66:174–8.

10. Agrawal V, Wagh M, Krishnamachary M, Rao GN, Gupta S. Traumatic wound dehiscence after penetrating keratoplasty. Cornea 1995;14:601– 3.

11. Tseng SH, Lin SC, Chen FK. Traumatic wound dehiscence after penetrating keratoplasty: clinical features and outcome in 21 cases. Cornea 1999;18:553–8.

12. Rehany U, Rumelt S. Ocular trauma following penetrating keratoplasty: incidence, outcome, and postoperative recommendations. Arch Ophthalmol 1998;116:1282–6.

13. Lam FC, Rahman MQ, Ramaesh K. Traumatic wound dehiscence after penetrating keratoplasty-a cause for concern. Eye (Lond) 2007;21:1146– 50.

14. Schlote T, Rohrbach M. Traumatic glaucoma-a survey [Article in German]. Klin Monatsbl Augenheilkd 2005;222:772–82.

15. Elder MJ, Stack RR. Globe rupture following penetrating keratoplasty: how often, why, and what can we do to prevent it? Cornea 2004;23:776– 80.

16. Tran TH, Ellies P, Azan F, Assaraf E, Renard G. Traumatic globe rupture following penetrating keratoplasty. Graefes Arch Clin Exp Ophthalmol

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17. Steinberg J, Eddy MT, Katz T, Fricke OH, Richard G, Linke SJ. Traumatic wound dehiscence after penetrating keratoplasty: case series and literature review. Eur J Ophthalmol 2012;22:335–41.

2005;243:525–30.

22. Liang H, Baudouin C, Daull P, Garrigue JS, Brignole-Baudouin F. Ocular safety of cationic emulsion of cyclosporine in an in vitro corneal woundhealing model and an acute in vivo rabbit model. Mol Vis 2012;18:2195– 204.

18. Kawashima M, Kawakita T, Shimmura S, Tsubota K, Shimazaki J. Characteristics of traumatic globe rupture after keratoplasty. Ophthalmology 2009;116:2072–6.

23. Kartal B, Kandemir B, Set T, Kuğu S, Keleş S, Ceylan E, Akmaz B, Apil A, Ozertürk Y. Traumatic wound dehiscence after penetrating keratoplasty. Ulus Travma Acil Cerrahi Derg 2014;20:181–8.

19. Filipec M, Phan TM, Zhao TZ, Rice BA, Merchant A, Foster CS. Topical cyclosporine A and corneal wound healing. Cornea 1992;11:546–52.

24. Hiratsuka Y, Sasaki S, Nakatani S, Murakami A. Traumatic wound dehiscence after penetrating keratoplasty. Jpn J Ophthalmol 2007;51:146– 7.

20. Gasset AR, Dohlman CH. The tensile strength of corneal wounds. Arch Ophthalmol 1968;79:595–602.

21. Nagra PK, Hammersmith KM, Rapuano CJ, Laibson PR, Cohen EJ. Wound dehiscence after penetrating keratoplasty. Cornea 2006;25:132–5.

25. Watson AP, Simcock PR, Ridgway AE. Endothelial cell loss due to repeated traumatic wound dehiscence after penetrating keratoplasty.

Cornea1987;6:216–8.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Penetran keratoplasti sonrası travmatik yara yeri ayrılması Dr. Evin Şingar Özdemir,1 Dr. Ayşe Burcu,1 Dr. Züleyha Yalnız Akkaya,1 Dr. Barış Oral,2 Dr. Firdevs Örnek1 1 2

Ankara Eğitim ve Araştırma Hastanesi, Göz Hastalıkları Kliniği, Ankara Ağrı Devlet Hastanesi, Göz Hastalıkları Kliniği, Ağrı

AMAÇ: Çalışmamızda, penetran keratoplasti (PK) sonrası künt travmaya bağlı yara açılmasını etkileyen faktörleri ve klinik sonuçları araştırmak amaçlanmıştır.

GEREÇ VE YÖNTEM: 1995–2015 tarihleri arasında PK sonrası künt travmaya bağlı yara açması gelişen olgular geriye dönük olarak tarandı. Travma insidansı ve etiyolojisi, keratoplasti ve glob rüptürü arasındaki zaman, greft durumu, en iyi düzeltilmiş görme keskinliği (EDGK), komplikasyonlar, ikincil ameliyatlar ve yaralanma boyutunu etkileyebilecek faktörler kaydedildi.

BULGULAR: Çalışmaya yaş ortalaması 42.66±16.66 yıl olan, 23’ü erkek, 16’sı kadın, toplam 39 hasta dahil edildi. Yara yeri açılma insidansı %2.3 idi. Penetran keratoplasti ve travmatik yara yeri açılması arasındaki ortalama süre 25.91±47.24 ay, ortalama takip süresi 34.43±51.02 ay idi. En yaygın travma mekanizmasının künt bir nesnenin çarpması (%53.8), en sık yara yeri ayrılmasının görüldüğü kadranın temporal (%30.8) idi ve yara yeri ayrılma büyüklüğünün 45° ile 270° arasında olduğu saptandı. Hastalar yara yeri ayrılma büyüklüğüne göre dört gruba ayrıldı; yara yeri ayrılma büyüklüğü arttıkça, erkek cinsiyete daha sık rastlandığı, nazal ve üst kadranlarda yara yeri ayrılmasının daha sık görüldüğü, lens hasarının, arka segment komplikasyonlarının daha sık ve greft şeffaflığının daha düşük oranda sağlandığı izlendi.

TARTIŞMA: Penetran keratoplasti sonrası ortaya çıkan travmatik yara yeri ayrılması nadir görülen ancak ömür boyu karşılaşılabilecek bir komplikasyondur. Göz kaybı gibi ciddi sonuçlar doğurduğundan, hastalar yara yeri ayrılma riskleri ve sekelleri açısından bilgilendirilmelidir.

Anahtar sözcükler: Penetran keratoplasti; travma; yara yeri ayrılması.

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doi: 10.5505/tjtes.2018.44450

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ORIG I N A L A R T IC L E

The effectiveness of non-operative treatment in high-grade liver and spleen injury in children Kıvılcım Karadeniz Cerit, M.D.,1 Rabia Ergelen, M.D.,2 Tural Abdullayev, M.D.,1 Halil Tuğtepe, M.D.,1 Tolga Emrullah Dağlı, M.D.,1 Gürsu Kıyan, M.D.1 1

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

2

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

ABSTRACT BACKGROUND: Although a nonoperative treatment approach is preferred for blunt liver and spleen trauma in childhood, there are significant differences between clinics in the algorithms used. The approach to high-grade liver and spleen injury is still controversial, particularly as grade V liver and spleen injuries are not included in the American Pediatric Surgical Association guideline. The aim of this study was to present experience with a non-operative treatment approach to children with high-grade liver and spleen injuries.

METHODS: Pediatric patients who were referred to Marmara University Hospital’s emergency department between January 2012 and January 2017 due to liver and spleen injury related to blunt abdominal trauma and who were followed up in the clinic were included in the study. The data were analyzed retrospectively in terms of age, sex, type of trauma, degree of organ damage, accompanying organ damage, duration of intensive care unit (ICU) and hospital stay, need for transfusion, and treatment method (operative-nonoperative).

Grade I, II, or III organ damage was classified as low-grade, while grade IV and V organ lesions were classified as high-grade.

RESULTS: Of 2800 patients who were diagnosed by radiological imaging with liver and spleen injuries due to blunt abdominal trauma and hospitalized in the clinic, 88 were included in the study. Isolated liver injury was determined in 41 patients, while 39 had an isolated spleen injury, and 8 had injuries to both organs. An accompanying organ injury was observed in 30 (34%) patients. In all, 83 (94%) patients underwent non-operative treatment and a surgical approach was required for 5 patients (6%). Patients with high-grade liver injury had a significantly longer period of hospitalization, duration of ICU stay, and greater transfusion requirement, compared with patients with low-grade liver injury (p=0.001, 0.001, and <0.001, respectively). A surgical approach was more common among patients with a highgrade liver injury than for patients with a low-grade injury (p=0.045). There was no significant difference between patients with a high- or low-grade spleen injury in terms of age, sex, duration of hospitalization, duration of ICU stay, transfusion requirement, or accompanying organ injury (p=0.254, 0.739, 0.114, 0.135, 0.057, 0.721, respectively). Similarly, there was no significant difference in terms of non-surgical or surgical treatment approach between the patients with high-grade spleen injury and those with low-grade spleen injury (p=0.488).

CONCLUSION: Non-operative treatment is a feasible treatment method in pediatric patients with a high-grade blunt liver or spleen injury. Nonetheless, pediatric surgeons should bear in mind that patients with high-grade liver damage may require more surgical treatment.

Keywords: Blunt abdominal trauma; liver injury; non-operative management; pediatric trauma; spleen injury.

INTRODUCTION Despite the improvements and success in measures undertaken for child safety, trauma is still an important cause of

mortality and morbidity during childhood.[1] Although the main cause of death is head trauma in this population, abdominal injuries also affect 10% to 15% of children experiencing medical trauma.[2]

Cite this article as: Karadeniz Cerit K, Ergelen R, Abdullayev T, Tuğtepe H, Dağlı TE, Kıyan G. The effectiveness of non-operative treatment in high-grade liver and spleen injury in children. Ulus Travma Acil Cerrahi Derg 2018;24:569-574.

Address for correspondence: Kıvılcım Karadeniz Cerit, M.D. Fevzi Çakmak Mah., Mimar Sinan Cad., No: 41, Üst Kaynarca, Pendik, İstanbul, Turkey Tel: +90 216 - 421 22 22 E-mail: kcerit@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(6):569-574 DOI: 10.5505/tjtes.2018.83573 Submitted: 01.11.2017 Accepted: 16.01.2018 Online: 17.01.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Pediatric surgeons have pioneered non-operative management techniques for blunt solid organ injury, and conservative treatment has become the standardized approach in hemodynamically stable patients. Several studies have shown that the rate of surgery performed significantly decreased when pediatric surgeons participated in the evaluation of childhood trauma cases.[3] Non-operative management approaches to blunt liver and spleen trauma in childhood have become preferable; however, there are significant differences between clinics in the algorithms used. Although there are many publications related to non-operative approaches to childhood liver and spleen trauma overall, there are only a few discussing the success of non-operative management in patients with severe liver and spleen injury (Grade IV-V).

week of follow-up in the hospital setting, potential discharge is assessed using repeat ultrasonography. Patients who had a splenectomy were recommended to follow a vaccination schedule (meningococcal and pneumococcal vaccination and penicillin prophylaxis).

Statistical Analysis

The aim of the present study was to present experience with a non-operative management approach to young patients with high-grade blunt liver and spleen injuries.

Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 20.0 software (IBM Corp., Armonk, NY, USA). Descriptive statistics were expressed as mean±SD for continuous variables and as numbers and percentages for categorical variables. According to the distribution of the variables, an independent samples t-test or the Mann-Whitney U test was used to compare continuous variables. A chisquare test was used to compare categorical variables. An exact test, Pearson’s chi-square, Yates correction, and Fisher’s exact test were used, as appropriate. A p value of <0.05 was considered statistically significant.

MATERIALS AND METHODS

RESULTS

Pediatric patients who were admitted to the emergency department and followed up in the clinic due to a blunt abdominal trauma-induced liver and spleen injuries between January 2012 and January 2017 were included in this study. Data related to age, sex, trauma type, degree of organ injury, associated organ injury, length of intensive care unit (ICU) stay and hospitalization, transfusion requirement, and treatment method (operative vs non-operative) were retrieved from the hospital database and retrospectively analyzed. Grade I, II, and III organ injuries were classified as low-grade, while Grade IV and V organ injuries were classified as high-grade.

A written informed consent was obtained for each patient.

The present study was approved by the Ethics Committee (09.2017.284) and conducted in accordance with the principles of the Declaration of Helsinki.

A total of 2,800 general trauma patients who were admitted to the emergency department of Marmara University Hospital during the study period, and 960 patients had an abdominal trauma. Of these, 88 patients who had liver and spleen injuries due to blunt abdominal trauma as assessed with imag-

A physical examination, evaluation of hemodynamics according to cardiac and saturation monitoring, measurement of hemoglobin and biochemical values as part of the laboratory parameters assessed, and computerized tomography (CT) imaging constitute the initial steps as routine practice in the emergency setting at the hospital. The CT scans used for organ injury grading were performed by a single radiologist (RE) using the classification of the American Association for the Surgery of Trauma. After the initial evaluation, the patients were taken to the ICU or ward, depending on their hemodynamic status. Patients with massive hemorrhage (requiring blood transfusion >40 mL/kg), and those whose hemodynamic findings did not recover despite fluid and blood transfusion support underwent urgent surgery. A non-operative management decision may be made for patients who are hemodynamically stable after fluid and blood transfusion support. Non-operative management involves close followup of the hemodynamic findings of patient and measurement of hemoglobin values every 4 hours until stabilization. After 1 570

Table 1. Clinical variables of the patients Age (months, mean±SD)

105.90±57.75

Sex, n (%)

Male

61 (69)

Female

27 (31)

Type of trauma, n (%)

Falling from a height

47 (53)

In-car traffic accident

26 (30)

Pedestrian traffic accident

Bicycle/motorcycle accident

4 (5) 11 (12)

Type and degree of injury (n)

Liver (Low-grade/high-grade)

29/17

Spleen (Low-grade/high-grade)

21/21

Treatment, n (%)

Non-operative

Operative

Length of hospitalization (days, mean±SD)

83 (94) 5 (6) 10.42±9.53

Duration of intensive care unit stay (days, mean±SD)

2.85±5.68

Blood transfusion requirement, n (%)

Yes

33 (37)

No

55 (63)

Numbers after the decimal point were rounded off in percentages.

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Karadeniz Cerit et al. The effectiveness of non-operative treatment in high-grade liver and spleen injury in children

(a)

(b)

(c)

Figure 1. (a) Linear hypodense intraparenchymal grade III laceration with perihepatic fluid and splenic grade V laceration, active bleeding, and perisplenic fluid as seen on a contrast-enhanced axial computed tomography image. (b) Coronal contrast-enhanced computed tomography image revealing a large subscapcular hematoma and active intraparenchymal bleeding, a grade V liver injury. (c) Deep lacerations consistent with a grade IV splenic injury seen on an axial contrast-enhanced computed tomography image.

performed due to Grade V liver injury in 2 patients. Another patient with Grade V hepatic injury for whom non-operative management was initiated was treated with drainage due to the development of a biloma. Among 2 (2.3%) non-survivors, 1 died in the emergency department due to Grade V liver injury before the operation, while the other patient, also with Grade V liver injury, died due to disseminated intravascular coagulation after packing was performed. Pleural effusion developed as a complication in 2 patients with Grade V spleen injury, which was treated with chest tube drainage. In 1 of the patients with Grade V spleen injury who underwent a splenectomy, hemothorax developed and a thoracoscopy was performed, as the lung had not expanded after the insertion of the chest tube.

ing studies and who were hospitalized were included in the study. The clinical data of the patients included in the study are presented in Table 1.

Isolated liver injury was observed in 41 patients, isolated spleen injury in 39 patients, and injury in both organs in 8 patients. The patients with injury in both organs were added to the group reflecting the organ with a greater degree of injury (Fig. 1a). A total of 29 high-grade liver injuries (Fig. 1b) and 17 low-grade liver injuries were observed. A total of 21 highgrade spleen injuries (Fig. 1c) and 21 low-grade spleen injuries were recorded. In 34% (n=30) of the patients, an associated organ injury was present. Thoracic injury was present in 21 (23.9%) patients, cranial injury in 1 (1%) patient, orthopedic injury in 1 (1%) patient, kidney injury in 1 (1%) patient, and multi-organ injury in 6 (6.8%) patients.

A comparison of the clinical data for high- and low-grade liver injuries is shown in Table 2. There was no significant difference between the patients with high-grade liver injury and those with low-grade liver injury in terms of age, sex, or associated organ injuries (p=0.135, p=0.149 and p=0.800, respectively). However, among the patients with high-grade

Non-operative management was pursued in 83 patients (94%), and surgery was indicated in 5 (6%) patients. Among the patients requiring surgery, a splenectomy was performed due to Grade V spleen injury in 2 cases, and packing was

Table 2. Comparison of clinical variables between high- and low-grade liver injuries Liver injuries

High-grade (n=17)

Low-grade (n=29)

p

Age (months)

101.29±58.80

75.51±41.25

=0.135

14/3

18/11

=0.149

Length of hospitalization (days)

Male/female ratio

12.82±8.45

6.27±3.04

=0.001

Intensive care unit stay (days)

5.11±7.02

1.10±1.34

=0.001

Transfusion requirement (yes/no)

12/5

5/24

<0.001

Associated organ injuries (yes/no)

6/9

9/16

=0.800

Treatment approach Conservative

14

29

Surgery

3

0

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=0.045

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Karadeniz Cerit et al. The effectiveness of non-operative treatment in high-grade liver and spleen injury in children

Table 3. Comparison of clinical variables between high- and low-grade spleen injuries Spleen injuries

Age (months) Male/female ratio Length of hospitalization (days) Intensive care unit stay (days)

High-grade (n=21)

Low-grade (n=21)

p

118.42±62.73

139.09±52.43

=0.254

15/6

14/7

=0.739

14.66±14.90

9.95±7.35

=0.114

4.66±8.96

1.61±2.06

=0.135

Transfusion requirement (yes/no)

11/10

5/16

=0.057

Associated organ injuries (yes/no)

5/14

6/13

=0.721

19

21

=0.488

2

0

Treatment approach

Conservative

Surgery

liver injury, the length of hospitalization, the duration of ICU stay, and the transfusion requirement were significantly higher than in patients with low-grade liver injury (p=0.001, p=0.001, and p<0.001, respectively). In addition, the patients with high-grade liver injury underwent more surgical interventions than those with low-grade liver injury (p=0.045).

A comparison of the clinical data for the high- and low-grade spleen injuries is shown in Table 3. There was no significant difference between the high- and low-grade spleen injury groups in terms of age, sex, length of hospitalization, duration of ICU stay, transfusion requirement, or associated organ injuries (p=0.254, p=0.739, p=0.114, p=0.135, p=0.057, and p=0.721, respectively). Similarly, there was no significant difference in terms of non-surgical or surgical treatment approach between the patients with high-grade spleen injury and those with low-grade spleen injury (p=0.488).

DISCUSSION In cases of blunt trauma to the liver and spleen, non-operative management has become an effective treatment approach with low mortality. Repeated clinical evaluations supported by radiological imaging and laboratory analysis constitute the basis of non-operative management, thus preventing unnecessary surgical interventions.[4] The trauma committee of the American Pediatric Surgical Association (APSA) developed guidelines to eliminate differences in the approach to patients with isolated blunt trauma to the liver and spleen and to establish standardization in the approach to these patients.[5,6] In these guidelines, only Grade IV patients are admitted to the ICU, and the length of hospitalization is calculated by adding 1 day to the determination based on the degree of organ injury as assessed by CT. The fact that the transfusion rate was 2% to 10% and the operation rate less than 3% supported patients with Grade I-III injuries not being followed-up in the ICU. Significant differences were observed in transfusion and operation rates between Grade III-IV patients, suggesting an increase in the clinical severity of those patients.[5] 572

However, since the APSA guideline does not include Grade V blunt liver and spleen injury, the approach to these patients is still controversial.[5,6] St. Peter et al.[7] established a prospective protocol with a shortened hospitalization period and included the category of Grade V blunt liver and spleen injury.

The data of patients with Grade I-V liver and spleen injuries were analyzed retrospectively. Grade I-II patients were hospitalized for 1 night, while higher grades were hospitalized for 2 nights. After 2 days of hospitalization, they observed that none of the patients without clinical evidence of hemorrhage required surgery. St. Peter et al.[8,9] also presented 2 prospective studies to evaluate the reliability and efficacy of the protocol that they established reducing the length of hospitalization. One night of hospitalization was recommended for Grade I-II patients and 2 nights for those with a more severe classification.

Yang et al.[10] reported their experiences with a non-surgical approach to patients with Grade IV-V liver and spleen injuries.

The data revealed that patients with a high-grade liver injury had a significantly longer ICU stay and hospitalization period than those with a similar grade of spleen injury, and that the requirements for transfusion and radiological imaging, and hospital costs were also significantly higher. In our study, the length of hospitalization, the duration of ICU stay, and transfusion requirements were significantly higher for patients with a high-grade liver injury than for those with lowgrade liver injury. Though St. Peter et al.[8,9] recommended an abbreviated bed rest protocol regardless of injury grade, we think that ICU follow-up is important on the first day to perform non-operative management effectively and to correctly determine the timing of surgical intervention, particularly in patients with high-grade liver injury.

Landau et al.[11] presented 22 years of experience in the approach to blunt liver trauma. In the past, due to the belief that a significant liver injury could not heal itself, an aggressive approach and early surgical intervention was considered to be Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

Karadeniz Cerit et al. The effectiveness of non-operative treatment in high-grade liver and spleen injury in children

the best method. However, they observed that the mortality was high, due to both unnecessary surgeries and difficult surgical techniques. In our study, non-operative management in patients with a liver injury had a success rate of 93%. It was also found that patients with a high-grade liver injury underwent more surgical treatment than those with low-grade liver injury. Therefore, we recommend that it should be taken into account that surgical treatment may be needed more frequently in patients with high-grade liver injury, and that all of the preparations for surgery be completed within the first hour after admission while closely monitoring hemodynamic status.

Furthermore, Davies et al.[12] retrospectively analyzed cases of spleen trauma that were admitted to their clinics during 4 different multi-year time periods. They observed that the length of hospitalization and the rate of transfusion both declined steadily. In the past, these patients were followed-up in the hospital for at least 5 days. Since the implementation of the APSA guideline, the reported length of hospitalization is expected to continue to reflect a decline over the next few years. In our study, non-operative management was successful in 95% of patients with a spleen injury. In addition, there was no significant difference between high- and low-grade spleen injury patients in terms of the length of hospitalization or duration of ICU unit stay, transfusion requirement, or non-operative or operative treatment approach. It can be concluded that the abbreviated bed rest protocol can be implemented more safely in patients with spleen trauma.

Nance et al.[13] analyzed patients defined as having solid organ injury according to the national trauma database from a 12year period. The mean time to surgery was 2.4 hours. For 61.7% of the patients, surgical intervention was performed within the first 3 hours, for 79.4% it was within the first 6 hours, and for 89.7% it occurred within the first 24 hours.

The rate of surgical intervention was highest in cases with spleen injury (8.7%), while it was 3.5% for patients with a liver injury and 3.0% for those with a kidney injury. According to the patient series, an abdominal operation was performed within the first 24 hours in 90% of the patients who required surgery. This study also indicated that the probability of nonoperative management failure is <10% in patients who do not require surgery within the first 24 hours. In our study, 4 patients with non-operative management failure who underwent surgery were taken into the operation in less than 3 hours. Surgery was not required after 24 hours for any of patients for whom non-operative management was applied.

This also supports the abbreviated bed rest protocol recommended by St. Peter, which suggests that 1 night of bed rest is sufficient for patients with a low-grade spleen or liver injury.

Tataria et al.[14] reviewed patients from a 10-year period who had been treated for blunt abdominal injury. They defined 2 groups: immediate surgery, performed for 58%; and failed non-operative management, which was initiated in 42%, and Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

due to failure of the treatment, led to surgery >3 hours after admission. The authors indicated that there was no significant difference between the groups in terms of mortality rate, duration of ICU stay, length of hospitalization or blood transfusion requirement. These results support the use of non-operative management as initial therapy in patients with blunt spleen and liver trauma. However, close follow-up of the hemodynamic findings of patients is important in this process.

The retrospective design and small sample size are the primary limitations of the present study. Although the power of this study is low due to the small number of patients, the limited number of publications in the literature about nonoperative management success in patients with high-grade (Grade IV-V) liver and spleen injury in childhood increases the value of our research.

Finally, it is important to inform family members of patients about proper bed rest at home in order to shorten the length of hospitalization and ICU stay. In addition to what we have learned from the APSA guidelines and recent studies, further prospective studies are needed in order to develop thorough recommendations that will reduce the length of ICU stay and hospitalization.

Conclusion In conclusion, non-operative management is a feasible method for the treatment of patients with high-grade blunt liver and spleen injury. Close follow-up of hemodynamic findings constitutes the basis of this treatment. The surgical approach is necessary in hemodynamically unstable patients; however, this probability decreases to 10% after 24 hours. Although the APSA guidelines recommend that the length of hospitalization should be determined according to the CT grade of the patient, the hemodynamic status of patients may be a more effective gauge of the length of hospitalization required.

Acknowledgements None Conflict of interest: None declared.

REFERENCES 1. Falcone RA Jr, Brown RL, Garcia VF. The epidemiology of infant injuries and alarming health disparities. J Pediatr Surg 2007;42:172–7.

2. Gaines BA. Intra-abdominal solid organ injury in children: diagnosis and treatment. J Trauma 2009;67:135–9.

3. Stylianos S, Ford HR. Outcomes in pediatric trauma care. Semin Pediatr Surg 2008;17:110–5.

4. Raza M, Abbas Y, Devi V, Prasad KV, Rizk KN, Nair PP. Non operative management of abdominal trauma - a 10 years review. World J Emerg Surg 2013;8:14.

5. Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg 2000;35:164–9.

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Karadeniz Cerit et al. The effectiveness of non-operative treatment in high-grade liver and spleen injury in children 6. Stylianos S. Liver/Spleen Trauma Study Group. Compliance with evidence-based guidelines in children with isolated spleen or liver injury: A prospective study. J Pediatr Surg 2002;37:453–6.

7. St Peter SD, Keckler SJ, Spilde TL, Holcomb GW 3rd, Ostlie DJ. Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg 2008;43:191–4.

8. St Peter SD, Sharp SW, Synder CL, Sharp RJ, Andrews WS, Murphy JP et al. Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg 2011;46:173–7.

9. St Peter SD, Aguayo P, Juang D, Sharp SW, Synder CL, Holcomb GW 3rd, et al. Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg 2013;48:2437–41.

10. Yang JC, Sharp SW, Ostlie DJ, Holcomb GW 3rd, St Peter SD. Natural history of nonoperative management for grade 4 and 5 liver and spleen injuries in children. J Pediatr Surg 2008;43:2264–7.

11. Landau A, van As AB, Numanoglu A, Millar AJ, Rode H. Liver injuries in children: The role of selective non-operative management. Injury 2006;37:66–71.

12. Davies DA, Pearl RH, Ein SH, Langer JC, Wales PW. Management of blunt splenic injury in children: evolution of the nonoperative approach. J Pediatr Surg 2009;44:1005–8.

13. Nance ML, Holmes JH 4th, Wiebe DJ. Timeline to operative intervention for solid organ injuries in children. J Trauma 2006;61:1389–92.

14. Tataria M, Nance ML, Holmes JH 4th, Miller CC 3rd, Mattix KD, Brown RL et al. Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental. J Trauma 2007;63:608–14.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Yüksek dereceli karaciğer ve dalak hasarında nonoperatif tedavinin etkinliği Dr. Kıvılcım Karadeniz Cerit,1 Dr. Rabia Ergelen,2 Dr. Tural Abdullayev,1 Dr. Halil Tuğtepe,1 Dr. Tolga Emrullah Dağlı,1 Dr. Gürsu Kıyan1 1 2

Marmara Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, İstanbul Marmara Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, İstanbul

AMAÇ: Her ne kadar çocukluk çağında künt karaciğer ve dalak travmasında nonoperatif tedavi yaklaşımı tercih edilir olsa da, klinikler arasında kullanılan algoritmalarda ciddi farklılıklar bulunmaktadır. Amerikan Pediatrik Cerrahi Birliği (APSA) rehberinin grade V karaciğer ve dalak hasarını içermemesi ile birlikte, yüksek dereceli karaciğer ve dalak hasarına yaklaşım halen tartışmalıdır. Bu çalışmanın amacı; yüksek dereceli karaciğer ve dalak hasarı olan hastalara nonoperatif tedavi yaklaşımıyla ilgili tecrübelerimizi sunmaktır.

GEREÇ VE YÖNTEM: Ocak 2012–Ocak 2017 tarihleri arasında Marmara Üniversitesi Hastanesi Acil Servisine başvuran hastalardan künt karın travmasına bağlı karaciğer ve dalak hasarı nedeniyle kliniğimizde takip edilen hastalar çalışmaya alındı. Hastaların yaş, cinsiyet, travma şekli, organ hasarının derecesi, eşlik eden organ hasarı, yoğun bakımda ve hastanede kalış süresi, transfüzyon ihtiyacı olması, tedavi yöntemi (operatif-nonoperatif ) şeklinde olan verileri geriye dönük olarak analiz edildi. Grade I, II, III derece olan organ hasarları düşük dereceli olarak; grade IV, V olan organ hasarları ise yüksek dereceli olarak sınıflandırıldı.

BULGULAR: Acil servise başvuran 2800 çocuk travma olgusundan künt karın travmasına bağlı radyolojik görüntülemelerinde karaciğer ve dalak hasarı tespit edilip kliniğimizde yatırılan 88 hasta çalışmaya dahil edildi. Hastaların 41’inde izole karaciğer hasarı, 39’unda izole dalak hasarı, 8’inde ise her iki organda hasar izlendi. Her iki organda hasar izlenen hastalarda yüksek dereceli hasarı olan organ hangisiyse o gruba dahil edildi. Yüksek dereceli (29), düşük dereceli (17) karaciğer hasarı izlendi. Yüksek dereceli (21), düşük dereceli (21) dalak hasarı izlendi. Hastaların %34’ünde (30 hastada) eşlik eden organ hasarı izlendi. Nonoperatif tedavi 83 hastaya (%94) uygulanabildi; 5 hastaya (%6) ise cerrahi uygulanması gerekti. Yüksek dereceli karaciğer hasarı olan hastalarda düşük dereceli karaciğer hasarı olanlara göre, hastanede yatış süresi, yoğun bakım ünitesinde (YBÜ) yatış süresi ve transfüzyon ihtiyacı anlamlı ölçüde yüksek bulundu (sırasıyla p; 0.001, 0.001, <0.001’dir). Yüksek dereceli karaciğer hasarı olan hastalarda düşük dereceli karaciğer hasarı olanlara göre daha fazla cerrahi yaklaşım uygulandı (p=0.045). Yüksek ve düşük dereceli dalak yaralanmalarında her iki grup arasında yaş, cinsiyet, hastanede yatış süresi, YBÜ’de yatış süresi, transfüzyon ihtiyacı, eşlik eden organ hasarı açısından fark bulunmadı (sırasıyla p; 0.254, 0.739, 0.114, 0.135, 0.057, 0.721). Benzer şekilde yüksek dereceli dalak hasarı olanlarla düşük dereceli dalak hasarı olanlar arasında nonoperatif veya operatif tedavi yaklaşımı açısından da fark izlenmedi (p=0.488).

TARTIŞMA: Yüksek dereceli künt karaciğer ve dalak hasarı olan hastalarda nonoperatif tedavi uygulanabilir bir yöntemdir. Ancak yüksek dereceli karaciğer hasarı olanlarda düşük dereceli karaciğer hasarı olanlara göre cerrahi tedaviye daha fazla başvurulabileceği dikkate alınmalıdır.

Anahtar sözcükler: Dalak hasarı; karaciğer hasarı, künt batın travması; nonoperatif tedavi; pediatrik travma.

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doi: 10.5505/tjtes.2018.83573

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ORIG I N A L A R T IC L E

Is tranexamic acid safe and reliable during tibial intramedullary nailing?

Sefa Giray Batıbay, M.D.,1 İsmail Türkmen, M.D.,1 Sedat Duman, M.D.,1 Savaş Çamur, M.D.,1 Necdet Sağlam, M.D.,1 Sevilay Batıbay, M.D.2 1

Department of Orthopedics and Traumatology, Health Sciences University Ümraniye and Training and Research Hospital, İstanbul-Turkey

2

Department of Physical Medicine and Rehabilitation, Health Sciences University Haydarpaşa Numune Training and Research Hospital,

İstanbul-Turkey

ABSTRACT BACKGROUND: The aim of this study was to determine if the use of tranexamic acid (TXA) during intramedullary reaming treatment for tibial diaphyseal fractures was safe, reduced blood loss, or affected cost effectiveness.

METHODS: A total of 70 patients with a tibia diaphysis fracture were randomized into 2 groups and prospectively followed for data on blood loss, thrombosis, and fracture healing. Preoperative TXA was administered intravenously to Group A, and Group B served as the control group.

RESULTS: While there was no significant difference between the preoperative and postoperative 1-hour hemoglobin (Hb) and hematocrit (Hct) levels of the patients, there was a statistically significant difference in the comparison of the postoperative 24-hour and 48-hour Hb and Hct levels. There was no need for an allogenic blood transfusion to any patient in Group A; however, 2 patients in Group B each received 1 unit of erythrocyte suspension because their Hct values dropped below 27%. There was no deep vein thrombosis or embolism observed in any of the patients.

CONCLUSION: The application of intravenous TXA during the preoperative period in the treatment of tibial fractures with intramedullary nailing reduced the bleeding seen in the postoperative period. It did not lead to intravascular thrombosis in the postoperative period, and had no adverse effect on bone healing.

Keywords: Intramedullar nailing; tibia diaphyseal fracture; tranexamic acid.

INTRODUCTION Tranexamic acid (TXA) is a popular antifibrinolytic agent used by orthopedic surgeons.[1] Greater efficacy in arthroplasty procedures and reduced need for blood replacement in trauma patients are common surgical goals.[2] However, many questions about the use of TXA remain, including the effective dose, the dose interval, whether intravenous (IV) or intra-articular application is optimal, and whether the drug should be delivered in a bolus or perioperative infusion. Few relevant studies have been published in the literature.

Tibial diaphysis fractures are commonly seen in emergency departments. The treatments include plate fixation, the use of screws, intramedullary nailing (IMN), and the use of external fixators and plaster (conservative treatments). Currently, the most commonly used treatment options are fixation with IMN and plate fixation. Nails are superior to plates in terms of early loading.[3] Tibial fractures are often associated with hemorrhage, hematoma, and superficial/deep infections.[4] The objective of this study was to examine whether TXA could be used safely to treat patients with tibial diaphyseal fractures treated via

Cite this article as: Batıbay SG, Türkmen İ, Duman S, Çamur S, Sağlam N, Batıbay S. Is tranexamic acid safe and reliable during tibial intramedullary nailing? Ulus Travma Acil Cerrahi Derg 2018;24:575-580.

Address for correspondence: Sefa Giray Batıbay, M.D. Ümraniye Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul, Turkey Tel: +90 216 - 632 18 18 E-mail: sefabatibay@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):575-580 DOI: 10.5505/tjtes.2018.42147 Submitted: 28.10.2017 Accepted: 21.03.2018 Online: 12.09.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Batıbay et al. Is tranexamic acid safe and reliable during tibial intramedullary nailing?

IMN, and if it reduced blood loss and increased cost-effectiveness.

MATERIALS AND METHODS All of the study procedures met the ethical standards of the institutional and national research committees and all of the tenets of the 1964 Helsinki declaration and later amendments thereto, and/or comparable ethical standards. Written informed consent was obtained from all of the participants.

We did not use any animals in the present research. The study was approved by the ethics committee of Beykoz State Hospital (number: 177/C).

A total of 80 patients were enrolled. All were admitted to the emergency department with leg pain and were thought to have a tibial fracture based on a physical examination, had a tibial diaphysis fracture confirmed on X-ray, and agreed to participate in the study. Closed fractures were categorized using the AO/OTA Classification of Fractures and Dislocations system[5] and open fractures were classified using the Gustilo/Anderson system.[6] The inclusion criteria were: an isolated diaphyseal fracture displacing both the tibia and the fibula, fixation using the IMN system, use of a transtendinous approach, and an international normalized ratio of 0.8–1.2. The exclusion criteria were polytrauma, a need for open reduction, a need for additional orthopedic surgical intervention, a Gustilo/Anderson type 2 or 3 fracture, any contraindication for the use of TXA (chronic renal or liver failure), an American Society of Anesthesiologists score ≥4, and/or any cerebrovascular event. The 80 patients were randomly divided into 2 groups and followed up prospectively.

Nine patients (3 with multi-trauma, 3 with Gustilo/Anderson type 3b–c open fractures, 1 on acetylsalicylate medication, 1 with a pathological fracture, 1 with sickle-cell anemia, and 1 with incomplete follow-up) were excluded. One patient was also lost to follow-up. In all, 70 patients were included in the study. Randomization to TXA treatment was performed with a sealed envelope, which was opened in the operating room before the skin incision was made. After the operation, all of the assessments were performed by 2 orthopedic residents blinded to TXA injection status.

Two orthopedic surgeons (SGB and SC) performed all of the surgeries with the patients under spinal anesthesia and without a tourniquet. TXA (10 mg/kg IV bolus) was administered to group A patients 30 minutes before the surgery. A longitudinal incision (ca. 5 cm in length) was created through the midline of the patellar tendon. A nail entry point was fashioned in the midline using a curved awl. A guidewire was inserted through the hole and passed into the distal fragment, with reduction. The medullary cavity was reamed to be 1 mm greater than the nail diameter. Two proximal and 2 distal static locking screws were positioned (Trigen; Smith & Nephew, Memphis, TN, USA). Absorbable sutures were used for closure. No cast or brace was applied for immobilization.

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Isometric quadricep and active ankle dorsiflexion-plantar flexion exercises were initiated immediately after surgery. A standard antibiotic regimen was prescribed. Cefazolin sodium (1g IV bolus) was administered to all of the patients 30 minutes before the operation and applied 3 times in 24 hours.

Subcutaneous injection of enoxaparin sodium [1×40 mg (0.4 mL)] on each of 30 days after surgery was used to prevent the development of deep vein thrombosis (DVT). All of the patients were advised to use 2 crutches and to employ touchdown weight bearing for 2 to 3 weeks, to be followed by full weight-bearing as tolerated.

At the 1-month follow-up evaluation, the patients were advised to use 1 crutch on the contralateral side, and were told to stop using assistive walking devices whenever they felt that they were unnecessary. Patient data regarding age, gender, weight, length of time until surgery, preoperative hemoglobin (Hb) and hematocrit (Hct) levels, and the postoperative 1-hour, and 24-hour, and 48-hour Hb and Hct levels were recorded. Any need for an erythrocyte suspension was noted. Patients were examined 2, 4, 6, and 12 weeks postoperatively. Radiological fracture healing was recorded using the Radiologic Union Scale for Tibia Fractures (RUST) criteria.[7] DVT status was evaluated in the inpatient clinic with Doppler ultrasonography (US) at the 4-week follow-up. Patients with open fractures were prescribed triple antibiotics (cefazolin, gentamycin, and metronidazole) after wound debridement.

Statistical Analysis The statistical analysis was performed using SPSS for Windows, Version 11.0 (SPSS, Inc., Chicago, IL, USA). Data satisfying the conditions are expressed as the mean±SD, and intergroup comparisons were performed using Student’s ttest. Data not satisfying the conditions were presented as the median and interquartile range. Intergroup comparisons were performed using the Mann-Whitney U test.

RESULTS In this study group, 47 patients were male and 23 were female.

The mean age of Group A patients was 36.51±11.91 years (range: 17–56 years) and that of Group B was 35.03±14.49 years (range: 16–64 years). The age distribution did not differ 42 A1 42 A2

GROUP A

42 A3 42 B1 42 B2 42 B3

GROUP B

42 C1 42 C2 0

5

10

15

20

25

30

35

40

42 C3

Figure 1. The fracture type distribution in Group A and Group B patients, derived using the AO Classification.

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Batıbay et al. Is tranexamic acid safe and reliable during tibial intramedullary nailing?

Table 1. Hemoglobin level (g/dL) and hematocrit (%) differences between the groups

Group A

Group B

Mean±SD (Median)

Mean±SD (Median)

12.95±1.55 (13.3)

12.83±1.53 (12.8)

Postoperative 1-h Hb level

11.83±1.85 (11.4)

11.43±1.59 (11.4)

0.3333

Postoperative day 1 Hb level

11.38±1.71 (11.4)

10.34±1.37 (10)

0.0067

Preoperative Hb level

p*

0.7519

Postoperative day 2 Hb level

10.78±1.19 (10.5)

9.98±0.91 (9.9)

0.0023

Preoperative Hct

38.58±4.99 (39.6)

38.24±4.21 (37.6)

0.7629

Postoperative 1-h Hct

35.78±5.38 (35.4)

33.88±4.20 (34)

0.1033

Postoperative 24-h Hct

33.95±4.53 (33.9)

31.21±3.85 (30.4)

0.0082

Postoperative 48-h Hct

32.33±3.36 (31.2)

30.05±3.05 (29.9)

0.004

T-test. Hb: Hemoglobin; Hct: Hematocrit; SD: Standard deviation.

*

Table 2. The fracture healing and hospitalization time of the two groups

Group A

Group B

Mean±SD (Median)

Mean±SD (Median)

14.14±1.48 (14)

15.23±2.30 (16)

0.04228

2.03±0.92 (2)

1.97±0.98 (2)

0.72113

Fracture healing time (weeks) Hospitalization time (days)

p*

Mann-Whitney U test. SD: Standard deviation.

*

significantly between the groups (p=0.6409). Seven Group A and 5 Group B patients had type 1 Gustilo/Anderson open fractures. In Group A, the distribution of fractures according to the AO/OTA classification was AO 42A1: n=9; 42A2: n=4; 42A3: n=10; 42B2: n=9; and 42C1: n=3; in Group B, the figures were AO 42A1: n=14; 42A2: n=6; 42A3: n=10; 42B2: n=2; 42B3: n=2; and 42C2: n=1 (Fig. 1).

The pre- and postoperative 1-hour Hb and Hct levels did not differ significantly between the groups, but differences were evident in the 24- and 48-hour levels (Table 1). No Group A patient required an allogeneic blood transfusion (ABT), but 1 unit of an erythrocyte suspension was given to 2 Group B patients because the Hct value fell below 27%. No DVT or embolism was noted in any patient. Two Group A patients exhibited wound detachment, 2 Group B patients developed superficial infections, and 1 Group B patient developed a hematoma.

In addition, 1 group A patient complained of vomiting.

No significant between-group difference was observed in terms of the length of hospital stay. All of the fractures healed; however, the fracture healing time of patients given TXA was significantly shorter than that of the other group (Table 2).

DISCUSSION We conducted a prospective, randomized, double-blinded study of the utility of preoperative IV TXA in patients with Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

tibia diaphysis fractures treated via IMN. This is the first published study to evaluate TXA efficacy and safety in this context. It is common to use tourniquets during plate placement in trauma patients with tibial fractures. However, the use of tourniquets during IMN can cause friction burns, especially in patients with narrow medullae.[8] Hemorrhage, hematoma, and ecchymosis developing after tibial IMN can trigger wound site complications. Peripheral soft tissue damage, hematomas, and ecchymoses forming in the fracture region or under the skin may predispose the site to infection by creating microenvironments that encourage bacterial colonization; this is detrimental to the patient, as infection retards healing.[9] TXA is a synthetic lysine derivative that blocks lysine-binding sites on plasminogen and thus prevents plasmin activation.

Plasmin breaks fibrin clots; TXA thus prevents clot breakup but does not contribute to clot formation. Further, TXA may exert an anti-inflammatory effect because the pathways of coagulation and inflammation overlap.[10,11] TXA has long been used for epistatic prophylaxis in patients with dysfunctional uterine bleeding and to treat hereditary hemorrhagic telangiectasia.[12,13] ABT after orthopedic surgery is risky in terms of surgical wound infection.[14] In addition, ABT is associated with various side effects, including febrile reactions, hemolysis, allergic reactions, circulatory overload, and infectious disease, as well 577

Batıbay et al. Is tranexamic acid safe and reliable during tibial intramedullary nailing?

as a high cost.[15] Husted et al.[16] showed that blood transfusion after total knee prosthesis (TKP) placement increased the length of the hospital stay. Many efforts have been made to reduce perioperative bleeding after TKP placement, to reduce the need for ABT, and to prevent side effects. These include preoperative erythropoietin, iron, and adrenaline therapy; fibrin glue placement; and local and systemic TXA.[17–19] The need for blood transfusion is reduced in patients given TXA.[20] TXA is now administered to patients with orthopedic trauma; those requiring major procedures such as spinal and pelvic fixation, and those with less serious trauma, such as calcaneus fractures.[21–23] We found that TXA reduced postoperative blood loss after tibial IMN. The preoperative Hgb and Hct values were compared with the early and later postoperative values and TXA prevented significant decreases in the Hgb and Hct levels.

We used Doppler US to evaluate DVT status at postoperative week 4. No DVT was noted in any patient of either group. The effect of TXA was not what we predicted. The fracture-healing time of the TXA-treated group was shorter than that of the control group. We suggest that TXA may stabilize hematomas in the fracture region. TXA is supposed to exert anti-inflammatory activity, but its effect on fracturehealing should be evaluated in future studies with larger numbers of patients.[24] Johansson et al.[25] compared a total hip reconstruction (THR) group given 15 mg/kg TXA IV preoperatively with a placebo group and observed that TXA significantly reduced bleeding.

Reduced bleeding and less need for postoperative ABT have been reported in THR patients to whom TXA was given systemically.[26] When TXA was administered at 10 mg/kg IV preoperatively and 3 times daily perorally postoperatively for 5 days (250 mg in capsules), it was reported to reduce postoperative blood loss and the need for transfusion without increasing the risk of thromboembolism.[27] In addition, Singh et al.[28] gave IV TXA to half of a group of patients undergoing primary THR (the other half served as a control group).

Blood loss did not differ between the groups, but ABT was not required for any TXA patient Hourlier and Fnemma[29] compared patients given 2 mg/kg TXA IV for 20 hours and found no significant difference (compared to a control group) in terms of total bleeding. Our results are similar to those of studies on patients given single TXA doses systemically. We believe that TXA is useful when given as an IV bolus.

TXA can theoretically trigger intravascular thrombosis, cerebrovascular events, myocardial infarction, DVT, and pulmonary embolism (PE).[20] However, such complications have not, in fact, been reported. TXA has not been associated the complications of DVT or PE when given after major arthroplasty procedures. In a meta-analysis of 19 clinical trials, Alshryda et al.[1] found that TXA significantly reduced the need for blood transfusion and did not increase the risk of 578

DVT or PE. Another meta-analysis found that TXA reduced bleeding without increasing the thromboembolism rate. We performed DVT scans (using Doppler US) on all patients 1 month postoperatively. No DVT or embolism was evident, either clinically or radiologically, in any patient of either group. This may be attributable to postoperative enoxaparin prophylaxis and early patient mobilization.

TXA can also be applied locally to areas of large-joint arthroplasty to reduce bleeding and the need for ABT. Konig et al.[18] found that local application of 3 g of TXA to patients who had undergone primary THR with the placement of a total knee prosthesis significantly reduced postoperative blood loss and the need for transfusion. Yue and Kang[30] demonstrated that the local application of 3 g of TXA significantly reduced bleeding and the need for ABT in patients who had undergone THR. In addition, both IV TXA and TXA given locally reduced bleeding after TKP.(1) We sought to achieve hemostasis after a surgical procedure that is not amenable to the local application of agents to the wound site; therefore, we administered IV TXA to our IMN patients.

Farrokhi et al.[22] compared patients undergoing spinal fixation surgery with 10 mg/kg IV TXA and placebo groups. Although blood loss was lower in the TXA group, there was no statistically significant difference. That may be explained by an insufficient TXA dose for spinal fixation surgery.

Xie et al.[23] used TXA (15 mg/kg IV) preoperatively for calcaneal fracture fixation patients. No significant difference was found in peroperative blood loss, but 24 hours after the operation, the blood loss was lower in the TXA group, similar to what we observed in our study. The use of a tourniquet in calcaneal fracture surgery may have contributed to this result.

Zufferey et al.[2] used TXA (15 mg/kg IV) for hip fracture surgery and compared patients with a placebo group. The TXA group had less blood loss but a high rate of vascular complications. The nature of hip fracture surgery, the TXA dose, and patients of an older age should be considered in the large number of vascular events.

Our study had certain limitations, including the relatively small number of patients, the absence of any quantitative measure of ecchymosis, or indirect bleeding evaluation via measurement of Hgb and Hct levels. However, the fact that this is the first report of IMN to treat long bone fractures renders the work unique.

Conclusion According to our results, IV TXA given preoperatively to patients with tibial fractures treated via IMN reduced postoperative bleeding, did not trigger intravascular thrombosis, and did not compromise bone healing.

Conflict of interest: None declared.

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Batıbay et al. Is tranexamic acid safe and reliable during tibial intramedullary nailing?

REFERENCES 1. Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, Mason JM. Tranexamic acid in total knee replacement: a systematic review and metaanalysis. J Bone Joint Surg Br 2011;93:1577–85.

2. Zufferey PJ, Miquet M, Quenet S, Martin P, Adam P, Albaladejo P, et al; tranexamic acid in hip-fracture surgery (THIF) study. Tranexamic acid in hip fracture surgery: a randomized controlled trial. Br J Anaesth 2010;104:23–30.

3. Kubiak EN, Beebe MJ, North K, Hitchcock R, Potter MQ. Early weight bearing after lower extremity fractures in adults. J Am Acad Orthop Surg 2013;21:727–38.

4. Koval KJ, Clapper MF, Brumback RJ, Ellison PS Jr, Poka A, Bathon GH, et al. Complications of reamed intramedullary nailing of the tibia. J Orthop Trauma 1991;5:184–9.

5. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture and Dislocation Classification Compendium - 2007: Orthopaedic Trauma Association Classification, Database and Outcomes Committee. J Orthop Trauma 2007;21: S1–133.

6. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 1984;24:742–6.

7. Kooistra BW, Dijkman BG, Busse JW, Sprague S, Schemitsch EH, Bhandari M. The radiographic union scale in tibial fractures: reliability and validity. J Orthop Trauma 2010;24 Suppl 1:S81–6.

8. Giannoudis PV, Snowden S, Matthews SJ, Smye SW, Smith RM. Friction burns within the tibia during reaming. Are they affected by the use of a tourniquet? J Bone Joint Surg Br 2002;84:492–6.

9. Utvåg SE, Grundnes O, Reikerås O. Effects of lesion between bone, periosteum and muscle on fracture healing in rats. Acta Orthop Scand 1998;69:177–80.

10. Grundnes O, Reikerås O. The role of hematoma and periosteal sealing for fracture healing in rats. Acta Orthop Scand 1993;64:47–9.

11. Shiraishi A, Kushimoto S, Otomo Y, Matsui H, Hagiwara A, Murata K; Japanese Observational Study for Coagulation and Thrombolysis in Early Trauma ( J-OCTET) investigators. Effectiveness of early administration of tranexamic acid in patients with severe trauma. Br J Surg 2017;104:710–7.

12. Winkler UH. The effect of tranexamic acid on the quality of life of women with heavy menstrual bleeding. Eur J Obstet Gynecol Reprod Biol 2001;99:238–43.

13. Gaillard S, Dupuis-Girod S, Boutitie F, Rivière S, Morinière S, Hatron PY, et al; ATERO Study Group. Tranexamic acid for epistaxis in hereditary hemorrhagic telangiectasia patients: a European cross-over controlled trial in a rare disease. J Thromb Haemost 2014;12:1494–502.

14. Hill GE, Frawley WH, Griftith KE, Forestner JE, Minei JP. Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a

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meta-analysis. J Trauma 2003;54:908–14.

15. Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP. Transfusion medicine. Second of two parts-blood conservation. N Engl J Med 1999;340:525–33.

16. Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop 2008;79:168–73.

17. Levy O, Martinowitz U, Oran A, Tauber C, Horoszowski H. The use of fibrin tissue adhesive to reduce blood loss and the need for blood transfusion after total knee arthroplasty. A prospective, randomized, multicenter study. J Bone Joint Surg Am 1999;81:1580–8.

18. Konig G, Hamlin BR, Waters JH. Topical Tranexamic Acid Reduces Blood Loss and Transfusion Rates in Total Hip and Total Knee Arthroplasty. J Arthroplasty 2013;28:1473–6.

19. Wind TC, Barfield WR, Moskal JT. The Effect of Tranexamic Acid on Transfusion Rate in Primary Total Hip Arthroplasty. J Arthroplasty 2014;29:387–9.

20. Raveendran R, Wong J. Tranexamic acid reduces blood transfusion in surgical patients while its effects on thromboembolic events and mortality are uncertain. Evid Based Med 2013;18:65–6.

21. Piggott RP, Leonard M. Is there a role for antifibrinolytics in pelvic and acetabular fracture surgery? Ir J Med Sci 2016;185:29–34.

22. Farrokhi MR, Kazemi AP, Eftekharian HR, Akbari K. Efficacy of prophylactic low dose of tranexamic acid in spinal fixation surgery: a randomized clinical trial. J Neurosurg Anesthesiol 2011;23:290–6.

23. Xie B, Tian J, Zhou DP. Administration of Tranexamic Acid Reduces Postoperative Blood Loss in Calcaneal Fractures: A Randomized Controlled Trial. J Foot Ankle Surg 2015;54:1106–10.

24. Robertshaw HJ. An anti-inflammatory role for tranexamic acid in cardiac surgery? Crit Care 2008;12:105.

25. Johansson T, Pettersson LG, Lisander B. Tranexamic acid in total hip arthroplasty saves blood and money Acta Orthopaedica 2005;76:314–9.

26. Ekbäck G, Axelsson K, Ryttberg L, Edlund B, Kjellberg J, Weckström J, et al. Tranexamic acid reduces blood loss in total hip replacement surgery.

Anesth Analg 2000;91:1124–30.

27. Charoencholvanich K, Siriwattanasakul P. Tranexamic acid reduces blood loss and blood transfusion after TKA: a prospective randomized controlled trial. Clin Orthop Relat Res 2011;469:2874–80.

28. Singh J, Ballal MS, Mitchell P, Denn PG Effects of tranexamic acid on blood loss during total hip arthroplasty. J Orthop Surg 2010;18:282–6.

29. Hourlier H, Fennema P. Single tranexamic acid dose to reduce perioperative morbidity in primary total hip replacement: a randomised clinical trial. Hip Int 2014;24:63–8.

30. Yue C, Kang P, Yang P, Xie J, Pei F. Topical application of tranexamic acid in primary total hip arthroplasty: a randomized double-blind controlled trial. J Arthroplasty 2014;29:2452–6.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Tibia kırıklarının intramedüller çivileme ile tedavisinde traneksamik asit kullanımı güvenli ve güvenilir mi?

Dr. Sefa Giray Batıbay,1 Dr. İsmail Türkmen,1 Dr. Sedat Duman,1 Dr. Savaş Çamur,1 Dr. Necdet Sağlam,1 Dr. Sevilay Batıbay2 1 2

Sağlık Bilimleri Üniversitesi Ümraniye Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul Sağlık Bilimleri Üniversitesi Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, Fiziksel Tıp ve Rehabilitasyon Kliniği, İstanbul

AMAÇ: Tibia diyafiz kırıklarında intramedüller çivileme yapılırken traneksamik asit kullanımının güvenli olup olmadığını, kan kaybını azaltacağını ve maliyet etkinliğini etkilemeyeceğini belirlemektir.

GEREÇ VE YÖNTEM: Tibia diafiz kırığı olan 70 hasta randomize olarak iki gruba ayrıldı ve ileriye yönelik olarak kan kaybı, tromboz ve kırık iyileşmesi açısından izlendi. Birinci gruba ameliyat öncesi traneksamik asit intravenöz olarak uygulandı. İkinci grup kontrol grubu olarak belirlendi.

BULGULAR: İki grup arasında ameliyat öncesi ve sonrası birinci saat hemoglobin (Hb) ve hematokrit (Hct) değerleri arasında farklılık saptanmadı. İki grup arasında ameliyat sonrası 24–48. saat Hb ve Hct değerleri arasında anlamlı farklılık saptandı. Traneksamik asit uygulanan grupta (Grup A) ameliyat sonrası allojenik kan transfüzyonu gereksinimi olmadı. Traneksamik asit kullanılmayan grupta (Grup B) iki hastaya Hb ve Hct değerleri düşük saptanması üzerine (Hct<27) bir ünite eritrosit süspansiyonu uygulandı. Hiçbir hastada derin ven trombozu ve emboli gözlenmedi.

TARTIŞMA: İntramedüller çivileme ile tibia kırıkların tedavisinde ameliyat öncesi dönemde intravenöz traneksamik asit uygulanması ameliyat sonrası dönemde kanama miktarını azalttığı gözlendi. Ameliyat sonrası dönemde hastalarda intravasküler tromboza yol açmadığı gibi kemik iyileşmesini de olumsuz etkilemediği gözlenmiştir.

Anahtar sözcükler: İntramedüller çivileme; tibia diyafiz kırığı; traneksamit asit.

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doi: 10.5505/tjtes.2018.42147

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ORIG I N A L A R T IC L E

Can double fluoroscopy in the oblique position reduce surgical time and radiation exposure during intertrochanteric femur fracture nailing?

Haluk Çelik, M.D.,1 Adnan Kara, M.D.,2 Yavuz Sağlam, M.D.,3 Serkan Aykut, M.D.,4 Mehmet Erdil, M.D.2

İsmail Türkmen, M.D.,1

1

Department of Orthopaedics and Traumatology, Ümraniye Training and Research Hospital, İstanbul-Turkey

2

Department of Orthopaedics and Traumatology, İstanbul Medipol University Faculty of Medicine, İstanbul-Turkey

3

Department of Orthopaedics and Traumatology, Biruni University Faculty of Medicine, İstanbul-Turkey

Department of Orthopaedics and Traumatology, Metin Sabancı Baltalimanı Bone Diseaeses Training and Research Hospital, İstanbul-Turkey

4

ABSTRACT BACKGROUND: The purpose of this study was to determine the comparative effectiveness of the use of single fluoroscopy versus double fluoroscopy during intramedullary nailing in the oblique position for intertrochanteric femur fractures in terms of surgery and radiation time.

METHODS: Fifty-two patients (20 men, 32 women; average age: 78.2 years; range: 69-88 years) were included in the study. While double fluoroscopy was used for 25 patients, single fluoroscopy was used for the remaining 27 patients. Data of the preparation time between anesthesia and surgery, surgery time, radiation time, bleeding volume, postoperative collodiaphyseal angle between the fractures and intact parts, and the tip-apex distance (TAD) were compared.

RESULTS: The surgery time in the double and single fluoroscopy groups averaged 34.48±8.92 minutes and 50.37±16.63 minutes, respectively (p<0.01). The radiation time was 42.72±16.00 seconds for the double-fluoroscopy group and 68.22±21.53 seconds for the single-fluoroscopy group (p<0.01). The surgical preparation time, bleeding volume, collodiaphyseal angle and TAD distance did not vary significantly between groups (p>0.05).

CONCLUSION: The use of double fluoroscopy in the oblique position in the surgical treatment of intertrochanteric femur fractures reduced the surgical time and the anesthesia time for patients, as well as the exposure to radiation, thereby also reducing the risk of complications.

Keywords: Intertrochanteric femur fracture; proximal femur intramedullary nailing; radiation time; single versus double fluoroscopy.

INTRODUCTION It is estimated that around 6.3 million hip fractures will occur worldwide by 2050.[1] As a result of the already growing number of intertrochanteric femur fractures, intramedullary (IM) nailing is becoming an increasingly popular treatment technique among orthopedic surgeons.[2] IM nailing is commonly performed using a traction table or, in the supine or lateral decubitus positions, a radiolucent table.[3] The use of

fluoroscopy during IM nailing may result in high rates of radiation exposure regardless of patient position. In addition, during the surgery, the position of the fluoroscope has to be changed to provide anteroposterior (AP) and lateral images and this necessity can lead to unnecessary views. It might be possible to decrease the time of exposure to radiation with newly developed fluoroscopic techniques.

Cite this article as: Çelik H, Kara A, Sağlam Y, Türkmen İ, Aykut S, Erdil M. Can double fluoroscopy in the oblique position reduce surgical time and radiation exposure during intertrochanteric femur fracture nailing? Ulus Travma Acil Cerrahi Derg 2018;24:581-586.

Address for correspondence: Haluk Çelik, M.D. Ümraniye Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Ümraniye, 34766 İstanbul, Turkey Tel: +90 216 - 632 18 18 E-mail: drhalukcelik@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):581-586 DOI: 10.5505/tjtes.2018.04048 Submitted: 14.11.2017 Accepted: 16.04.2018 Online: 12.09.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Çelik et al. Double fluoroscopy in the oblique position for intertrochanteric fracture nailing

In this study, IM nailing for an intertrochanteric fracture was performed in the oblique position, a modified lateral decubitus position. The objective was to examine the differences between single and double fluoroscopy in IM nailing performed in the oblique position in terms of the preparation time between anesthesia and surgery, surgery time, radiation time, bleeding volume and postoperative radiological results. The research hypothesis was that the use of double fluoroscopy in the oblique position would reduce the surgery time and radiation time.

MATERIALS AND METHODS Patient Population-Treatment Groups The sample group comprised patients who underwent IM nailing for intertrochanteric femur fractures at Medipol Mega Hospital between March 2013 and March 2015. This was a retrospective study that included patients whose fracture was type A1 or A2 according to the AO/OTA Fracture and Dislocation Classification, whose injury had been diagnosed as a non-pathological isolated intertrochanteric femur fracture, and those who underwent nailing with closed reduction in the oblique position. Of 84 patients who underwent IM nailing for an intertrochanteric femur fracture, the following patients were excluded from the study: 4 patients with a pathological fracture, 3 patients with multi-trauma, 2 patients who underwent open reduction, 11 patients with type A3 fractures according to the AO/OTA classification, and 12 patients who underwent operations in positions other than the oblique position (Table 1). In all, 52 patients (20 men, 32 women) were included in the study. The average age was 78.2 years (range: 69–88 years). The causes of the fracture included falling from a height in 2 cases, a traffic accident in 5, and a simple fall for 45 patients. The mean time interval between the trauma and the operation was 3.5 days (range: 1–7 days). Double fluoroscopy was used for 25 patients, and single fluoroscopy was used for 27 patients.

Table 1. Patient distribution according to AO fracture

classification OTA/AO fracture classification

Patients with hip fractures

Double fluoroscopy Single fluoroscopy (n=25) (n=27)

A1-2 A1-3 3 2 4 2 A2-1

5 6

A2-2

11 13

A2-3

4 2

582

Written informed consent was obtained from each patient before enrollment. All of the study procedures involving human participants were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Approval for the study was obtained from the local ethical committee.

Technique All of the surgeries were performed using a closed technique under spinal anesthesia. An anti-rotational screw anterograde proximal femur intramedullary nail (Intertan; Smith & Nephew plc, London, UK) was used. After the induction of anesthesia, all of the patients were placed in the oblique position on the radiolucent table at 70° to the floor in order to prevent two-hip superposition (Fig. 1). In order to maintain the position, silicon supports were placed behind the hips and under the feet.

Philips BV Endura fluoroscopes (Koninklijke Philips N.V., Amsterdam, Netherlands) were used for all patients. The fluoroscopes were positioned before sterile draping, and AP and lateral images of the proximal femur were taken. When double fluoroscopy was used, the fluoroscope used to take AP images was placed such that the X-ray tube was behind the hips and the image intensifier was in front of the patient.

A 20° tilt was applied in the caudal direction in order to ease the entrance of the fluoroscope used to record the lateral images. The fluoroscope used to take lateral images was placed at a 90° angle to the floor in the caudocranial direction such that the image intensifier was above. Once suitable images were obtained, the positions of fluoroscopes were marked on the floor with adhesive bandages. After sterile draping, the fluoroscopes were also draped and returned to the marked areas. Reduction of the fracture was provided by an assistant using manual longitudinal traction and internal rotation. Once a longitudinal skin incision was made proximal to the greater trochanter, a guide pin was inserted into the trochanteric region under fluoroscopic guidance. An entry reamer was then inserted and reamed to the level of the lesser trochanter. The appropriate nail size was selected for each patient according to the preoperative planning. Once the nail was inserted, the guide pin was placed into the neck-head. Under manual traction, the quality of the reduction and the position of the guide pin were evaluated with AP and lateral images. After obtaining the appropriate position, a lag screw and interlocking screw were placed. A single distal locking screw was then inserted through the guide of the nail (Figs. 2 and 3). It was determined that it was not necessary to change the position of the fluoroscope during surgery.

In all of the operations performed with single fluoroscopy, draping was performed after checking the preoperative AP and lateral proximal femur images. In the various operative phases, the fluoroscope’s position was changed by a single raUlus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

Ă&#x2021;elik et al. Double fluoroscopy in the oblique position for intertrochanteric fracture nailing (a)

(b)

(c)

(d)

Figure 1. (a-d) To prevent the superposition of both hips, the patient is positioned on the operating table in a 70° oblique position. (a)

(c)

(d)

(b)

Figure 2. (a-d) The position of the fluoroscopes and anteroposterior-lateral images taken during surgery. (a)

(b)

(c)

Figure 3. (a) Preoperative radiograph of a right intertrochanteric femur fracture; (b, c) Postoperative radiographs of the patient after treatment with proximal femoral intramedullary nailing.

diology technician with 7 years of experience. All of the surgeries were performed by 2 very experienced, senior trauma surgeons (AK and ME).

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Variables The surgical preparation time between anesthesia induction and the incision, the surgical time between the incision and 583

Çelik et al. Double fluoroscopy in the oblique position for intertrochanteric fracture nailing

Table 2. Comparison of fluoroscopy groups

Double fluoroscopy (n=25)

Single fluoroscopy (n=27)

Surgical preparation time in the OR (min); mean±SD

19.36±7.35

17.26±6.83

a

Surgical time (min); mean±SD

34.48±8.92

50.37±16.63

a

42.72±16.00 (38)

68.22±21.53 (65)

b

Bleeding volume (mL); mean±SD

210.61±49.88

230.62±62.55

a

Collo-diaphyseal angle (degrees); mean±SD

128.63±6.62

124.22±3.86

a

TAD (mm); mean±SD

20.81±2.22

24.41±3.55

a

Radiation time (sec); mean±SD (median)

p 0.291

0.001* 0.001* 0.212 0.069 0.301

TAD <25 mm; n (%)

21 (80.0)

22 (81.5)

c

TAD >25 mm; n (%)

4 (20.0)

5 (18.5)

c

1.000 1.000

Student’s t-test; bMann-Whitney U test; cFisher’s Exact test. *p<0.01. OR: Operating room; TAD: Tip-apex distance; SD: Standard deviation.

a

closure, bleeding volume, and the total radiation time during surgery were recorded for both groups. Collodiaphyseal angles were evaluated in comparison with the intact hip on a postoperative graph. The apex distance between the implant end and the femoral head and the position of the screw within the head was then compared.

Statistical Analysis NCSS 2007 and PASS 2008 statistical software programs (NCSS LLC, Kaysville, UT, USA) were used for the statistical analyses. While evaluating the study data, in addition to the definitive statistical methods (average, SD, median, frequency, and ratio), the conformity of the variables with normal distribution was evaluated using the Kolmogorov-Smirnov test. The Student’s t-test was used for inter-group comparisons of the variables with normal distribution. The Mann-Whitney U test was used to compare variables that did not have normal distribution. The results were evaluated within a 95% confidence interval and at a significance level of p<0.05.

RESULTS No complication was noted in either group. There were no significant differences between the 2 groups in terms of surgical preparation time (p>005). The surgical time was 15.89 minutes shorter (p<0.01) and the radiation time was 25.5 seconds shorter (p<0.01) in the double-fluoroscopy group compared with the single-fluoroscopy group. Bleeding volume, collodiaphyseal angle and type, and apex distance did not vary significantly between the groups (p>0.05) (Table 2).

DISCUSSION As closed surgery has become more and more popular, fluoroscopy has become the third eye of orthopedic surgeons.

However, due to the ionizing radiation emitted during the fluoroscopy, it may have harmful effects on the surgical team and the patient.[4,5] If the time of fluoroscopy exceeds 1.7 minutes during an operation, radiation exposure increases signif584

icantly.[6] A study of radiation-exposed and unexposed personnel found that the tumor risk in orthopedic surgeons had increased significantly after 24 years.[7] Another clinical study demonstrated that the incidence of breast cancer among female orthopedic surgeons is higher than that of the general population.[8] The radiation exposure represents a relatively small increased risk of future cancer development in the patients who undergo fluoroscopy-dependent surgeries.[9] In light of this information, the principle of as low as reasonably achievable (ALARA) was developed in order to decrease radiation exposure.[10] Methods to decrease radiation exposure were discussed and collected under the title of Distance, Exposure, Barriers and Techniques/Technologies (DEBT).[11] The purpose of this study was to develop a new technique to decrease radiation exposure. Since type-A3 fractures may be accompanied by several complications during surgery, this type of fracture has not been included in the present study in order to be able to evaluate the effectiveness of doublefluoroscopy used with an oblique position. In addition, the experience of the surgeon is one of the important factors affecting radiation exposure, and senior surgeons can significantly reduce the radiation dose.[12] Thus, all of the surgeries were performed by 2 experienced, senior trauma surgeons.

In order to obtain 2-directional images during surgical attempts, the position of the C-arm fluoroscopy must be adjusted. Extra and often unnecessary images can be taken in order to obtain the appropriate image and, as a result, the radiation exposure time increases. This can be prevented by using 2 fluoroscopes in fixed positions under appropriate conditions. There are a limited number of studies in the literature pertaining to the use of double-fluoroscopy during orthopedic procedures. A study that researched the effectiveness of single- and double-fluoroscopy in intramedullary nailing for intertrochanteric fractures determined that the radiation exposure time decreased by 29% in the group undergoing double fluoroscopy.[13] The study results indicated that the surgical time decreased in statistically significant terms in the double fluoroscopy group. In that study, the surgeries Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

Çelik et al. Double fluoroscopy in the oblique position for intertrochanteric fracture nailing

were performed on traction tables, and the bleeding volume, collodiaphyseal angles and TAD distances were not evaluated. According to a similar study on traction tables, in the double fluoroscopy group, the duration of surgery was 15.9 min. shorter, and the radiation time was 25.7 seconds shorter than in the single fluoroscopy group.[14] To the best of our knowledge, there are no other studies in the literature that evaluate the effectiveness of double fluoroscopy in IM nailing for proximal femur fractures; however, a study in which an evaluation of the effectiveness of single and double fluoroscopy during slipped capital femoral percutaneous screwing determined that the radiation time in the double fluoroscopy group decreased by 34%.[15] A similar study reported that use of double fluoroscopy did not significantly extend the surgical preparation time and increased the accuracy of the screw position.[16] We found that double fluoroscopy decreased the radiation exposure time by 37.4% in the oblique position. This suggests that unnecessary images taken during single fluoroscopy in order to obtain the appropriate images occurred much more frequently than previously suspected.

The use of double fluoroscopy appears to minimize the number of unnecessary images and significantly decrease radiation exposure.

Shorter orthopedic surgical times provide many benefits.

It has been reported that the infection risk is higher in extended surgeries.[17,18] The techniques used to decrease surgical time are particularly important for major trauma centers, and adoption of these techniques can also decrease patients’ total hospitalization time as well as costs.[19] We observed in our study that the time of operations using double fluoroscopy were shorter by 31.5% compared with single fluoroscopy. The preoperative preparation phase was longer in the double fluoroscopy group than in the single fluoroscopy group. However, the difference was not significant. There were also no significant differences between the 2 groups in the evaluation of the bleeding amount.

In the treatment of intertrochanteric femur fractures, reduction is essential for surgical stability. When we compared the operated collodiaphyseal angles with those of intact hips on postoperative graphs and evaluated the TAD and screw positions, we did not detect any significant differences between the 2 groups. We can conclude that use of double fluoroscopy did not have any positive effects on reduction and screw position.

There are certain limitations to this study. First, the number of patients was limited. Second, more powerful data could have been obtained by measuring the amount of the dose with a dosimeter (badge) as well as radiation time. However, the present study is the first study in the literature to evaluate the benefits of the double fluoroscopy technique in the oblique position. Further studies are necessary to evaluate larger patient samples and complicated fracture types.

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Conclusion The use of double fluoroscope while a patient is in the oblique position during surgical treatment of intertrochanteric femur fractures may decrease the potential complications of long surgical and anesthesia times for the patient and it may help prevent the side effects of radiation by lessening radiation exposure.

Conflict of interest: None declared.

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3. Bishop JA, Rodriguez EK. Closed intramedullary nailing of the femur in the lateral decubitus position. J Trauma 2010;68:231–5.

4. Blakely EA. Biological effects of cosmic radiation: deterministic and stochastic. Health Phys 2000;79:495–506.

5. Dewey P, George S, Gray A. Ionising radiation and orthopaedics. Curr Orthop 2005;19:1–12.

6. Sanders R, Koval KJ, DiPasquale T, Schmelling G, Stenzler S, Ross E. Exposure of the orthopaedic surgeon to radiation. J Bone Joint Surg Am 1993;75:326–30.

7. Mastrangelo G, Fedeli U, Fadda E, Giovanazzi A, Scoizzato L, Saia B. Increased cancer risk among surgeons in an orthopaedic hospital. Occup Med (Lond) 2005;55:498–500.

8. Chou LB, Chandran S, Harris AH, Tung J, Butler LM. Increased breast cancer prevalence among female orthopedic surgeons. J Womens Health (Larchmt) 2012;21: 683–9.

9. Beebe MJ, Jenkins P, Rothberg DL, Kubiak EN, Higgins TF. Prospective Assessment of the Oncogenic Risk to Patients From Fluoroscopy During Trauma Surgery. J Orthop Trauma 2016;30:e223–9.

10. Giordano BD, Grauer JN, Miller CP, Morgan TL, Rechtine GR 2nd.

Radiation exposure issues in orthopaedics. J Bone Joint Surg Am 2011;93:e69.

11. Agarwal A. Radiation Risk in Orthopedic Surgery: Ways to Protect Yourself and the Patient. Operative Techniques in Sports Medicine 2011;19:220–3.

12. Botchu R, Ravikumar K. Radiation exposure from fluoroscopy during fixation of hip fracture and fracture of ankle: Effect of surgical experience.

Indian J Orthop 2008;42:471–3.

13. Brin YS, Palmanovich E, Aliev E, Laver L, Yaacobi E, Nyska M, et al.

Closed reduction and internal fixation for intertrochanteric femoral fractures is safer and more efficient using two fluoroscopes simultaneously.

Injury 2014;45:1071–5.

14. Kara A, Celik H, Seker A, Uzun M, Sonmez MM, Erdil M. Procedural outcomes of double vs. single fluoroscopy for fixing intertrochanteric femur fractures. Arch Orthop Trauma Surg 2016;136:929–34.

15. Klug R, McCarthy JJ, Eilert RE. The use of a two C-arm technique in the treatment of slipped capital femoral epiphysis. Orthopedics 2004;27:1041–2.

16. Westberry DE, Davids JR, Cross A, Tanner SL,Blackhurst DW. Simultaneous biplanar fluoroscopy for the surgical treatment of slipped capital femoral epiphysis. J Pediatr Orthop 2008;28:43–8.

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18. Lee J, Singletary R, Schmader K, Anderson DJ, Bolognesi M, Kaye KS.

Surgical site infection in the elderly following orthopaedic surgery. Risk factors and outcomes. J Bone Joint Surg Am 2006;88:1705–12.

19. Lawrence TM, White CT, Wenn R, Moran CG. The current hospital costs of treating hip fractures. Injury 2005;36:88–91.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

İntertrokanterik femur kırıklarında oblik pozisyonda uygulanan femur intramedüller çivilemesi sırasında çift skopi kullanımı cerrahi süre ve skopi süresini azaltabilir mi?

Dr. Haluk Çelik,1 Dr. Adnan Kara,2 Dr. Yavuz Sağlam,3 Dr. İsmail Türkmen,1 Dr. Serkan Aykut,4 Dr. Mehmet Erdil2 Ümraniye Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul İstanbul Medipol Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul Biruni Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul 4 Metin Sabancı Baltalimanı Kemik Hastalıkları Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul 1 2 3

AMAÇ: Bu çalışmada intertrokanterik femur kırıklarında, oblik pozisyonda uygulanan intramedüller çivileme esnasında çift skopi kullanımının tek skopi kullanımına üstün olup olmadığı araştırılmıştır.

GEREÇ VE YÖNTEM: İntertrokanterik femur kırığı sonrası oblik pozisyon kullanılarak intramedüller çivileme yapılan 52 hasta çalışmaya dahil edildi.

Hastaların 20’si erkek, 32’si kadın ve ortalama yaş: 78.2 (dağılım: 69–88) idi. Kırıklar AO/OTA sınıflamasına göre tip A1 ve tip A2 kırıklardan oluşmakta idi. Yirmi beş hastada çift skopi kullanılırken, 27 hastada tek skopi kullanıldı. Anestezi ile cerrahi arasındaki hazırlık süresi, cerrahi süresi, skopi kullanım süresi, kanama miktarı, cerrahi sonrası kollodiafiziyal açı ve tip-apeks mesafesi iki grup arasında karşılaştırıldı.

BULGULAR: Cerrahi süresi çift ve tek skopili gruplarda sırası ile 34.48±8.92 dakika ve 50.37±16.63 dakika idi (p<0.01). Skopi kullanım süresi çift skopili grupta 42.72±16.00 iken, tek skopili grupta 68.22±21.53 idi (p<0.01). Cerrahi hazırlık süreleri, kanama miktarı, kollodiafiziyel açı ve tipapeks mesafeleri karşılaştırmalarında iki grup arasında istatistiksel fark saptanmadı (p>0.05).

TARTIŞMA: İntertrokanterik femur kırıkları cerrahi tedavisinde oblik pozisyonda çift skopi kullanılarak yapılan intramedüller çivilemede tek skopi kullanımına göre daha az radyasyon maruziyeti ile daha kısa sürelerde cerrahiyi tamamlamak mümkündür.

Anahtar sözcükler: Çift skopi kullanımı; intertrokanterik femur kırığı; proksimal femur intramedüller çivileme; radyasyon zamanı.

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doi: 10.5505/tjtes.2018.04048

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ORIG I N A L A R T IC L E

Distribution characteristics of combat-related shrapnel and relationship to weapon type and conflict location: Experience of an operational field hospital Sinan Akay, M.D.,1

Mehmet Burak Aşık, M.D.,2

Sami Eksert, M.D.3

1

Department of Radiology, Dr. Aşkım Tüfekçi State Hospital, Adana-Turkey

2

Department of Ear-Nose-Throat Diseases, Gülhane Training and Research Hospital, Ankara-Turkey

3

Department of Anesthesia and Reanimation, Gülhane Training and Research Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: The aim of this study was to investigate the characteristics of shrapnel distribution in the body and a possible relationship to the type of weapon and type of location of the conflict.

METHODS: The records of 246 patients admitted to a level-III trauma center with any kind of firearm injury were examined retrospectively. Ninety patients who had at least 1 radiologically-proven piece of shrapnel in their body were included in the study. For the purposes of the study, the body was divided into 5 regions (head/neck, thorax/back, abdomen/pelvis/waist, upper extremities, and lower extremities) and shrapnel distribution was noted according to these divisions. Medical data and detailed information regarding the weapon type (long-barreled weapon, rocket-propelled grenade [RPG], or improvised explosive device [IED]), conflict location (residential or rural area), and all radiological examinations (radiography and/or computed tomography) were carefully reviewed. The relationship between these variables and the shrapnel distribution in the body was investigated.

RESULTS: No statistically significant differences were seen between weapon type and shrapnel distribution (p>0.05), except a significantly higher percentage of head/neck region shrapnel injuries as a result of RPG and IED injuries (p=0.002). There was no statistically significant relationship between the shrapnel distribution characteristics and conflict location, classified as either residential or rural (p>0.05).

CONCLUSION: Secondary blast injuries induced by penetrating shrapnel are the most common type of explosion- and combatrelated injuries. In the current study, a significantly higher rate of head/neck region shrapnel injuries was observed in RPG and IED injuries compared with long-barreled weapon-induced injuries. The primary reason is likely the more unexpected nature of those 2 types of attacks, which allow no time to shield that part of the body.

Keywords: Blast injury; combat-related injury; computed tomography; radiography; shrapnel.

INTRODUCTION Blast injuries are commonly classified as primary, secondary, tertiary, or quaternary. Primary blast injuries are overpressure injuries due to explosion effects. Secondary injuries are caused by traveling shrapnel fragments secondary to the explosion, while tertiary injuries are due to falling or being thrown due to the power of the blast. Quaternary blast in-

juries are caused by fire, radioactive and biological agents, and chemicals related to the explosion.[1,2] In recent years, global terrorism has become a larger concern all over the world, and armed terrorist groups perform many sensational acts targeting both city centers and rural areas. They often use tactics and weapons such as ambush trap-bombs, improvised explosive devices (IEDs), and rock-

Cite this article as: Akay S, Aşık MB, Eksert S. Distribution characteristics of combat-related shrapnel and relationship to weapon type and conflict location: Experience of an operational field hospital. Ulus Travma Acil Cerrahi Derg 2018;24:587-593.

Address for correspondence: Sinan Akay, M.D. Eski Adana Asker Hastanesi, Radyoloji Bölümü, 01010 Adana, Turkey Tel: +90 322 - 239 93 39 E-mail: akaysinan04@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(6):587-593 DOI: 10.5505/tjtes.2018.13402 Submitted: 22.06.2017 Accepted: 16.04.2018 Online: 09.11.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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et-propelled grenades (RPGs) as part of their attacks. As a result, various blast and weapon injuries have become a more common reason for hospital admissions. Among those admissions, secondary blast injuries induced by penetrating shrapnel are the most common source of explosion- and combatrelated injuries.[2,3] Shrapnel damage is an important subset of blast injury.

Depending on the shape, weight, and size of the fragment, as well as the distance from the explosion, shrapnel may cause both low- and high-energy injuries.[4,5] Shrapnel distribution in the body depends primarily on tissue resistance.[6] The objective of this research was to investigate the distribution characteristics of shrapnel caused by firearm injuries, and the possible relationship between distribution and weapon type (long-barreled weapon, RPG, or IED). The relationship between weapon type, conflict location (residential versus rural), and shrapnel distribution was also examined.

MATERIALS AND METHODS Review board approval was obtained from Kecioren Training and Research Hospital for this retrospective study. The medical data and radiological examinations of 246 cases of a firearm injury of any type who presented at this level-III trauma center between June 2015 and January 2016 were reviewed. The data were gathered during military operations in the southeastern part of Turkey, and all of the patients were either soldiers or police officers. Radiological examinations, including plain radiography and computed tomography (CT), were carefully examined for shrapnel. Excluded were patients with no shrapnel evidenced in their body, including those who did not undergo any radiological investigation because of immediate transfer to the operating room and those with only entire bullets in their body without shrapnel fragments. Ninety patients with at least 1 shrapnel fragment, confirmed by either visual examination, radiography, and/or CT were included in the study.

The localization of the shrapnel was classified as in the region of the head/neck, thorax/back, abdomen/pelvis/waist, upper extremity (arm/forearm/hand), or lower extremity (thigh/leg/ foot).

The injuries were also divided into 3 groups according to weapon type. The first group consisted of shrapnel injuries exclusively from long-barreled weapons. Those injuries were mainly bullet fragments that entered the body just after being shot into a nearby object, such as a wall, glass, or metal. Injuries caused by RPGs comprised the second group. Patients in the third group had IED injuries.

The type of location of the conflict was also noted. In the analyzed time interval, there were conflicts in both city centers and rural areas. For this reason, we wanted to investigate a possible difference in shrapnel distribution characteristics 588

between injuries that occurred in city centers and those that occurred in rural areas. The conflicts that occurred in areas outside a city center were classified as rural, and those that occurred in city centers were classified as residential.

In some of the patients, the injuries were heterogeneous. In addition to shrapnel injuries, bullet wounds, injuries associated with the blast effects of IEDs and RPGs, injuries caused by a fall during the conflict, and combinations of these injuries were noted. Additionally, most of the patients had shrapnel in more than 1 body region, and this significantly complicated the picture. As a result of this heterogeneity of injuries, identifying an exact injury pattern specific to shrapnel was very difficult in some cases. Due to this complicated situation, the distribution characteristics of the shrapnel, which was the only common point in the study group, and the relationship to the variables of conflict location and weapon type, rather than the injury pattern caused by shrapnel, were the focus of the investigation.

Image Analysis Plain radiographs were carefully reviewed for the existence and localization of shrapnel using a USX-RAY workstation (US-XRAY Röntgen A.Ş, Bolu, Turkey). All CT examinations were completed with a Somatom Emotion Duo CT Scanner (Siemens Healthineers, Siemens Healthcare GmbH, Erlangen, Germany). Windows of soft tissue and bone demonstrated the presence of shrapnel, and multiplanar-reformatted images (MPR) provided a more specific localization of the objects.

Statistical Analysis IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA) was used to analyze descriptive statistics, as well as the frequency and percentage of discrete variables (injury type, injury location, and injured body region). For continuous variables (i.e., age), mean±SD was used. Chi square tests were performed to determine the statistical differences between groups. Statistical significance was established at p<0.05.

RESULTS The plain radiographs and CT examinations of 90 male cases were analyzed. The mean age of the study group was 30.1±8.1 years (range: 20–50 years). Eighty-five cases (94.4%) had at least 1 radiographical examination, and 26 cases (28.9%) had a CT examination.

For the purposes of the study, 5 body regions were identified: head/neck, thorax/back, abdomen/pelvis/waist, upper extremities, and the lower extremities. The shrapnel distribution according to body region is shown in Table 1.

The injuries were divided into 3 groups according to the source of the injury. Long-barreled weapons were responsible for the injury in 47 cases (52.2%). In 30 of the 90 cases (33.3%), the injury was caused by an RPG. In the remaining Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

Akay et al. Distribution characteristics of combat-related shrapnel and relationship to weapon type and conflict location

Table 1. Shrapnel distribution in the body according to weapon type Shrapnel localizations

Weapon type

Total (n=90)

p*

Long-barreled Rocket-propelled Improvised weapon grenade explosive device (n=47) (n=30) (n=13)

n % n % n % n %

Head/neck

7 14.9 15 50 6 46.2 28 31.1 0.002

Thorax/back

8 17 8 26.7 5 38.5 21 23.3 0.235

Abdomen/pelvis/waist

7 14.9 7 23.3 5 38.5 19 21.1 0.171

Upper extremity

18 38.3 17 56.7 5 38.5 40 44.4 0.256

Lower extremity

30 63.8 13 43.3 9 69.2 52 57.8 0.137

*: Chi square test.

13 cases (14.4%), the injury was caused by an IED. The shrapnel distribution according to weapon type is also shown in Table 1. The only statistically significant relationship between weapon type and shrapnel distribution was the large number of head/neck region injuries caused by RPGs and IEDs. The percentage of injuries to the head/neck region was significantly greater than that of other body regions with those 2 weapons (p=0.002).

Shrapnel distribution characteristics according to the type of conflict location were also investigated. The location of the injury was classified as a residential area or a rural area.

Shrapnel distribution according to conflict location is shown in Table 2. No statistically significant difference was found between those 2 variables (p>0.005).

Finally, relationships between weapon type and conflict lo-

Table 2. Shrapnel distribution in the body according to conflict location Shrapnel localizations

Conflict location

Total (n=90)

p*

Residential area Rural area (n=66) (n=24)

n % n % n %

Head/neck

21 31.8 7 29.2 28 31.1 0.81

Thorax/back

15 22.7 6 25 21 23.3 0.822

Abdomen/pelvis/waist 14 21.2 5 20.8 19 21.1 0.969 Upper extremity

31

47

9

37.5

40

44.4

0.424

Lower extremity

39 59.1 13 54.2.3 52 57.8 0.676

*: Chi square test.

Table 3. Relationship between conflict location and weapon type Weapon type

Conflict location

p*

Residential area Rural area (n=66) (n=24)

n % n %

Long-barreled weapon

33

50

14

58.3

Rocket-propelled grenade

23

34.8

7

28.2

Improvised explosive device

10

15.2

3

12.5

0.783

*: Chi square test.

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(a)

(b)

(c)

(d)

Figure 1. Severe maxillofacial bone fractures and soft tissue damage in a 28-year-old male injured with shrapnel after a rocket-propelled grenade attack. Scanogram (a) shows multiple pieces of shrapnel (white arrows) affecting the maxillofacial and cranial regions. Segmental fractures in the maxillary sinuses, extensive hemorrhage filling the paranasal sinuses, and free air in the soft tissue are readily seen on axial computed tomography images (b and c). Also visible is the prominent misalignment of the teeth and dislocation of teeth to the right maxillary sinus and adjacent soft tissue. Segmental fracture of the mandible and extensive free air are seen on (d).

In most cases, the shrapnel was located in superficial areas of the body and treated without any intervention other than a simple dressing, removing some fragments in emergency room conditions, and short-term observation.

However, 11 cases had extremity fractures attributable to

shrapnel and 5 underwent open surgery. The remaining patients were treated with simple casting. Five cases had vascular damage to the extremities, and surgery using native and prosthetic vascular grafts was performed. Patients who had shrapnel in the head/neck (8 of 28 cases), thorax/ back (5 of 21 cases), and abdomen/pelvis/waist regions (4 of 19 cases), underwent emergency surgery. Those operations were mainly performed to repair maxillofacial bone fractures that caused persistent bleeding and to remove

(a)

(b)

cation were analyzed and the results are presented in Table 3. There were no statistically significant differences between those variables (p=0.783).

Figure 2. Twenty-five-year-old male injured in a rocket-propelled grenade attack. On axial computed tomography images of the mediastinum and lung window (a and b), a piece of shrapnel (white arrow) located in the lower lobe of the right lung causing unilateral mild hemothorax and pneumothorax (black arrow), and subcutaneous emphysema of the lateral side of the right hemithorax is observed. A chest tube (white arrowhead) can also seen in image (b).

(a)

(b)

(c)

(d)

Figure 3. Intra-abdominal shrapnel injury caused by a long-barreled weapon in a 30-year-old male. Axial contrast-enhanced computed tomography images (a and b) reveal 2 small pieces of shrapnel (white arrows) located in the left upper quadrant very close to the inferior vena cava and the abdominal aorta, respectively. In image (c), extensive infradiaphragmatic free air is readily visible. Image (d) shows free fluid in the pelvic region secondary to multilevel small bowel perforation confirmed by laparotomy.

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(a)

(b)

Figure 4. Extensive shrapnel injury affecting the right upper extremity caused by a long-barreled weapon in a 25-year-old male.

Upper extremity X-rays (a and b) demonstrate multiple small pieces of shrapnel affecting the right arm, forearm, and hand regions without causing any fractures.

(a)

(b)

Figure 5. Twenty-five-year-old male injured in a long-barreled weapon attack. Anteroposterior (a) and lateral (b) X-rays reveal a bullet (circle) and multiple pieces of shrapnel in the soft tissue of the leg. A mildly displaced fibular fracture (dashed black arrow) is also visible.

fragments from the lungs and abdomen to establish hemodynamic stability.

DISCUSSION In this study, there were significantly more shrapnel injuries affecting the head/neck region as a result of terrorist attacks Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

using RPG and IED weapons, compared with attacks using only long-barreled weapons (p=0.002). However, there was no statistically significant difference found in the shrapnel distribution to other body regions (e.g., thorax/back or extremities). No statistically significant relationship was detected between shrapnel distribution and the type of conflict location (residential or rural). Furthermore, no statistically significant relationship was determined between weapon type (long-barreled weapon, RPG, or IED) and conflict location.

Shrapnel is the term commonly used to describe various types of fragmented material ejected from an explosion.

[4] Debris carried by the blast wind causes injury,[7] and the result of the penetration of these fragments is considered a secondary blast injury.[1,2] The distribution of shrapnel in the body is directly affected by tissue resistance; shrapnel will most often travel in a straight line through the body until a bone structure is encountered.[6] However, fragments of certain shapes and dimensions may disperse in various ways and can affect every structure in the body (Figs. 1â&#x20AC;&#x201C;5).

A primary part of this study was the analysis of a possible relationship between weapon type and shrapnel distribution.

The study hypothesis included the proposition that RPG and IED injuries would be more common in the head/neck and thorax/abdomen regions due to the higher firepower of those weapons compared with long-barreled weapons.

During conflicts in which only long-barreled weapons are used, oftentimes the combatants can see one another and may be able to partially protect themselves by sheltering in a covered position. It was hypothesized that this protection would decrease head/neck and thorax/abdomen injuries. On the other hand, due to the unexpected and unpredictable nature of RPG and IED attacks, soldiers often cannot protect themselves, which makes them a more vulnerable target. However, we found a significant difference only in shrapnel injuries to the head/neck region when the injuries resulting from those weapons were compared with longbarreled weapon injuries. The body armor used in all of the study cases likely protected the subjects from thorax/ abdomen shrapnel. Breeze et al.[8] conducted a study characterizing explosive fragments that caused neck injuries in 110 UK service personnel deployed to Afghanistan. They also divided the injuries into groups defined as IED and RPG/ mine injuries and compared fragment shapes in both groups.

However, to the best of our knowledge, the medical literature contains no study describing the relationship between shrapnel distribution and weapon type.

At the beginning of this study, it was hypothesized that head/ neck and thorax/abdomen injuries would occur more often in residential area attacks due to the unexpected nature of RPG and IED attacks, and the limited ability of security forces to protect themselves in that environment. In such a location, soldiers may also be distracted by members of 591

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the community. In rural areas, troops are able to proceed more cautiously and are generally able to be more prepared for extraordinary events. However, we did not detect any relationship between those variables. To the best of our knowledge, there is no other study examining the relationship between shrapnel distribution and conflict location in the medical literature.

Lastly, we investigated a possible relationship between weapon type and conflict location. However, no statistically significant relationship was seen in these variables. Again, we did not find a study of this subject in the medical literature.

Singh et al.[1] reported radiological imaging features of blast injuries seen in 43 patients wounded in the Boston Marathon bombing and mentioned the high percentage of shrapnel injuries. They also indicated that evaluation with radiography and contrast-enhanced CT played an integral part in the diagnostic assessment. Yazgan et al.[9] studied the radiological features of blast-related injuries observed in the 2015 Ankara bombing victims. They also specified that the most common injury pattern was secondary to blast injury, and that the torso was the most commonly injured body part in unarmored civilians. Singh et al.[10] also reported that secondary blast injuries were seen in the patients with abdominal and pelvic injuries who were admitted after the Boston Marathon bombing. In addition, Brook et al.[4] reported their experience using multiplanar CT images to show the trajectory of shrapnel.

This study has some limitations. First, there was no way to know if long-barreled weapons were also used on patients who reported attacks with RPGs or IEDs. This could have affected shrapnel distribution. Second, nonhomogeneous injuries hindered a comprehensive evaluation of injury patterns specific to shrapnel. Third, there were fewer patients exposed to IED shrapnel (13 cases) than those injured with long-barreled weapons or RPGs (47 and 30 cases, respectively). Finally, there was a prominent difference between the number of cases where the injury occurred in a residential area and those in rural areas (66 versus 24 cases). These circumstances may have also affected the statistical analysis.

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In conclusion, secondary blast injury is caused by high velocity shrapnel and is the most common type of explosion-related injury. These compose the majority of combat-related injuries. Rapid radiological assessment plays an integral role in the evaluation of firearm injuries, and radiologists should be familiar with possible pathologies that can be challenging.

In our study, the head/neck region was the location for more shrapnel injuries as a result of RPGs and IEDs compared with other body regions. We believe the main reason for this result is the unexpected nature of these types of attacks; however, more studies are needed to gather further information on the subject.

Conflict of interest: None declared.

REFERENCES 1. Singh AK, Goralnick E, Velmahos G, Biddinger PD, Gates J, Sodickson A. Radiologic features of injuries from the Boston Marathon bombing at three hospitals. AJR Am J Roentgenol 2014;203:235–9.

2. Eskridge SL, Macera CA, Galarneau MR, Holbrook TL, Woodruff SI, MacGregor AJ, et al. Injuries from combat explosions in Iraq: injury type, location, and severity. Injury 2012; 43:1678–82.

3. Champion HR, Holcomb JB, Young LA. Injuries from explosions: physics, biophysics, pathology, and required research focus. J Trauma 2009;66:1468–77.

4. Brook OR, Eran A, Engel A. CT multiplanar reconstructions (MPR) for shrapnel injury trajectory. Emerg Radiol 2012;19:43–51.

5. Covey DC. Blast and fragment injuries of the musculoskeletal system. J Bone Joint Surg Am 2002;84:1221–34.

6. Hollerman JJ, Fackler ML, Coldwell DM, Ben-Menachem Y. Gunshot wounds: 1. Bullets, ballistics, and mechanisms of injury. AJR Am J Roentgenol 1990;155:685–90.

7. Singh AK, Ditkofsky NG, York JD, Abujudeh HH, Avery LA, Brunner JF, et al. Blast Injuries: From Improvised Explosive Device Blasts to the Boston Marathon Bombing. Radiographics 2016;36:295–307.

8. Breeze J, Leason J, Gibb I, Allanson-Bailey L, Hunt N, Hepper A, et al.

Characterisation of explosive fragments injuring the neck. Br J Oral Maxillofac Surg 2013;51:e263–6.

9. Yazgan C, Aksu NM. Imaging features of blast injuries: experience from 2015 Ankara bombing in Turkey. Br J Radiol 2016;89:20160063.

10. Singh AK, Sodickson A, Abujudeh H. Imaging of abdominal and pelvic injuries from the Boston Marathon bombing. Emerg Radiol 2016;23:35– 9.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Çatışmaya bağlı şarapnellerin dağılım karakteristikleri ile bu dağılımın silah tipi ve çatışma bölgesi ile ilişkisi: Operasyon bölgesi hastanesindeki deneyimler Dr. Sinan Akay,1 Dr. Mehmet Burak Aşık,2 Dr. Sami Eksert3 Dr. Aşkım Tüfekçi Devlet Hastanesi, Radyoloji Kliniği, Adana Gülhane Eğitim ve Araştırma Hastanesi, Kulak-Burun-Boğaz Kliniği, Ankara 3 Gülhane Eğitim ve Araştırma Hastanesi, Anestezi ve Reanimasyon Kliniği, Ankara 1 2

AMAÇ: Şarapnele bağlı blastik yaralanmalar çatışmalar sırasında en sık görülen yaralanma şeklidir. Bu çalışmada, şarapnellerin vücuttaki dağılım karakteristiklerini, bu dağılımın silah tipleri ve çatışma bölgeleri ile olası ilişkisini araştırmayı amaçladık.

GEREÇ VE YÖNTEM: Operasyon bölgesinde bulunan hastanemize ateşli silah yaralanması nedeniyle getirilen 246 ardışık hastanın tıbbi kayıtları geriye dönük olarak değerlendirildi. Vücuduna radyolojik olarak kanıtlanmış en az bir şarapnel isabet etmiş olan 90 hasta çalışmaya dahil edildi. Tüm vücut beş bölgeye (baş-boyun, göğüs-sırt, batın-bel, üst ve alt ekstremite) ayrılarak şarapnellerin vücuttaki dağılımı not edildi. Silah tipi (uzun namlulu silah, roket veya el yapımı patlayıcı-mayın), çatışma bölgesi (şehir içi ve kırsal alan) ve hastalara ait tüm radyolojik incelemeler (radyografi ve/veya bilgisayarlı tomografi) değerlendirildi. Şarapnel dağılımı ile bu değişkenler arasındaki olası ilişki araştırıldı.

BULGULAR: Roket ve el yapımı patlayıcı-mayın yaralanmaları ile baş-boyun bölgesi yaralanmaları arasında istatistiksel olarak anlamlı ilişkinin dışında (p=0.002) silah tipleri ve şarapnel dağılımı arasında anlamlı fark bulamadık (p>0.05). Şarapnel dağılımı ile çatışma bölgesi arasında ise anlamlı farklılık saptamadık (p>0.05).

TARTIŞMA: Penetran şarapnellere bağlı sekonder blastik yaralanmalar patlayıcı ve çatışma ile ilişkili yaralanmaların en sık görülen şeklidir. Bu çalışmada, roket ve el yapımı patlayıcı-mayın ile oluşan yaralanmalarda uzun namlulu silah yaralanmalarına göre baş-boyun bölgesi şarapnel yaralanmalarının belirgin olarak daha yüksek oranda olduğunu bulduk. Bu tip yaralanmaların beklenmedik zamanlarda oluşması ve rutin olarak kullanılmakta olan koruyucu çelik yeleğin torakoabdominal şarapnel yaralanmalarına karşı koruyucu etkisinin bu sonucun ana nedenleri olduğuna inanıyoruz.

Anahtar sözcükler: Bilgisayarlı tomografi; blastik yaralanma; çatışmaya bağlı yaralanma; radyografi; şarapnel.

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Duodenal intramural hematoma due to early postoperative anticoagulant treatment after a renal transplant: A case report Adem Bayraktar, M.D., Leman Damla Ercan, M.D., Hüseyin Bakkaloğlu, M.D., Ali Fuat Kaan Gök, M.D., Mehmet İlhan, M.D., Ali Emin Aydın, M.D. Department of General Surgery, İstanbul University İstanbul Faculty of Medicine, İstanbul-Turkey

ABSTRACT A spontaneous intramural duodenal hematoma is a rare complication in patients receiving anticoagulation therapy. Presently described is a case of intramural duodenal hematoma in a patient with a cadaveric renal transplant who was under oral anticoagulant treatment due to paroxysmal atrial fibrillation. The patient was admitted with intense abdominal pain, nausea, vomiting, and a total obstruction of duodenum. After a diagnosis of intramural hematoma, a good prognosis was achieved with conservative care.

Keywords: Anticoagulant; intramural duodenal hematoma, renal transplantation.

INTRODUCTION The intramural duodenal hematoma was first reported as “a false aneurysm” of the intestinal wall by McLauchlan during an autopsy in 1838.[1] An intramural duodenal hematoma usually occurs secondary to blunt abdominal trauma.[2,3] There are cases in the literature where an intramural duodenal hematoma occurs spontaneously and consequently the patient presents with abdominal pain due to partial gut obstruction. Spontaneous intramural duodenal hematomas are commonly associated with coagulopathy, anticoagulating drugs or sometimes with endoscopic procedures.[4–7] Warfarin is one of the usual suspects in these cases with a frequency of one case per 2500 anticoaugulated patients annually.[8]

CASE REPORT Fourty eight years old female patient had a cadaveric renal transplantation for end-stage renal disease secondary to hypertension and vesicoureteral reflux. She suffered early post-operative tachycardia diagnosed as paroxysmal atrial fibrillation which was managed with warfarin therapy. At the time of her discharge renal functions were normal and the

International Normalised Ratio (INR) level was 2.1. Approximately 45 days after the transplant she was admitted to the emergency department with a two days history of epigastric pain, nausea and recurrent vomiting with no prior history of trauma. Abdominal examination was non-specific except for a relatively mild epigastric tenderness. Laboratory workup showed an increase in white cell count (14000 cells/mm3), but both liver and kidney functions were normal (creatine: 0.7 mg/dL). INR was 6.2 at the time and she was given fresh frozen plasma (FFP)/vitamin K combination to reduce INR levels. Plain graphies of the abdomen suggested intestinal obstruction. A nasogastric (NG) tube was inserted and 1500 cc bile colored intestinal fluid aspirated.

Upper gastrointestinal (UGI) water soluble contrast series showed minimal contrast passage to distal part and a collection of the barium in the 3rd portion of the duodenum (Fig. 1a, b). A subsequent UGI endoscopy confirmed dilatation of the 3rd portion of the duodenum and a total obstruction with an accumulation of drug tablets proximal to this level (Fig. 1c, d). CT scan of the abdomen/pelvis region with oral contrast demonstrated a non-enhanced, mildly hyperdense duo-

Cite this article as: Bayraktar A, Ercan LD, Bakkaloğlu H, Gök AFK, İlhan M, Aydın AE. Duodenal intramural hematoma due to early postoperative anticoagulant treatment after a renal transplant: A case report. Ulus Travma Acil Cerrahi Derg 2018;24:594-596.

Address for correspondence: Adem Bayraktar, M.D. İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 414 20 00 E-mail: dradem61@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):594-596 DOI: 10.5505/tjtes.2018.43637 Submitted: 13.09.2018 Accepted: 24.11.2018 Online: 29.11.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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(b)

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Figure 1. (a) AXR image on admission. (b) Collection of barium contrast in the duodenum in upper GI series. (c, d) Thickened third segment of the duodenum, total obstruction of the duodenum, accumulated tablets in the third segment of the duodenum.

denal mass with a dilated intestinal segment proximal to this mass (Fig. 2a-d). The exact size of the mass cannot be measured due to the lack of IV contrast. Spontaneous intramural hematoma of the 4th portion of duodenum was suspected to be the cause and prolonged coagulopathy was thought to be the etiology of this situation.

to usage of anticoagulant drugs. Oral anticoagulants such as warfarin are widely used and the most common complication is bleeding.[9] According to recent studies spontaneos intramural hematomas most commonly involve jejenum followed by ileum and duodenum; which is different than the traumatic intramural hematomas which mostly involves duodenum.[10]

After the initial diagnosis, decompression with a NG tube was obtained and a conservative treatment modality was followed through. In the following period, drainage from the NG tube decreased steadily. After removal of the NG tube, the patient was given standard oral feeding regimen which was tolerated without any problems.

A spontaneous intramural duodenal hematoma usually presents with intense abdominal pain followed by nausea and vomiting. Patients can be symptomatic for several days prior to presentation or diagnosis.[11â&#x20AC;&#x201C;14] Several radiographic features have been described. These include a thickened intestinal wall on ultrasonography or circumferential wall thickening, intramural hyperdensity, luminal narrowing and intestinal obstruction on CT.[15,16] The problem is; these kind of radiologic abnormalities are not specific for intestinal tract hematomas and can resemble other pathologies.[16] So the clinician should have a low threshold in suspecting of a possible intramural hematoma diagnosis.

In the end, no operative intervention was needed and obstructive symptoms resolved under conservative therapy without any complications. The patient was discharged with low molecular weight heparin treatment which was continued for six months. After an uneventful six months, the treatment ended and no additional intervention was needed in this time period.

DISCUSSION Spontaneous intramural duodenal hematoma is commonly associated with coagulation abnormalities resulting secondary

(a)

(b)

Apart from conventional USG and CT, UGI endoscopy is also a powerful tool in these cases. With the help of endoscopy, it is possible to both visualize and cure small-bowel hematomas.

[17,18] Young Lee et al.[19] presented a case of an intramural

(c)

(d)

Figure 2. (a, b) Duodenal wall thickening. (c) A thickened third segment of the duodenum. (d) Radio-opaque image of accumulated tablets in the third segment of the duodenum.

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duodenal hematoma secondary to acute pancreatitis, which was cured by endoscopic decompression.

For management of spontaneous intestinal hematoma, there is not a global concensus on one specific approach. It usually responds well to conservative management within 10–15 days.

[12,13] The conservative management consists of stopping oral anticoagulants immediately and starting a simultaneous infusion of FFP/vitamin K for reversal of anticoagulant effects. If the patient presents with obstructive symptoms; a NG tube should be administered swiftly and the drainage should be monitored closely.

Most cases have good prognosis with conservative care and the hematoma can start to regress as early as the first week.

But more often, a two-month period is needed for complete resolution. If a lesion persists for more than 2 months without any significant resolution, other causes such as inflammatory bowel disease, tuberculosis, lymphoma, etc. should be suspected and investigated thoroughly.[14] Both short-term and long-term outcomes are good in the absence of any other concurrent conditions.

A spontaneous intramural intestinal hematoma especially a duodenal one is a rare complication stemming from anticoagulating treatment modalities. Even though it is sometimes hard to diagnose properly, once the diagnosis is made it has a mild prognosis and it is a manageable complication with conservative means.

Conflict of interest: None declared.

REFERENCES 1. McLauchlan, J. Fatal false aneurysmal tumour occupying nearly the whole of the duodenum. Lancet 2 1838;30:203–5.

2. Hayashi K, Futagawa S, Kozaki S, Hirao K, Hombo Z. Ultrasound and CT diagnosis of intramural duodenal hematoma. Pediatr Radiol 1988;18:167–8.

3. Jewett TC Jr, Caldarola V, Karp MP, Allen JE, Cooney DR. Intramural hematoma of the duodenum. Arch Surg 1988;123:54–8.

4. Polat C, Dervisoglu A, Guven H, Kaya E, Malazgirt Z, Danaci M, et al. Anticoagulant-induced intramural intestinal hematoma. Am J Emerg Med 2003;21:208–11.

5. Tseng CY, Fan JS, Yang SC, Huang HH, Chen JD, Yen DH, et al. Anti-

coagulant-induced intramural intestinal hemorrhage. Am J Emerg Med 2010;28:937–40.

6. Abbas MA, Collins JM, Olden KW. Spontaneous intramural smallbowel hematoma: imaging findings and outcome. AJR Am J Roentgenol 2002;179:1389–94.

7. Grasshof C, Wolf A, Neuwirth F, Posovszky C. Intramural duodenal haematoma after endoscopic biopsy: case report and review of the literature. Case Rep Gastroenterol 2012;6:5–14.

8. Bettler S, Montani S, Bachmann F. Incidence of intramural digestive system hematoma in anticoagulation. Epidemiologic study and clinical aspects of 59 cases observed in Switzerland (1970-1975). [Article in French]. Schweiz Med Wochenschr 1983;113:630–6.

9. Palareti G, Leali N, Coccheri S, Poggi M, Manotti C, D’Angelo A, et al.

Bleeding complications of oral anticoagulant treatment: an inception-cohort, prospective collaborative study (ISCOAT). Italian Study on Complications of Oral Anticoagulant Therapy. Lancet 1996;348:423–8.

10. Chaiteerakij R, Treeprasertsuk S, Mahachai V, Kullavanijaya P. Anticoagulant-induced intramural intestinal hematoma: report of three cases and literature review. J Med Assoc Thai 2008;91:1285–90.

11. Gutstein DE, Rosenberg SJ. Nontraumatic intramural hematoma of the duodenum complicating warfarin therapy. Mt Sinai J Med 1997;64:339–41.

12. Sorbello MP, Utiyama EM, Parreira JG, Birolini D, Rasslan S. Spontaneous intramural small bowel hematoma induced by anticoagulant therapy: review and case report. Clinics (Sao Paulo) 2007;62:785–90.

13. Takishima T, Hirata M, Kataoka Y, Naito T, Ohwada T, Kakita A. Delayed development of obstructive jaundice and pancreatitis resulting from traumatic intramural hematoma of the duodenum: report of a case requiring deferred laparotomy. J Trauma 2000;49:160–2.

14. Abbas MA, Collins JM, Olden KW, Kelly KA. Spontaneous intramural small-bowel hematoma: clinical presentation and long-term outcome.

Arch Surg 2002;137:306–10.

15. Lane MJ, Katz DS, Mindelzun RE, Jeffrey RB Jr. Spontaneous intramural small bowel haemorrhage: importance of non-contrast CT. Clin Radiol. 1997 May;52(5):378-80.

16. Rauh P, Uhle C, Ensberg D, Rickes S, Mönkemüller K, Fry L, et al. Sonographic characteristics of intramural bowel hematoma. J Clin Ultrasound 2008;36:367–8.

17. Shinozaki S, Yamamoto H, Kita H, Yano T, Miyata T, Sunada K, et al. Direct observation with double-balloon enteroscopy of an intestinal intramural hematoma resulting in anticoagulant ileus. Dig Dis Sci 2004;49:902–5.

18. Kwon CI, Ko KH, Kim HY, Hong SP, Hwang SG, Park PW, et al. Bowel obstruction caused by an intramural duodenal hematoma: a case report of endoscopic incision and drainage. J Korean Med Sci 2009;24:179–83.

19. Lee JY, Chung JS, Kim TH. Successful endoscopic decompression for intramural duodenal hematoma with gastric outlet obstruction complicating acute pancreatitis. Clin Endosc 2012;45:202–4.

OLGU SUNUMU - ÖZET

Böbrek nakli sonrası erken dönemde antikoagülan kullanımına bağlı gelişen duodenum intramural hamatomu: Olgu sunumu Dr. Adem Bayraktar, Dr. Leman Damla Ercan, Dr. Hüseyin Bakkaloğlu, Dr. Ali Fuat Kaan Gök, Dr. Mehmet İlhan, Dr. Ali Emin Aydın İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul

Spontan duodenal hematom, antikolagülan tedavi uygulanan hastalarda nadir rastlanan bir komplikasyondur. Bu olgu örneğinde, kadavradan böbrek nakli sonrası gelişen paroksismal atriyal fibrillasyon nedeniyle oral antikoagülan tedavi almakta olan hastada karşılaşılan spontan duodenal hematom olgusu sunulmaktadır. Karın ağrısı, bulantı-kusma şikayetleriyle başvuran ve tam duodenal obstrüksiyon saptanan hastada spontan duodenal hematom tanısı konulduktan sonra konservatif tedavi ile iyi bir prognoz sağlanmıştır.

Anahtar sözcükler: Antikoagülan; böbrek nakli; intramural duodenal hematom.

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The importance of clinical approach in aggravated sexual abuse: Case report Gökmen Karabağ, M.D.,1 Halil İbrahim Tanrıverdi, M.D.,2 Mehmet Sunay Yavuz, M.D.,1 Abdülkadir Genç, M.D.,2 Ufuk Akın, M.D.,1 Selma Saraç, M.D.1 1

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

2

Department of Pediatric Surgery, Manisa Celal Bayar University Faculty of Medicine, Manisa-Turkey

ABSTRACT The reported rate of sex crimes, some of the most severe acts of violence that can be perpetrated against an individual, is increasing across all societies, regardless of gender or age of the victim. Sexual abuse has been defined, in part, as the involvement of a child in sexual activity for which they are incapable of giving consent, that they cannot fully comprehend, or for which they are developmentally immature. Molestation of the anorectal region is frequently encountered when the victim of sexual abuse is a male child. Tenderness around the anus, ecchymosis, and detachment in the anal sphincter and rectum mucosa may be observed in the acute examination of children who have been subjected to aggravated sexual abuse; however, injuries related to the anus or the rectum may also occur as a result of an accident. An 11-year-old male patient was referred from another health center with a report of being at risk of death.

The injury that was said to be the result of accidentally sitting on a knife. An examination in the lithotomy position revealed perianal ecchymosis, a superficial laceration at 1 and 6 o’clock, and a deep laceration at 7 o’clock. Based upon a suspicion of sexual abuse, anal and rectal swab specimens were obtained. The pediatric surgery department performed a primary repair of the lacerations. The microscopic examination of the swab specimens revealed cells showing sperm morphology, and therefore the appropriate forensic statements were made and the swab specimens were sent to the judicial authority for genetic analysis. This report emphasizes the importance of the awareness of physicians regarding the prompt collection and submission of potentially evidential biological samples in a case of suspected sexual abuse though it may be presented as an accident.

Keywords: Biological sample; forensic medicine; sexual abuse.

INTRODUCTION The reported number of sex crimes, which are among the most serious crimes that may committed against an individual, has been increasing in recent years, with victims of both sexes and from all age groups.[1,2] Acts of sexual abuse against males are most often seen in childhood, especially in the puberty phase, when psychosexual development has occurred.

[3–5] Sexual abuse cases are assessed on a broad spectrum, from the level of basic contact to penetration. If the victim is a male child, in most cases, the exploiter uses the anorectal region for sexual intercourse.[3,6] In the examination of

these cases, physicians may observe acute symptoms, such as ecchymosis around the anus and laceration of the sphincter or rectum; however, similar lesions might also be seen in cases of accidents.[7] In the differential diagnosis between lacerations and incised wounds, tissue bridging is present in laceration injuries, and is typically accompanied by irregular wound edges and ecchymoses, while sharp object injuries do not demonstrate these characteristics.[8,9] This case of apparent aggravated sexual abuse presented with an anamnesis of an accident. It emphasizes the importance of the clinical physicians’ approach algorithms when encoun-

Cite this article as: Karabağ G, Tanrıverdi Hİ, Yavuz MS, Genç A, Akın U, Saraç S. The importance of clinical approach in aggravated sexual abuse: Case report. Ulus Travma Acil Cerrahi Derg 2018;24:597-600.

Address for correspondence: Gökmen Karabağ, M.D. Manisa Celal Bayar Üniversitesi, Dekanlık Binası, Adli Tıp Anabilim Dalı, Uncubozköy, 45030 Manisa, Turkey Tel: +90 236 - 201 10 00 E-mail: gkmnkrbg@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):597-600 DOI: 10.5505/tjtes.2018.60063 Submitted: 12.06.2018 Accepted: 28.08.2018 Online: 13.11.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Figure 1. (a-c) Preoperative photograph of the patient.

tering symptoms of possible sexual abuse and highlights the importance of properly obtaining samples that might be considered evidence.

CASE REPORT An 11-year-old male patient who had presented at another health care center with the statement of having sustained an accidental injury as the result of accidentally sitting on a knife was sent to our hospital on the same day with a statement that he could be at grave risk. The general examination indicated that the patient was conscious, cooperative, and had stable vital signs. An anal examination of the patient in the lithotomy position revealed a 1.5-cm superficial laceration at the 1 o’clock position that passed through the dentate line with involvement of the mucosa; another superficial laceration approximately 1 cm in length at the 6 o’clock position, also involving the mucosa, but not crossing the dentate line; a 3-cm long area of deep lacerations at the 7 o’clock position that passed through dentate line and included the mucosa and some parts of the lower internal sphincter; an ecchymotic halo around the anus; and a significant reduction in anal sphincter tone (Fig. 1a-c). Outside of the anorectal region, there were no trauma marks or visible injuries to the body. A swab was taken from the anus and the rectum and analyzed microscopically (Fig. 2). Subsequently, following staining and sterile draping in the lithotomy position, the superficial lacerations at the 1 and 6 o’clock positions were primarily repaired with separate sutures under general anesthesia, and primary repair of the mucosa for the deep laceration at the 7 o’clock position was performed after the muscle layers were individually pulled together (Fig. 3). Subsequent examination with an anal stimulator indicated that contraction was present in all quadrants around the anus except at the site of the laceration line at 7 o’clock.

The results of Gram staining of samples from the laceration areas, perianal ecchymotic halo, and swab specimens revealed cells with sperm morphology, and accordingly, the case was processed as potential aggravated sexual abuse. The required forensic reports were completed and the samples obtained were sent to the office of the chief public prosecutor for genetic analysis.

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Figure 2. Sperm cells observed in the smear preparation from the anal swab sample.

Figure 3. Postoperative photograph of the patient.

DISCUSSION Child abuse, a serious problem that may have traumatic consequences for the physical, mental, and social development of victims, has been defined, in part, by the World Health Organization as acts and omissions committed by an adult, society, or state that affect the child’s physical, psychological, Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

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and social development.[10] Sexual abuse, defined within the category of child abuse, has been defined as the use of a child for sexual stimulation by an adult or another child.[11–13] According Article 103 of the Turkish Penal Code, sexual abuse is defined as any sexual act committed against a minor under the age of 15, or one who, in spite of having reached 15 years of age, lacks the competence to understand the legal significance and consequences of such acts, as well as sexual acts committed against minors by means of force, threat, deception or any other means of influence. Article 280 of the Turkish Penal Code states that health workers, such as doctors, nurses, and psychologists, etc., who suspect that an act of child abuse may have occurred are obliged to inform the appropriate authorities.[14] Turkish healthcare professionals have ethical and legal obligations related to the diagnosis and treatment of child abuse and need to be well informed.[15]

the appropriate authorized court under the Child Protection Law No. 5395 of 03/07/2005 regarding the well-being of juveniles. Institutions and individuals who are responsible for the care of a juvenile can apply to the Social Services and Child Protection Agency to take the juvenile under protection and the case is sent to the relevant court. Children who urgently require preventive protective measures may be taken into custody and cared for by governmental or private organizations until the court decision.[17,18] The objective of presenting this report of child sexual abuse in a patient who presented with an accident anamnesis was to illustrate the importance of the approach applied by physicians who suspect abuse and the appropriate collection and conveyance of evidential biological samples to judicial authorities.

Conflict of interest: None declared.

The initial examination in the present case, which was presented with the anamnesis of accidental sitting on a knife, led the doctors to suspect aggravated anal sexual abuse based upon the observation of lacerations in 3 quadrants of the anal region that were unlike the laceration expected in a case of a perforating injury. Furthermore, observation of an ecchymotic halo around the anus and a significant reduction in anal sphincter tone strongly supported this suspicion. Therefore, photographs were taken and a swab specimen was collected pre-operatively, which yielded a result of cells with sperm morphology, further supporting the conclusion of aggravated anal sexual abuse. Prompt transmission of these evidential biological samples to the relevant judicial authorities to reduce any possibility of deterioration or loss is a good example of the use of the sexual abuse approach algorithm in the clinic.

Most cases of sexual violence are not reported to the judicial authorities due to social pressure and moral concerns.[3] As in other cases of sexual abuse and assault, there is a tendency among male victims to conceal the event.[3,6] Similarly, our patient had been trying to hide this act of sexual exploitation and stated that the injury to the anal region was the result of his own act of accidentally sitting on a knife.

It is crucial to follow a scientific, systematic, multidisciplinary, and robust approach to the prevention of violence, which is a multidimensional public health problem, just as it is in the case of other diseases.[16] According to the 6th article of the Child Protection Law in our country, judicial and administrative authorities, law enforcement officers, health and education institutions, and non-governmental organizations are obliged to report children who need protection to the Social Services and Child Protection Agency. Both the child and the person responsible for the care of the child may apply to the Social Services and Child Protection Agency for the protection of the child. According to the 22nd article of the Social Service Law, for children who need protection, the decision for any necessary relevant injunction can be made by Ulus Travma Acil Cerrahi Derg, November 2018, Vol. 24, No. 6

REFERENCES 1. Glover K, Olfson M, Gameroff MJ, Neria Y. Assault and mental disorders: a cross-sectional study of urban adult primary care patients. Psychiatr Serv 2010;61:1018–23.

2. Luce H, Schrager S, Gilchrist V. Sexual assault of women. Am Fam Physician 2010;81:489–95.

3. Pınarbaşılı RDT, Özkök MS, Katkıcı U, Erel Ö, Dirlik M. Male sexual abuse in Aydın [Article in Turkish]. Adli Tıp Bülteni 2003;8:41–7.

4. King M, Wollett E. Sexually assaulted males: 115 men consulting a counseling service. Arch Sex Behav 1997;26:579–88.

5. Kairys SW, Alexander RC, Block RW, Everret VD, Hymel KP, Johnson CF, et al. Guidelines for the evaluation of sexual abuse of children. Pediatrics 1999;103:186–91.

6. Bartuçu, Yavuz MF, Çetin G. Problems Faced by the Victims of Sexual Assault [Article in Turkish]. Adli Tıp Bülteni 1999;4:41–53.

7. Koç S. Adli tıpta rapor hazırlama tekniği ve rapor örnekleri. In: Soysal Z, Çakalır C, editors. Adli Tıp. Volume III. İstanbul: İstanbul Üniversitesi Basımevi ve Film Merkezi; 1999. p. 1587–9.

8. DiMaio VJ, DiMaio D. Blunt trauma wounds. In: DiMaio VJ, DiMaio D, editors. Forensic Pathology. 2nd ed. London: CRC Press; 2001. p.

91–116.

9. Prahlow JA. Sharp force injuries. In: Froede RC, editor. Handbook of Forensic Pathology. 2nd ed. Illinois: CRC Press; 2003. p. 159–73.

10. Polat O, İnanıcı MA, Aksoy ME. Adli Tıp Ders Kitabı. İstanbul: Nobel Tıp Kitabevleri; 1997. p. 291–2.

11. Tıraşçı Y, Gören S. Child Abuse and Neglect [Article in Turkish]. Dicle Tıp Dergisi 2007;34:70–4.

12. Polat O. Adli Tıp. İstanbul: Der Yayınları; 2000. p. 207–16.

13. Türk Tabipler Birliği. Çocuk istismarı ve ihmali. In: Birinci Basamak İçin Adli Tıp El Kitabı. Nisan 1999. p. 135–46.

14. Türk Ceza Kanunu. Available at: http://www.mevzuat.gov.tr/MevzuatMetin/1.5.5237.pdf. Accessed Sep 3, 2018.

15. Ovayolu N, Uçan Ö, Serindağ S. Sexual Abuse in Child and Its Effects [Article in Turkish]. Fırat Sağlık Hizmetleri Dergisi 2007;2:13–22.

16. Kara B, Biçer Ü, Gökalp AS. Child abuse [Article in Turkish]. Çocuk Sağlığı ve Hastalıkları Dergisi 2004;47:140–51.

17. Çocuk Koruma Kanunu. Available at: http://www.resmigazete.gov.tr/ eskiler/2005/07/20050715-1.htm. Accessed Sep 3, 2018.

18. Sosyal Hizmetler Kanunu. Available at: http://www.mevzuat.gov.tr/ MevzuatMetin/1.5.2828.pdf. Accessed Sep 3, 2018.

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Karabağ et al. The importance of clinical approach in aggravated sexual abuse

OLGU SUNUMU - ÖZET

Nitelikli cinsel istismarda klinik yaklaşımın önemi: Olgu sunumu Dr. Gökmen Karabağ,1 Dr. Halil İbrahim Tanrıverdi,2 Dr. Mehmet Sunay Yavuz,1 Dr. Abdülkadir Genç,2 Dr. Ufuk Akın,1 Dr. Selma Saraç1 1 2

Manisa Celal Bayar Üniversitesi Tıp Fakültesi, Adli Tıp Anabilim Dalı, Manisa Manisa Celal Bayar Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Manisa

Bireye karşı işlenen en ağır eylemlerden olan cinsel suçlar, cinsiyet ve yaş farkı gözetmeksizin giderek tüm toplumlarda artış göstermektedir. Çocukların cinsel istismarı; gelişimsel olarak olgunlaşmamış çocukların, bilinçli bir şekilde onay vermeye muktedir olmadıkları ve bütünüyle algılayamadıkları cinsel aktivitelerde taraf olmalarıdır. Cinsel istismarda anorektal bölgenin kullanılması sıklıkla erkek çocukların kurban olduğu olaylarda karşımıza çıkmaktadır. Anal yoldan nitelikli cinsel istismara uğrayan çocukların yapılan muayenesinde; akut bulgu olarak anüs etrafında hassasiyet, ekimoz, anal sfinkterde ve rektum mukozasında yırtılmalar görülebilmekle birlikte; kaza sonucu da anüs veya rektumu ilgilendiren yaralanmalar oluşabilir.

Bıçağın üzerine oturma sonucu yaralandığı ve hayati tehlikesi olduğu için dış merkezden hastanemize yönlendirilen 11 yaşında erkek olgunun litotomi pozisyonunda yapılan muayenesinde; perianal ekimoz, saat bir ve altı hizasında yüzeyel, saat yedi hizasında derin laserasyon hattı görülmüş, cinsel istismardan şüphelenilmesi üzerine anüs ve rektumdan sürüntü örnekleri alınmış, daha sonra çocuk cerrahisi tarafından operasyona alınarak laserasyonlar primer olarak onarılmıştır. Alınan sürüntülerden hazırlanan preparatın mikroskopik incelemesinde sperm morfolojisine sahip hücreler izlenmiş ve adli bildirim yapılarak alınan örnekler genetik çalışmalar için ilgili yargı makamına gönderilmiştir. Çalışmamızda, kaza öyküsü ile başvuran fakat yapılan muayenelerinde nitelikli cinsel istismardan şüphelenilenmesi üzerine operasyon öncesi örnekleri alınan bir olgu sunularak, klinikte cinsel istismardan şüphelenen hekimlerin olguya bakış açısı, delil niteliğinde sayılabilecek biyolojik materyallerin bozulmadan ve kaybolmadan elde etmenin ve ilgili adli makamlara ulaştırmanın önemi vurgulanmıştır.

Anahtar sözcükler: Adli tıp; biyolojik örnek; cinsel istismar.

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CAS E R EP O RT

Treatment with vacuum-assisted closure system: A case of anastomotic leak after upper gastrointestinal surgery Seracettin Eğin, M.D., Ali Alemdar, M.D., Burak Güney, M.D., Hakan Güven, M.D.

Fazıl Sağlam, M.D.,

Department of General Surgery, University of Health Sciences, Okmeydanı Training and Research Hospital, İstanbul-Turkey

ABSTRACT Presently described is a case treated via stent and vacuum-assisted closure (VAC). The patient developed an oesophagojejunostomy leak (OL) on the ninth postoperative day after a radical total gastrectomy. The patient was a 55-year-old male patient with adenocarcinoma localized to the small curvature on the corpus of the stomach. Relaparatomy was performed for the OL, including placement of an uncovered stent. The abdomen was washed 4 times. As the OL did not decrease, 2 covered stents (22 mm and 18 mm in diameter and 80 mm long) were inserted endoscopically.The OL continued to contaminate the abdomen. One tip of the VAC sponge was placed next to the anastomosis, and the other tip was removed from the left upper quadrant. Another VAC closure set was placed in the abdomen. Both VAC closures were connected to separate vacuum devices with 75 mmHg of pressure.VAC dressings were changed at regular intervals every 3 days, and these steps were repeated 7 times over 21 days. The covered stents were removed endoscopically in the final operation. Fistulography revealed that the OL was completely closed, and the VAC dressings were removed. The skin was closed by separating the subcutaneous oil layer of the fascia.VAC therapy can not only provide serious abdominal sepsis treatment and primary source control, but also accelerate granulation development and, in this case, quickly closed the anastomotic leakage.

Keywords: Anastomotic leak; oesophageal stent; open abdomen; vacuum assisted closure.

INTRODUCTION Anastomotic leak (AL) after upper gastrointestinal system surgery is life-threatening. Endoscopically applied oesophageal stents and percutaneous drainage via radiological imaging are conventional minimally invasive strategies for the treatment of AL. When a leak is stented and treatment with minimally invasive methods, such as percutaneous drainage, is attempted, a continuing leak can become the primary origin of abdominal sepsis. Minimally invasive treatment modalities are sometimes not sufficient for source control and sepsis management, and therefore there can be a high mortality rate in these patients. Although the popularity and frequency of use of the Bogota bag have decreased, this procedure is still used in a staged laparotomy after intra-abdominal irrigation and passive drainage. This application can increase the inci-

dence of enteroatmospheric fistula, as well as damage to the fascia and skin. Sometimes, abdominal irrigation in repeated laparotomies is used to try to control intra-abdominal sepsis.

Mortality and morbidity increase with repeated operations.

Moreover, the length of hospital stay is extended.

Presently described is a case in which, within a short time, the open abdomen (OA) technique with vacuum-assisted closure (VAC) was implemented in addition to oesophageal stent applications for an oesophagojejunostomy leak originating from open radical total gastrectomy and D2 lymph node dissection.

CASE REPORT An open radical total gastrectomy was performed for a

Cite this article as: Eğin S, Alemdar A, Sağlam F, Güney B, Güven H. Treatment with vacuum-assisted closure system: A case of anastomotic leak after upper gastrointestinal surgery. Ulus Travma Acil Cerrahi Derg 2018;24:601-603.

Address for correspondence: Seracettin Eğin, M.D. Sağlık Bilimleri Üniversitesi, Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey Tel: +90 212 - 314 55 55 E-mail: seracettin_egin@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):601-603 DOI: 10.5505/tjtes.2018.23238 Submitted: 10.08.2017 Accepted: 15.10.2018 Online: 01.11.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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EÄ&#x;in et al. Treatment with vacuum-assisted closure system: A case of anastomotic leak after upper gastrointestinal surgery

55-year-old male patient on October 24, 2016. AL was verified with computerized tomography on October 30, 2016, and the case was observed conservatively until the postoperative ninth day. Relaparotomy was performed on the postoperative ninth day. Endoscopy was performed during the operation and a 5-mm patency was seen on the blind small intestine side of the oesophagojejunostomy line. An uncovered stent passed through the anastomosis line was positioned.

The inside of the abdomen was cleaned with saline and the skin was closed. The procedure was performed twice more on the postoperative 10th and 13th days. On the postoperative 14th day, a fluoroscopic examination was performed using contrast. An AL was identified in the abdomen (Fig. 1a). On the postoperative 15th day, 2 covered stents, 22 mm and 18 mm in diameter, were inserted within the earlier stent. On the postoperative 17th day, a VAC management system was applied (ABThera Open Abdomen Management System; Kinetic Concepts Inc./Acelity, L.P. Inc., San Antonio, TX, USA).

One of the additional sponge extensions was extracted from the management system. One tip of the extracted additional sponge extension was placed next to the anastomosis under the left diaphragm and the other tip was taken out of the left upper quadrant. Five additional sponge extensions were carried out the intra-abdominal cavity. Both were separately connected to 2 vacuum devices with 75 mmHg pressure. The external appearance after the first VAC application can be seen in Figure 1b. VAC procedures were carried out with a 3-day interval, taking a liquid culture from the abdomen and washing the abdomen. The second VAC procedure is shown in Figure 1c. The suppurative collection in the left subdiaphragmatic cavity is illustrated in Figure 1d. It was observed during the fluoroscopic examination performed on the postoperative 29th day that the AL persisted (Fig. 1e). On the postoperative 34th day, the covered stents were removed, but

(a)

(f)

(b)

(c)

(g)

the uncovered stent could not be extracted. A fluoroscopic examination was performed on the postoperative 36th day and the AL was not present (Fig. 1f). The seventh and last VAC procedure was performed on the postoperative 37th day. No collection in the left subdiaphragmatic cavity was observed during this procedure (Fig. 1g). The VAC dressing was removed on the postoperative 41st day. The subcutaneous layer was then dissected from the fascial layer of the anterior wall of the abdomen (Fig. 1h). The abdominal skin was closed without tension (Fig. 1i). The entire clinical course of the case is summarized in the illustration (Fig. 1). The patient was discharged on the postoperative 58th day.

DISCUSSION The two-way VAC technique was added to the treatment plan when the intra-abdominal contamination and sepsis parameters did not resolve despite the application of oesophageal stents and planned re-laparotomies, in order to control the primary source. This technique can localize the peritoneal contamination by creating a separate tract for the AL. Thus, peritoneal contamination can be limited to a narrow region under the diaphragm, and the AL will not infect the intraabdominal cavity. In addition, VAC quickly improves granulation and completely closes the leak in a short amount of time. This patient was our first case using this strategy after an AL following upper gastrointestinal system surgery. To the best of our knowledge, there is no other case like ours in the literature.

Most leaks are minor and can be managed conservatively with nasogastric suction, local drainage, antibiotics, and jejunal feeding. If there is continuing or worsening sepsis, an early operation may be necessary for a good outcome. Recently, endoscopic interventions, such as esophageal stenting, have

(d)

(e)

(h)

(i)

Figure 1. (a) The leak was identified from oesophagojejunostomy. (b) The external appearance of the final state of VAC. (c) The appearance of the intestine during second VAC. (d) Collection in the left subdiaphragmatic cavity. (e) Anastomosis leak on the postoperative 29th day. (f) No contrast leak on the postoperative 36th day. (g) No collection in the left subdiaphragmatic cavity. (h) The subcutaneous layer dissected from the fascia. (i) The abdomen was closed with skin layer. VAC: Vacuum-assisted closure.

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been successfully used for the management of AL.[1] But these interventions may not always be sufficient for primary source control and abdominal sepsis management.

The high mortality rate is usually due to sepsis and the comorbidities of patients undergoing relaparotomy. A conservative approach should always be considered as the treatment of choice, as most leaks are minor and only demonstrated radiologically.[2] Reoperation may be necessary in cases of wide dehiscence or when other treatments fail. Major leakage from the oesophagojejunal anastomosis following total gastrectomy for gastric malignancy usually occurs early (within 72 hours of surgery) and mediastinitis is often fatal. Surgical re-exploration is warranted: either dismantling the anastomosis and performing a primary repair if feasible (but which is often futile), or the creation of a controlled fistula, and in all cases, performing washout, drainage, and insertion of feeding jejunostomy.[3,4] The best results can be achieved in leaks occurring after the very early postoperative phase with a covered self-expanding stent.[5] In delayed leaks, the decision is radiological drainage or surgical re-exploration.[3] Abdominal sepsis is the host’s systemic inflammatory response to bacterial or yeast peritonitis.[6] Severe sepsis is defined as sepsis associated with organ dysfunction or tissue hypoperfusion.[7] The OA technique may be an important option in the surgical management of severe peritonitis.[8] In OA, VAC techniques have used extensively as a method to achieve temporary abdominal wall closure.

In conclusion, VAC therapy not only provides serious abdominal sepsis treatment and primary source control, but also accelerates granulation development and closes the AL in a short period of time.

Conflict of interest: None declared.

REFERENCES 1. Schaheen L, Blackmon SH, Nason KS. Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review. Am J Surg 2014;208:536–43.

2. Sano T, Sasako M, Yamamoto S, Nashimoto A, Kurita A, Hiratsuka M, et al. Gastric cancer surgery: morbidity and mortality results from a prospective randomized controlled trial comparing D2 and extended para-aortic lymphadenectomy-Japan Clinical Oncology Group study 9501. J Clin Oncol 2004;22:2767–73.

3. Aurello P, Magistri P, D’Angelo F, Valabrega S, Sirimarco D, Tierno SM, et al. Treatment of esophagojejunal anastomosis leakage: a systematic review from the last two decades. Am Surg 2015;81:450–3.

4. Etoh T, Inomata M, Shiraishi N, Kitano S. Revisional surgery after gastrectomy for gastric cancer: review of the literature. Surg Laparosc Endosc Percutan Tech 2010;20:332–7.

5. Hoeppner J, Kulemann B, Seifert G, Marjanovic G, Fischer A, Hopt UT, et al. Covered self-expanding stent treatment for anastomotic leakage: outcomes in esophagogastric and esophagojejunal anastomoses. Surg Endosc 2014;28:1703–11.

6. Sartelli M, Catena F, Di Saverio S, Ansaloni L, Malangoni M, Moore EE, et al. Current concept of abdominal sepsis: WSES position paper. World J Emerg Surg 2014;9:22.

7. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, et al; International Surviving Sepsis Campaign Guidelines Committee; American Association of Critical-Care Nurses; American College of Chest Physicians; American College of Emergency Physicians; Canadian Critical Care Society; European Society of Clinical Microbiology and Infectious Diseases; et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.

Crit Care Med 2008;36:296–327.

8. Schein M. Surgical management of intra-abdominal infection: is there any evidence? Langenbecks Arch Surg 2002;387:1–7.

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Vakum yardımlı kapama sistemi ile tedavi: Üst gastrointestinal cerrahiden sonra anastomoz kaçağı olan bir olgu Dr. Seracettin Eğin, Dr. Ali Alemdar, Dr. Fazıl Sağlam, Dr. Burak Güney, Dr. Hakan Güven Sağlık Bilimleri Üniversitesi, Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

Radikal total gastrektomi sonrası ameliyat sonrası dokuzuncu günde ozofagojejunostomiden kaçak nedeniyle stent ve vakum yardımlı kapatma uyguladığımız olguyu sunmayı amaçladık. Mide korpus küçük kurvatüründe adenokarsinom olan 55 yaşındaki erkek hastaya radikal total gastrektomi yapıldı. Ameliyat sonrası dokuzuncu günde anastomoz kaçağı saptanması nedeniyle, kapsız stent yerleştirilmesini de içeren relaparatomi yapıldı.

Daha sonra karın dört defa yıkandı. Kaçak azalmadığından 22 ve 18 mm çapında 80 mm uzunluğundaki 2 kaplı stent içiçe endoskopik olarak yerleştirildi. Kaçak batını kirletmeye devam etti. Beşinci defa batın yıkama esnasında vakum yardımlı kapama (VAC) sistemi ile tedavi yönetimine karar verildi. VAC süngerinin bir ucu anastomozun yanına yerleştirildi ve diğer ucu sol üst kadrandan çıkarıldı. Batın içine başka bir VAC kapama seti yerleştirildi. Her iki VAC, 75 mmHg basınç ile iki ayrı vakum cihazına bağlandı. VAC değişiklikleri her üç günde bir düzenli aralıklarla 21 gün içinde yedi defa tekrarlandı. Kaplı stentler son operasyonda endoskopik olarak çıkarıldı. Ameliyat sonrası 36. gündeki fistülografide kaçağın tamamen kapandığını görüldü ve VAC sistemi çıkarıldı. Cilt, fascia üzerindeki subkütan yağ tabakasını ayırarak kapatıldı. VAC sistemlerinin uygulanması, ciddi batın içi sepsis tedavisi ve birincil kaynak kontrolü sağlamakla kalmaz aynı zamanda granülasyon gelişimini hızlandırır ve anastomoz kaçağını daha kısa zaman içinde kapatır Anahtar sözcükler: Açık karın; anastomoz kaçağı; özofagus stenti; vakum yardımlı kapama.

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doi: 10.5505/tjtes.2018.23238

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