TJTES 2019-1

ISSN 1306 - 696X

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

Volume 25 | Number 1 | January 2019

www.tjtes.org

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi Editor-in-Chief Recep Güloğlu Editors Kaya Sarıbeyoğlu 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): January (Ocak) 2019 • 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 25

Number - Sayı 1 January - Ocak 2019

Contents - İçindekiler ix-x Editorial - Editörden

Deneysel Çalışma - Experimental Experimental Studies - DeneyselStudy Çalışma 1-6 Effects of alpha-tocopherol on acute pancreatitis in rats Sıçanlarda alfa tokoferolün akut pankreatit üzerine etkileri Özgül H, Tatar C, Özer B, Aydın H, Sarı S, Peltek Özer S. 7-11 Effect of curcumin on lung injury induced by skeletal muscle ischemia/reperfusion in rats Sıçanlarda akciğer hasarının oluşturduğu iskelet kası iskemi/reperfüzyonu üzerine zerdeçalın etkisi Takhtfooladi HA, Takhtfooladi MA

Original Articles - Orijinal Çalışma 12-19 Is it beneficial to use clinical scoring systems for acute appendicitis in adults?

Yetişkinlerde akut apendisit için klinik skorlama sistemlerinin kullanılması yararlı mı?

Köse E, Hasbahçeci M, Aydın MC, Toy C, Saydam T, Özsoy A, Karahan SR 20-28 First step toward a better trauma management: Initial results of the Northern Izmir Trauma Registry System for children Çocuklarda daha iyi travma yönetimi için ilk adım: Kuzey İzmir Travma Kayıt Sistemi’nin ilk sonuçları Öztan MO, Anıl M, Anıl AB, Yaldız D, Uz İ, Turgut A, Köse I, Acar K, Sofuoğlu T, Akbulut G 29-33 Incidence, etiology, and patterns of maxillofacial traumas in Syrian patients in Hatay, Turkey: A 3 year retrospective study Türkiye Hatay’daki Suriyeli maksillofasial travmalı hastaların insidansı, etyolojisi ve örneği: Üç yıllık geriye dönük çalışma Arlı C, Özkan M, Karakuş A 34-38 Do the stump knotting technique and specimen retrieval method effect morbidity in laparoscopic appendectomy?

Laparoskopik apendektomide güdük bağlama tekniği ve spesimen çıkarma metodu morbiditeyi etkiliyor mu?

Ağalar C, Derici ZS, Çevlik AD, Aksoy SÖ, Egeli T, Boztaş N, Özbilgin M, Sarıoğlu S, Ünek T 39-45 A 4-year single-center experience in the management of esophageal perforation Özofagus perforasyonları yönetiminde tek merkez 4 yıllık deneyimimiz Sarı S, Bektaş H, Ulusan K, Koçak B, Gürbulak B, Çolak Ş, Çakar E, Buykara Ulusan M 46-54 Prognostic evaluation of cases with thoracic trauma admitted to the intensive care unit: 10-year clinical outcomes Yoğun bakım ünitesine başvuran toraks travmalı olguların prognostik değerlendirmesi: On yıllık sonuçlar Pehlivanlar Küçük M, Küçük AO, Aksoy İ, Aydın D, Ülger F 55-59 Relationship between the albumin level and the anesthesia method and the effect on clinical course in patients with major burns Majör yanıklı hastaların albümin düzeyinin anestezi yönetimi ile ilişkisi ve klinik gidişte etkinliği Çakırca M, Sözen İ, Tozlu Bindal G, Baydar M, Yastı AÇ 60-65 Complicated or not complicated: Stoma site marking before emergency abdominal surgery Komplike ya da değil: Acil abdominal cerrahi öncesinde stoma yeri işaretlenmesi Gök AFK, Özgür İ, Altunsoy M, Üçüncü MZ, Bayraktar A, Bulut MT, Keskin M Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

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TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 25

Number - Sayı 1 January - Ocak 2019

Contents - İçindekiler 66-70 Efficacy and cost-effectiveness of the cell saver system in instrumented posterior fusion with thoracic and lumbar vertebral fractures Torakal ve lomber vertebra kırıklarında enstrümentasyon ve posterior füzyon uygulanmış hastalarda maliyet ve hücre koruyucu sistemin etkinliği Başaran SH, Bayrak A, Sayit E, Öneş HN, Gözügöl K, Kural C 71-74 Admission neutrophil-to-lymphocyte ratio and postoperative mortality in elderly patients with hip fracture Kalça kırıklı yaşlı hastalarda nötrofil-lenfosit oranı ve ameliyat sonrası mortalite Temiz A, Ersözlü S 75-79 The ANK nail treatment of lateral malleolar fractures with syndesmosis injury: Clinical outcomes at 10 years of follow-up Synesmoz yaralanmasının eşlik ettiği lateral malleol kırıklarının ANK çivisi ile tedavisi: On yıllık tedavi sonuçları Kahraman S, Ceylan HH, Sönmez MM, Kara AN

Case Reports - Olgu Sunumu 80-82 Management of enteroatmospheric fistula thanks to new isolation technique Yeni izolasyon tekniği ile enteroatmosferik fistülün yönetimi Eğin S, Gökçek B, Yeşiltas M, Sağlam F, Güney B 83-85 Gastrointestinal stromal tumor leading to acute abdomen and hypovolemic shock in a trauma patient Travmalı hastada akut batın ve hipovolemik şok yapan gastrointestinal stromal tümör Gökçe AH 86-88 Airbag cover impact: a rarely seen reason for mandibular defects Hava yastığı kapağı çarpması: Mandibula defektinin nadir görülen bir sebebi Akşam E, Sönmez E, Karaaslan Ö, Durgun M 89-92 Improvement of a duodenal leak: Two-way vacuum-assisted closure Duodenal kaçağın iyileştirilmesi: İki yönlü vakum yardımlı kapama Eğin S, Gökçek B, Yeşiltaş M, Hot S, Karakaş DÖ

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Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

EDITORIAL

Dear readers, We are proud to share with you the great happiness of commemorating the 25th year of the Turkish Journal of Trauma and Emergency Surgery. We have grown over the years and continue to increase our reach and standing in the scientific world as a member of important professional databases. The contributions of the experimental and clinical studies performed by researchers from both our country and many others cannot be denied. For a quarter of a century we have worked to improve the health of present and future generations, and we look forward to continuing this journey.

Only 62 of 782 scientific journals published in our country and screened by the TUBITAK Ulakbim TR Index (the Turkish National Academic Network and Information Center) are included in the Science Citation Index Expanded database. We are proud to be among them. Our articles indexed with PubMed received an average of 2500 visits last year, and this year , nearly 4000 articles in our journal were visited monthly. According to the Clarivate Analytics Journal Citation Report results of 2018, our impact factor increased from 0.473 in 2017 to 0.525. The current target for our journal is to reach and surpass an impact factor of 1.

As of 2018, we integrated the use of the Open Researcher and Contributor ID (ORCID ID), designed to disambiguate researchers from one another, into our JournalAgent peer review and acceptance system. In addition, new features have been introduced to the JournalAgent system to facilitate follow-up and control of manuscripts by the editorial board and publishers.

The editorial board eagerly anticipates presenting you with more high-quality studies in the field of trauma and emergency surgery performed both in our country and around the world.

We wish you health and success.

Respectfully yours, Recep Güloğlu, Kaya Sarıbeyoğlu, M. Mahir Özmen, Hakan Yanar

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EDİTÖRDEN

Sevgili Okurlarımız, Bilimsel dünyanın dijital ve başarılı veri tabanlarında giderek daha fazla değer kazanan “Ulusal Travma ve Acil Cerrahi Dergimizin” 25 yaşına ayak basıyor olmasının büyük mutluluğunu sizlerle paylaşmanın gururunu hep birlikte yaşıyoruz. Çeyrek yüzyılın arkasında ülkemizin yanı sıra birçok kıtadan çalışmacının emekleri ile deneysel ve klinik çalışmaların ortaya koyduğu sonuçların günümüz ve gelecek nesillerin sağlığına katkısı yadsınamaz. Ülkemizde yayınlanan ve TÜBİTAK Ulakbim TR Dizin tarafından taranan 782 bilimsel derginin sadece 62’si SCI-Expanded kapsamındadır. Bu indekste yer alan dergimiz için sevindirici haber olarak, bilimsel seviyesinin her geçen gün ciddi bir şekilde arttığını ölçme ve değerlendirme yöntemleriyle tespit edebiliyoruz. PubMed’de taranan yazılarımız, geçtiğimiz yıl aylık ortalama 2500 ziyaret alıyorken, bu yıl aylık ortalama 4000’e yakın ziyaret almıştır. 2018 yılı Clarivate’nin “Journal Citation Report” sonucuna göre 2017’de 0.473 olan impact factor’ümüz (IF) 0.525’e yükselmiştir. Dergimiz için şimdiki hedef IF’nin 1’in üstüne çıkmasıdır.

2018 yılı itibariyle, yazarların kendi adı için alabildiği tek olarak tanımlanmış kimlik numarası sistemi-Open Researcher and Contributor ID (ORCID ID) dergimizin JournalAgent hakemli makale değerlendirme ve kabul sistemi ile entegre edilmiş ve ORCID kayıt sistemi dergimizde de kullanılmaya başlanmıştır. Bunun yanında JournalAgent sistemine kazandırılan yeni özellikler ile Yayın Kurulu ile Yayımcılar için yazı takibinin ve kontrolünün kolaylaştırılması amaçlanmıştır.

Editörler kurulu olarak önümüzdeki yıllarda da ülkemizde ve dünyada travma ve acil cerrahi alanında daha kaliteli çalışmalar ile sizleri buluşturabilme dileğiyle.

Sağlık ve başarılar dileriz.

Saygılarımızla.

Recep Güloğlu, Kaya Sarıbeyoğlu, M. Mahir Özmen, Hakan Yanar

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EXPERIMENTAL STUDY

Effects of alpha-tocopherol on acute pancreatitis in rats Halit Özgül, M.D.,1 Soner Sarı, M.D.,2

Cihad Tatar, M.D.,1 Bahri Özer, M.D.,1 Songül Peltek Özer, M.D.3

Hüsnü Aydın, M.D.,1

1

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

2

Department of Biochemistry, Haseki Training and Research Hospital, İstanbul-Turkey

3

Department of Pathology, Haseki Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Acute pancreatitis is a disease with high morbidity and mortality, despite all the advances in technology. The overall mortality rate of acute pancreatitis is 10%, whereas the mortality rate in infected necrotizing pancreatitis is approximately 35%. In this study, we aimed to establish acute pancreatitis in rats in order to try out the alpha-tocopherol treatment protocol and to reveal the results biochemically and histopathologically.

METHODS: Twenty-four male male Sprague–Dawley rats weighing between 300 and 350 g were used in the study. In Group 1, 80 µg/kg of normal saline was subcutaneously injected into eight rats; in Group 2, 80 µg/kg of cerulein was subcutaneously injected into eight rats; and in Group 3, 80 µg/kg of cerulein was subcutaneously injected into eight rats. In addition, 30 mg/kg of alpha-tocopherol was intraperitoneally injected into eight rats.

RESULTS: The mean Schoenberg score, serum amylase, and lipase and Neutrophil Gelatinase-Associated Lipocalin (NGAL) levels were statistically significantly higher in Group 2 than in Group 1. The mean Schoenberg score and serum amylase and lipase levels were statistically significantly lower in Group 3 than in Group 2.

CONCLUSION: In this experimental study rat model of cerulein-induced acute pancreatitis, 30 mg/kg of alpha-tocopherol was injected intraperitoneally to examine its effect on pancreatitis. The improvement was observed in the histopathological examination of pancreatic tissues. We think that alpha-tocopherol may have a therapeutic effect on pancreatic tissue.

Keywords: Alpha-tocopherol; pancreatitis; rat.

INTRODUCTION Acute pancreatitis is an acute non-bacterial inflammation in which the pancreas is autodigested by its regurgitated own enzymes when they are in the active form and which can regress clinically and histologically.[1] Acute pancreatitis is a disease with high morbidity and mortality, despite all the advances in technology.[2] Acute pancreatitis may have a broad spectrum of pathologic findings, ranging from mild interstitial edema to severe hemorrhagic gangrene and necrosis. Similarly, clinical manifestations may occur in varying degrees, ranging from mild abdominal pain to hypotension, fluid sequestration, metabolic disturbances, and sepsis. The overall mortality rate of acute pancreatitis is 10%, whereas the mor-

tality rate in infected necrotizing pancreatitis is approximately 35%.[3] Respiratory complications are the leading cause of mortality in the short term in 95% of cases.[3] In experimental pancreatitis models, studies are still being conducted to examine the efficacy of various therapeutic agents on treatment and to determine the parameters that can be used in measuring this efficacy. Cerulein is a cholecystokinin analog that leads to bile reflux into the pancreatic duct and thus pancreatitis by relaxing the sphincter of Oddi and stimulating the gallbladder contraction.[4] Cerulein has

Cite this article as: Özgül H, Tatar C, Özer B, Aydın H, Sarı S, Peltek Özer S. Effects of alpha-tocopherol on acute pancreatitis in rats. Ulus Travma Acil Cerrahi Derg 2018;24:1-6.

Address for correspondence: Cihad Tatar, M.D. Haseki Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey.

Tel: +90 212 - 529 44 00 E-mail: tatarcihad@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(6):1-6 DOI: 10.5505/tjtes.2018.30413 Submitted: 16.12.2017 Accepted: 16.04.2018 Online: 10.12.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Özgül et al. Effects of alpha-tocopherol on acute pancreatitis in rats

been administered by the intravenous, subcutaneous, and intraperitoneal routes in experimental pancreatitis models.[5,6]

groups were compared statistically to each other. A p-value <0.05 was considered statistically significant.

In this study, we aimed to establish acute pancreatitis in rats in order to try out the treatment protocol and to reveal the results biochemically and histopathologically.

Histopathological Examinations

MATERIALS AND METHODS This experimental study was approved by the Ethics Committee of Bezmialem University Faculty of Medicine. It was carried out at the Experimental Animals Laboratory of Bezmialem University. Twenty-four male Sprague–Dawley rats weighing between 300 and 350 g (standard pelleted diet) were used in the study. Twenty-four rats were randomly divided into three groups of equal numbers.

Group 1: 80 µg/kg of normal saline (an equivalent volume of cerulein) was subcutaneously injected into eight rats 6 times at 1-hour intervals.

Group 2: 80 µg/kg of cerulein was subcutaneously injected into eight rats 6 times at 1-hour intervals.

Group 3: 80 µg/kg of cerulein was subcutaneously injected into eight rats 6 times at 1-hour intervals. In addition, 30 mg/kg of alpha-tocopherol was intraperitoneally injected into eight rats 2 times at 1-hour intervals.

Decapitation was performed 7 hours after the first injection of cerulein.

Biochemical Analysis Approximately 7–8 cc of blood was obtained from each rat heart after decapitation and was kept at room temperature for 40 min. Then, the serum was separated by centrifugation at 3500 rpm at +4°C for 10 minutes. For amylase, lipase, Neutrophil Gelatinase-Associated Lipocalin (NGAL), myeloperoxidase (MPO), AST, and ALT, 0.5 cc of serum was placed into Eppendorf tubes to the biochemistry laboratory.

It was measured according to the International Federation of Clinical Chemistry and Laboratory Medicine with the Roche Preanalytical Modular System device. The results of the

After decapitation, the rats were laparotomized with a median incision. Pancreatic tissue was removed for histopathological evaluation. Specimens were fixed with a 10% formaldehyde solution. Pancreatic tissue sections were stained with the hematoxylin–eosin stain and examined under the light microscope. Edema, inflammation, vacuolization, and necrosis in pancreatic tissue were assessed using a score range of 0–4 (Schoenberg index) (Table 1). Moreover, pancreatic tissues of the groups with acute pancreatitis were stained with immunohistochemical stains. Myeloperoxidase staining demonstrated neutrophil infiltrates in pancreatic tissues. Neutrophil infiltration in pancreatic tissues was shown with the staining of IL-8 (also called neutrophil-activating peptide).

Statistical Analysis The SPSS 16.0 statistical software package (SPSS Inc., Chicago, USA) was used for statistical analysis. Categorical variables were expressed as number and percentage. Numerical variables were expressed as the mean and standard deviation. If numerical variables were normally distributed, the one-way analysis of variance was used to compare more than two independent groups. If numerical variables were not normally distributed, the Kruskal–Wallis test was used to compare more than two independent groups. Subgroup analyzes were performed by the Tukey test (parametric test) and the Mann– Whitney U test (non-parametric test), and they were interpreted by the Bonferroni correction. A p-value <0.05 was considered statistically significant.

RESULTS Amylase The mean serum amylase level was 1537.00±123.26 in Group 1, 3316.13±432.49 in Group 2, and 2531.38±433.93 in Group 3. The mean serum amylase level was statistically significantly higher in Group 2 than in Group 1 (p<0.001). The mean serum amylase level was statistically significantly lower in Group 3 than in Group 2 (p<0.001) (Table 2).

Table 1. Schoenberg’s scoring[10] Edema

Inflammation

Vacuolization

Necrosis

0 No

No

No

No

1

Diffuse expansion of interlobar septa

Periductal

Periductal (<5%)

1–4 necrotic cells*

2

1 (+) Diffuse expansion of interlobular septa

Parenchymal (<50% lobules)

Focal (5%–20%)

5–10 necrotic cells

3

2 (+) Diffuse expansion of interacinar septa

Parenchymal (51%–75% lobules)

Diffuse (21%–50%)

11–16 necrotic cells

4

3 (+) Diffuse expansion of intercellular septa

Parenchymal (>75% lobules)

Severe (>50%) 27

>16 necrotic cells

*(microscopic field). 2–5 = mild pancreatitis. 5–8 = moderate pancreatitis. 8 and above = severe pancreatitis.

2

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Özgül et al. Effects of alpha-tocopherol on acute pancreatitis in rats

Table 2. Statistical results of biochemical parameters

Group 2

Mean±SD Mean±SD Mean±SD

Aspartate aminotransferase Alanine aminotransferase

Group 3

Group 1

p

196.63±162.96

155.88±29.42

128.38±22.83

0.161

75.50±14.73

78.13±10.59

74.75±12.71

0.859

Amylase 3316.13±432.49#¥ 2531.38±433.93*¥ 1537.00±123.26*# <0.001 Lipase 3459.63±500.60#¥ 2450.38±808.69*¥ 216.38±81.81*# <0.001 NGAL 14.43±5.13¥ 10.37±2.38 6.77±1.48*# 0.001 Myeloperoxidase

14.39±1.77

Pathology score

5.38±0.52#¥ 3.50±0.53*¥ 0.50±0.53*# <0.001

14.90±1.92

12.71±2.16

0.088

*Different from Group 2. #Different from Group 3. ¥Different from Group 1. NGAL: Neutrophil Gelatinase-Associated Lipocalin; SD: Standard deviation.

Lipase The mean serum lipase level was 216.38±81.81 in Group 1, 3459.63±500.60 in Group 2, and 2450.38±808.69 in Group 3. The mean serum lipase level was statistically significantly higher in Group 2 than in Group 1 (p<0.0001). The mean serum lipase level was statistically significantly lower in Group 3 than in Group 2 (p=0.016) (Table 2).

Table 3. Subgroup analyzes

Group 2 vs Group 3

Group 1 vs Group 2

Group1 vs Group 3

p p p

Amylase (IU/mL)

0.001

Lipase

0.016 0.001 0.001

NGAL

NGAL

0.074 0.002 0.006

The mean serum NGAL level was 6.77±1.48 in Group 1, 14.43±5.13 in Group 2, and 10.37±2.38 in Group 3. The mean serum NGAL level was statistically significantly higher in Group 2 than in Group 1 (p=0.002). There was no statistically significant difference between Groups 2 and 3 in terms of the mean serum NGAL level (p=0.074) (Tables 2, 3).

Pathology score

0.001

MPO The mean serum MPO level was 10.37±2.38 in Group 1, 14.39±1.77 in Group 2, and 14.90±1.92 in Group 3. There was no statistically significant difference between Groups 1 and 2 in terms of the mean serum MPO level. There was no statistically significant difference between Groups 2 and 3 in terms of the mean serum MPO level (p=0.088) (Tables 2, 3).

Histopathological Findings

<0.001

0.001

<0.001

0.001

NGAL: Neutrophil Gelatinase-Associated Lipocalin;

3.50±0.53 in Group 3. The mean Schoenberg score was statistically significantly higher in Group 2 than in Group 1 (p<0.001).

The mean Schoenberg score was statistically significantly lower in Group 3 than in Group 2 (p<0.001) (Tables 2, 3).

Moreover, pancreatic tissues of the groups with acute pancreatitis were stained with immunohistochemical stains.

Myeloperoxidase staining demonstrated neutrophil infiltrates in pancreatic tissues. Neutrophil infiltration in pancreatic tissues was shown with the staining of IL-8 (also called neutrophil-activating peptide).

DISCUSSION

In our study, pancreatitis was proven histologically in all 16 rats (Groups 2 and 3) in which it was planned to be established with subcutaneous injection of cerulein (80 µg/kg).

Histopathological examinations revealed fat necrosis, interstitial edema, vacuolization, and polymorphonuclear cell infiltration in the groups with acute pancreatitis compared with the control group.

Pancreatitis is mainly caused by the auto-digestion of the pancreatic tissue resulting from the abnormal activation of pancreatic enzymes.[8,9] In the course of acute pancreatitis, systemic inflammatory conditions besides localized events occur. Oxygen free radicals play an important role in the pathogenesis of acute pancreatitis.[10]

In our experimental rat model of cerulein-induced acute pancreatitis, neutrophil infiltration, vacuolization, fat necrosis, and edema in pancreatic tissue were evaluated by histopathological examination (Schoenberg index).[7] The mean Schoenberg score was 0.50±0.53 in Group 1, 5.38±0.52 in Group 2, and

Impaired microcirculation is also one of the important steps in the pathogenesis. There is an increase in the permeability of the endothelial layer of arterioles and venules. As a result, edema and microhemorrhages occur in the tissue due to extravasation of plasma and erythrocytes.[11] Willemer

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Özgül et al. Effects of alpha-tocopherol on acute pancreatitis in rats

et al.[12] showed that interstitial edema occurred due to the PNL accumulation in pulmonary capillary vessels, damage to alveolar epithelial cells, and increased vascular permeability in cerulein-induced experimental acute pancreatitis model in rats. They also reported that these findings peaked at 12 hours and completely disappeared at 84 hours. For this reason, they emphasize the importance of early treatment. In many experimental studies, edematous pancreatitis has been established, and it has been aimed to prevent systemic complications.[13–17] Although different methods are used in experimental models of acute pancreatitis, an increase in pancreatic secretion is one of the most preferred methods for the pathophysiology of acute pancreatitis. Cerulein has been successfully used in many experimental studies with this effect.[7,10] The effect of cerulein on the pancreas is dependent on the dose and duration. Cerulein dose and duration of administration are determined according to the form of pancreatitis to be created.[13,18,19] Strowski et al.[18] created an experimental model of acute edematous pancreatitisin rats where 10 µg/ kg of cerulein was administered five times at 1-hour intervals.

Konturek et al.[20] created an experimental model of acute edematous pancreatitisin rats where 10 µg/kg of cerulein was administered subcutaneously.

The data obtained from many comprehensive experimental studies show that oxygen free radicals are produced as important mediators in the pathogenesis of many tissue injuries.

[7,9,10,19,21] Oxygen free radicals are involved in both the initial and later stages of the pathophysiology of acute pancreatitis.

[7,10,22] For this reason, experimental studies have been carried out to remove the efficacy of oxygenfree radicals in acute pancreatitis. In our study, 80 µg/kg of cerulein was subcutaneously injected into the rats six times at 1-hour intervals to create an experimental model of acute pancreatitis.

Acute pancreatitis was created histopathologically and biochemically in the cerulein-treated groups (Groups 2 and 3).

When these groups (Groups 2 and 3) were compared with the control group (Group 1), histopathological evaluations and biochemical measurements were found to be statistically significant (Table 3).

In experimental models of acute pancreatitis, serum amylase, and lipase levels were used as parameters to show the formation of pancreatitis.[10] Serum amylase levels are elevated in acute pancreatitis, acute exacerbation of chronic pancreatitis, perforated and penetrating peptic ulcer, postoperative period of upper abdominal surgery, pancreatic duct obstruction, acute alcohol intake or poisoning, salivary gland diseases, and advanced chronic renal insufficiency. The serum amylase level begins to rise within 3–6 hours in acute pancreatitis. Its urinary level begins to increase 6–10 hours after its serum level is increased. This alone has very little meaning.

The amylase–creatinine clearance ratio (ACCR) is calculated.

An ACCR greater than 5% suggests acute pancreatitis.[23] We 4

did not use this ratio because we also used lipase levels and histopathological evaluations in our study. Serum lipase levels are elevated in acute pancreatitis, perforated and penetrating peptic ulcer, and pancreatic duct obstruction. Lipase level can remain high until 14 days after the amylase level returns to normal.[23] While NGAL was initially characterized by its presence in neutrophil lysosomes, it was later observed that NGAL was expressed in various tissues, such as renal tubular epithelium, colon, prostate, and breast. Lipocalin (NGAL) is synthesized from the cells under stress. Infection, inflammation (synthesized from the secondary granules of active neutrophils), ischemia, and neoplastic transformation enhances NGAL expression.[24,25] In our study, the mean serum NGAL level was statistically significantly higher in Group 2 than in Group 1, whereas there was no statistically significant difference between Groups 2 and 3 in terms of the mean serum NGAL level.

MPO is found in large quantities in neutrophils. This enzyme, stored in azurophilic granules of these cells, is responsible for killing of pathogenic microorganisms. These granulocytic cells engulf microorganisms via phagocytosis and break down and digest pathogens by producing reactive oxygen species, such as superoxide and hydrogen peroxide.[26,27] In our study, there was no statistically significant difference between Groups 1 and 2 and between Groups 2 and 3 in terms of the mean serum MPO level (Table 3).

It has been reported that superoxide dismutase and catalase reduced the ultrastructural and biochemical injury associated with cerulein-induced acute pancreatitis in rats. According to the authors, active neutrophils secrete oxygen radicals and cause endothelial injury.[17,28] In a study by O’Donovan et al.[29] conducted in an experimental rat model of cerulein-induced acute pancreatitis, endothelial cell injury, and edema formation were detected in pancreatic tissue, and this event was thought to be related to neutrophils. In experimental pancreatitis models, acute pancreatitis showed the same morphological characteristics with that in humans. A clinical condition was also established to be biochemically similar to that in humans by increased serum amylase and lipase levels. It was also seen that non-fatal pulmonary injury occurred in acute pancreatitis and was similar to that in humans.[29] Alpha-tocopherol has a protective effect on membrane stabilization and an inhibitory effect on lipid peroxidation. It is also known as an antioxidant. It easily wedges between the membrane phospholipids due to its high lipid solubility and reduces unsaturated fatty acids with 20 carbon atoms. Thus, it prevents lipid peroxidation in biomembranes caused by oxygen free radicals. Moreover, alpha-tocopherol is converted into alpha-tocopheryl quinone by combining with oxygen free Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

Özgül et al. Effects of alpha-tocopherol on acute pancreatitis in rats

radicals, and thus it undertakes the free radical scavenging process.

Jiang et al.[30] showed that alpha-tocopherol and tocotrienolrich fraction reduce oxidative stress, ameliorate inflammation and fibrosis, and down-regulate the mRNA expression of TGF-β1 and collagen-α1 in chronic pancreatitis.

Li et al.[31] investigated the effects of alpha-tocopherol on pancreatic fibrosis and survival in rats with experimental chronic pancreatitis. They reported that alpha-tocopherol treatment elevates the survival rate, extenuates fibrosis, and increases relative pancreatic weight in the chronic pancreatitis model.

It has been reported that the oral administration of alpha-tocopherol significantly ameliorated the symptoms of diabetic nephropathy.[32] Previous studies have highlighted the potential of using alphatocopherol for cancer chemoprevention.[33] However, several studies indicated that alpha-tocopherol might be ineffective in the prevention of prostate cancer, lung cancer, and breast cancer.[34–38] In our experimental rat model of cerulein-induced acute pancreatitis, 30 mg/kg of alpha-tocopherol was injected intraperitoneally at 1-hour intervals 2 hours after the first injection of ceruleinin to examine its effect on pancreatitis. While the serum amylase, lipase, and NGAL levels and the mean Schoenberg score were statistically significantly higher in Group 2 than in Group 1, the serum amylase and lipase levels and the mean Schoenberg score were statistically significantly lower in Group 3 than in Group 2.

In this experimental study, we aimed to establish an acute pancreatitis model in rats, to reveal the natural process of acute pancreatitis, and to examine the efficacy of the agent which can be tried in treatment. We observed that acute pancreatitis developed as both histopathological and laboratory findings in rats after subcutaneous injection of cerulein. In an experimental model of acute pancreatitis, it was seen that the serum lipase, amylase, and NGAL levels increased significantly statistically, the serum MPO level did not increase significantly statistically, and the serum amylase and lipase levels decreased significantly statistically in the rats given alpha-tocopherol. In addition, the improvement was observed during the histopathological examination of pancreatic tissues. These findings suggest that alpha-tocopherol may have a positive effect on treatment.

Conclusion In conclusion, we think that alpha-tocopherol may have a therapeutic effect on pancreatic tissue. However, new studies need to be conducted with this regard.

Conflict of interest: None declared.

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17. Guice KS, Miller DE, Oldham KT, Townsend CM Jr, Thompson JC. Superoxide dismutase and catalase: A possible role in established pancreatitis. Am J Surg 1986;151:163–9.

18. Strowski MZ, Sparmann G, Weber H, Fiedler F, Printz H, Jonas L, et al.

Caerulein pancreatitis increases mRNA but reduces protein levels of rat pancreatic heat shock proteins. Am J Physiol 1997;273:G937–45.

19. Steer ML, Rutledge PL, Powers RE, Saluja M, Saluja AK. The role of oxygen-derived free radicals in two models of experimental acute pancreatitis: effects of catalase, superoxide dismutase, dimethylsulfoxide, and allopurinol. Klin Wochenschr 1991;69:1012–7.

20. Konturek PC, Dembinski A, Warzecha Z, Ihlm A, Ceranowicz P, Konturek SJ, et al. Comparison of epidermal growth factor and transforming growth factor-beta1 expression in hormone-induced acute pancreatitis in

5

Özgül et al. Effects of alpha-tocopherol on acute pancreatitis in rats rats. Digestion 1998;59:110–9.

21. Dembiński A, Warzecha Z, Konturek PC, Ceranowicz P, Stachura J, Tomaszewska R, et al. Epidermal growth factor accelerates pancreatic recovery after caerulein-induced pancreatitis. Eur J Pharmacol 2000;398:159– 68.

22. Sanfley H, Bulkley GB, Cameron JL. The role of oxygen-derived free radicals in the pathogenesis of acute pancreatitis. Ann Surg 1984;200:405– 13.

23. Wallach J. Interpretation of diagnostic tests. 5th ed. Boston: Little, Brown, & Co.; 1992. p. 61–3.

24. Cowland JB, Borregaard N. Molecular characterization and pattern of tissue expression of the gene for neutrophil gelatinase-associated lipocalin from humans. Genomics 1997;45:17–23.

25. Soni SS, Cruz D, Bobek I, Chionh CY, Nalesso F, Lentini P, et al. NGAL: a biomarker of acute kidney injury and other systemic conditions. Int Urol Nephrol 2010;42:141–50.

26. Andrews PC, Krinsky NI. Human myeloperoxidase and hemi-myeloperoxidase. Methods Enzymol 1986;132:369–79.

27. Andersen MR, Atkin CL, Eyre HJ. Intact form of myeloperoxidase from normal human neutrophils. Arch Biochem Biophys 1982;214:273–83.

28. Guice KS, Oldham KT, Caty MG, Johnson KJ, Ward PA. Neutrophildependent, oxygen-radical mediated lung injury associated with acute pancreatitis. Ann Surg 1989;210:740–7.

29. O’Donovan DA, Kelly CJ, Abdih H, Bouchier-Hayes D, Watson RW, Redmond HP, et al. Role of nitric oxide in lung injury associated with experimental acute pancreatitis. Br J Surg 1995; 82:1122–6.

30. Jiang F, Liao Z, Hu LH, Du YQ, Man XH, Gu JJ, et al. Comparison of antioxidative and antifibrotic effects of α-tocopherol with those of

tocotrienol-rich fraction in a rat model of chronic pancreatitis. Pancreas 2011;40:1091–6.

31. Li XC, Lu XL, Chen HH. α-tocopherol treatment ameliorates chronic pancreatitis in an experimental rat model induced by trinitrobenzene sulfonic acid. Pancreatology 2011;11:5–11.

32. Hayashi D, Ueda S, Yamanoue M, Ashida H, Shirai Y. Amelioration of diabetic nephropathy by oral administration of d-α-tocopherol and its mechanisms. Biosci Biotechnol Biochem 2018;82:65–73.

33. Yang CS, Suh N, Kong AN. Does vitamin E prevent or promote cancer?

Cancer Prev Res (Phila) 2012;5:701–5.

34. Gaziano JM, Glynn RJ, Christen WG, Kurth T, Belanger C, MacFadyen J, et al. Vitamins E and C in the prevention of prostate and total cancer in men: the Physicians’ Health Study II randomized controlled trial. JAMA 2009;301:52–62.

35. Klein EA, Thompson IM Jr, Tangen CM, Crowley JJ, Lucia MS, Goodman PJ, et al. Vitamin E and the risk of prostate cancer: the Selenium and Vitamin E Cancer Prevention Trial (SELECT). JAMA 2011;306:1549–56.

36. Lippman SM, Klein EA, Goodman PJ, Lucia MS, Thompson IM, Ford LG, et al. Effect of selenium and vitamin E on risk of prostate cancer and other cancers: the Selenium and Vitamin E Cancer Prevention Trial (SELECT). JAMA 2009;301:39–51.

37. Lee IM, Cook NR, Gaziano JM, Gordon D, Ridker PM, Manson JE, et al. Vitamin E in the primary prevention of cardiovascular disease and cancer: the Women’s Health Study: a randomized controlled trial. JAMA 2005;294:56–65.

38. Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. N Engl J Med 1994;330:1029–35.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Sıçanlarda alfa tokoferolün akut pankreatit üzerine etkileri Dr. Halit Özgül,1 Dr. Cihad Tatar,1 Dr. Bahri Özer,1 Dr. Hüsnü Aydın,1 Dr. Soner Sarı,2 Dr. Songül Peltek Özer3 Haseki Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul Haseki Eğitim ve Araştırma Hastanesi, Biyokimya Kliniği, İstanbul 3 Haseki Eğitim ve Araştırma Hastanesi, Patoloji Kliniği, İstanbul 1 2

AMAÇ: Akut pankreatit, teknolojideki tüm gelişmelere rağmen morbiditesi ve mortalitesi yüksek bir hastalıktır. Akut pankreatitte mortalite oranı tüm hastalar için %10 iken, bu oran enfekte olmuş nekrotizan pankreatitli hastalarda yaklaşık olarak %35’tir. Biz, bu çalışmada öncelikle sıçanlarda akut pankreatit oluşturmayı, alfa tokoferol tedavi protokolünü denemeyi ve sonuçları biyokimyasal ve histopatolojik olarak ortaya koymayı amaçladık.

GEREÇ VE YÖNTEM: Çalışmada 24 adet erkek sıçan kullanıldı. Grup 1: Kontrol grubu olarak sekiz sıçana birer saatlik arayla altı kez toplam 80 mikrogram/kg (cerulein ile eş hacimli) serum fizyolojik subkutan enjekte edildi. Grup 2: Sekiz sıçana birer saat ara ile altı kez toplam 80 ug/kg cerulein subkutan enjekte edildi. Grup 3: Sekiz sıçana birer saat ara ile toplam 80 mikrogram/kg cerulein ve birer saat arayla iki kez 30 mg/kg alfa-tokoferol intraperitoneal enjekte edildi.

BULGULAR: Ortalama Schoenberg skoru, serum amilaz, lipaz ve NGAL seviyeleri Grup 2’de Grup 1’e göre istatistiksel olarak anlamlı derecede yüsekti. Ortalama Schoenberg skoru, serum amilaz ve lipaz seviyeleri Grup 3’de Grup 2’ye göre istatistiksel olarak anlamlı derecede düşüktü.

TARTIŞMA: Cerulein ile oluşturulan pankreatit modelinde pankreatitin üzerine olan etkisini incelemek amacıyla 30 mg/kg alfa-tokoferol intraperitoneal olarak uygulandı. Alfa-tokoferolün pankres dokusu üzerine tedavi edici etkisi olabileceğini düşünmekteyiz.

Anahtar sözcükler: Alfa tokoferol; pankreatit; sıçan.

Ulus Travma Acil Cerrahi Derg 2018;24(6):1-6

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doi: 10.5505/tjtes.2018.30413

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

EXPERIMENTAL STUDY

Effect of curcumin on lung injury induced by skeletal muscle ischemia/reperfusion in rats Hamed Ashrafzadeh Takhtfooladi, M.D.,1

Mohammad Ashrafzadeh Takhtfooladi, M.D.2

1

Department of Pathobiology, Science and Research Branch, Islamic Azad University, Tehran-Iran

2

Young Researchers and Elites Club, Science and Research Branch, Islamic Azad University, Tehran-Iran

ABSTRACT BACKGROUND: The aim of the present study was to investigate the effects of curcumin on lung damage following ischemia/reperfusion (I/R) injury after hind limb ligation.

METHODS: Forty Wistar rats were divided into four groups: sham (G1), I/R (G2), curcumin plus sham (G3), and curcumin plus I/R (G4). Curcumin was administered (200 mg/kg) daily for 2 weeks before the study. I/R was induced by placement of rubber tourniquets at the greater trochanters for 2 h, followed by reperfusion for 4 h.

RESULTS: Curcumin pretreatment had significantly lower level of malondialdehydes and higher level of superoxide dismutase in the lung tissues (p<0.05) than the I/R group. Glutathione peroxidase activity was not significantly different among the groups (p>0.05). I/R caused severe histopathological injury (p<0.05), including inflammatory cell infiltration and intra-alveolar hemorrhage.

CONCLUSION: These results suggest that curcumin pretreatment has protective effects against lung injury induced by muscle I/R. Keywords: Curcumin; ischemia/reperfusion; lung; skeletal muscle.

INTRODUCTION Ischemia/reperfusion (I/R) injury of the skeletal muscles is inevitable in various clinical conditions. This type of injury can occur from long surgical interventions on the extremities. It can damage parenchymal and endothelial cells, induce granulocyte and macrophage reactions, and trigger humoral factors (e.g., coagulation factors and oxygen free radicals).[1,2] It is possible for I/R injuries to extend further than the ischemic region and cause damage to remote organs. One of the major causes of morbidity and mortality is lung injury following I/R damage to the extremities according to the literature. Increased microvascular permeability, as well as pulmonary edema, characterizes this type of injury.[3] Inflammatory mediators, particularly oxygen free radicals and neutrophils, contribute to the development of lung injuries associated with I/R damage according to previous studies.[4–7]

Efforts have been made to develop novel treatment methods in order to prevent or limit damage to remote organs.

Accordingly, various studies have used different pharmacological agents for this purpose.[8–10] Curcumin with anticarcinogenic and anti-inflammatory effects is recognized as a potential stimulator of heat shock protein expression induced by stress.[11] It can improve I/R damages in the kidneys, myocardium, and nervous tissues based on recent studies.[12–16] However, to our knowledge, no studies have examined the effects of this compound on the lungs following I/R damage to the muscles. Accordingly, we examined the effectiveness of curcumin against muscle I/R damage. Histological and biochemical analyses were performed in order to assess its protective effects.

MATERIALS AND METHODS The Animal Experiments Committee of Islamic Azad University approved the study protocol (2015-A2/017-4). The Pas-

Cite this article as: Takhtfooladi HA, Takhtfooladi MA. Effect of curcumin on lung injury induced by skeletal muscle ischemia/reperfusion in rats.

Ulus Travma Acil Cerrahi Derg 2019;25:7-11.

Address for correspondence: Mohammad Ashrafzadeh Takhtfooladi, M.D. Science and Research Branch, Islamic Azad University, Tehran, Iran.

Tel: 00989132004875 E-mail: dr_ashrafzadeh@yahoo.com Ulus Travma Acil Cerrahi Derg 2019;25(1):7-11 DOI: 10.5505/tjtes.2018.83616 Submitted: 14.08.2017 Accepted: 07.03.2018 Online: 30.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

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Takhtfooladi et al. Effect of curcumin on lung injury induced by skeletal muscle ischemia/reperfusion in rats

Table 1. Histological grading according to Koksel’s protocol Grade 0

Normal appearance

Grade 1

Mild-moderate interstitial congestion and neutrophil

leukocyte infiltration

Grade 2

Perivascular edema formation, partial destruction of

pulmonary architecture, and moderate neutrophil

leukocyte infiltration

Grade 3

Complete destruction of the pulmonary architecture

and dense neutrophil leukocyte

teur Institute of Iran supplied 40 adult male Wistar rats. The mean weight of the rats was 230±20 g. The rats were kept at a temperature of 22 °C±2 °C (relative humidity, 45%±5% and 12:12 h light/dark cycle) with access to food and water.

The rats were randomly allocated to four groups (10 rats each): sham (G1), I/R (G2), curcumin plus sham (G3), and curcumin plus I/R (G4). Curcumin (Sigma Co., MO, USA) was administered via oral gavage at a dose of 200 mg/kg/day. It was dissolved in corn oil (C8267; Sigma Co.) for 2 weeks before the study.

Ketamine (50 mg/kg) and xylazine (5 mg/kg) were administered to induce anesthesia. Ischemia was induced by placing orthodontic rubber bands at both hip joints for 2 h. Body temperature was kept constant using a warming pad. After reperfusion for 4 h, the rats were euthanized, and the lungs were removed. Then, the left lungs were placed in a 10% formalin solution and prepared for histopathological examination via light microscopy.

The supernatants of the right lung homogenates were prepared as described by Yildirim et al.[17] The malondialdehyde (MDA) level was determined via thiobarbituric acid reactions based on the study by Yagi.[18] In addition, superoxide dismutase (SOD) activity was analyzed spectrophotometrically (560 nm) by determining the capacity to inhibit photochem-

(a)

(b)

ical nitroblue tetrazolium reduction based on the method proposed by Winterbourn et al.[19] Moreover, glutathione peroxidase (GSH-Px) activities were spectrophotometrically (340 nm) determined using the method proposed by Paglia and Valentine.[20] Standard methods were used to process the left lung specimens. Cross-sectional cuts (5 µm in thickness) were made in the middle of the lungs. The hematoxylin and eosin method was applied for staining the slides. Lung injuries were examined in accordance with Koksel’s protocol[21] (Table 1).

Data were analyzed using SPSS version 18.0 (SPSS Inc., Chicago, IL, USA). The Mann–Whitney U test was used for non-parametric analyses of biochemical variables. The ANOVA and Tukey’s tests were used for comparison of data.

A P value <0.05 was considered significant.

RESULTS No significant lung histological changes were found in the G1 and G3 groups based on light microscopy (p>0.05). After reperfusion for 4 h, extensive infiltration of inflammatory cells and intra-alveolar hemorrhage were reported in the G2 group (Figs. 1a, b). At this time, lung damage was less in the G4 group (Fig. 1c). Therefore, lung injuries caused by muscle I/R were more severe in the G2 group than in the G4 group (p<0.05; Fig. 2).

The G2 group showed a significantly higher MDA level than others (p<0.05; Fig. 3). On the other hand, SOD activity was significantly lower in the G2 group (p<0.05; Fig. 4). Based on the findings, the groups were significantly different in terms of GSH-Px activity (p>0.05; Fig. 5). No significant difference was found among the G1, G3, and G4 groups according to the biochemical results (p>0.05).

DISCUSSION I/R injury is characterized by a sequence of events, resulting in damage to the cells and organ dysfunction.[22] Various

(c)

Figure 1. (a and b) Light photomicrographs of the lung tissues from rats subjected to ischemia/reperfusion without curcumin pretreatment (G2). (a) Inflammatory cell infiltration. (b) Intra-alveolar hemorrhage. (c) Light photomicrograph of the lung tissues from rats pretreated with 200 mg/kg/day curcumin for 2 weeks before ischemia/reperfusion (G4), showing nearly normal alveolar architecture and less of the slight neutrophil infiltration; (haematoxylin–eosin, original magnification ×400).

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Takhtfooladi et al. Effect of curcumin on lung injury induced by skeletal muscle ischemia/reperfusion in rats

3.5

160

80

*

2.5

SOD (U/g tissue)

Histological lung scores

3.0

2.0 1.5

60

*

40

1.0 20 0.5 0

G1

G2

G3

Figure 2. Histological lung injury scores in the experimental groups.

Sham (G1), ischemia/reperfusion (G2), curcumin plus sham (G3), and curcumin plus I/R (G4). *P<0.05.

160

0

G4

G2

G3

G4

Figure 4. The graph shows the superoxide dismutase (SOD) activity of different groups. Each group contains mean±SD of seven animals. Sham (G1), ischemia/reperfusion (G2), curcumin plus sham (G3), and curcumin plus I/R (G4). *P<0.05.

*

140

G1

800

600 100

GSH-Px (U/g protein)

MDA (mmol/g tissue)

120

80 60 40

400

200 20 0

G1

G2

G3

G4

Figure 3. The graph shows the malondialdehyde (MDA) level of different groups. Each group contains mean±SD of ten animals.

Sham (G1), ischemia/reperfusion (G2), curcumin plus sham (G3), and curcumin plus I/R (G4). *P<0.05.

studies have been performed on the role and importance of neutrophils in I/R damage.[23,24] Based on speculations, one of the major pathological dysfunctions in lung injury is endothelial cell damage, resulting from neutrophil activation, which can lead to inflammatory cytokine production and release of oxygen free radicals.[25] Curcumin is regarded as an effective compound in eliminating I/R damage to different organs.[26,27] It can be effective against I/R injuries of the muscles according to a recent study by Avci et al.[28] This compound has been shown to be effective in human and animal models of I/R injury. Moreover, it can be useful in the treatment of diseases, such as cancer, diabetes, cardiovascular disorders, and arthritis.[26] Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

0

G1

G2

G3

G4

Figure 5. The graph shows the glutathione peroxidase (GSHPx) activity of different groups. Each group contains mean±SD of seven animals. Sham (G1), ischemia/reperfusion (G2), curcumin plus sham (G3), and curcumin plus I/R (G4). There was not significantly different among the groups (p>0.05).

The protective effects of curcumin are attributed to improved oxidative stress and inhibitory activities of protein kinases, adhesion molecules, inflammatory transcription factors, and inflammation.[26,27,29] Some studies have revealed its potential for scavenging free radicals to prevent lipid peroxidation and increase the level of intracellular antioxidants.[30–34] In the present study, light microscopy indicated the disruption of alveolar architecture, as well as neutrophil infiltration in histopathological sections in the G2 group. However, sections from the group receiving curcumin demonstrated decreased histological damage. It appears that curcumin can significantly attenuate leukocyte recruitment in the lung tissues 9

Takhtfooladi et al. Effect of curcumin on lung injury induced by skeletal muscle ischemia/reperfusion in rats

after muscle I/R, as demonstrated by the significantly higher number of neutrophils and greater histological damage to the lungs in the G2 group than in others.

One of the important causes of lung injury is lipid peroxidation, triggered by oxygen free radicals.[35] In our study, lung injury after muscle I/R was associated with high MDA levels in the lung tissues (a proper marker of lipid peroxidation).[36] Nevertheless, curcumin could significantly decrease the MDA level. This finding is in line with previous studies, representing curcumin as an inhibitor of lipid peroxidation.[30] Additionally, evidence has revealed the antioxidant activities of curcumin (especially inhibition of lipid peroxidation).[30] In the current study, the protective effects of curcumin on the cells against lipid peroxidation might be attributed to its direct antioxidant and anti-inflammatory activities.

Based on the present findings, pretreatment with curcumin can reduce lung injuries resulting from muscle I/R. Inhibition of neutrophil aggregation, as well as oxidative damage in the injured lung, might be the underlying mechanisms. Further research is required to confirm the clinical effectiveness of this compound.

Funding: None.

Ethical approval: All applicable international, national, and/or institutional guidelines for the care and use of animals were followed.

Conflict of interest: None declared.

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16. Gaddipati JP, Sundar SV, Calemine J, Seth P, Sidhu GS, Maheshwari RK. Differential regulation of cytokines and transcription factors in liver by curcumin following hemorrhage/resuscitation. Shock 2003;19:150–6.

17. Yildirim Z, Kotuk M, Erdogan H, Iraz M, Yagmurca M, Kuku I, et al.

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18. Yagi K. Lipid peroxides and related radicals in clinical medicine. In: Armstrong D, editor. Free radicals in diagnostic medicine. New York: Plenum Press; 1994. p.1–15.

19. Winterbourn CC, Hawkins RE, Brian M, Carrell RW. The estimation of red cell superoxide dismutase activity. J Lab Clin Med 1975;85:337–42.

20. Paglia DE, Valentine WN. Studies on the quantitative and qualitative characterization of erythrocyte glutathione peroxidase. J Lab Clin Med 1967;70:158–69.

21. Koksel O, Yildirim C, Cinel L, Tamer L, Ozdulger A, Bastürk M, et al. Inhibition of poly(ADP-ribose) polymerase attenuates lung tissue damage after hind limb ischemia-reperfusion in rats. Pharmacol Res 2005;51:453–62.

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27. Aggarwal BB, Harikumar KB. Potential therapeutic effects of curcumin, the anti-inflammatory agent, against neurodegenerative, cardiovascular, pulmonary, metabolic, autoimmune and neoplastic diseases. Int J Biochem Cell Biol 2009;41:40–59.

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DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Sıçanlarda akciğer hasarının oluşturduğu iskelet kası iskemi/reperfüzyonu üzerine zerdeçalın etkisi Dr. Hamed Ashrafzadeh Takhtfooladi,1 Dr. Mohammad Ashrafzadeh Takhtfooladi2 1 2

İslam Azad Üniversitesi, Pathobiyoloji, Bilim ve Araştırma Bölümü, Tahran, İran İslam Azad Üniversitesi, Genç Araştırmacılar ve Seçkinler Kulübü, Bilim ve Araştırma Dalı, Tahran, İran

AMAÇ: Bu çalışma sıçanların arka bacakları bağlandıktan sonra oluşan akciğer hasarı üzerine zerdeçalın etkilerini araştırmak üzere yapıldı.

GEREÇ VE YÖNTEM: Kırk adet Wistar sıçanı plasebo (G1), İ/R (G2), zerdeçal + plasebo (G3) ve zerdeçal +İ/R (G4) gruplarına ayrıldı. Çalışmadan önce iki hafta boyunca günde 200 mg/kg dozda zerdeçal verildi. Büyük trokanterlere iki saat boyunca turnike uygulandıktan sonra dört saat reperfüzyon için beklenerek İ/R oluşturuldu.

BULGULAR: Zerdeçalla öntedavi I/R grubuna göre akciğer dokularında malondialdehitlerin düzeyini anlamlı derecede düşürdü ve süperoksit dismütaz düzeyini yükseltti (p<0.05). Gruplar arasında glutatyon peroksidaz aktivitesi açısından anlamlı farklılık yoktu (p>0.05). İ/R, enflamatuvar hücre infiltrasyonu ve alveoller içine kanama olmak üzere ciddi derecede histopatolojik hasara neden oldu (p<0.05).

TARTIŞMA: Bu sonuçlar zerdeçalla öntedavinin kas İ/R’nin neden olduğu akciğer hasarına karşı koruyucu etkileri olduğunu akla getirmektedir.

Anahtar sözcükler: Akciğer; iskelet kası; iskemi/reperfüzyon; zerdeçal.

Ulus Travma Acil Cerrahi Derg 2019;25(1):7-11

doi: 10.5505/tjtes.2018.83616

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

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ORIG I N A L A R T IC L E

Is it beneficial to use clinical scoring systems for acute appendicitis in adults?

Emin Köse, M.D.,1 Mustafa Hasbahçeci, M.D.,2 Mehmet Can Aydın, M.D.,1 Tuba Saydam, M.D.,1 Ayhan Özsoy, M.D.,1 Servet Rüştü Karahan, M.D.1 1

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

2

Department of General Surgery, Medical Park Fatih Hospital, İstanbul-Turkey

Canberk Toy, M.D.,1

ABSTRACT BACKGROUND: Clinical scoring systems have been used to reduce negative appendectomy rate for several decades. However, the use of these systems has been questioned due to differences in their diagnostic accuracies. The aim of this prospective study was to develop a new clinical scoring system using a combination of all previously described variables for the diagnosis of acute appendicitis (AA).

METHODS: Consecutive patients who underwent emergency appendectomy for AA between December 2016 and April 2017 were prospectively included in the study. During admission, a prepared questionnaire including variables obtained from the previously used clinical scoring systems was administered. Histopathological analysis was regarded as the main outcome. Patients with no histopathological evidence of AA were defined as negative appendectomy. All variables were analyzed separately to assess their association with AA. A receiver operating characteristic curve with area under curve analysis was performed to obtain the cut-off values for numerical variables.

RESULTS: There were 200 patients with a mean age of 30.8±12.8 years with a negative appendectomy rate of 5.5%. There was no significant association between the variables and the detection of histologically proven AA except increased white blood cell count >11.05/mm3 and proportion of the polymorphonuclear leukocytes >71.2% (p=0.003 and p=0.015, respectively).

CONCLUSION: The present study shows that the development and/or use of scoring systems does not significantly improve the diagnostic accuracy of AA. Keywords: Appendicitis; decision support techniques; diagnosis.

INTRODUCTION For the past two centuries, acute appendicitis (AA) has been the most common indication for emergent abdominal surgery. The rate of diagnostic errors of AA cases still remains approximately 20%–45% despite the widespread use of imaging techniques.[1–3] This rate increases up to the higher levels especially in women who are in the reproductive age group, children, and elderly patients.[1,3] In most of the cases, surgical removal of the macroscopically and microscopically normal appearing appendix vermiformis is performed, resulting in unnecessary surgeries with a negative appendectomy rate of 20%–45%.[1,4] The use of ultra-

sound or computed tomography (CT) is recommended to increase the diagnostic accuracy of AA.[5] However, variable accuracy, cost, ionizing radiation for tomography, and further delay in diagnosis and surgery should be considered before implementing imaging techniques in the current practice.[6,7] Clinical scoring systems have been used to reduce the negative appendectomy rate without increasing morbidity and mortality due to AA for several decades.[1,4] There have been >10 such scoring systems including Alvarado, Ohmann, Eskelinen, RIPASA, Fenyo, Lintula, Tzakis, and others.[1,4,8] Assignment of point values obtained from the patient’s history, physical examination, and simple laboratory tests have been used to determine the probability of AA in the patient.[1] Although

Cite this article as: Köse E, Hasbahçeci M, Aydın MC, Toy C, Saydam T, Özsoy A, et al. Is it beneficial to use clinical scoring systems for acute appendicitis in adults? Ulus Travma Acil Cerrahi Derg 2019;25:12-19.

Address for correspondence: Mustafa Hasbahçeci, M.D. Medical Park Fatih Hastanesi, Genel Cerrahi Kliniği, Fatih, İstanbul, Turkey Tel: +90 212 - 621 94 99 E-mail: hasbahceci@yahoo.com Ulus Travma Acil Cerrahi Derg 2019;25(1):12-19 DOI: 10.5505/tjtes.2018.22378 Submitted: 18.01.2018 Accepted: 21.06.2018 Online: 26.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Köse et al. Is it beneficial to use clinical scoring systems for acute appendicitis in adults?

there has been excellent predictive accuracy reported by the authors who developed these clinical scoring systems, the differences in the sensitivities and specificities in subsequent studies lead to the uncertainty of the scoring systems’ reliability.[3,9–11] It has been thought that if these scoring systems were applied to the populations in which they were originally created, the diagnostic accuracy increases.[8] Additionally, the presence of variances for the differential diagnosis of AA according to several geographic areas with ethnic and linguistic differences and the different spectra of AA may impair the widespread application of these scoring systems.[5,8] Based on prospectively collected data, the aim of the present study was to develop a new clinical scoring system for the diagnosis of AA using a combination of all variables that were previously described in the clinical scoring systems.

MATERIALS AND METHODS Consecutive patients who underwent appendectomy for suspected AA between December 2016 and April 2017 were prospectively included in the study. The local ethics committee approved the study in accordance with the Declaration of Helsinki. Written informed consent was obtained from all patients. All patients were ≥17 years old, presented with right iliac fossa pain, and underwent emergency appendectomies as the only surgical treatment modality for suspected AA. Patients who had an appendectomy as part of other emergent surgeries, who had an elective appendectomy, and with incomplete data were excluded from the study. The diagnosis of AA was established by using clinical history, physical examination, laboratory examination, and imaging techniques including ultrasound and CT in selected cases.

and combined into a simple questionnaire comprised of 20 variables (Table 1). All nominal and categorical variables were dichotomized based on the previous scoring systems as stated above. The severity of pain was graded as mild, moderate, or severe. “Age” was classified as <40 years and ≥40 years for numerical variables. Duration of complaints and elevated body temperature were each classified into two groups: <48 h and ≥48 h and <37.5 °C and ≥37.5 °C. Body temperature was measured from the axillary region, and measurements >37.5 °C were regarded as increased body temperature. Bowel sounds were regarded as abnormal if absent, tinkling, or high-pitched. Dysuric complaints, such as burning during urination, frequent or intense urge for urination, and any change in color or smell of urine, were questioned, and in suspicious cases, this condition was confirmed by a urinalysis.

The absence of blood, neutrophils, or bacteria was regarded as negative urinalysis. Being a foreigner as the variable found in the RIPASA scoring system was excluded from the questionnaire due to its invalidity to the present study.

Demographic data (age and gender), symptoms (right iliac fossa pain, migratory pattern to the right iliac fossa, intensity of pain as severe and moderate or mild, progression of Table 1. Summary of the variables found in the scoring systems for acute appendicitis No

Scoring systems

Variable

1

A, E, F, I, O, L, T

Right iliac fossa rebound tenderness

2

A, E, F, I, O, R, T

Leukocytosis

3

A, F, L, O, R

Migration of pain

4

A, E, F, I, L, O, R

Muscular guarding or rigidity

5

A, E, I, L, O, R, T

Right iliac fossa pain

Patients’ demographic data (age and gender) were recorded.

During admission to the emergency department, a prepared questionnaire was administered by the 2nd to 4th year general surgery residents after collecting patients’ history, thorough physical examination, and laboratory tests. Laboratory tests included white blood cell (WBC) count (upper normal limit: 10,500/mm3), proportion of the polymorphonuclear (PMN) leukocytes (upper normal limit: 78%), and serum C-reactive protein (CRP) level (upper normal limit: 5 mg/dL) during the initial presentation of the patients. Before completing the questionnaire, a brief explanation in relation to the variables was given by the chief surgeon to the general surgery residents. All completed forms were later collected by the chief surgeon, as the study coordinator, in a separate folder.

6

A, F, I, L, R

Nausea/vomiting

7

E, F, R,

Duration of complaints

8

F, L, R

Gender

9

A, I, L, R

Fever

10

A, R

Anorexia

11 O,R

Age

12

Negative urinalysis/no dysuric

O, R

symptoms

13

A, R

Right iliac fossa tenderness

14

F

Progression of pain

15

A, I

Left shift in WBC differential

16

F

Aggravation with cough

17

L

Bowel sounds

Questionnaire

18

O

Continuous pain

The variables were obtained from the previously used clinical scoring systems for AA including Alvarado, Eskelinen, Ohmann, Tzakis, Lintula, Fenyo, RIPASA, and the Appendicitis Inflammatory Response Score (AIRS).[1,4,8] The variables in these systems were evaluated by two authors (EK and MH)

19

L

Intensity of pain

20

I

C-reactive protein

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A: Alvarado; E: Eskelinen; F: Fenyo; I: Appendicitis inflammatory response; O: Ohmann; L: Lintula; T: Tzakis; R: RIPASA.

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Köse et al. Is it beneficial to use clinical scoring systems for acute appendicitis in adults?

pain as increased and decreased or the same, continuous pattern of pain, aggravation with cough, duration of complaints, anorexia, nausea and/or vomiting, and dysuric symptoms), clinical findings (elevated body temperature, right iliac fossa tenderness, right iliac fossa rebound tenderness, muscular guarding or rigidity, and bowel sounds), and laboratory test results (CRP, WBC count, and proportion of PMN leukocytes) were collected.

The decision to perform surgical treatment was made by the attending surgeon who was blind to the results of the questionnaires. Open or laparoscopic appendectomy was performed according to the decision of the attending surgeon. All specimens were analyzed histopathologically. A diagnosis of AA was confirmed in the presence of infiltration of the muscularis propria by PMN leukocytes. Patients with no histopathological evidence of AA were defined as negative appendectomy. The results of the histopathological reports were regarded as the main outcome.

Statistical Analysis The variables found in the questionnaire were analyzed according to the results of the histopathological reports. Statistical analysis was performed using SPSS version 20 (SPSS, Chicago, IL, USA). Data were expressed as mean±standard deviation as well as frequencies and percentages for normally distributed continuous and categorical variables, respectively.

First, all variables were analyzed separately to assess their association with AA as confirmed histopathologically. All nominal and categorical variables were dichotomized into two.

The severity of pain was graded as mild or moderate and severe. For numerical variables, “age” was classified as <40 years and ≥40 years. Duration of complaints and elevated body temperature were classified into two groups as <48 h and ≥48 h and <37.5 °C and ≥37.5 °C. For WBC, proportion of PMN leukocytes and CRP dichotomization as increased or normal was used according to the upper normal limits set by the laboratory. The Mann–Whitney U test was used to assess

significant differences in continuous variables, as appropriate.

The Pearson chi-square and Fisher’s exact tests were used for categorical variables. A p value <0.05 was considered statistically significant.

At the secondary level, a receiver operating characteristic (ROC) curve with area under curve analysis was performed for these numerical values to obtain the cut-off values based on the optimal combination of sensitivity and specificity.

Based on the cut-off values of each, other dichotomization was used as increased or normal. This led to the following cut-off values for WBC count and proportion of PMN leukocytes as 11.05/mm3 and 71.2%, respectively.

RESULTS A total of 200 patients were included in the study. The mean age of the patients was 30.8±12.8 years. There were 131 (65.5%) male and 69 (34.5%) female patients. Final histopathological analysis revealed that there were 11 normal appendix vermiformis indicating a negative appendectomy rate of 5.5%.

Patients with and without AA were similar except in WBC count and proportion of PMN leukocytes (Table 2). Patients with AA had significantly higher WBC count and proportion of PMN leukocytes.

The results of the variables found in the questionnaire and clinical and laboratory findings are detailed in Table 3.

There was no significant association between the variables and the detection of histologically proven AA except increased WBC (p=0.026) (Table 3). There were more patients with increased WBC in patients with AA than those in patients without AA. Sensitivity analysis revealed that the highest sensitivity was detected with right iliac fossa pain, right iliac fossa tenderness, and muscular guarding or rigidity. The highest specificity was calculated for increased duration of complaints and no dysuric symptoms and/or negative urinalysis (Table 3).

Table 2. Comparison of patients with and without AA Feature

Overall

Patients with AA

200 (100)

189 (94.5)

Age (year)*

30.8±12.6 30.7±12.8

Patients without AA

p

11 (5.5) 32.6±10.6 0.381

Gender Female**

69 (34.5)

64 (33.9) 125 (66.1)

Male

131 (65.5)

Duration of the complaints (h)*

31.2±29.1 31.4±29.6

White blood cell count (mm )

14.3±4.4 14.5±4.3

**

3 *

Proportion of polymorphonuclear leukocytes (%)* 75.9±10.4 C-reactive protein (mg/dL) *

76.4±10.1

47.1±73.1 48.3±74.7

5 (45.5)

0.517

6 (54.5) 28.0±20

0.957

10.3±3.9 0.003 68.1±11.7

0.015

26.3±34.5 0.220

*: Mean±standard deviation; **: N (%). AA: Acute appendicitis.

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KĂśse et al. Is it beneficial to use clinical scoring systems for acute appendicitis in adults?

Table 3. Sensitivity and specificity analyses of the variables Feature

Subgroup

Overall

Patients with AA Patients without AA

n (%)

n (%)

n (%)

200 (100)

189 (94.5)

11 (5.5)

40 (20)

37 (19.6)

3 (27.3)

p

0.463

Sensitivity Specificity

Age (years)

â&#x2030;Ľ40

<40

160 (80)

152 (80.4)

8 (72.7)

Gender

Male

131 (65.5)

125 (66.1)

6 (54.5)

Female

69 (34.5)

64 (33.9)

Right iliac fossa pain

Yes

198 (99)

187 (98.9)

No

2 (1)

2 (1.1)

0.517

19.6 66.1

72.7 45.5

5 (45.5) 11 (100.0)

1.000

98.9

0.0

0 (0)

Migratory pattern to

Yes

128 (64)

121 (64.0)

7 (63.6)

the right iliac fossa

No

72 (36)

68 (36.0)

4 (36.4)

1.000

Severity of pain

Severe

80 (40)

75 (39.7)

5 (45.5)

Mild-moderate 120 (60)

114 (60.3)

6 (54.5)

Progression of pain

Yes

77 (38.5)

73 (38.6)

4 (36.4)

No

123 (61.5)

116 (61.4)

7 (63.6)

Continuous pattern of pain

Yes

110 (55)

105 (55.6)

5 (45.5)

No

90 (45)

84 (44.4)

6 (54.5)

0.757 1.000 0.548 0.733

64.0 39.7 38.6 55.6

Aggravation with cough

Yes

142 (71)

135 (71.4)

7 (63.6)

No

58 (29)

54 (28.6)

4 (36.4)

Increased duration of

Yes

25 (12.5)

24 (12.7)

1 (9.1)

1.000

71.4 12.7

complaints (>48 h)

No

175 (87.5)

165 (87.3

10 (90.9)

Anorexia

Yes

133 (66.5)

127 (67.2

6 (54.5)

No

67 (33.5)

62 (32.8)

5 (45.5)

Nausea/vomiting

Yes

89 (44.5)

83 (43.9)

6 (54.5)

No

111 (55.5)

106 (56.1)

5 (45.5)

No dysuric symptoms and/

Yes

26 (13)

25 (13.2

1 (9.1)

0.512 0.544 1.000

67.2 43.9 13.2

or negative urinalysis

No

174 (87)

164 (86.8)

10 (90.9)

Elevated body temperature

Yes

55 (27.5)

53 (28.0)

2 (18.2)

No

145 (72.5)

136 (72.0)

9 (81.8)

Right iliac fossa tenderness

Yes

193 (96.5)

183 (96.8)

10 (90.9)

No

7 (3.5)

6 (3.2)

0.731 0.331

28.0 96.8

36.4 54.5 63.6 54.5 36.4 90.9 45.5 45.5 90.9 81.8 9.1

1 (9.1)

Right iliac fossa rebound

Yes

174 (87)

165 (87.3)

9 (81.8)

tenderness

No

26 (13)

24 (12.7)

2 (18.2)

Muscular guarding or rigidity

Yes

193 (96.5)

182 (96.3)

No

7 (3.5)

7 (3.7)

Abnormal bowel sounds

Yes

41 (20.5)

38 (20.1)

3 (27.3)

No

159 (79.5)

151 (79.9)

8 (72.7)

Increased WBC

Yes

165 (82.5)

159 (84.1)

6 (54.5)

No

35 (17.5)

30 (15.9)

5 (45.5)

Increased % PMN leukocytes Yes

99 (49.5)

96 (50.8)

3 (27.3)

No

101 (50.5)

93 (49.2)

8 (72.7)

CRP

Yes

143 (71.5)

137 (72.5)

6 (54.5)

No

57 (28.5)

52 (27.5)

5 (45.5)

11 (100.0)

0.639 1.000

87.3 96.3

18.2 0.0

0 (0) 0.699 0.026 0.214 0.300

20.1 84.1 50.8 72.5

72.7 45.5 72.7 45.5

AA: Acute appendicitis; WBC: White blood cell count; PMN: Polymorphonuclear; CRP: C-reactive protein.

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Kรถse et al. Is it beneficial to use clinical scoring systems for acute appendicitis in adults?

Table 4. ROC curve analysis of WBC count and proportion of PMN leukocytes Parameter

Value

p

AUC

Sensitivity

Specificity

95% CI Lower bound

Upper bound

WBC count

>11.05

0.003

0.770

81

63.6

0.625

0.915

% PMN leukocytes

>71.2

0.015

0.717

74.6

63.6

0.571

0.864

WBC: White blood cell; PMN: Polymorphonuclear; AUC: Area under curve; CI: Confidence interval.

ROC curve analysis of WBC count and proportion of PMN leukocytes revealed that WBC count higher than 11.05/mm3 and proportion of PMN leukocytes higher than 71.2% were also significantly associated with AA (p=0.003 and p=0.015, respectively) (Table 4) (Fig. 1).

DISCUSSION An accurate diagnosis of AA is still a controversial issue for most of the cases.[12] Although many probabilistic approaches, such as scoring systems, computer models, and algorithms, have been used to facilitate the accurate diagnosis and management of AA for the last several decades, the level of diagnostic errors has remained the same.[1] In addition to the use of modern diagnostic tools, operator dependency for ultrasound, unavailability and risks for CT, and diagnostic laparoscopy, there is no consensus for an algorithm in association with the diagnosis of AA.[8] Therefore, clinical scoring systems are usually based on clinical evaluations that are inexpensive and non-invasive and utilize easy diagnostic tools. It can be possible to improve the diagnostic accuracy of AA and to help to select patients for immediate surgery, follow-up, or additive tests.[3,8,10,12,13] ROC Curve

1.0

ROC Curve

1.0

0.8

0.8

0.6

0.6

Sensitivity

Sensitivity

Two of the most widely used scoring systems since 1986 include Alvarado and modified Alvarado, both of which were developed in the West.[5] However, there were significant differences in sensitivity and specificity levels depending on the cut-off threshold levels and the geographic variation of the countries in which they were applied. In addition, there have been some studies in which the diagnostic accuracy of AA did not improve after the use of such scoring systems.[9,10,14,15] There have even been worse outcomes when such scoring systems were performed in countries or hospitals where the scores were not originally developed, possibly due to a constant feedback to the clinician.[3,7,9,11,16] This difference has been thought to be higher in cases in which a scoring system that is developed in the West is used in a country located in the East. In the retrospective study by Ohmann,[11] it has been shown that there were significant differences between 10 different scoring systems, even if the cut-off points were varied systematically. Owing to the presence of optimistic biases, it has been believed that the evaluation of such scores on different clinical environments rather than the original and local database resulted in poor performances. Therefore, it should be kept in mind that there are some major limitations including definite ethnic differences and optimistic biases for world-

0.4

0.4 AUC: 0.770

AUC: 0.717

0.2

0.0

0.2

WBC 0.0

0.2

0.4 0.6 1 - Specificity

0.8

% Neutrophils 1.0

0.0

0.0

0.2

0.4 0.6 1 - Specificity

0.8

1.0

Figure 1. ROC curve analysis of WBC count and proportion of PMN leukocytes showing AUC values as 0.770 and 0.717, respectively.

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wide acceptance and use of these scoring systems. Although the use of standardized questionnaires for such scoring systems helps physicians to improve their data and provide a more systematic approach, the clinical benefit of diagnostic scoring systems in AA remains controversial and needs to be clarified by prospective studies.[3] Considering definite ethnic differences and optimistic biases, the development and use of local scoring systems are more helpful for physicians to reach more significant outcomes. By that way, selection of the study groups with narrow geographic or demographic limitations would have less variability in presentation and consequently more diagnostic accuracy.[17] In the present study, we aimed to develop a new scoring system for AA that is to be developed and used in a local manner. For that purpose, the scoring systems for AA were evaluated and summarized in a variable list to develop a new system.

The majority of the systems that have been used for the diagnosis of AA showed high sensitivity and positive predictive values.[1] However, it has also been reported that there are low specificity and negative predictive values causing delayed diagnosis and consequent events. Comparison of two or more scoring systems has been performed previously in different studies from several regions. Yılmaz et al.[18] showed that the Alvarado score is more useful to predict AA than the Ohmann score that provides more guidance to eliminate AA. In the study by Walczak,[1] comparison of six different scoring systems (Alvarado, Fenyo, Eskelinen, Ohman, Tzakis, and RIPASA) revealed that the Tzakis scoring system’s highest positive predictive value is 81% with sensitivity and specificity rates of 65% and 62%, respectively. The Alvarado, Eskelinen, Ohmann, and RIPASA scoring systems have been studied

by Erdem et al.[8] They found that the Ohmann and RIPASA scoring systems have the highest sensitivity for AA. Based on these controversial findings, it cannot be possible to reach a significant conclusion. Therefore, any scoring system should not be used alone to or not to diagnose AA. Instead, it may be regarded as a diagnostic aid to manage the treatment or follow-up protocol as immediate surgery, close observation at home, or further diagnostic tests.[6] However, our results did not support this hypothesis.

In previous studies, it has been shown that the sensitivity and specificity of the Alvarado scoring system vary with age, gender, and duration of symptoms.[13,18–20] Therefore, there may be some modifications by adding or excluding some local parameters. The RIPASA scoring system has been one example that was developed for this purpose.[5] However, this system still has no widespread acceptance. In the studies by Jawaid and Teicher,[3,21] the authors used some predictive factors using a pretested questionnaire that collected information on demographics, clinical signs and symptoms, and laboratory and radiological investigations. After exclusion of the nonsignificant variables, Jawaid tried to describe a new scoring system using 19 variables with sensitivity and specificity rates of 78% and 89%, respectively.[3] In the study by Teicher et Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

al.,[21] they described seven predictive factors including sex, age, duration of symptoms, genitourinary symptoms, involuntary right lower quadrant muscle spasm, right-sided rectal mass, and WBC count and thought of the elimination of over one-third of the unnecessary laparotomies by using a scoring system. In the study by Lintula et al.,[22] they described a diagnostic model using six medical history and three clinical finding variables in pediatric patients with AA. In this study, by using the diagnostic model, the negative appendectomy rate would have been reduced from 27% to 13%. In another study, several variables including pain in the right lower quadrant, pain relocation, tenderness at the right lower quadrant, muscular guarding, WBC count, proportion of PMN leukocytes, and CRP levels have been shown to be associated with AA.[23] For this purpose, this study was designed as a prospective study using all variables described previously in the scoring systems. Although such methodology was selected to obtain an optimum variable list, only one significant association was detected between an increased WBC level and the presence of AA. Therefore, a predictive and diagnostic model for AA using logistic regression analysis could not be constructed due to the absence of significant prognostic variables. The negative appendectomy rate as 5.5% in the present study may have a negative impact on detecting significant associations for developing a new scoring system. Therefore, the development and use of such scoring systems based on the variables with statistically significant associations should be questioned.

There have been different variables including symptoms, signs, and routine laboratory findings in these previously described clinical scoring systems for the diagnosis of AA. Assessment of the patients by such questionnaires may show variances due to different physicians with varying clinical experiences and communication abilities.[3] In addition, evaluation of some variables may be open to inter- or intra-observer variation.

[6,14] It can be difficult to evaluate the severity of pain as mild, moderate, or severe for the Lintula score. In addition, similar difficulty is still present in the grading of rebound tenderness and muscular defense as light, medium, and strong for the AIRS. Lack of objective definitions of anorexia, nausea, or relocation of pain is another controversial issue during the use of these scoring systems.[6] Determination of different numerical values for the variables in some scoring systems may also cause different outcomes due to the variances in the study populations originated from different regions of the world. Some authors have tried to use alternative cutoff values of each scoring system to increase their accuracy in the selected populations.[1,17] Owing to the fact that the determination of the cut-off values has shown great variances depending on the overstatement of sensitivity or specificity by the authors, this issue should be regarded as the main limitation of the scoring systems for their widespread use.

[3] In the present study, we tried to grade and categorize all variables into dichotomous data to prevent the loss of diagnostic information.[6] In addition to this effort, there was 17

Köse et al. Is it beneficial to use clinical scoring systems for acute appendicitis in adults?

only one significant association for AA. Therefore, logistic regression analysis and backward regression analysis were not performed to develop a new diagnostic model.

Our study has some limitations. A relatively small number of patients in the present study were the main limitation. Inability to perform statistical analysis for developing a new diagnostic model may be regarded as another drawback. However, absence of conservative treatment for AA, inclusion of only patients with AA, and prospective data collection using structured forms were important factors for the accuracy of the conclusions of the study. Although the imaging techniques are widely used for the diagnosis of AA, we did not evaluate the possible impact of these techniques on diagnostic accuracy.

In conclusion, the present study shows that the development and/or use of scoring systems do not significantly improve the diagnostic accuracy of AA. Among the laboratory measurements, increased WBC count and proportion of PMN leukocytes are shown to be significantly associated with AA. Therefore, recommendation for the use of such scoring systems does not seem to be logical for the diagnostic accuracy of AA in adult patients.

Conflict of interest: None declared.

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2. Cipe G, Idiz O, Hasbahceci M, Bozkurt S, Kadioglu H, Coskun H, et al.

Laparoscopic versus open appendectomy: where are we now? Chirurgia (Bucur) 2014;109:518–22.

3. Jawaid A, Asad A, Motiei A, Munir A, Bhutto E, Choudry H, et al. Clinical scoring system: a valuable tool for decision making in cases of acute appendicitis. J Pak Med Assoc 1999;49:254–9.

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

Ann R Coll Surg Engl 1994;76:418–9.

5. Chong CF, Adi MI, Thien A, Suyoi A, Mackie AJ, Tin AS, et al. Development of the RIPASA score: a new appendicitis scoring system for the diagnosis of acute appendicitis. Singapore Med J 2010;51:220–5.

6. Andersson M, Andersson RE. The appendicitis inflammatory response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg 2008;32:1843–9.

7. Enochsson L, Gudbjartsson T, Hellberg A, Rudberg C, Wenner J, Ringqvist I, et al. The Fenyö-Lindberg scoring system for appendicitis increases positive predictive value in fertile women-a prospective study in

18

455 patients randomized to either laparoscopic or open appendectomy.

Surg Endosc 2004;18:1509–13.

8. 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.

9. Sitter H, Hoffmann S, Hassan I, Zielke A. Diagnostic score in appendicitis. Validation of a diagnostic score (Eskelinen score) in patients in whom acute appendicitis is suspected. Langenbecks Arch Surg 2004;389:213– 8.

10. Lintula H, Kokki H, Pulkkinen J, Kettunen R, Gröhn O, Eskelinen M. Diagnostic score in acute appendicitis. Validation of a diagnostic score (Lintula score) for adults with suspected appendicitis. Langenbecks Arch Surg 2010;395:495–500.

11. Ohmann C, Yang Q, Franke C. Diagnostic scores for acute appendicitis.

Abdominal Pain Study Group. Eur J Surg 1995;161:273–81.

12. Yoldas O, Karaca T, Tez M. External validation of Lintula score in Turkish acute appendicitis patients. Int J Surg 2012;10:25–7.

13. Tekeli MT, Ilhan E, Ureyen O, Senlikci A, Yeldan E, Ozturk M, et al.

How much Reliable Is Alvarado Scoring System in Reducing Negative Appendectomy? Indian J Surg 2017;79:106–10.

14. 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.

15. Yüksel Y, Dinç B, Yüksel D, Dinç SE, Mesci A. How reliable is the Alvarado score in acute appendicitis? Ulus Travma Acil Cerrahi Derg 2014;20:12–8.

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

17. Kharbanda AB, Monuteaux MC, Bachur RG, Dudley NC, Bajaj L, Stevenson MD, Macias CG, et al; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics.

A Clinical Score to Predict Appendicitis in Older Male Children. Acad Pediatr 2017;17:261–6.

18. Yılmaz EM, Kapçı M, Çelik S, Manoğlu B, Avcil M, Karacan E. Should Alvarado and Ohmann scores be real indicators for diagnosis of appendicitis and severity of inflammation? Ulus Travma Acil Cerrahi Derg 2017;23:29–33.

19. Shchatsko A, Brown R, Reid T, Adams S, Alger A, Charles A. The Utility of the Alvarado Score in the Diagnosis of Acute Appendicitis in the Elderly. Am Surg 2017;83:793–8.

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

21. Teicher I, Landa B, Cohen M, Kabnick LS, Wise L. Scoring system to aid in diagnoses of appendicitis. Ann Surg 1983;198:753–9.

22. Lintula H, Pesonen E, Kokki H, Vanamo K, Eskelinen M. A diagnostic score for children with suspected appendicitis. Langenbecks Arch Surg 2005;390:164–70.

23. Sammalkorpi HE, Mentula P, Leppäniemi A. A new adult appendicitis score improves diagnostic accuracy of acute appendicitis-a prospective study. BMC Gastroenterol 2014;14:114.

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Köse et al. Is it beneficial to use clinical scoring systems for acute appendicitis in adults?

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Yetişkinlerde akut apandisit için klinik skorlama sistemlerinin kullanılması yararlı mı?

Dr. Emin Köse,1 Dr. Mustafa Hasbahçeci,2 Dr. Mehmet Can Aydın,1 Dr. Canberk Toy,1 Dr. Tuba Saydam,1 Dr. Ayhan Özsoy,1 Dr. Servet Rüştü Karahan1 1 2

Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul Medical Park Fatih Hastanesi, Genel Cerrahi Kliniği, İstanbul

AMAÇ: Klinik skorlama sistemleri, son yıllarda negatif apandektomiyi azaltmak için kullanılmaktadır. Bununla birlikte, bu sistemlerin kullanımı, teşhis doğruluğundaki farklılıklardan dolayı sorgulanmaktadır. Bu ileriye yönelik çalışmada akut apandisit tanısında daha önce tanımlanan tüm değişkenlerin bir kombinasyonu kullanılarak yeni bir klinik skorlama sistemi geliştirilmesi amaçlanmıştır.

GEREÇ VE YÖNTEM: Aralık 2016 ile Nisan 2017 arasında akut apandisit için acil apandisit ameliyatı yapılan ardışık hastalar ileriye dönük olarak çalışmaya dahil edildi. Hastaların ilk başvurusu esnasında, daha önce kullanılan klinik skorlama sistemlerinden alınan değişkenleri içeren hazır bir anket uygulandı. Histopatolojik analiz ana sonuç değişkeni olarak kabul edildi. Histopatolojik olarak akut apandisit bulgusu olmayan hastalar negatif appendektomi olarak tanımlandı. Tüm değişkenlerin akut apandisit ile olan ilişkilerini belirlemek için istatistiksel değerlendirme yapıldı. Nümerik değişkenlerin kestirim (cut-off ) değerlerini belirlemek için ROC ve AUC analizleri yapıldı.

BULGULAR: Ortalama yaşları 30.8±12.8 yıl ve negatif apendektomi oranı %5.5 olan 200 hasta çalışmaya dahil edildi. 11.05/mm3’den daha yüksek lökosit sayısı ve %71.2’den daha yüksek nötrofil oranı dışında diğer değişkenler ile histopatolojik olarak kanıtlanmış akut apandisit arasında anlamlı bir ilişki gösterilemedi (sırasıyla, p=0.003 ve p=0.015).

TARTIŞMA: Bu çalışmada elde edilen bulgular, skorlama sistemlerinin geliştirilmesinin ve/veya kullanılmasının akut apandisitin tanısal doğruluğunu anlamlı bir şekilde iyileştirmediğini göstermektedir.

Anahtar sözcükler: Apandisit; karar destek teknikleri; tanı.

Ulus Travma Acil Cerrahi Derg 2019;25(1):12-19

doi: 10.5505/tjtes.2018.22378

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

19

ORIG I N A L A R T IC L E

First step toward a better trauma management: Initial results of the Northern Izmir Trauma Registry System for children Mustafa Onur Öztan, M.D.,1 Murat Anıl, M.D.,2 Ayşe Berna Anıl, M.D.,3 Demet Yaldız, M.D.,4 İlhan Uz, M.D.,5 Ali Turgut, M.D.,6 Işıl Köse, M.D.,7 Kerim Acar, M.D.,8 Turhan Sofuoğlu, M.D.,9 Gökhan Akbulut, M.D.10 1

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

2

Pediatric Emergency Care Unit, University of Health Sciences, Tepecik Training and Research Hospital, İzmir-Turkey

3

Department of Pediatrics, Intensive Care Unit, Katip Çelebi University Faculty of Medicine, İzmir-Turkey

Department of Chest Surgery, University of Health Sciences, Suat Seren Chest Diseases and Surgery Training and Research Hospital, İzmir-Turkey

4 5

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

6

Department of Orthopedics and Traumatology, University of Health Sciences, Tepecik Training and Research Hospital, İzmir-Turkey

7

Department of Anesthesiology and Intensive Care Unit, University of Health Sciences, Tepecik Training and Research Hospital, İzmir-Turkey

8

Department of Emergency Medicine, Menemen State Hospital, İzmir-Turkey

9

Department of Ambulance Services, University of Health Sciences, Tepecik Training and Research Hospital, İzmir-Turkey

10

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

ABSTRACT BACKGROUND: Trauma is an important health problem in children, and improvement in trauma care on the national level is possible only through the knowledge gathered from trauma registry systems. This information is not available in our country, because there is no current trauma registry system in the hospitals. Our aim in this paper is to explain the trauma registry system we have developed and to present the first year’s data.

METHODS: The planned trauma registry system was integrated into the emergency department registry system of 14 hospitals in the Izmir province. The data of pediatric patients with multiple trauma have been recorded automatically through the registry system.

Demographics, vital signs, mechanism, the type of trauma, anatomical region, Injury Severity Score (ISS), Pediatric Trauma Score (PTS), Glasgow Coma Scale (GCS) score, the length of hospital stay, and the need for blood transfusion/endotracheal intubation/surgery/ hospitalization were evaluated by the patient transfer status and outcome.

RESULTS: At the end of one year, a total of 356 pediatric major trauma patients were included in the study. The most common type of trauma was blunt trauma (91.9%), and the most common mechanism was vehicle-related traffic accident (28.1%). In the group with the Glasgow Outcome Scale ≤3; the age was greater, ISS was higher, and PTS was lower. Motorcycle accidents, sports injuries, and penetrating injuries were more frequent in this group. All scores were significantly different between direct and transferred patients. The referral time to the hospital of the transferred patients was longer than directly admitted patients, but the results were not different.

CONCLUSION: Pediatric major trauma is an important cause of mortality and morbidity, and our trauma registry system, which is a successful example abroad, is insufficient in our country. We hope that the trauma registry system we planned and the pilot application we started will be expanded to include other hospitals throughout the country with the aim of developing a national registry system.

Keywords: Major trauma; pediatric trauma; trauma registry; trauma system.

Cite this article as: Öztan MO, Anıl M, Anıl AB, Yaldız D, Uz İ, Turgut A, et al. First step toward a better trauma management: Initial results of the Northern Izmir Trauma Registry System for children. Ulus Travma Acil Cerrahi Derg 2019;25:20-28.

Address for correspondence: Mustafa Onur Öztan, M.D. Katip Çelebi Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, İzmir, Turkey.

Tel: +90 232 - 469 69 69 / 3255 E-mail: mustafaonur.oztan@ikc.edu.tr Ulus Travma Acil Cerrahi Derg 2019;25(1):20-28 DOI: 10.5505/tjtes.2018.82780 Submitted: 10.03.2018 Accepted: 04.09.2018 Online: 26.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

20

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

Ă&#x2013;ztan et al. Initial results of the Northern Izmir Trauma Registry System for children

INTRODUCTION

MATERIALS AND METHODS

Trauma is a leading cause of death and disability among children, 950,000 of whom are fatally injured every year worldwide.[1] Disabilities caused by severe injuries are estimated to affect approximately 10 million children annually.[2] Whether death or severe disability follows a major trauma depends not only on the mechanism and severity of the trauma, but also on the effectiveness of the treatment at the scene, during ambulance transport, and in the hospital.[3] Understanding the patterns of pediatric injury is crucial when developing and implementing effective preventive programs.[4]

Ministry of Health Izmir Northern Secretariat Public Hospitals Association

Izmir is the third largest city in Turkey and has a population of 4.2 million. The hospitals in the northern region of the city constitute a microcosm of the entire country and include research hospitals and hospitals with and without pediatric surgical services or intensive care units. Our hospital is the top-level referral and research hospital in the regionâ&#x20AC;&#x201D;we offer a pediatric emergency service, a pediatric intensive care unit, and a pediatric surgery service. To provide a coordinated service, we sought to first understand the local clinical and sociodemographic characteristics of pediatric trauma patients by establishing a well-designed trauma registry.[5] To the best of our knowledge, no trauma recording system is presently routinely used by emergency services in Turkey.

We established a trauma recording system including all the emergency services associated with the Izmir Northern Secretariat Public Hospitals Association.

The aim of this study was to report the first-year results of the pediatric trauma registry system maintained by 14 hospitals in the Northern Izmir Region. We compared the clinical outcomes of children referred from other hospitals to our hospital with those of children transported to us directly from the accident scene, and we identified the factors affecting the clinical probabilities of dying or becoming severely disabled.

There are 14 hospitals in the Ministry of Health Izmir Northern Secretariat Public Hospitals Association (INSA) region, and these serve 2.5 million of the 4 million people living in the Izmir province. There were 2,109,387 patients admitted to the emergency departments of these hospitals; 339,212 of these patients were admitted to the pediatric emergency department of our instutition (Tepecik Training and Research Hospital - TTRH), which is the most appropriate hospital in the region for treating the most severely injured patients. Pediatric emergency specialists and pediatric surgeons are available at all times in this hospital. The TTRH has a Level 3 pediatric intensive care unit, and surgical intervention is available immediately and at all times when necessary. For this reason, most seriously injured patients are transferred to this hospital either directly from the accident scene or from other hospitals.

Izmir Trauma Team At the beginning of the project, in 2013, a Trauma Coordination Unit was established under the management of INSA. It was developed to collect and coordinate all statistical information related to trauma. The project team, which was formed from trauma-related departments (i.e., general surgery, pediatric surgery, and thoracic surgery), included adult and pediatric emergency medicine specialists, adult and pediatric intensive care specialists, and the director of the ambulance services of the province. After the team was formed, meetings were held every Wednesday for 1 year. At these meetings, the measures to be taken, work plans, and task assignments were determined. All hospitals in the region were informed through official channels about the project. A physician in each centerâ&#x20AC;&#x2122;s emergency department was identified as a trauma officer and was responsible for ensuring that data on major trauma patients were entered into a data-

Table 1. Details of the planning process for the first year of the trauma project Process Months

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Review of the literature

X

X

X

Assessment of the hospitals

X

X

X

X

X

X

X

X

X

Design of the registry

X

Modeling X X Training of the personnel X X X First applications and controls X X X Design of the computer program

X

X

X

X

Intermediate report X Final report X

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Öztan et al. Initial results of the Northern Izmir Trauma Registry System for children

base on a daily basis. A training program was initiated for all personnel involved in the use of the registry. During this training, the proper use of the dedicated software was taught to all registry personnel, and efforts were made to increase the awareness of the registry among emergency service staff.

Workshops were held at the four largest hospitals in the region to identify deficiencies in trauma management, and recommendations were made. One workshop report and two progress reports were published after 6 months and at the end of the first year, respectively (Table 1).

Table 2. Characteristics of patients recorded in the trauma registry system 1. Patients with vital sign abnormalities

- For adults: Blood pressure <90/60 mmHg, heart rate >100

beats/min, respiratory rate >20 breaths /min, peripheral oxygen saturation <90%.

- The critical vital signs for children are shown in Table 2.

2. Patients with Glasgow Coma Scores <14 3. Patients requiring airway support (temporary or permanent)

In terms of existing guidelines, the “Field Trauma Triage and Hospitals Leveling Guide in Izmir–Turkey” was published before this study began.[6] It was planned that the physical infrastructure, staff and equipment capacities, and staff educational levels in all hospitals would be equalized. Fourteen hospitals in the Northern Izmir Region were visited by the trauma team and evaluated in terms of their trauma management capacities. During this evaluation, the problems encountered when managing trauma patients, the personnel levels, and the lists of the available medical devices and equipment for the treatment of adults and children were noted using on-site audit forms. Based on these data, for the first time in our country, all hospitals were classified as “Level 1,” “Level 2,” or “Level 3” in terms of adult patient acceptance and as “Level 2” or “Level 3” in terms of pediatric patient acceptance. According to this system, TTRH is classified at Level 3 in terms of both the adult and pediatric trauma patient acceptance, and three other hospitals (Menemen State Hospital, Karsiyaka State Hospital, and Buca Seyfi Demirsoy State Hospital) are Level 2; the other hospitals are Level 1.

Izmir Northern Region Trauma Registry

14. Ejection from a car, intrusion into a car, motorcycle crash,

We used the criteria from the “Guidelines for Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage” published by the Centers for Disease Control and Prevention to identify the cases of major trauma (Tables 2–4).[7] We added a software module to our hospital registry system so that major trauma patients could be identified by the system. First, all International Classification of Diseases (ICD-10) codes related to trauma were determined, and the system was instructed to open an additional window when these codes were entered. This extra window listed the major trauma criteria to be checked. If the patient met at least one of these criteria, the patient was labeled a “major trauma patient” in the registry system.

The following data were subsequently recorded: • Demographic characteristics (name, surname, sex, age) • Date and hour of admission (00:00–08:00, 08:00–16:00, and 16:00–00:00 hours) • Transfer status • Vital signs (heart rate, respiratory rate, oxygen saturation level, and blood pressure) • Mechanism of injury (MOI) 22

for any reason

4. Suspected or documented stabbing/gunshot injuries to the torso 5. Epidural hematoma, subdural hematoma, traumatic

subarachnoid hemorrhage, depressed head fracture, basal

skull fracture, or suspicion of any of these

6. Patients fulfilling the major burn criteria (Table 3) 7. Two or more proximal long bone fractures (i.e., the femur

and humerus)

8. Complete or near-total amputation proximal to the wrist or ankle 9. Death in the same passenger compartment 10. Falls:

- Adults: >2 floors or > 5 meters

- Children: >3 times the height of the child

11. Injury to an extremity and lack of a distal pulse 12. Suspected or documented pelvic fracture 13. Flailed chest

bicyclist/pedestrian-vehicle crash

15. Deep neck injuries (to levels below the sternocleidomastoid

muscle), enlarged neck hematoma, post-traumatic

hoarseness, active bleeding

16. Proximal limb (elbow and knee injuries) injuries with active bleeding 17. Special considerations: women at >20 weeks of gestation,

patients with advanced respiratory failure, patients on chronic

dialysis, patients using anticoagulants, age over 65 years

• Type of trauma (blunt/penetrating) • Anatomical region and severity of injury • Injury Severity Score (ISS), Pediatric Trauma Score (PTS), and Glasgow Coma Scale (GCS) score • Number of tests and consultations required • Need for blood transfusion, endotracheal intubation, surgery, or hospitalization • Outcomes • Length of stay in the hospital • Total hospital cost Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

Öztan et al. Initial results of the Northern Izmir Trauma Registry System for children

Table 3. Critical vital findings for children (the trauma registry system inclusion criteria) Age

Respiratory rate (Breaths/min)

Pulse (when awake) (Beats/min)

Pulse (when asleep) (Beats/min)

Systolic blood pressure (mmHg)

Newborn 30–60

100–180

80–160

60–90

<1 year

30–60

100–160

75–160

87–105

1–2 years

24–40

80–110

60–90

85–102

3–5 years

22–34

70–110

60–90

89–108

6–12 years

18–30

65–110

60–90

94–120

13–17 years

12–16

60–90

50–90

107–132

Table 4. Trauma registry system inclusion criteria for burns 1. Second-degree burns:

- Age 10–50 years: >25% of the total body surface area

- Age <10/>50 years: >20% of the total body surface area

2. Third-degree burns:

Burns >10% of the total body surface area

3. Second- or third-degree burns involving the face, genital area,

or hands

4. Second- or third-degree burns surrounding the limbs 5. Inhalation injuries (wheezing, injury to the mouth and in the

mouth, dyspnea, low oxygen saturation, poor vocalization)

6. High-voltage electrical burns 7. Burns combined with major injuries (fractures, internal organ

injuries [actual or suspected])

8. Additional comorbid diseases (such as respiratory failure,

liver failure, or renal failure)

9. Suspicion of child/elder abuse 10. Psychiatric disorder/possibility of suicide

Study Population Data from 356 pediatric patients who had sustained a major trauma and were admitted either directly or transferred to the TTRH were analyzed in the study for 1 year. Information on all patients was prospectively recorded from the time of admission until the time of discharge. Data on all cases were obtained from our patient registry system. The ISS and PTS were calculated automatically using the online calculators available at www.trauma.org/archive/scores/web page.[8] To identify factors affecting outcomes, the Glasgow Outcome Scale (GOS) scores were calculated when patients were discharged from the hospital. The differences between patients who died or who were discharged with sequelae (Group 1: GOS score ≤3) and healthy discharged patients (Group 2: GOS score >3) were examined.[9] The patients were also classified in terms of referral to the hospital as either “direct” Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

(directly admitted) or “transfer” admissions to evaluate the effectiveness of the peripheral emergency services.

The exclusion criteria were failure to meet the guidelines, unspecified injuries, suicide, caustic injuries, foreign body ingestion, and non-traumatic mechanisms of injury.

Ethical approval for this study was granted by the Committee on Ethics in Non-interventional Clinical Studies of our institution (Number 2017-1/3).

Statistical Analysis Analysis of normality using the Kolmogorov–Smirnov test showed that the numerical data were not distributed normally, and we therefore used the Mann–Whitney U test to compare the two independent groups. The data are expressed as medians with interquartile ranges (IQRs). Categorical data are expressed as numbers (n) with percentages (%). To compare the categorical data from the two independent groups, either the chi-square or Fischer’s exact test was used. A pvalue <0.05 was considered to be statistically significant. All analyses were performed using the SPSS software (SPSS for MAC version 20.0; SPSS Inc., Chicago, IL, USA).

RESULTS In total, 356 pediatric patients with major trauma were studied. The median age was 6 years (IQR: 2–11 years), and the majority of patients were male (63.8%). Most incidents involved blunt trauma (91.9%, n = 327). The most common MOIs were pedestrian accidents (100; 28.1%), falls from heights (98; 27.5%), contact with hard objects (33; 9.3%), motor vehicle collisions (29; 8.1%), intentional injuries (28; 7.9%), sports injuries (28;7.9%), motorcycle accidents (17; 4.7%), bicycle accidents (12; 3.4%), electric shocks (7; 2.0%), and other causes (4; 1.1%). The first admitting centers were distributed as follows: Level 1 (10 patients, 2.8%); Level 2 (49 patients, 13.7%); Level 3 (293 patients, 82.3%); another university hospital (1 patient, 0.3%); and a private hospital (3 patients, 0.9%). One hundred and fifty-five (43.5%) children had multiple injuries. Head-and-neck injuries were present in 88 (24.7%), facial injuries in 40 (11.2%), chest injuries in 7 23

Öztan et al. Initial results of the Northern Izmir Trauma Registry System for children

(2%), abdominal injuries in 3 (0.8%), musculoskeletal injuries in 56 (15.7%), and superficial wounds in 7 (2%). Four patients died (1.1%), and 9 patients were discharged with sequelae (2.5%) (Group 1: GOS score ≤3).

When we compared Groups 1 and 2, we found that the patients were older, the ISS was higher, and the PTS was lower in Group 1 than in Group 2 (p<0.05). Motorcycle accidents, sports injuries, and penetrating injuries were more common in Group 1 (p<0.05) (Table 5).

Seventy-one (20.2%) patients had been transferred from other hospitals; the others had been transported directly from the accident scene. The ISSs, PTSs, GCS scores, and the number of consultations differed significantly between directly admitted patients and patients transferred/referred to our hospital for further treatment (Table 6). The mean times of arrival at our hospital (from the time of the accident) were 115 min for transferred patients and 30 min for directly admitted patients (p<0.05).

Table 5. Demographic and injury characteristics of admitted patients by outcomes after trauma Characteristic n (%) or median (IQR)

Patient with GOS score ≤3 n=13 (3.7%)

Patients with GOS score >3 n=343 (96.3%)

p

14 (5–15)

6 (2–11)

0.010

Motor vehicle collision

1 (7.7)

28 (8.2)

<0.001

Age Trauma mechanism

Motorcycle accident

4 (30.8)

13 (3.8)

Pedestrian accident

1 (7.7)

99 (28.9)

Fall

0

98 (28.5)

Bicycle accident

0

12 (3.5)

Contact with hard object

1 (7.7)

32 (9.3)

Intentional injury

2 (15.4)

26 (7.6)

Sports injury

4 (30.8)

24 (7)

Electricity

0

7 (2)

Other

0

4 (1.2)

Trauma type

Blunt

8 (61.5)

319 (93)

Penetrating

5 (38.5)

24 (7)

Head-and-neck

1 (7.7)

87 (25.4)

4 (30.8)

36 (10.5)

0

7 (2)

0.002

Trauma region

Face

Thorax

Abdomen

0

3 (0.9)

Extremity

2 (15.4)

54 (15.7)

Superficial

Multiple traumas

0.351

0

7 (2)

6 (46.2)

149 (43.5)

08:00–16:00

2 (15.4)

99 (28.9)

16:00–00:00

10 (76.9)

224 (65.3)

00:00–08:00

1 (7.7)

20 (5.8)

Transport time (min)

30 (24.5–59)

37 (30–75)

0.388

Injury Severity Score

16 (13–38)

9 (4–16)

<0.001

Pediatric Trauma Score

8 (6–11)

10 (9–11)

0.042

Glasgow Coma Scale <14

3 (23.1)

36 (10.6)

0.164

398.88 (185.48–1921.64)

200.81 (91.29–419.64)

0.076

1 (1–3)

2 (1–3)

0.431

Time zone

Invoice (Turkish Lira) Consultations

0.555

IQR: Interquartile range; GOS: Glasgow Outcome Scale.

24

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Öztan et al. Initial results of the Northern Izmir Trauma Registry System for children

Table 6. Demographic and injury characteristics of all patients by transfer status Characteristic n (%) or median (IQR) Age

Direct admission (n=285)

Transferred patients (n=71)

p

5 (2–8)

6 (2–11.5)

0.185

23 (8.1)

6 (8.5)

0.209

Trauma mechanism

Motor vehicle collision

Motorcycle accident

13 (4.6)

4 (5.6)

Pedestrian accident

75 (26.3)

25 (35.2)

Fall

75 (26.3)

23 (32.4)

Bicycle accident

Contact with hard object

8 (2.8)

4 (5.6)

31 (10.9)

2 (2.8)

Intentional injury

24 (8.4)

4 (5.6)

Sports injury

26 (9.1)

2 (2.8)

Electricity

6 (2.1)

1 (1.4)

Other

4 (1.4)

0

261 (91.6)

66 (93)

24 (8.4)

5 (7)

Trauma type

Blunt

Penetrating

0.682

Trauma region

Head-and-neck

76 (26.7)

12 (16.9)

Face

34 (11.9)

6 (8.5)

Thorax

5 (1.8)

2 (2.8)

Abdomen

2 (0.7)

1 (1.4)

Extremity

47 (16)

9 (12.7)

Superficial

7 (2.5)

0

Multiple trauma

114 (40)

41 (57.7)

0.156

Time zone

08:00–16:00

85 (29.8)

20 (28.2)

16:00–00:00

186 (65.3)

44 (66)

00:00–08:00

14 (4.9)

7 (9.9)

Transport time (min)

30 (25–51)

115 (68–222)

0.298

<0.001

Injury Severity Score

13 (5–18)

9 (4–16)

0.003

Pediatric Trauma Score

9 (8–10)

10 (9–11)

0.004

Glasgow Coma Scale <15

14 (19.7)

25 (8.9)

0.009

1 (1–3)

3 (1–5)

<0.001

238.75 (100.11–431.44)

195.68 (92.57–440.23)

0.540

117.7 (78.3–217.7)

130.0 (94.7–194.4)

0.300

Consultations Overall cost to the hospital (TL) Laboratory cost

189 (93–401)

190 (86–346)

0.881

Hospitalized patients

Salary units for the physicians

51 (17.9)

25 (35.2)

<0.001

Hospitalization, days

3 (1–11)

4 (2–10)

0.365

Pediatric intensive care hospitalization

2 (2.8)

4 (1.4)

0.349

Transfusion

2 (2.8)

3 (1.1)

0.266

Endotracheal intubation

1 (0.8)

3 (3.2)

>0.999

5 (7)

12 (4.3)

0.353

2 (2.8)

11 (3.9)

>0.999

Operation Glasgow Outcome Scale score ≤3 IQR: Interquartile range; TL: Turkish Lira.

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Öztan et al. Initial results of the Northern Izmir Trauma Registry System for children

DISCUSSION In this study, we evaluated the value of the pediatric major trauma registry system covering 14 hospitals located in the third largest city of Turkey. Hospitals were divided into three groups in terms of their trauma acceptance capacities. The top level contained only one hospital (TTRH). Nearly all cases involved blunt traumas, and the most common causes of trauma were traffic accidents and falls from heights. Twenty-one percent of cases were referred from other hospitals.

Motorcycle accidents, sports injuries, and penetrating injuries were more frequent in patients who died or suffered severe disabilities, and the trauma scores of these patients were higher. Compared with data from those patients who were directly admitted, the trauma scores of transferred patients were lower, but the number of emergency consultations and the hospitalization rates were higher. There was no difference between the two groups in mortality or in the proportion of patients discharged with sequelae.

A trauma registry is a database that helps to document the epidemiology, procedures, and outcomes of trauma care.[10] Trauma systems are developed using the data obtained from the registries, to reduce the mortality of trauma patients by standardizing medical interventions and treatments. For a variety of reasons, it is not feasible to use the trauma systems of the high-income countries in developing countries.

[11–13] According to our literature review and current level of knowledge, no research has yet been conducted to establish a mechanism for recording the injuries and outcomes of pediatric patients who have sustained major trauma in our country.[10] We planned our study with this in mind, creating a registry that complies with our hospital system and that can be used without additional personnel or cost. We decided to publish the first results obtained using this system, as we had some promising findings to describe.

In Izmir, 168 people died and 15,109 were injured in 10,703 traffic accidents in 1 year. The Ministry of Health Izmir 112 Emergency Medical System transferred a total of 169,495 patients by ambulance, out of which 7,065 (4.2%) were pediatric trauma patients.[14] Our results show that major trauma to children in our region (the third largest city in Turkey) is primarily attributable to traffic accidents (pedestrians struck by motor vehicles, motor vehicle collisions, persons falling from motorcycles or bicycles; 44.3%), followed by falls from heights (27.8%). These findings are consistent with the study performed by Mitchell et al.,[15] which reported very similar results (41.8% and 27.9%, respectively).

The recent study conducted by Haider et al.[16] suggested that the MOI could be an independent predictor of fatality rates and functional outcomes after injury. In our study, we found that children who had motorcycle or sports accidents had the worst outcomes (GOS score ≤3) (p<0.05). It is a fact that most motorcycle accident victims in Turkey do not 26

wear helmets and ride solo without drivers’ licenses. Force application and energy transfer are major factors affecting patient outcomes and may be the principal contributors to the observed differences. These results also highlight the importance of control and preventive efforts, which must be increased.

The other factors associated with mortality or severe disability were older age and penetrating trauma. Tracy et al.[4] also reported that being 14–18 years of age and having sustained penetrating injuries were associated with higher ISSs. Two studies concluded that penetrating injuries accounted for 7.5% and 7.4% of the MOIs, respectively.[4,17] In our study, the mean age and the frequency of penetrating trauma were higher in patients with GOS scores ≤3 compared with GOS scores >3. According to the forensic reports on our patients, most of these patients were referred to the emergency service with stab wounds received during fights. We believe that such behavior among adolescents in our region explains the results, which must be shared with local authorities. Additionally, steps must be taken to institute preventive strategies.

The PTS is a quick and simple prognostic tool whereby a child can be rapidly assessed and accurately evaluated.[18] It is known that children with PTSs of 6 and below are at an increased risk of both mortality and morbidity. Unlike the PTS, the ISS is not simple to calculate in emergency room settings when evaluating how severely a child is injured; because the ISS is an anatomical scoring system, one has to determine the severity of injuries via extensive examinations.[19] In our study, patients with GOS scores ≤3 had higher ISSs but lower PTSs, which in accordance with the observations made above.

The PTS calculations can be performed by any care provider, and the results are important for both triage and referral of the patient to an appropriate center.[18] It was found that transferred patients had higher mean ISSs than directly admitted patients.[20–22] In contrast, we found that transferred patients had lower ISSs and higher PTSs than directly admitted patients. The proportion of patients with GCS scores below 14 was lower among transferred than among directly admitted patients. Despite these findings, although the hospitalization rates and consultation needs of transferred patients were higher than those of directly admitted patients, the outcomes of the two groups were similar. The reasons may be as follows: 1) More severely injured patients were referred from the accident scene to TTRH because this is the bestequipped medical center in the northern region of Izmir; 2) some patients were stabilized at other hospitals before the transfer to TTRH; and 3) some severely injured patients were transferred to other university hospitals, which were not included in our registry system.

Disagreement continues as to whether a delay in reaching the final hospital destination increases mortality or morbidity. In a review of 36 studies, Hill et al.[23] reported no difference in Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

Öztan et al. Initial results of the Northern Izmir Trauma Registry System for children

mortality between transferred and direct admissions. In our study, we noted significant delays when patients were transferred from their first hospitals to their final hospitals (30 min for directly admitted vs. 115 min for transferred patients), but this did not affect the outcomes, as the GOS scores did not differ significantly between these groups. We also noticed that one documented reason for patient transfer was “lack of a pediatric surgeon/neurosurgeon/orthopedic surgeon,” triggering a need to perform more consultations because of legal obligations. However, as we found no between-group difference in transfusion requirements; the need for surgery, pediatric intensive care hospitalization; or the length of hospital stay, we suggest that some of the transferred patients could have been treated or observed at the first center visited. The next step in reducing such secondary over-triage may involve education of the emergency service staff or the rearrangement the shifts of the consultants at the hospitals.

In conclusion, this report presents a new computerized trauma registry system, which was developed by a group of clinicians actively involved in trauma care and which has been integrated successfully with hospital registry systems. We are presenting our results, to the best of our knowledge, as the first in Turkey with the hope to expand our trauma registry concept to include other hospitals in Turkey and establishing a national system. An analysis of acquired data will make it possible to understand the burden of trauma, leading to improvements in injury prevention and both pre-hospital and hospital procedures.

2016;51:1341–5.

6. Trauma Triage in the Field and Leveling of the Hospitals. Izmir Trauma Group. 1st ed. Izmir: Imaj Basım Merkezi; 2013.

7. Guidelines for Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage, 2011. Available at: https://www. cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm. Accessed Dec 14, 2018.

8. Glasgow Outcome Score. Available at: http://www.trauma.org/archive/ scores/. Accessed Dec 14, 2018.

9. Teasdale GM, Pettigrew LE, Wilson JT, Murray G, Jennett B. Analyzing outcome of treatment of severe head injury: a review and update on advancing the use of the Glasgow Outcome Scale. J Neurotrauma 1998;15:587–97.

10. O’Reilly GM, Cameron PA, Joshipura M. Global trauma registry mapping: a scoping review. Injury 2012;43:1148–53.

11. Callese TE, Richards CT, Shaw P, Schuetz SJ, Paladino L, Issa N, et al.

Trauma system development in low- and middle-income countries: a review. J Surg Res 2015;193:300–7.

12. Moore L, Clark DE. The value of trauma registries. Injury 2008;39:686– 95.

13. Nathens AB, Jurkovich GJ, Rivara FP, Maier RV. Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation. J Trauma 2000;48:25–30.

14. Turkish Statistical Institute. Traffic accident statistics in Turkey. Available at: https://biruni.tuik.gov.tr/bolgeselistatistik/degiskenlerUzerindenSorgula.do. Accessed Dec 14, 2018.

15. Mitchell RJ, Curtis K, Chong S, Holland AJ, Soundappan SV, Wilson KL, et al. Comparative analysis of trends in paediatric trauma outcomes in New South Wales, Australia. Injury 2013;44:97–103.

Funding Source

16. Haider AH, Crompton JG, Oyetunji T, Risucci D, DiRusso S, Basdag H, et al. Mechanism of injury predicts case fatality and functional outcomes in pediatric trauma patients: the case for its use in trauma outcomes studies. J Pediatr Surg 2011;46:1557–63.

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

17. Nielsen JW, Shi J, Wheeler K, Xiang H, Kenney BD. Resource use in pediatric blunt and penetrating trauma. J Surg Res 2016;202:436–42.

Conflict of interest: None declared.

18. Tepas JJ 3rd, Mollitt DL, Talbert JL, Bryant M. The pediatric trauma score as a predictor of injury severity in the injured child. J Pediatr Surg 1987;22:14–8.

REFERENCES 1. World Health Statistics 2011. Geneva, Switzerland: WHO Press; 2011.

Available at: https://www.who.int/whosis/whostat/WHS2011_addendum.pdf?ua=1. Accessed Dec 14, 2018.

2. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Course for Doctors. Chicago: American College of Surgeons; 1997.

3. UNICEF. World report on child injury prevention. Geneva; 2008.

Available at: http://apps.who.int/iris/bitstream/10665/43851/1/ 9789241563574_eng.pdf. Accessed Dec 14, 2018.

4. Tracy ET, Englum BR, Barbas AS, Foley C, Rice HE, Shapiro ML. Pediatric injury patterns by year of age. J Pediatr Surg 2013;48:1384–8.

5. Cleves D, Gómez C, Dávalos DM, García X, Astudillo RE. Pediatric trauma at a general hospital in Cali, Colombia. J Pediatr Surg

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19. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187–96.

20. Locke T, Rekman J, Brennan M, Nasr A. The impact of transfer on pediatric trauma outcomes. J Pediatr Surg 2016;51:843–7.

21. Amini R, Lavoie A, Moore L, Sirois MJ, Emond M. Pediatric trauma mortality by type of designated hospital in a mature inclusive trauma system. J Emerg Trauma Shock 2011;4:12–9.

22. Acosta CD, Kit Delgado M, Gisondi MA, Raghunathan A, D’Souza PA, Gilbert G, et al. Characteristics of pediatric trauma transfers to a level i trauma center: implications for developing a regionalized pediatric trauma system in california. Acad Emerg Med 2010;17:1364–73.

23. Hill AD, Fowler RA, Nathens AB. Impact of interhospital transfer on outcomes for trauma patients: a systematic review. J Trauma 2011;71:1885–900.

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Öztan et al. Initial results of the Northern Izmir Trauma Registry System for children

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Çocuklarda daha iyi travma yönetimi için ilk adım: Kuzey İzmir Travma Kayıt Sistemi’nin ilk sonuçları Dr. Mustafa Onur Öztan,1 Dr. Murat Anıl,2 Dr. Ayşe Berna Anıl,3 Dr. Demet Yaldız,4 Dr. İlhan Uz,5 Dr. Ali Turgut,6 Dr. Işıl Köse,7 Dr. Kerim Acar,8 Dr. Turhan Sofuoğlu,9 Dr. Gökhan Akbulut10 Katip Çelebi Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, İzmir Sağlık Bilimleri Üniversitesi, Tepecik Eğitim ve Araştırma Hastanesi, Çocuk Acil Servis Ünitesi, İzmir Katip Çelebi Üniversitesi Tıp Fakültesi, Çocuk Sağlığı ve Hastalıkları Anabilim Dalı, Çocuk Yoğun Bakım Bilim Dalı, İzmir 4 Sağlık Bilimleri Üniversitesi, Suat Seren Göğüs Hastalıkları ve Cerrahisi Eğitim ve Araştırma Hastanesi, Göğüs Cerrahisi Kliniği, İzmir 5 Ege Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İzmir 6 Sağlık Bilimleri Üniversitesi, Tepecik Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İzmir 7 Sağlık Bilimleri Üniversitesi Tepecik Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Yoğun Bakım Ünitesi, İzmir 8 Menemen Devlet Hastanesi, Acil Tıp Kliniği, İzmir 9 Sağlık Bilimleri Üniversitesi, Tepecik Eğitim ve Araştırma Hastanesi, Ambulans Servisleri Bölümü, İzmir 10 Sağlık Bilimleri Üniversitesi, Tepecik Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İzmir 1 2 3

AMAÇ: Travma, çocuklarda önemli bir sağlık sorunudur ve ulusal travma yönetimindeki olumlu yöndeki gelişmeler için travma kayıt sistemlerinden edinilen anlık doğru bilgilere ihtiyaç vardır. Ülkemizde hastaneler arası güncel bir kayıt sistemi olmaması nedeniyle bu bilgilere ulaşılamamaktadır.

Amacımız, geliştirdiğimiz travma kayıt sistemini açıklayıp ilk yıl verilerini sunmaktır.

GEREÇ VE YÖNTEM: Planlanan travma kayıt sistemi, İzmir ilindeki 14 hastanenin acil servis kayıt sistemine entegre edildi. Pediatrik çoklu travma hastalarının verileri özel olarak kayıt altına alındı. Demografik özellikler, sevk durumu, yaşamsal veriler, mekanizma, travma tipi, anatomik bölge, yaralanma şiddeti ölçeği (ISS), pediatrik travma ölçeği (PTS), Glasgow koma ölçeği (GKS), kan transfüzyonu/endotrakeal entübasyon/cerrahi/ hastaneye yatma ihtiyacı ve hastanede kalma süresi ile ilgili veriler değerlendirildi.

BULGULAR: Bir yılın sonunda, toplam 356 pediatrik çoklu travma hastası çalışmaya alındı. En sık travma tipi künt travma (%91.9) ve mekanizması araç dışı trafik kazası (%28.1) idi. Glasgow sonuç ölçeğine göre daha kötü sonuç alınan grupta yaş daha büyük, ISS daha yüksek ve PTS daha düşüktü.

Motosiklet kazaları, spor yaralanmaları ve penetran yaralanmalar bu grupta daha sık gözlendi. Tüm ölçekler direkt başvuran ve sevk edilen hastalar arasında anlamlı farklılık gösterdi. Hastaneye başvuru zamanı sevk edilen hastalar için doğrudan başvuran hastalara kıyasla daha uzundu, ancak sonuçları farklı değildi.

TARTIŞMA: Pediatrik çoklu travma mortalite ve morbiditenin önemli bir nedeni olmakla birlikte, yurtdışında başarılı örnekleri olan travma kayıt sistemimiz ülke çapında yeterli değildir. Planladığımız ve pilot uygulamasını başlattığımız travma kayıt sisteminin, ülke genelinde diğer hastaneleri de kapsayacak şekilde genişletilerek işlevsel olmasını umuyoruz.

Anahtar sözcükler: Majör travma; pediatrik travma; travma kayıt sitemi.

Ulus Travma Acil Cerrahi Derg 2019;25(1):20-28

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doi: 10.5505/tjtes.2018.82780

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

ORIG I N A L A R T IC L E

Incidence, etiology, and patterns of maxillofacial traumas in Syrian patients in Hatay, Turkey: A 3 year retrospective study Cengiz Arlı, M.D.,1

Mustafa Özkan, M.D.,2

Ali Karakuş, M.D.3

1

Department of Otorhinolaryngology, Mustafa Kemal University Faculty of Medicine, Hatay-Turkey

2

Department of Plastic Surgery, Mustafa Kemal University Faculty of Medicine, Hatay-Turkey

3

Department of Emergency Medicine, Mustafa Kemal University Faculty of Medicine, Hatay-Turkey

ABSTRACT BACKGROUND: This study aimed to assess the demographics, clinical features, and treatment costs of maxillofacial trauma cases referred to our hospital during the Syrian civil war.

METHODS: The study included 80 cases of maxillofacial trauma. Patients with additional pathologies were excluded from the study.

The patients were examined with respect to their demographics and clinical characteristics, Injury Severity Score (ISS), Glasgow Coma Score (GCS), treatments applied, costs, and outcomes.

RESULTS: A total of 80 patients included 76 (95%) males and 4 (5%) females, with the mean age of 29.05±9.97 years (range, 13–56 years), and 72 (90%) of them were Syrians injured in the war. The most common mechanism of trauma was the firearms injury in 72 (90%) cases, and the most frequently seen lesion was the mandible fracture (n=48, 60%). The ISS of all the patients was <16, as a severe trauma score. The GCS value was 8–12 in 4 (5%) patients, and 15 in 76 (95%). The most common treatment applied were the reduction and fixation, and graft-flap following fracture (n=12, 15%). The mean duration of hospitalization was 15.27±13.0 days (range, 2–60 days). All patients were discharged from hospital. The mean cost per case was calculated as 5,581.55±56.3 Turkish Lira (range, 772–18,697 TL) or 1,251.24±14.2 US Dollars (US$173–4,192). There was a significant correlation between the costs and the length of hospitalization (p<0.001, r=+0.729) and trauma scores (p=0.004, r=−0.616).

CONCLUSION: Firearms-injured young males with mandible fractures were the most common group of maxillofacial trauma cases seen during the Syrian war. The intensity of patients and the cost of the hospital stay have significantly increased because of the ongoing conflict in the neighboring country of Syria.

Keywords: Costs; firearms; intensity; mandible fractures.

INTRODUCTION Maxillofacial trauma is a frequently seen type of injury, requiring diagnosis of fractures and soft tissue injuries, and a subsequent application of appropriate treatment, which may sometimes entail emergency intervention.[1] Maxillofacial trauma is often accompanied by head trauma, and when respiratory problems and brain parenchyma injuries are involved, this represents a patient group with life-threatening injuries. For

patients in a life-threatening situation, first the ABC (airway– breathing–circulation) must be provided, and then, emergency surgery is necessary.[2,3] The most commonly affected region in patients with maxillofacial trauma is the mandible.

As the anatomic structure of the mandible is complex, an injury to facial nerves and other soft tissue damage affects the prognosis and the appearance of the patient.[3,4]

Cite this article as: Arlı C, Özkan M, Karakuş A. Incidence, etiology, and patterns of maxillofacial traumas in Syrian patients in Hatay, Turkey: A 3 year retrospective study. Ulus Travma Acil Cerrahi Derg 2019;25:29-33.

Address for correspondence: Cengiz Arlı, M.D. Mustafa Kemal Üniversitesi Tıp Fakültesi, Kulak Burun Boğaz Anabilim Dalı, 31100 Hatay, Turkey.

Tel: +90 326 - 229 10 00 E-mail: drkarakus@yahoo.com Ulus Travma Acil Cerrahi Derg 2019;25(1):29-33 DOI: 10.5505/tjtes.2018.16243 Submitted: 17.11.2017 Accepted: 16.07.2018 Online: 26.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Arlı et al. Incidence, etiology, and patterns of maxillofacial traumas in Syrian patients in Hatay, Turkey

The Syrian civil war is an ongoing multisided armed conflict, in which almost 11.5% of Syria’s population has been killed or severely injured, including citizens, rebels, and army forces.

Patients with critical and complicated trauma injuries have been transported to neighboring countries to receive an adequate treatment. In this period, many patients have also arrived to the Hatay province in Turkey. In the present study, we aimed to assess the demographics, clinical characteristics, patient treatment, outcome, and costs of maxillofacial trauma cases from Syrian civil war, who were admitted to the Emergency Department in the province of Hatay.

MATERIALS AND METHODS In this study, a retrospective analysis included 80 patients with maxillofacial trauma in Hatay Mustafa Kemal University Medical School between 2014 and 2017. The study protocol was approved by Research Hospital and the Medical Ethics Committee at Mustafa Kemal University (Protocol Code: 2015-13172/98).

The data obtained from the medical records of patients seeking treatment for maxillofacial trauma in the Emergency Department of Hatay Mustafa Kemal University were the basis of this study. Age, gender, fracture etiology, anatomic localization, distribution of traumas, and treatment methods were examined. Records for each patient were also taken for the Injury Severity Score (ISS), Glasgow Coma Score (GCS), the length of hospital stay, and costs. Patients with any additional pathology were excluded from the study. The lesions were classified as bone fractures, soft tissue, facial nerve, and parotid and external ear canal pathologies. Informed consent was obtained from all the patients.

The best scoring system that shows the severity of the trauma is ISS. The ISS has been defined evaluating the six regions (head/neck, face, chest, abdomen, extremities, and external) used in the Abbreviated Injury Scale (AIS) scoring system. The three regions most severely affected were taken and scored between 1 and 5. Then the total of the squared values was calculated (0–75 points). The squared values were used because the effect of trauma in multiple injuries is greater than the effect of a single injury. A total greater than 16 was evaluated as severe and equal to or greater than 25 as very severe. Thus, the effects on morbidity, mortality, and the length of hospital stay were examined. The GCS was used in the evaluation of patient consciousness. Motor, eyes, and verbal responses of patients were evaluated in GCS. The illness was scored between 3 and 15. The scores between 3 and 8 scores are poor, between 9 and 13 are medium, and between 14 and 15 are good.

The interventions applied were grouped as graft, flap, reduction, fixation, screw, wire, plate, debridement, and facial and parotid repair. Costs were evaluated together with trauma severity and the length of hospital stay.

30

Statistical Analysis The data collected from the patient files in the archive were analyzed using the SPSS version 16.0 software (IBM, Armonk, NY, USA). Categorical variables were stated as the mean± standard deviation. In the median values comparison, the Mann–Whitney U test was used. The relationship between the study parameters was assessed using the Pearson’s correlation analysis. The correlation coefficient values were defined as follows: strong correlation (≥0.8); moderate correlation (0.6–0.8); fair correlation (0.3–0.5), and poor correlation (≤0.3). A p-value of <0.05 was accepted as statistically significant.

RESULTS In this retrospective study, a total of 80 patients with maxillofacial fractures were evaluated. There were 76 (95%) males and 4 (5%) females with the mean age of 29.05±9.87 years (range, 3–56 years). There was a significant difference determined between the genders (chi square, p<0.001).

The most common etiological factor of the maxillofacial trauma was the gunshot injury in 72 (90%), followed by a traffic accident in 8 (10%) patients. The most common site of the fracture was the mandible (60%) (Figs. 1a and 2a). The mean length of the hospital stay was 15.27±13.0 days (range, 2–60 days). (a)

(b)

Figure 1. (a) Foreign body and the ultrafragmante sepere deplase fracture in the left mandible (preoperative). (b) Repair with screw implants and mini plate (postoperative). (a)

(b)

Figure 2. (a) Multifragmante deplase fractures in the right mandible ramus (preoperative). (b) Mini plate and screw implant in the right mandible ramus (postoperative).

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Arlı et al. Incidence, etiology, and patterns of maxillofacial traumas in Syrian patients in Hatay, Turkey

Table 1. Distribution of types of facial fractures

Table 3. The distribution of clinics where patients are treated

Fractures and nerve and gland injuries

Count n %

Mandible

48

60.0

Mandible - Maxilla

4

5.0

Maxilla - Zygoma

4

5.0

Mandible - facial nerve injury

4

5.0

Mandible - Maxilla - external ear trauma

4

5.0

Mandible - Zygoma - facial nerve injury

4

5.0

Mandible - facial nerve injury -parotid injury

4

5.0

Maxilla - Zygoma - facial nerve injury

4

5.0

Mandible - Maxilla - Zygoma - facial nerve injury

4

5.0

Total

80 100

Table 2. The distribution of surgery techniques according to the facial bone fractures Count

n %

Grafting - flapping

12

15.0

Fixation - reduction

12

15.0

Reduction

4 5.0

Screw implants

4

5.0

Grafting - flapping - debridement

4

5,0

Fixation - wire

4

5.0

Fixation - mini plate

4

5.0

Wire - reduction

4

5.0

Reduction - facial repair

4

5.0

Debridement - mini plate

4

5.0

Mini plate - screw implants

4

5.0

Grafting - flapping - mini plate - screw implants

4

5,0

Grafting - flapping - mini plate - facial repair

4

5.0

Fixation - reduction - mini plate

4

5.0

Reduction - mini plate - screw implants

4

5.0

facial repair

4

5.0

Total

80 100

Grafting - flapping - parotid repair - mini plate -

Demographic and clinical characteristics of patients with maxillofacial trauma are shown in Table 1.

In the ISS evaluation of the patients, all were below the critical value of <16. The GCS was determined to range between 8 and 12 in 4 (5%) patients, and it was 15 in 76 (95%) patients.

The treatment protocol is summarized in Table 2. Fixation and reduction were applied to 12 (15%) patients, and graftUlus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

Clinic

n %

Plastic surgery clinic

52

65.0

Ear nose throat clinic

24

30.0

Anesthesia intensive care clinic

4

5.0

Total

80 100

flap was applied to 12 (15%) (Figs. 1b and 2b). The clinics where the patients were treated are shown in Table 3. The mean cost per patient was calculated as 5,581.55±56.3 Turkish Lira (range, 772–18,697 TL) or 1,251.24±14.2 US Dollars (US$ 173–4,192). A positive correlation was found between the length of hospital stay and cost (p<0.001). There was a significant moderately strong correlation between the cost and hospitalization length (p<0.001, r=+0.729), and trauma scores (p=0.004, r=−0.616).

DISCUSSION There is an increasing incidence of head and neck trauma in modern warfare. In particular, when the degree of efficiency of explosive materials is high, this rate increases.[1–4] Firearms injuries are rarely seen in general, but the frequency increases in war, and they are often seen in young males.[5–7] When the injuries caused by the conflict in Syria are examined, which is taking place in our region, it can be seen that young males are the population often injured by bombs and shrapnel. Keller et al.[8] in their study mentioned that 239 maxillofacial trauma patients who were assessed during the war were young men (99.2%).

Trauma to the lower region of the face is often seen following maxillofacial trauma. Fractures of the orbital and maxillary and zygomatic fractures may be seen after trauma. A previous study reported that orbital fractures were most often encountered,[1] whereas in the literature, the mandible is the most commonly affected bone in the case of injuries of the lower region of the face. Another study about maxillofacial trauma reported that mandible fractures were the most common fractures with the ratio of 33.4%.[9] In the current study, mandible fractures were the most common injuries, just like in the previous study.

Maxillofacial trauma constitutes a problem group with respect to airway control, especially in emergency and anesthesia. There can be problems in the acute period such as airway and intracranial injuries. Especially, patients with complicated mandible fractures have difficult airway management.[10] Bahouth et al. mentioned that 12 out of 50 patients with mandible fractures caused by shrapnel needed acute intubation because of airway obstruction.[11] Keller et al.[8] reported that 51.4 of the maxillofacial trauma patients underwent 31

Arlı et al. Incidence, etiology, and patterns of maxillofacial traumas in Syrian patients in Hatay, Turkey

acute intubation because of the airway obstruction during the war. None of our maxillofacial trauma patients needed acute intubation.

In the later period, there may be a soft tissue infection, function loss, and cosmetic problems.[12] In addition to bone fractures, soft tissue, and facial nerve injures may be seen during maxillofacial trauma. In cases determined with fracture, fixators such as screws, wire, or a plate may be used for fixation following reduction. In addition, the facial nerve, parotid, and soft tissue repair are necessary, and if there is a tissue defect, the application of graft and flap is required. In the treatment of these types of injuries, a multidisciplinary approach is suitable with a follow-up and rehabilitation of the patient by brain surgeons, neurologists, and plastic surgeons.[1,13,14] Regarding the subject of repair, the importance of operations to be performed by the ear, nose, and throat and plastic surgeons is paramount. Patient prognosis and the sequelae, which could develop, should be monitored through a regular follow-up.

In the evaluation of trauma severity, various trauma classifications are used such as the Revised Trauma Score (RTS), AIS, ISS, and the Trauma Injury Severity Score. In a study of 100 polytrauma patients by Karakuş et al., trauma severity was compared with the length of hospital stay, and the results of the ISS, RTS, and GCS were found to be significant.[15] In the same study, when the severity of trauma and mortality rates were compared, the ISS was determined as the most significant trauma score.[1,16] In patients with head trauma, the best follow-up parameter for the brain parenchyma involvement is GCS. In the cases that were followed up in this study, the ISS values were all below the critical level of 16, and the GCS values were determined as 15. The patients who were included in the current study had a low ISS and high GCS because of having only maxillofacial trauma and no injury in other parts of the body.

When the trauma scores of the patients, the length of hospital stay, the outcomes, and costs were evaluated, they were found to be significantly consistent with previous reports in the literature.

In a study by Allareddy Nalliah et al.[17] in the United States using the Nationwide Inpatient Sample, assault was found to be the leading cause (36.5%) of hospitalization for the reduction of facial fractures, followed by motor vehicle accidents (16%), falls (15%), and other transportation accidents (3.5%). In a study conducted in southern Turkey, Erol et al.[18] reported that the most common etiological factor in maxillofacial trauma were traffic accidents (1,104 patients, 38%), closely followed by falls (1,065 patients, 36.7%).

The causes of the maxillofacial trauma were determined as a motor vehicle accident in 1,104 (38%), falls in 1,065 (36.7%), and assault in 10%. Similarly, in a 2014 study by Arslan et al.[19] 754 patients in the Ankara region were reviewed.

32

Atilgan et al.[16] examined cases in the period from 2000 to 2005 and reported that the most common cause of maxillofacial injury in young patients are falls (65%), and in adults, the primary cause were road traffic accidents (88%). Similarly, Bereket et al.[20] found that falls (40.2%) were the major cause of mandible fractures, followed by traffic accidents and assault. The fractures were seen in the mandible anatomical sites of the condyle (34.6%), body, and symphysis.

Mass events such as natural disasters, wars, and bombings increase patient traffic in hospitals and especially in Emergency Departments, making the functioning more difficult and increasing costs. In these cases, disaster plans are put into operation in hospitals. However, unwanted events entail cost evaluations, and accounts are negatively affected.[15] In a cost-effective study, a long treatment period of the patients injured during war and a negative effect of this condition on the overall budget was reported.[21] When the mean costs of the cases not injured in the war were compared to the costs of cases following the war, a two-fold increase was found. This was defined as a negative effect on both the hospital budget and the general health care budget.

Conclusion Young males with mandible fractures caused by firearms were the most common group of the maxillofacial trauma patients during the Syrian war. The intensity of patients, hospital workload, and costs were determined to have increased because of the ongoing conflict in the region.

Conflict of interest: None declared.

REFERENCES 1. Keller MW, Han PP, Galarneau MR, Gaball CW. Characteristics of maxillofacial injuries and safety of in-theater facial fracture repair in severe combat trauma. Mil Med 2015;180:315–20.

2. Brennan J. Head and neck trauma in Iraq and Afghanistan: different war, different surgery, lessons learned. Laryngoscope 2013;123:2411–7.

3. Feldt BA, Salinas NL, Rasmussen TE, Brennan J. The joint facial and invasive neck trauma ( J-FAINT) project, Iraq and Afghanistan 20032011. Otolaryngol Head Neck Surg 2013;148:403–8.

4. Levin L, Zadik Y, Peleg K, Bigman G, Givon A, Lin S. Incidence and severity of maxillofacial injuries during the Second Lebanon War among Israeli soldiers and civilians. J Oral Maxillofac Surg 2008;66:1630–3.

5. Karakuş A, Yengil E, Akkücük S, Cevik C, Zeren C, Uruc V. The reflection of the Syrian civil war on the emergency department and assessment of hospital costs. Ulus Travma Acil Cerrahi Derg 2013;19:429–33.

6. Inci M, Karakuş A, Rifaioglu MM, Yengil E, Atçi N, Akin Ö, et al. A practice report of bladder injuries due to gunshot wounds in Syrian refugees. Ulus Travma Acil Cerrahi Derg 2014;20:371–5.

7. Uruc V, Ozden R, Duman IG, Dogramacı Y, Yengil E, Karapınar S, et al. Major musculoskeletal injuries and applied treatments in the current conflicts in Syria. Acta Medica Mediterranea 2014;30:637–44.

8. Keller MW, Han PP, Galarneau MR, Brigger MT. Airway Management

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9.

10.

11.

12.

13.

14.

in Severe Combat Maxillofacial Trauma. Otolaryngol Head Neck Surg 2015;153:532–7.

Abramowicz S, Allareddy V, Rampa S, Lee MK, Nalliah RP, Allareddy V. Facial Fractures in Patients with Firearm Injuries: Profile and Outcomes.

J Oral Maxillofac Surg 2017;75:2170–6.

Jose A, Nagori S, Agarwal B, Bhutia O, Roychoudhury A. Management of maxillofacial trauma in emergency: An update of challenges and controversies. J Emerg Trauma Shock 2016;9:73–80.

Bahouth H, Ghantous Y, Rachmiel A, Amodi O, Abu-Elnaaj I. Maxillofacial Injuries Related to the Syrian War in the Civilian Population. J Oral Maxillofac Surg 2017;75:995–1003.

Available at: http:www.acilci.net. Accessed Sep 20, 2017.

Lew TA, Walker JA, Wenke JC, Blackbourne LH, Hale RG. Characterization of craniomaxillofacial battle injuries sustained by United States service members in the current conflicts of Iraq and Afghanistan. J Oral Maxillofac Surg 2010;68:3–7.

Breeze J, Gibbons AJ, Shieff C, Banfield G, Bryant DG, Midwinter MJ. Combat-related craniofacial and cervical injuries: a 5-year review from the British military. J Trauma 2011;71:108–13.

15. Karakuş A, Kekeç Z, Akçan R, Seydaoğlu G. The relationship of trauma severity and mortality with cardiac enzymes and cytokines at multiple trauma patients. Ulus Travma Acil Cerrahi Derg 2012;18:289–95.

16. Atilgan S, Erol B, Yaman F, Yilmaz N, Ucan MC. Mandibular fractures: a comparative analysis between young and adult patients in the southeast region of Turkey. J Appl Oral Sci 2010;18:17–22.

17. Allareddy V, Allareddy V, Nalliah RP. Epidemiology of facial fracture injuries. J Oral Maxillofac Surg 2011;69:2613–8.

18. Erol B, Tanrikulu R, Gorgun B. Maxillofacial Fractures. Analysis of demographic distribution and treatment in 2901 patients (25-year experience). J Craniomaxillofac Surg 2004;32:308–13.

19. Arslan ED, Solakoglu AG, Komut E, Kavalci C, Yilmaz F, Karakilic E, et al. Assessment of maxillofacial trauma in emergency department. World J Emerg Surg 2014;9:13.

20. Bereket C, Şener I, Şenel E, Özkan N, Yılmaz N. Incidence of mandibular fractures in black sea region of Turkey. J Clin Exp Dent 2015;7:e410– 3.

21. Karakus A, Kuvandik G, Atalay E. Evaluation of Extremity Injuries Presented to Emergency Department. Arch Iran Med 2017;20:646–8.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Türkiye Hatay’daki Suriyeli maksillofasial travmalı hastaların insidansı, etyolojisi ve örneği: Üç yıllık geriye dönük çalışma Dr. Cengiz Arlı,1 Dr. Mustafa Özkan,2 Dr. Ali Karakuş3 1 2 3

Mustafa Kemal Üniversitesi Tıp Fakültesi, Kulak Burun Boğaz Anabilim Dalı, Hatay Mustafa Kemal Üniversitesi Tıp Fakültesi, Plastik Cerrahi Anabilim Dalı, Hatay Mustafa Kemal Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Hatay

AMAÇ: Bu çalışmada Suriye’deki sivil savaş sırasında hastanemize getirilen maksillofasial travmalı olguların demografik, klinik özellikleri, tedavileri ve maliyetlerinin değerlendirilmesi amaçlanmıştır.

GEREÇ VE YÖNTEM: Maksillofasial travmalı 80 olgu çalışmaya dahil edildi. Ek patolojisi olan olgular çalışma dışı bırakıldı. Olgular demografik ve klinik özellikleri, Injury Severity Score (ISS), Glaskow Koma Skoru (GKS), uygulanan tedaviler, maliyetleri ve sonuçları açısından incelendi.

BULGULAR: Olguların 76’sı (%95) erkek, dördü (%5) kadın, yaş ortalamaları 29.05±9.97 (13–56) idi. Suriye savaş yaralıları %90.0 (n=72) oranında idi. En sık travma oluş mekanizması ateşli silah yaralanması 72 (%90.0) idi. En sık lezyonun mandibula kırığı (n=48, %60.0) olduğu saptandı. ISS değeri tüm hastalarda şiddetli travma değeri olan 16’nın altında bulundu. GKS değeri dört (%5) hastada 8–12, 76 (%95) hastada 15 olarak tespit edildi. Kırık sonrası tespit, redüksiyon ve greft-flep uygulamaları (n=12, %15) en sık yapılan tedavi uygulamaları idi. Ortalama yatış süresi 15.27±13.0 (2–60 gün) idi. Tüm olgular taburcu edildi. Olguların maliyeti ortalama 5581.55±56.3 (772–18697 TL) veya 1.251.24±14.2 (173–4.192 dolar) olarak bulundu.

Travma skoru (p=0.004, r=-0.616), hastanede kalış süresi (p<0.001, r=+0.729) ve maliyet arasında önemli derecede uyumluluk vardı.

TARTIŞMA: Suriye savaşı sırasında görülen maksillofasial travmalı olgularda ateşli silah yaralanmalı mandibula kırıklı genç erkekler en sık görülen gruptu. Komşu ülke Suriye’deki savaş nedeniyle hastane yoğunluk ve maliyetinin arttığı belirlendi.

Anahtar sözcükler: Ateşli silah; maliyet; mandibula kırığı; yoğunluk.

Ulus Travma Acil Cerrahi Derg 2019;25(1):29-33

doi: 10.5505/tjtes.2018.16243

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ORIG I N A L A R T IC L E

Do the stump knotting technique and specimen retrieval method effect morbidity in laparoscopic appendectomy?

Cihan Ağalar, M.D.,1 Zekai Serhan Derici, M.D.,1 Ali Durubey Çevlik, M.D.,1 Süleyman Özkan Aksoy, M.D.,1 Tufan Egeli, M.D.,1 Nilay Boztaş, M.D.,2 Mücahit Özbilgin M.D.,1 Sülen Sarıoğlu, M.D.,3 Tarkan Ünek, M.D.1 1

Department of General Surgery, Dokuz Eylül University Faculty of Medicine, İzmir-Turkey

2

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

3

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

ABSTRACT BACKGROUND: Stump closure is the most important part of a laparoscopic appendectomy (LA). Closing the appendix base with knot tying is the most cost-effective method. The defined risk factor for surgical site infection (SSI) after LA is the contamination of trocar entry area by inflamed appendicitis. This study aims to compare the single and double knot technique for stump control and specimen removal methods in LA. METHODS: The data of patients who underwent LA between January 2015 and January 2017 were obtained from prospectively collected database. Single and double knot technique, specimen removal method, operation duration, hospital stay, and perioperative– postoperative complications were compared.

RESULTS: Extracorporeal double knot was used in 134 patients (63%), and single knot was used in 79 patients (37%). There was no difference between operation duration in the two groups (p=0.97). No stump leakage was observed in any patient. Intraabdominal abscess developed in three patients (1.4%). Appendix was removed from the abdomen directly in 101 patients (47%) and using specimen retrieval bag in 112 (53%). SSI developed in five patients (2.3%), and appendices of all of these five patients were removed from abdomen without using specimen retrieval bag. No SSI was detected in the group that used the specimen retrieval bag (p=0.02).

CONCLUSION: Single or double knot(s) tying can be defined as safe and cost-effective stump closure method. The risk of developing SSI can be reduced using specimen retrieval bag.

Keywords: Extracorporeal knot tying; laparoscopic appendectomy; Specimen retrieval bag; stump; surgical site infection.

INTRODUCTION Laparoscopic appendectomy (LA) was first performed by Semm in 1983; and since then, it has been widely used for minimally invasive treatment for acute appendicitis.[1] Nowadays, LA is the standard method in many centers.

Laparoscopic appendectomy has advantages such as less postoperative pain, shorter hospital stay, better cosmetic results, lower wound infection risk, and faster return to normal

bowel function than open appendectomy.[2–4] Potential disadvantages are high cost,[5] long operation duration, especially during the learning curve, and encounter of more frequent intraabdominal abscess.[2,3,6–8] The most feared complication of LA is the fistula or intraabdominal sepsis that develops secondary to stump leaks. Several methods have been described to close the appendix stump such as endostapler, endoloop, clip, extracorporeal or intracorporeal knot tying, and stump transection with bipolar

Cite this article as: Ağalar C, Derici ZS, Çevlik AD, Aksoy SÖ, Egeli T, Boztaş N, et al. Do the stump knotting technique and specimen retrieval method effect morbidity in laparoscopic appendectomy? Ulus Travma Acil Cerrahi Derg 2019;25:34-38.

Address for correspondence: Cihan Ağalar, M.D. Dokuz Eylül Üniversitesi Tıp Fakültesi Hastanesi, Genel Cerrahi Anabilim Dalı, İnciraltı, Balçova, 35320 İzmir, Turkey.

Tel: +90 232 - 412 29 18 E-mail: cihan.agalar@deu.edu.tr Ulus Travma Acil Cerrahi Derg 2019;25(1):34-38 DOI: 10.5505/tjtes.2018.90382 Submitted: 12.02.2018 Accepted: 14.08.2018 Online: 24.10.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Ağalar et al. Tying and retrieval methods in appendectomy

or ligation devices. But these methods have not been demonstrated to be superior to each other in terms of effectiveness or safety.[4,9–17] Knot tying has cost advantages over other methods, but there is no consensus about tying method (single or double) in literature.

The defined risk factor for surgical site infection (SSI) after LA is the contamination of trocar entry area by inflamed appendicitis.[18–20] This study aims to compare the single and double extracorporeal knot technique for stump closure and specimen retrieval methods used in LA.

MATERIALS AND METHODS Patients who underwent LA with diagnosis of acute appendicitis between January 1, 2015, and January 1, 2017, were included to the study. Patients with incomplete data and those who underwent interval or open appendectomy were excluded from the study.

Figure 1. Duncan extracorporeal sliding knot method.

Detailed information about laparoscopic and open appendectomy was given to all patients before surgery, and their written informed consent was obtained. Approval was taken from the local ethical committee for this study (date: November 26, 2017; decision no: 2017/25-36).

The specimen was removed from the abdomen through the umbilical trocar with (Fig. 2) or without using specimen retrieval bag. The four-quadrant abdominal irrigation was performed for patients with perforated appendicitis, and silicon drain was placed to pelvis.

Acute appendicitis was diagnosed in patients who presented with abdominal pain to emergency service or polyclinic; with anamnesis, physical examination, complete blood test, and if necessary, abdominal ultrasonography (US) or computed tomography (CT) was used.

Patient’s age, sex, radiologic examinations, severity of appendicitis (inflamed, gangrenous, perforated, etc.), appendix base diameter, stump closure method, specimen retrieval method, operation duration, hospital stay, perioperative complications, and histopathologic findings were analyzed from the prospectively collected database. Complications were classified according to Clavien–Dindo (C-D) classification system.[23]

Operations were performed under general anesthesia; all patients received a single dose of first-generation cephalosporin prophylaxis. After Foley catheter insertion, three trocars were placed, 11 mm below the umbilicus, 5 mm above the pubis, and depending on the surgeon’s preference 5 or 11 mm to the left side of the patient. In all operations, reusable trocars and reusable laparoscopic hand instruments were used. Inflammatory appendicitis defined as uncomplicated, gangrenous, or perforated appendicitis was defined as complicated appendicitis.[21] High-frequency bipolar coagulation devices were used for dissection and sealing of the mesoappendix. The base of the appendix tied with single or double extracorporeal sliding knot and appendix was cut above the knot(s). The Duncan sliding knot technique (Fig. 1)[22] and 150-cm 2.0 polyglactin non-needle suture were used in each operation.

All participant surgeons used either the single or double tying method. The choice of single or double knot method is randomly determined, regardless of the patient’s clinic, complicated or uncomplicated appendicitis, and the diameter of appendix base.

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

All statistical analyses were performed using SPSS 16.0 statistical package (SPSS, Chicago, III). Independent samples t-test was used to compare normally distributed continuous variables. The non-normally distributed variables were compared with using the Mann–Whitney U test. Chi-square test was used for comparison of categorical data, and p<0.05 was considered as statistically significant.

Figure 2. Specimen retrieval method using specimen bag.

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Ağalar et al. Tying and retrieval methods in appendectomy

RESULTS Between January 1, 2015, and January 1, 2017, 213 consecutive patients [98 male (46%) and 115 female (54%)] were included in the study. The median age of patients was 33.5±13.77 (range: 16–82) years. Ultrasonography was used in 79 patients (37%), CT in 109 (51%), and physical examination and complete blood count in 25 (12%).

Complicated appendicitis was detected in 49 patients (23%) [30 perforated appendicitis (14%) and 19 (9%) gangrenous appendicitis], inflamed appendicitis in 156 (73%), and no inflammatory sign in 8 (4%). The median appendix base diameter was 86.4±24.7 mm (range 40–170). Extracorporeal double knot was used in 134 patients (63%), and single knot was used in 79 patients (37%). The median operation duration was recorded as 44.5±10.2 (range 20–99) min. The median operation duration in the single and double knot groups was 44.58±6.73 and 44.53±11.94 min, respectively. There was no statistically significant difference between operation duration (p=0.97, independent samples t-test). Appendix was removed from the abdomen directly in 101 patients (47%) and using specimen retrieval bag in 112 patients (53%).

The median hospitalization duration was 2.7±1.9 (range: 1–16) days. No stump leakage was observed in any patient during postoperative follow-up. Intraabdominal abscess developed in three patients (1.4%); two of them were treated

with interventional radiological methods, and the last patient underwent laparoscopic re-operation (2 C-D Grade IIIA; 1 C-D Grade IIIB). These three patients had perforated appendicitis. The rate of intraabdominal abscess in perforated group was 10% (3/30).

SSI developed in five patients (2.3%). Appendices of these five patients were removed from the abdomen without using specimen retrieval bag. No SSI was detected in the group that used the specimen retrieval bag (p=0.02; Fisher’s exact test).

The mean hospital stay of patients with and without SSI was 7.8±3.96 and 2.8±1.69 days, respectively. The hospitalization period of patients with SSI was significantly longer (p<0.001; Mann-Whitney U test). Patient demographics, operation, and follow-up data are summarized according to stump closure methods in Table 1.

DISCUSSION The debate on two topics continues in the stump closure methods in LA: the cost and the safety. The ideal method for the stump closure should be safe, technically easy, and costeffective. Endostaplers, clips, commercial endoloops, and intracorporeal or extracorporeal tying are the most commonly used methods in LA. Several experimental and clinical studies about using bipolar coagulation devices for stump closure have been published,[24,25] but these devices have not been routinely used for stump control. Endostapler has some advantages

Table 1. Patient demographics, operation, and follow-up data Stump closure method

Single knot

Double knot

All patients

79 (37%)

134 (63%)

213

36

62

98

Sex Male Female Age (mean±SD)

41

74

115

33.91±14.78

33.32±13.2

33.5±13.77

Complicated

9 (11.4)

40 (29.9)

49 (23)

Uncomplicated

67 (84.8)

89 (66.4)

156 (73)

No inflammation

3 (3.7)

5 (3.7)

8 (4)

82.4±26.7

87.2±29.6

86.4±24.7

4 (5)

26 (19)

30 (14)

44.58±6.73

44.53±11.94

44.5±10.2

Status of appendix, n (%)

Median appendix base diameter (mm), (mean±SD) Perforation, n (%) Operation time (minutes), (mean±SD) Using specimen retrieval bag, n (%)

No

57 (72.2)

44 (32.8)

101 (47)

Yes

22 (27.8)

90 (67.2)

112 (53)

Surgical site infection, n (%) Intraabdominal abscess, n (%) Median hospital stay (days), (mean±SD)

1 (1.2)

4 (3)

5 (2.3)

0 (0)

3 (2.2)

3 (1.4)

2.85±2.02

2.69±1.84

2.7±1.9

SD: Standard deviation.

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Ağalar et al. Tying and retrieval methods in appendectomy

such as ease of use and rapidity, which are preferred when the appendix base is necrotic and/or perforated,[4] the high cost, and the 12 mm. Trocar requirement is seen as a disadvantage.

Prospective studies about titanium and polymer clips have been published. The stump closure with both types of clips has been evaluated as practical and safe, but there are concerns about using clip when the appendix base is large and/or inflammation is intense.[26,27] Tying the appendix base with standard non-needle suture is the most cost-effective method in all these stump closure methods. Closing the appendix base with knots is considered as safe as compared to other stump closure methods in various series.[9–11,14,28] Single knot[9] and double knot technique[14] were used for closing the appendix stump in some studies, but there is no study in the literature that compares the single or double knot(s). In our study, no difference was observed in the median operation duration and stump safety in single or double knot(s) tying methods. In the light of these data and the literature, single or double knot(s) tying can be defined as safe and cost-effective stump closure method in the laparoscopic treatment of complicated or uncomplicated appendicitis.

The incidence of SSI after LA has been reported between 2.8% and 12.8%.[18,19] The use of specimen retrieval bag reduces the ratio of SSI after LA.[20] We obtained similar results with the literature; all of the five patients who developed SSI, their appendix were removed from the abdomen without using specimen retrieval bag. On the other hand, no SSI was observed in any of the patients in the group that used specimen retrieval bag. The risk of developing SSI, which is one of the factors that reduces the advantages of laparoscopic method, extends the length of hospital stay, which can be reduced with use of specimen retrieval bag in LA. The risk of developing intraabdominal abscess after appendectomy is related to the presence of perforation, and it is more common in LA than in open appendectomy.[8,29] Patients with perforated appendicitis can be safely treated by LA, despite the risk of developing intraabdominal abscess. In our series, intraabdominal abscess was detected in three patients.

All of these patients had perforated appendicitis. The risk of intraabdominal abscess can be reduced by four-quadrant irrigation.[30] We performed routine four-quadrant washout in perforated patients, this may explain our 10% intraabdominal abscess rate after LA in patients with perforated appendicitis, which reaches 24% in the literature.[8] The major limitations of our study are its retrospective design and no cost analysis. Our study includes the results of single center with heterogeneous surgeon group.

Conclusion In conclusion, during LA, single or double knot tying method Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

can be safely used for stump closure in complicated or uncomplicated appendicitis. Our study shows that using the specimen retrieval bag reduces the SSI in LA, but further prospective multicenter studies evaluating the costs are needed.

Conflict of interest: None declared.

REFERENCES 1. Semm K. Endoscopic appendectomy. Endoscopy 1983;15:59–64.

2. Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, Eubanks S et al. Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg 2004; 239:43–52 3. Yaghoubian A, Kaji AH, Lee SL. Laparoscopic versus open appendectomy: outcomes analysis. Am Surg 2012;78:1083–6.

4. Mayir B, Ensari CÖ, Bilecik T, Aslaner A, Oruç MT. Methods for closure of appendix stump during laparoscopic appendectomy procedure. Turk J Surg 2015;31:229–31.

5. Long KH, Bannon MP, Zietlow SP, Helgeson ER, Harmsen WS, Smith CD, et al; Laparoscopic Appendectomy Interest Group. A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: Clinical and economic analyses. Surgery 2001;129:390–400.

6. Rashid A, Nazir S, Kakroo SM, Chalkoo MA, Razvi SA, Wani AA. Laparoscopic interval appendectomy versus open interval appendectomy: a prospective randomized controlled trial. Surg Laparosc Endosc Percutan Tech 2013;23:93–6.

7. Tanaka S, Kubota D, Lee SH, Oba K, Matsuyama M. Effectiveness of laparoscopic approach for acute appendicitis. Osaka City Med J 2007;53:1–8 8. Krisher SL, Browne A, Dibbins A, Tkacz N, Curci M. Intra-abdominal abscess after laparoscopic appendectomy for perforated appendicitis.

Arch Surg 2001;136:438–41.

9. Nadeem M, Khan SM, Ali S, Shafiq M, Elahi MW, Abdullah F, et al.

Comparison of extra-corporeal knot-tying suture and metallic endo-clips in laparoscopic appendiceal stump closure in uncomplicated acute appendicitis. International Journal of Surgery Open 2016;2:11–4.

10. Arcovedo R, Barrera H, Reyes HS. Securing the appendiceal stump with the Gea extracorporeal sliding knot during laparoscopic appendectomy is safe and economical. Surg Endosc Other Interv Tech 2007;21:1764–7.

11. Bali I, Karateke F, Özyazıcı S, Kuvvetli A, Oruç C, Menekşe E, Emir S, Özdoğan M. Comparison of Intracorporeal Knotting and Endoloop for Stump Closure in Laparoscopic Appendectomy. Ulus Travma Acil Cerrahi Derg 2015;21:446–9.

12. Blake L, Som R. Best evidence topic: What is the best management of the appendix-stump in acute appendicitis: Simple ligation or stump invagination? Int J Surg 2015;24:20–3.

13. Kazemier G, in’t Hof KH, Saad S, Bonjer HJ, Sauerland S. Securing the appendiceal stump in laparoscopic appendectomy: Evidence for routine stapling? Surg Endosc Other Interv Tech 2006;20:1473–6.

14. Mayir B, Bilecik T, Ensari CO, Oruc MT. Laparoscopic appendectomy with hand-made loop. Wideochir Inne Tech Malo Inwazyjne 2014;9:152–6.

15. Rakić M, Jukić M, Pogorelić Z, Mrklić I, Kliček R, Družijanić N, et al.

Analysis of endoloops and endostaples for closing the appendiceal stump during laparoscopic appendectomy. Surg Today 2014;44:1716–22.

16. Rickert A, Bönninghoff R, Post S, Walz M, Runkel N, Kienle P. Appendix stump closure with titanium clips in laparoscopic appendectomy.

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Ağalar et al. Tying and retrieval methods in appendectomy Langenbeck’s Arch Surg 2012;397:327–31.

17. Shaikh FM, Bajwa R, McDonnell CO. Management of appendiceal stump in laparoscopic appendectomy--clips or ligature: a systematic review and meta-analysis. J Laparoendosc Adv Surg Tech A 2015;25:21–7.

18. Cho M, Kang J, Kim IK, Lee KY SS. Underweight body mass index as a predictive factor for surgical site infections after laparoscopic appendectomy. Yonsei Med J 2014;55:1611–6 19. Suh YJ, Jeong SY, Park KJ, Park JG, Kang SB, Kim DW, et al. Comparison of surgical-site infection between open and laparoscopic appendectomy. J Korean Surg Soc 2012;82:35–9.

20. Lasheen AE, Elaziz OA, Elaal SA, Alkilany M, Sieda B, Alnaimy T. Surgical Wound Infections After Laparoscopic Appendectomy With or Without Using Reusable Retrieval Bag: A Retrospective Study. J Minim Invasive Surg Sci 2016;5:e36894.

21. Yau KK, Siu WT, Tang CN, Yang GP, Li MK. Laparoscopic Versus Open Appendectomy for Complicated Appendicitis. J Am Coll Surg 2007;205:60–5.

22. Lo IK, Burkhart SS, Chan KC, Athanasiou K. Arthroscopic knots: determining the optimal balance of loop security and knot security.

Arthroscopy 2004;20:489–502.

23. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009;250:187–96.

24. Aslan A, Karaveli C, Elpek O. Laparoscopic appendectomy without clip or ligature. An experimental study. Surg Endosc 2008;22:2084–7.

25. Khanna S, Khurana S, Vij S. No clip, no ligature laparoscopic appendectomy. Surg Laparosc Endosc Percutan Tech 2004;14:201–3.

26. Partecke LI, Kessler W, Von Bernstorff W, Diedrich S, Heidecke CD, Patrzyk M. Laparoscopic appendectomy using a single polymeric clip to close the appendicular stump. Langenbecks Arch Surg 2010;395:1077– 82.

27. Rickert A, Krüger CM, Runkel N, Kuthe A, Köninger J, Jansen-Winkeln B, et al. The TICAP-Study (titanium clips for appendicular stump closure): A prospective multicentre observational study on appendicular stump closure with an innovative titanium clip. BMC Surg 2015;15:85.

28. Ates M, Dirican A, Ince V, Ara C, Isik B, Yilmaz S. Comparison of intracorporeal knot-tying suture (polyglactin) and titanium endoclips in laparoscopic appendiceal stump closure: a prospective randomized study.

Surg Laparosc Endosc Percutan Tech 2012;2:226–31.

29. Fleming FJ, Kim MJ, Messing S, Gunzler D, Salloum R, Monson JR. Balancing the risk of postoperative surgical infections: a multivariate analysis of factors associated with laparoscopic appendectomy from the NSQIP database. Ann Surg 2010;252:895–900.

30. Hussain A, Mahmood H, Nicholls J, El-Hasani S. Prevention of intraabdominal abscess following laparoscopic appendicectomy for perforated appendicitis: A prospective study. Int J Surg 2008;6:374–7.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Laparoskopik apendektomide güdük bağlama tekniği ve spesimen çıkarma metodu morbiditeyi etkiliyor mu?

Dr. Cihan Ağalar,¹ Dr. Zekai Serhan Derici,¹ Dr. Ali Durubey Çevlik,¹ Dr. Süleyman Özkan Aksoy,¹ Dr. Tufan Egeli,¹ Dr. Nilay Boztaş,² Dr. Mücahit Özbilgin,¹ Dr. Sülen Sarıoğlu,3 Dr. Tarkan Ünek¹ Dokuz Eylül Üniveritesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İzmir Dokuz Eylül Üniveritesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, İzmir 3 Dokuz Eylül Üniveritesi Tıp Fakültesi, Patoloji Anabilim Dalı, İzmir 1 2

AMAÇ: Güdük kapatılması laparoskopik apendektominin (LA) en önemli aşaması olarak görülmektedir. Güdüğün dikiş ile kapatılması maliyet açısından en etkin yöntemdir. LA sonrası yara yeri enfeksiyonu gelişmesi için tanımlanmış risk faktörü, trocar giriş alanının inflame apendiks ile kontamine olmasıdır. Bu çalışmanın amacı apendiks güdüğü kapatılmasında tek-çift bağlama teknikleri ve spesimen çıkarma yöntemlerinin karşılaştırılmasıdır.

GEREÇ VE YÖNTEM: Ocak 2015 ve Ocak 2017 tarihleri arasında ameliyat edilen hastalara ait bilgiler ileriye dönük olarak doldurulan veritabanının geriye dönük olarak incelenmesi ile elde edildi. Tek-çift bağlama teknikleri, spesimen çıkarma yöntemleri, ameliyat süresi, hastane kalış süresi, perioperative ameliyat sonrası komplikasyonlar karşılaştırıldı.

BULGULAR: Yüz otuz dört hastada (%63) ekstracorporeal çift bağlama, 79 hastada (%37) ekstracorporeal tek bağlama ile güdük kapatıldı. İki grupta ameliyat süreleri arasında fark saptanmadı (p=0.97). Hiçbir hastada güdük kaçağı gelişmedi. Üç hastada (%1.4) intraabdominal apse gelişti. Yüz bir hastada (%47) apendiks direkt yöntemle çıkarıldı, 112 hastada (%53) ise spesimen torbası kullanıldı. Beş hastada yara enfeksiyonu gelişti (%2.3), bu beş hastanın tümünde spesimen torbası kullanılmamıştı (p=0.02).

TARTIŞMA: Tek veya çift bağlama, güvenli ve uygun maliyetli güdük kapatma yöntemi olarak tanımlanabilir. Spesimen torbası kullanımı ile yara yeri enfeksiyonu gelişme riski azaltılabilir.

Anahtar sözcükler: Cerrahi alan enfeksiyonu; ekstrakorporeal düğüm bağlama; güdük; laparoskopik apendektomi; spesimen torbası.

Ulus Travma Acil Cerrahi Derg 2019;25(1):34-38

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doi: 10.5505/tjtes.2018.90382

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

ORIG I N A L A R T IC L E

A 4-year single-center experience in the management of esophageal perforation Serkan Sarı, M.D.,1 Hasan Bektaş, M.D.,1 Kıvılcım Ulusan, M.D.,1 Burak Koçak, M.D.,2 Bünyamin Gürbulak, M.D.,1 Şükrü Çolak, M.D.,1 Ekrem Çakar, M.D.,1 Melis Baykara Ulusan, M.D.2 1

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

2

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

ABSTRACT BACKGROUND: Esophageal perforation (EP) is a lethal surgical emergency that needs to be diagnosed and treated immediately.

Diagnosis and treatment options for EP are limited due to its lower incidence. There are scoring systems proposed for this purpose; however, they cannot be applied to every patient. The recent trend in the treatment of EP is toward the non-operative approach over the surgical treatment methods. The purpose of the present study was to evaluate our treatment methods and outcomes in patients with EP. METHODS: Thirteen patients with EP treated in our clinic between 2013 and 2017 were retrospectively reviewed. The Pittsburgh Perforation Severity Score (PSS), systemic condition status, and Clavien–Dindo Classification (CDC) score were assessed, and treatment methods were reviewed. Their effects on morbidity and mortality were examined using Fisher’s exact test and biserial correlation test.

RESULTS: A total of 13 patients (six males and seven females; median age 64 years) were included in the study. Ten patients were managed non-operative, and three were treated surgically. Of the 10 patients, two had additional surgery after non-operative management. The PSS, systemic condition status, CDC score, duration of stay in the hospital, time to diagnosis, presence of hypotension, and being in shock were strongly correlated with mortality (p<0.05). The PSS, CDC score, and stay in the intensive care unit were strongly correlated with morbidity (p<0.05). The comparison between the non-operative and operative groups did not yield a statistically significant difference in mortality and morbidity.

CONCLUSION: Even if the scoring systems help to understand the severity of the condition, they are inadequate to determine the treatment option. Early diagnosis and treatment are the most important steps in management. Operative and non-operative treatment options are not superior to each other, but their complementary use will be more beneficial for the patients.

Keywords: Esophageal perforation; Pittsburgh Perforation Severity Scoring system; systemic condition scoring system.

INTRODUCTION Esophageal perforation (EP) is a rare condition, and the management of this emergency situation is still controversial.

Despite advances in technology and surgical techniques, EP continues to be a life-threatening condition. The mortality and morbidity rates were reported up to 40%.[1,2] The most common cause of death in patients with EP is sepsis, which leads to multiorgan failure.[3] The esophagus has no serosal surface; thus, thoracic perforations could cause dissemination of the surrounding tissues and lead to mediastinitis. EP

has a wide etiological spectrum and is classified into three groups as spontaneous, traumatic, and iatrogenic perforation.

Spontaneous perforation was reported to be more common in previous studies. However, recent studies reported that iatrogenic perforations are up to 60% of all perforations due to the widespread use of endoscopic procedures. Regardless of its etiology, EP is an emergency.[4,5] A variety of clinical symptoms on presentation and follow-up might delay diagnosis, especially in asymptomatic patients. The mortality rate doubles if EP is not diagnosed in the first 24 h. Thus, early diagnosis is crucial in the treatment. Once EP is diagnosed, hemodynamic

Cite this article as: Sarı S, Bektaş H, Ulusan K, Koçak B, Gürbulak B, Çolak Ş, et al. A 4-year single-center experience in the management of esophageal perforation. Ulus Travma Acil Cerrahi Derg 2019;25:39-45.

Address for correspondence: Kıvılcım Ulusan, M.D. Sağlık Bilimleri Üniversitesi, İstanbul Eğitim ve Araştırma Hastanesi, Genel Cerrahi Anabilim Dalı, İstanbul, Turkey.

Tel: +90 212 - 459 60 00 E-mail: kivilcimulusan@hotmail.com Ulus Travma Acil Cerrahi Derg 2019;25(1):39-45 DOI: 10.5505/tjtes.2018.79484 Submitted: 16.05.2018 Accepted: 29.08.2018 Online: 28.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

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Sarı et al. A 4-year single-center experience in the management of esophageal perforation

monitoring and support and antibiotic therapy should be initiated. Extraluminal contamination should be controlled, and luminal integrity might be restored in selected cases. There are no widely accepted treatment algorithms and scoring systems that might influence the outcome of patients with EP.[6] Previously, an aggressive surgical approach was advocated. However, recent literature also supports conservative treatment for selected cases. Therefore, a multidisciplinary approach is important in this manner.[7–9] The purpose of the present study was to present a 4-year single-center experience in the management of EP.

MATERIALS AND METHODS Study Ethics The ethics review board of the University of Health Sciences, Istanbul Training and Research Hospital approved the study (no.: 01.12.2017/1131).

Study Design Patients with EP who were diagnosed and treated at our institution between 2013 and 2017 were retrospectively reviewed. Exclusion criteria were the following: (1) anastomotic leak after upper gastrointestinal (UGI) surgical procedures and (2) esophageal injuries that were diagnosed and treated intraoperatively. Selected patients were diagnosed with chest X-ray, UGI, and thoracic computed tomography (CT) with or without oral contrast and UGI endoscopy. Perforation was classified as etiology (spontaneous, traumatic, and iatrogenic), the location of perforation (cervical, thoracic, and abdominal), perforation size, and presence of additional esophageal pathology or cancer. Time to diagnosis, vital signs, and laboratory parameters at presentation were recorded.

Systemic conditions were classified according to the World Health Organization definition criteria as shock, systemic inflammatory response syndrome (SIRS), and non-SIRS. The Pittsburgh Perforation Severity Scores (PSSs) of all patients were calculated according to the study by Abbas et al. Patients were rated as follows: 1 point for age >75 years, tachycardia (>100 bpm), leukocytosis (>10,000 WBC/mL), and pleural effusion (on chest X-ray, CT, or barium swallow); 2 points for fever (>38.5 °C), uncontained leak (on barium swallow or CT), respiratory compromise (respiratory rate >30, increasing oxygen requirement, or need for mechanical ventilation), and time to diagnosis >24 h; and three points for presence of cancer and hypotension. With reference to that, patients were divided into three groups as low PSS (≤2), intermediate PSS (3–5), and high PSS (>5). The initial treatment was categorized as operative or non-operative management that included conservative observation, endoscopic stenting, and surgical drainage. Re-interventions following non-operative treatment, reoperation or endoscopic stenting after the initial treatment, necessary treatments in the intensive care 40

unit (ICU), duration of stay in the ICU and hospital, mortality, and morbidity were recorded for all patients.

Statistical Analysis Statistical data were analyzed using the SPSS version 20 software (SPSS Inc., Chicago, IL, USA). Continuous variables are presented as mean±standard deviation and median. Categorical variables are expressed as numbers. The Shapiro– Wilk test was used for testing the normality of continuous variables. Statistical comparison between the non-operative and surgical groups was made using non-parametric (Fisher’s exact test or chi-square test) or parametric tests (independent t-test) considering the distribution pattern of the data.

Although at the time of conceptualization of the study, it was planned to use regression analysis for assessing the association of risk factors with management strategies, this did not prove possible because the number of patients in our study was very small (n=13). Hence, simple correlation tests were used for the association of mortality and morbidity with pertinent variables. The correlation tests used were pointbiserial correlation test for dichotomous and continuous variables, rank-biserial correlation test for dichotomous and ordinal variables, and Fischer’s exact test for both dichotomous variables. For all statistical tests, a two-tailed p-value of <0.05 was considered significant.

RESULTS Thirteen patients with EP were admitted to our hospital.

Ten patients were managed non-operatively. Two out of 10 patients in the conservative treatment group went for surgical intervention in the follow-up. Surgical treatment was the initial approach for three patients. Among 13 patients, three were lost in the non-operative treatment group.

Detailed demographics and their pertinent clinical data are presented in Table 1. Comparison of patient demographics and clinical data are presented in Table 2. Comparison between the non-operative and operative groups yielded no statistically significant result.

The PSS and Clavien–Dindo Classification (CDC) score were strongly correlated with morbidity, with high PSS and CDC more associated with morbidity, rpb=0.61, p=0.026 and rpb=0.59, p=0.032, respectively. Duration of stay in the hospital, PSS score, and CDC score were strongly correlated with mortality, with longer duration of stay and higher PSS and CDC associated with mortality, rpb=0.56, p=0.043; rpb=0.58, p=0.034; and rpb=0.77, p=0.002, respectively. Time to diagnosis was strongly correlated with mortality, with the longer time associated with the presence of mortality, rpb=0.741, p=0.004. Presence of hypotension was associated with the presence of mortality, p=0.014. Duration of stay in the ICU was associated with the presence of morbidity, p=0.014. Systemic condition status was associated with mortality, with Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

Etiology

Time to Site

Size

Management

diagnosis

Surgery following

ICU PSS

SCS

Morbidity

Mortality

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1 thoracotomy

A&G: Age and gender; F: Female; M: Male; ICU: Intensive care unit; PSS: Pittsburgh Severity Score; SCS: Systemic Condition Score; C: Cervikal; T: Thoracic; A: Abdominal; SIRS: Systemic inflammatory response syndrome.

Hospital

7 10

60

23

19

9

x

x x

43

58

18

22

No

No

No

No

No

Yes

Yes Yes

No

No

No

No

stay (days)

No

non-operative management

1 64F Iatrogenic 3-24h C 5 mm Non-operative No No 1 NonSIRS No

Intubation Observed conservatively 2 86M Iatrogenic <3h T 10 mm Non-operative No No 8 NonSIRS No

Endoscopic balloon Endoscopic stenting

dilatation of tumor 3 52F Spontaneous 24-72h T 20 mm Non-operative Yes Diverticulum perforation Surgical drainage Thoracotomy +debridement+ Yes 6 NonSIRS Yes

without thoracotomy primary repair Leak of the esophageal repair → covered

stent application → fistula on the stent →

covered stent application via old stent 4 70M Spontaneous 3-24h A 40 mm Non-operative Yes Yes 10 Shock Yes

Boerhaave syndrome Surgical drainage without Laparotomy+ primary repair Evisceration → primary repair

thoracotomy covered with gastric fundus Pleural effusion → external

drainage catheter 5 21F Iatrogenic <3h C 20 mm Non-operative No Yes 6 SIRS Yes

Intraoperatively Bilaterally surgical drainage Pneumonia

tracheostomy procedure without thoracotomy 6 48F Iatrogenic <3h C 10 mm Operative x No 0 NonSIRS No

Endoscopic balloon Primary repair

dilatation of stricture 7 24F Traumatic >72h C 10 mm Non-operative No Yes 14 Shock Yes

Foreign body Surgical drainage Mediastinitis

without thoracotomy 8 82F Iatrogenic >72h C 4 mm Non-operative No Yes 9 Shock Yes

Intraoperatively Observation with Mediastinitis + acute renal failure

tracheostomy procedure nasogastric tube 9 59M Iatrogenic 24-72h T 100 mm Non-operative No Yes 10 Shock Yes

Boerhaave syndrome Surgical drainage without Mediastinitis + pleural empyema Sengstaken-Blakemore thoracotomy

tube insertion 10 66M Spontaneous 3-24h T 10 mm Operative x Yes 10 SIRS Yes

Tumor perforation Surgical drainage Mediastinitis + mediastinal abscess +

with thoracotomy esophageal fistula → covered stent application 11 84F Spontaneous <3h T 20 mm Non-operative No Yes 5 NonSIRS Yes

Mediastinal abscess Surgical drainage Mediastinitis + mediastinal abscess +

due to lung cancer without thoracotomy obstruction of the thorax tube →

changing thorax tube 12 60M Iatrogenic 3-24h T 12 mm Non-operative No No 6 NonSIRS Yes

Bronchoscopic biopsy Surgical drainage Esophageal fistula →

without thoracotomy covered stent application 13 71M Spontaneous <3h A 30 mm Operative x Yes 7 SIRS Yes

Boerhaave syndrome Laparotomy+primary repair Leak of the esophageal repair + mediastinal

abscess + esophageal fistula → covered stent

application + surgical drainage without

Case A&G

Table 1. Detailed patient demographics and their pertinent clinical data

Sarı et al. A 4-year single-center experience in the management of esophageal perforation

41

Sarı et al. A 4-year single-center experience in the management of esophageal perforation

Table 2. Comparison of patient demographics and clinical data Groups

Age (years; mean±SD/median) Gender (count; male/female) Etiology (count; spontaneous/Iatrogenic/traumatic)

Overall Non-operative Operative p (n=13) (n=10) (n=3) 60.5±20.4/64

60.2±22.9/62

61.6±12.1/66

.919

6/7

4/6

2/1

.437

5/7/1

3/6/1

2/1/0

.494

Perforation site in the esophagus (count; cervical/thoracic/abdominal) Perforation size (millimeters; mean±SD/median)

5/6/2 4/5/1 1/1/1 .612 22.3±25.4/12

24.1±28.6/16

16.6±11.5/10

.937

Presence of additional esophageal pathology (count; present/absent)

8/5 5/5 3/0 .196

Presence of esophageal cancer (count; present/absent)

2/11

1/9

1/2

5/4/2/2

3/3/2/2

2/1/0/0

.569

10/3

7/3

3/0

.420

Time to diagnosis (h; <3 h/3-24 h/24-72 h/>72 h) Body temperature (count; <38.5 ºC/>38.5 ºC)

.423

Heart beat per minute (count; <100 bpm/>100 bpm)

7/6

6/4

1/2

.437

Hypotension (count; present/absent)

4/9

4/6

0/3

.294

7/6

5/5

Respiratory compromise (count; present/absent) White blood cells (count; mean±SD/median)

17100±9200/13500 19400±9090/15250

2/1

.563

9300±4464/11200

.077

Hematocrit (count; mean±SD/median)

33.8±3.3/33200

34.1±3.4/33.4

33.1±3.6/32.1

.685

C-reactive protein (count; mean±SD/median)

45.7+113.2/10.9

57.5±128.1/13.2

6.6±5.2/8.7

.076

Pleural effusion (count; present/absent)

9/4

7/3

2/1

.706

Uncontained leak (count; present/absent)

9/4

7/3

2/1

.706

2/11

2/8

0/3

.577

8/1/4

7/1/2

1/0/2

.296

Surgery following non-operative management (count; present/absent) Intervention after the initial management strategy (count; absent/re-operation/endoscopic stenting) Stay in the ICU (count; yes/no) Duration of ICU stay (days; mean±SD/median)

9/4

7/3

2/1

.706

2.4±2.7/2

2.8±3/2

1.3±1.1/2

.573

Duration of hospital stay (days; mean±SD/median)

20.6±20.7/18

19.5±22.4/14

24.6±17.1/22

.573

Duration of feeding (days; mean±SD/median)

12.1±14.7/10

12.7±16.8/8.5

10.3±4.5/10

.811

7±3.7/7

7.5±3.5/7

5.6±5.1/7

.487

Pittsburgh Perforation Severity Scoring system (count; mean±SD/median) Systemic condition in presentation (count; shock/SIRS/non-SIRS) Clavien-Dindo classification (count; mean±SD/median)

4/3/6

4/1/5

0/2/1

.103

3.3±1.2/3

3.6±1.2/4

2.3±0.5/2

.160

Morbidity (count; present/absent)

10/3

8/2

2/1

.580

Mortality (count; present/absent)

3/10

3/7

0/3

.420

ICU: Intensive care unit; SIRS: Systemic inflammatory response syndrome; SD: Standard deviation.

being in shock (compared with SIRS and non-SIRS) correlated with mortality, p=0.012.

DISCUSSION EP is a rare condition seen in 3.1 per 1,000,000 people per year.[10] The incidence of injury during diagnostic endoscopy ranged from 0.006% to 2% and increased up to 7% when therapeutic esophageal procedures are included.[11–13] The rate of iatrogenic injury is increased with endoscopic examinations, 42

placement of tubes, stent application, submucosal dissection, and endomucosal resection and up to 60% in the most recent series.[1] Furthermore, there is substantial heterogeneity in the etiologies of perforation including Boerhaave syndrome, tumor perforation, thoracic trauma, swallowing foreign bodies, and acid or caustic substances.[14–16] In our study, the rate of iatrogenic perforation was 53.8% and spontaneous perforation was 38.5%. Although similar results are obtained in the literature, the iatrogenic perforation rate will be even higher when the injuries that occur during surgery are also included.

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Sarı et al. A 4-year single-center experience in the management of esophageal perforation

Diagnostic Tools The most common presenting symptoms of EP are thoracic pain (58%), dyspnea (30%), dysphagia (24%), vomiting and nausea (21%), coughing (9%), and hypovolemic shock (11%).

[1] Malignancy is the most frequently identified underlying pathology. CT is the most commonly used diagnostic tool in all perforation etiologies. Thoracic CT is the gold standard for the identification of EP and associated comorbidities.

In addition, some EPs can be diagnosed during endoscopy.

[5] If a perforation is noticed during the procedure, the first step is to close the air insufflation and switch to carbon dioxide (CO2). CO2 is rapidly resorbed and has been shown to reduce post-procedural mediastinal emphysema. The second step is to prevent the spread of pathogens by lowering the high intraluminal pressures due to gas insufflation. Even if diagnosed by endoscopic procedures, thoracic CT should still be performed for the diagnosis of mediastinitis, mediastinal emphysema, and early-stage collections.[17–19] WBC and CRP values may not be helpful in assessing the severity of the disease at an early-stage. Okumura et al. reported that WBC count ≤4000/μL indicates a very serious spontaneous perforation. Rather, in our mortal group, all three patients were in shock, and their WBC counts were 22,300/μL, 34,900/μL, and 10,700/μL respectively.

Scoring Systems Owing to the low incidence of EP, physicians have limited experience in diagnosis and treatment. The diagnosis could be easily overlooked and delayed. It has high mortality rates ranging from 4% to 40%.[5,6] In our study, we also found a mortality rate of 23%. Various scoring and classification systems were proposed to reduce the mortality rate. Okumura et al. classified EP into three groups: shock, SIRS, and non-SIRS. Abbas et al.[20] defined the severity scoring system, and Schweigert et al. conducted a multicenter study using this scoring system.

When this scoring system was applied to our patients, it was found that a high PS score was more associated with morbidity and mortality, and that the low-risk group had significantly better results in terms of morbidity, mortality, and duration of hospital stay. When the parameters forming the PS score were assessed separately, only time to diagnosis and hypotension were strongly associated with mortality.

Although these scoring systems alert us to the severity of the illness, it is inadequate to explain most clinical cases. One of the most important problems in our study was that many patients are collected in the same group. In our study, 10 (76.9%) patients were in the high PS score group. When a treatment algorithm is created using this score, the treatment is not selective. The same treatment applied to many patients does not yield sufficient results. On the other hand, when we classify patients according to the systemic condition scoring system, it appears that the groups are more homogeneous. Owing to this result, we think that the systemic Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

condition scoring system of Okumura et al. may be more effective to define a treatment algorithm. Their scoring system reflects the situation of the patients better, whereas we think that the PS score requires new subgroups or different scoring parameters.

Schweigert et al. recommend that the perforation site should be included in the score because cervical perforation is associated with significantly lower mortality than thoracic or abdominal rupture. On the contrary, in our study, two out of three patients who died had cervical EPs.

Treatment Options The treatment management of EP was evaluated into two main groups: surgical and non-surgical. Non-surgical management includes (1) observation with or without nasogastric tube placement, (2) nil per os status, (3) parenteral nutrition, (4) antibiotherapy, and (5) non-surgical drainage procedures.

[5] Non-operative techniques have become more popular recently because of the widespread use of endoscopic procedures, such as temporary stenting and clip application.[21–24] In addition, endoscopic vacuum-assisted closure has been reported as a new minimal invasive solution for mediastinal collection and mediastinal abscess that necessitates surgical treatment.[25] Surgical management generally includes primary surgical repair, surgical drainage, and esophageal resection procedures.

Direct closure with sutures is recommended only in patients with fresh perforations. Direct closure of the perforation site with single sutures following limited debridement is the therapeutic routine based on an infection or delayed treatment.

Primary resection is indicated only in patients with larger esophageal destruction and the last possible option in ultima ratio because of its higher mortality and morbidity rates in the presence of mediastinitis.[26–30] Some surgeons have adopted an additional reinforcement, such as pericardial and pleural flabplasties and fundoplication in patients who undergo surgical revision of a prior endoscopic or surgical treatment.[31] In our study, we had two patients who underwent surgery following non-operative management. The first patient was treated with debridement and primary repair that leaked from the repair site lately. The patient was brought back to the operating room and a covered stent was applied. The second patient was treated with debridement and primary repair and covered with gastric fundus that healed without any problem. According to our experience, additional reinforcement of the repair site following repair should be considered for revision cases.

Considering the results above, EP treatment is still controversial. Recent data in the literature support both surgical and non-surgical treatment methods. Moreover, a recent study showed that endoscopic interventions can be successful even in patients with sepsis with mediastinitis.[31] The treatment 43

Sarı et al. A 4-year single-center experience in the management of esophageal perforation

method might be chosen based on etiology, size or location of perforation, complications related to the mediastinum, or systemic condition of each patient.[3,6,11,24] However, surgical and non-surgical strategies have no superiority to each other, as seen both in the literature and our study. We think that the variable outcomes in the literature depend on patient selection. The results of the patients with a good systemic status are better.

The main group, which is controversial in EP treatment, is septic, low systemic condition, high-risk patients. Schweigert et al. reported that 40% of the patients in the non-operative group subsequently require surgical intervention. This rate is 20% in our series. Yet, when mortal patients are excluded from the study, this rate increases to 28.5%. Furthermore, 40% (4/10) of our surviving patients underwent esophageal stenting due to esophageal fistula and leak of esophageal repair during follow-up.

In conclusion, EP is a life-threatening emergency condition.

Early diagnosis and treatment are the most important steps in its management. Although the scoring systems may help us determine the severity of the disease, they may not be adequate for choosing the treatment alternatives. However, the groups can be divided more homogeneously using the systemic condition scoring system. Thus, a more effective treatment algorithm could be generated. Treatment methods are not absolute choices, but should be complementary to each other. A close, careful follow-up is more important than the management preference.

Funding The authors received no financial support for the research, authorship, and/or publication of this article.

Conflict of interest: None declared.

REFERENCES 1. Zimmermann M, Hoffmann M, Jungbluth T, Bruch HP, Keck T, Schloericke E. Predictors of Morbidity and Mortality in Esophageal Perforation: Retrospective Study of 80 Patients. Scand J Surg 2017;106:126–32.

2. Saxena P, Khashab MA. Endoscopic Management of Esophageal Perforations: Who, When, and How? Curr Treat Options Gastroenterol 2017;15:35–45.

3. Okumura H, Uchikado Y, Kita Y, Omoto I, Hayashi N, Matsumoto M, et al. Clinical analysis of the diagnosis and treatment of esophageal perforation. Esophagus 2016;13:146–50.

4. Garas G, Zarogoulidis P, Efthymiou A, Athanasiou T, Tsakiridis K, Mpaka S, et al. Spontaneous esophageal rupture as the underlying cause of pneumothorax: early recognition is crucial. J Thorac Dis 2014;6:1655–8.

5. Sudarshan M, Elharram M, Spicer J, Mulder D, Ferri LE. Management of esophageal perforation in the endoscopic era: Is operative repair still relevant? Surgery 2016;160:1104–10.

6. Schweigert M, Sousa HS, Solymosi N, Yankulov A, Fernández MJ, Beattie R, et al. Spotlight on esophageal perforation: A multinational study

44

using the Pittsburgh esophageal perforation severity scoring system. J Thorac Cardiovasc Surg 2016;151:1002–9.

7. Schwartz ML, McQuarrie DG. Surgical management of esophageal perforation. Surg Gynecol Obstet 1980;151:668–70.

8. Sepesi B, Raymond DP, Peters JH. Esophageal perforation: surgical, endoscopic and medical management strategies. Curr Opin Gastroenterol 2010;26:379–83.

9. de Aquino JLB, de Camargo JGT, Cecchino GN, Pereira DAR, Bento CA, Leandro-Merhi VA. Evaluation of urgent esophagectomy in esophageal perforation. Arq Bras Cir Dig 2014;27:247–50.

10. Vidarsdottir H, Blondal S, Alfredsson H, Geirsson A, Gudbjartsson T. Oesophageal Perforations in Iceland: a Whole Population Study on Incidence, Aetiology and Surgical Outcome. Thorac Cardiovasc Surg 2010;58:476–80.

11. Fernandez FF, Richter A, Freudenberg S, Wendl K, Manegold BC. Treatment of endoscopic esophageal perforation. Surg Endosc 1999;13:962– 6.

12. Antoniou D, Soutis M, Christopoulos-Geroulanos G. Anastomotic Strictures Following Esophageal Atresia Repair: A 20-year Experience With Endoscopic Balloon Dilatation. J Pediatr Gastroenterol Nutr 2010;51:464–7.

13. Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, et al; American Society for Gastrointestinal Endoscopy.. Complications of upper GI endoscopy. Gastrointest Endosc 2002;55:784–93.

14. Tamatey MN, Sereboe LA, Tettey MM, Entsua-Mensah K, Gyan B. Boerhaave’s syndrome: diagnosis and successful primary repair one month after the oesophageal perforation. Ghana Med J 2013;47:53–5.

15. Aronberg RM, Punekar SR, Adam SI, Judson BL, Mehra S, Yarbrough WG. Esophageal perforation caused by edible foreign bodies: A systematic review of the literature. Laryngoscope 2015;125:371–8.

16. Mamede RC, de Mello Filho FV. Ingestion of caustic substances and its complications. Sao Paulo Med J 2001;119:10–5.

17. Maeda Y, Hirasawa D, Fujita N, Obana T, Sugawara T, Ohira T, et al. A pilot study to assess mediastinal emphysema after esophageal endoscopic submucosal dissection with carbon dioxide insufflation. Endoscopy 2012;44:565–71.

18. Yeh DD, Hwabejire JO, de Moya M, King DR, Fagenholz P, Kaafarani HM, et al. Preoperative evaluation of penetrating esophageal trauma in the current era: An analysis of the National Trauma Data Bank. J Emerg Trauma Shock 2015;8:30–3.

19. Pasricha PJ, Fleischer DE, Kalloo AN. Endoscopic perforations of the upper digestive tract: a review of their pathogenesis, prevention, and management. Gastroenterology 1994;106:787–802.

20. Abbas G, Schuchert MJ, Pettiford BL, Pennathur A, Landreneau J, Landreneau J, et al. Contemporaneous management of esophageal perforation. Surgery 2009;146:749–56.

21. Cameron JL, Kieffer RF, Hendrix TR, Mehigan DG, Baker RR. Selective nonoperative management of contained intrathoracic esophageal disruptions. Ann Thorac Surg 1979;27:404–8.

22. van Heel NC, Haringsma J, Spaander MC, Bruno MJ, Kuipers EJ. ShortTerm Esophageal Stenting in the Management of Benign Perforations.

Am J Gastroenterol 2010;105:1515–20.

23. Persson S, Elbe P, Rouvelas I, Lindblad M, Kumagai K, Lundell L, et al. Predictors for failure of stent treatment for benign esophageal perforations - a single center 10-year experience. World J Gastroenterol 2014;20:10613–9.

24. Wu JT, Mattox KL, Wall MJ Jr. Esophageal Perforations: New Perspectives and Treatment Paradigms. J Trauma Inj Infect Crit Care 2007;63:1173–84.

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Sarı et al. A 4-year single-center experience in the management of esophageal perforation 25. Smallwood NR, Fleshman JW, Leeds SG, Burdick JS. The use of endoluminal vacuum (E-Vac) therapy in the management of upper gastrointestinal leaks and perforations. Surg Endosc 2016;30:2473–80.

26. Lawrence DR, Moxon RE, Fountain SW, Ohri SK, Townsend ER. Iatrogenic oesophageal perforations: a clinical review. Ann R Coll Surg Engl 1998;80:115–8.

27. Schmidt SC, Strauch S, Rösch T, Veltzke-Schlieker W, Jonas S, Pratschke J, et al. Management of esophageal perforations. Surg Endosc 2010;24:2809–13.

28. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk

JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg 2004;77:1475–83.

29. Keeling WB, Miller DL, Lam GT, Kilgo P, Miller JI, Mansour KA, et al.

Low Mortality After Treatment for Esophageal Perforation: A SingleCenter Experience. Ann Thorac Surg 2010;90:1669–73.

30. Bhatia P, Fortin D, Inculet RI, Malthaner RA. Current Concepts in the Management of Esophageal Perforations: A Twenty-Seven Year Canadian Experience. Ann Thorac Surg 2011;92:209–15.

31. Flynn AE, Verrier ED, Way LW, Thomas AN, Pellegrini CA. Esophageal Perforation. Arch Surg 1989;124:1211–5.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Özofagus perforasyonları yönetiminde tek merkez 4 yıllık deneyimimiz Dr. Serkan Sarı,1 Dr. Hasan Bektaş,1 Dr. Kıvılcım Ulusan,1 Dr. Burak Koçak,2 Dr. Bünyamin Gürbulak,1 Dr. Şükrü Çolak,1 Dr. Ekrem Çakar,1 Dr. Melis Baykara Ulusan2 1 2

Sağlık Bilimleri Üniversitesi, İstanbul Eğitim ve Araştırma Hastanesi, Genel Cerrahi Anabilim Dalı, İstanbul Sağlık Bilimleri Üniversitesi, İstanbul Eğitim ve Araştırma Hastanesi, Radyoloji Anabilim Dalı, İstanbul

AMAÇ: Özofagus perforasyonu (ÖP), hızlı tanı ve tedavi gerektiren, yaşamı tehdit eden acil cerrahi bir durumdur. Nadir görülmesi tanı ve tedavi seçeneklerini sınırlamaktadır. Bu amaçla bazı skorlama sistemleri önerilse de tüm hastalarda uygulanamamaktadır. Son yıllarda ÖP tedavisinde nonoperatif seçenekler operatif yöntemlere göre daha ön plana çıkmaktadır. Bu çalışmanın amacı ÖP olan hastalarına uygulanan tedavi yöntemlerini ve bunların sonuçlarını değerlendirmektir.

GEREÇ VE YÖNTEM: Kliniğimizde 2013 ve 2017 yılları arasında ÖP nedeniyle tedavi gören 13 hasta geriye dönük olarak değerlendirildi. Pitsburg şiddet skorlaması (PŞS), Sistemik kondisyon sınıflaması (SKS), Clavien-Dindo sınıflaması (KDS) tanımlandı ve tedavi yöntemleri incelendi. Bu parametrelerin morbidite ve mortaliteyle olan ilişkileri Fisher tam olasılık testi ve çift serili korelasyon testi ile değerlendirildi.

BULGULAR: Çalışmaya toplamda 13 hasta (6 erkek, 7 kadın; ortanca yaş 64 yıl) dahil edildi. On hastada non-operatif tedavi seçenekleri uygulanırken, üç hastaya cerrahi prosedürler uygulandı. Non-operatif tedavi seçenekleri uygulanan 10 hastadan ikisine sonrasında ek cerrahi prosedür uygulandı. Pitsburg şiddet skorlaması, SKS, KDS skoru, hastanede kalış süresi, tanıya kadar geçen süre, hipotansiyon varlığı ve şok mortalite ile koreleydi (p<0.05). Pitsburg şiddet skorlaması, KDS skoru ve yoğun bakım ünitesinde kalım morbidite ile güçlü korelasyon göstermekteydi (p<0.05).

Non-operatif ve operatif grup arasında mortalite ve morbidite açısından anlamlı fark izlenmedi.

TARTIŞMA: Skorlama sistemleri hastalığın şiddetini belirlemede yardımcı olsa da tedavi seçeneklerini belirlemede yetersiz kalmaktadır. Erken tanı ve tedavi hastalığın yönetiminde en önemli unsurdur. Operatif ve non-operatif prosedürlerin birbirine üstünlüğü yoktur. Fakat bu yöntemleri birbirlerinin tamamlayıcısı olarak kullanmak hastalar açısından daha faydalı olacaktır.

Anahtar sözcükler: Özofagus Perforasyonu; Pittsburgh şiddet skorlama sistemi; Sistemik kondisyon skorlama sistemi.

Ulus Travma Acil Cerrahi Derg 2019;25(1):39-45

doi: 10.5505/tjtes.2018.79484

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

45

ORIG I N A L A R T IC L E

Prognostic evaluation of cases with thoracic trauma admitted to the intensive care unit: 10-year clinical outcomes Mehtap Pehlivanlar Küçük, M.D.,1 Ahmet Oğuzhan Küçük, M.D.,2 İskender Aksoy, M.D.,3 Davut Aydın, M.D.,1 Fatma Ülger, M.D.1 1

Department of Anesthesiology and Reanimation, Division of Intensive Care Medicine, Ondokuz Mayıs University Faculty of Medicine,

Samsun-Turkey 2

Department of Anesthesiology and Reanimation, Division of Intensive Care Medicine, Faculty of Medicine Karadeniz Technical University,

Trabzon-Turkey 3

Department of Emergency Medicine, Ondokuz Mayıs University Faculty of Medicine, Samsun-Turkey

ABSTRACT BACKGROUND: Multiple traumas are a leading cause of mortality among young adults worldwide. Thoracic trauma causes approximately 25% of all trauma-associated deaths. This study aims to determine the independent prognostic factors of mortality in cases with thoracic trauma (isolated or with accompanying organ injuries) who were admitted to the intensive care unit (ICU).

METHODS: We retrospectively reviewed data from patients with thoracic trauma who were admitted to our ICU between 2007 and 2016. After excluding pediatric patients (aged <18 years), the study sample included 564 cases. From the records, we collected the patients’ demographical data, comorbid diseases, primary trauma as an indication for ICU admission, other traumas accompanying thoracic trauma, type of thoracic injury, and therapeutic interventions. The study sample was divided into two subsets: survival and non-survival groups. These two groups were compared with regards to first ICU day laboratory results and intensive care scores, mechanical ventilation times, and ICU stay lengths.

RESULTS: Of the 8063 patients admitted to the ICU between 2007 and 2016, 616 (7.6%) had thoracic trauma. The median age (min–max) of the 564 patients eligible for this study was 43 (18–87) years. Mortality occurred in 159 (28.1%) cases, while 405 (71.8%) were discharged from the ICU. Multivariate regression analyses were also performed, in which every increment in age was associated with a 1.025-fold increase in the odds of mortality due to thoracic trauma. Additionally, the presence of central nervous system (CNS) trauma was associated with a 2.147-fold increase, and the presence of pulmonary contusion was associated with a 1.752-fold increase.

CONCLUSION: Results of this study indicate that advanced age, the presence of pulmonary contusion, and accompanying CNS trauma are independent predictors of mortality in patients with thoracic trauma in the ICU. Our non-invasive approach is further supported by the trauma and injury severity score (TRISS) scoring system, which is one of the latest scoring systems used in trauma cases.

Keywords: Hospital mortality; intensive care unit; thoracic injuries; thoracic trauma; TRISS; Trauma Severity Indices.

INTRODUCTION Multiple traumas are often caused by fall from height or motor vehicle accidents. They are among the leading cause of mortality among young adults worldwide.[1] Six percent of patients with trauma have thoracic trauma. Thoracic trauma has been reported to be the cause of approximately 25% of

all trauma-associated deaths. It is considered a contributing factor for mortality in more than another 25%. These data may not be entirely accurate due to the inadequacy of trauma registry systems, and because minor injuries are often discharged without being registered.[2–7] Cases with thoracic traumas and other associated organ injuries often require intensive care because they need to be closely monitored

Cite this article as: Pehlivanlar Küçük M, Küçük AO, Aksoy İ, Aydın D, Ülger F. Prognostic evaluation of cases with thoracic trauma admitted to the intensive care unit: 10-year clinical outcomes. Ulus Travma Acil Cerrahi Derg 2019;25:46-54.

Address for correspondence: Mehtap Pehlivanlar Küçük, M.D. Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, Samsun, Turkey.

Tel: +90 362 - 312 19 19 E-mail: mehtap_phlvnlr@hotmail.com Ulus Travma Acil Cerrahi Derg 2019;25(1):46-54 DOI: 10.5505/tjtes.2018.97345 Submitted: 23.02.2018 Accepted: 16.07.2018 Online: 26.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Pehlivanlar Küçük et al. Prognostic evaluation of cases with thoracic trauma admitted to the intensive care unit

due to high mortality rates.[3,8] Indications for intensive care unit (ICU) admission typically include respiratory problems and hemodynamic instability. The most frequently affected anatomical structures in thoracic traumas are particularly the chest wall as well as the lung parenchyma, heart, diaphragm, and aorta.[9] With regards to management of thoracic trauma, conservative approaches are sufficient in 90% of the cases; however, a small number of patients require surgical interventions, including urgent thoracotomy.[10] Accurate risk stratification in patients with thoracic trauma who are admitted to the ICU is crucial to understand risk factors for late complications and improve the ICU outcomes. Several trauma-scoring systems have been developed to guide triage and predict mortality. This study aimed to identify independent prognostic factors of mortality in cases admitted to the ICU due to thoracic trauma, either isolated or with other organ injuries.

MATERIALS AND METHODS The STROBE guideline was used as a guide for this manuscript. In this study, we retrospectively reviewed clinical data from patients admitted to the Anesthesiology and Reanimation ICU due to single or multiple traumas to identify patients with thoracic trauma. Following approval from our university’s ethics committee (2016/387), data from patients admitted to the ICU between 2007 and 2016 were collected by reviewing the ICU patient follow-up charts, medical files, and hospital information system.

From the records, we collected the patients’ demographical data, comorbid diseases, primary trauma as an indication for ICU admission, other traumas accompanying thoracic trauma, type of thoracic injury and therapeutic interventions, Glasgow coma score (GCS), laboratory results (hemoglobin, creatinine, BUN, sodium, and platelet), inotropic-vasopressor use, injury severity score (ISS), revised trauma score (RTS), trauma and injury severity score (TRISS), mechanical ventilation (MV) state, ICU stay length, and patient outcomes. The diagnosis of thoracic trauma was based on thoracic CT and chest X-ray images. The RTS is a scoring system based on bed-side clinical and physiological data, including the GCS, systolic blood pressure (SBP), and respiratory rate (RR). It is calculated with the following formula: RTS = (0.9368 × GCS) + (0.7326 × SBP) + (0.2908 × RR). Results yield a value ranging from 0 to 7.8408, with higher scores indicating less severe injury. The ISS is an anatomical scoring system designed for patients with multiple traumas. The region with the highest score from the ISS (i.e., the region where the trauma is most severe or the region most likely to cause mortality) is called the primary trauma region. TRISS is calculated using RTS, ISS, and patient age.[11,12] The study sample was divided into two subsets: survival and non-survival groups. These two groups were compared with regards to first ICU day laboratory results and intensive care scores, MV times, and ICU stay lengths.

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

All data were analyzed using IBM SPSS V23 (Chicago, USA).

The Shapiro–Wilk test was used to determine whether the data were normally distributed. Comparisons of data that were not normally distributed were made with the Kruskal– Wallis test and the Mann–Whitney U test. Categorical data were analyzed with the Pearson chi-square test. The effects of the examined parameters on mortality were investigated with a logistic regression analysis. The ROC analysis was used to calculate the TRISS cut-off score. Non-normally distributed data were presented as median (min–max), while normally distributed data were presented as mean±standard deviation. Categorical data were expressed as frequency and percentage. Values of p<0.05 were considered significant.

RESULTS Of the 8063 patients who were admitted to our ICU during the 10-year study period (between 2007 and 2016), 616 (7.6%) had thoracic trauma. After excluding pediatric cases (aged <18 years), the remaining 564 cases were included in the study sample. Figure 1 is a schematic of patient selection.

The median age (min–max) of the 564 patients who were eligible for this study was 43 (18–87) years. There were 133 Patients admitted to ICU from 2007 to 2016 8063 Patients with trauma 1393

Presence of thoracic trauma 616

Patients without trauma 6670

Absent of thoracic trauma 777

Under 18 years of age 52 Study sample 564

Figure 1. Study sample.

2.48% 1.23%

Primary trauma Central nervous system

14.72%

25.71%

Spinal cord Thorax Abdominal

21.99% 13.48%

Orthopedic Cardiovascular

20.39%

Maxillofacial

Figure 2. Distribution of patients according to primary trauma sites.

47

Pehlivanlar Küçük et al. Prognostic evaluation of cases with thoracic trauma admitted to the intensive care unit

(23.5%) female and 431 (76.4%) male patients. The patient distribution according to primary trauma site is presented in Figure 2. Mortality occurred in 159 (28.1%) patients, while 405 (71.8%) were discharged. Among the fatal cases, 48 had sepsis, 28 were diagnosed with brain death, 25 developed hemorrhagic shock, 15 developed multiple organ dysfunction, 13 had ARDS, 10 developed malignant arrhythmia, seven developed disseminated intravascular coagulation, and 13 died due to sudden cardiac arrest as a result of clinical deterioration (due to various reasons).

Data from Survival and Non-Survival Patient Subsets There were significant differences between the two groups with regards to median age, BUN, creatinine, GCS, RTS, ISS, and TRISS. Evaluation of patient outcomes revealed that the ICU stay length was significantly shorter among surviving patients (p=0.007). Table 1 shows a summary of patient data on hospital admission.

There was no significant difference between the groups (survival, non-survival) regarding distribution of sex (p=0.441).

Of the 405 surviving patients, 306 (71%) were male, while 125 of the 159 deceased patients (29%) were male. Evaluation of trauma type as primary indication for the ICU admission revealed that patients with central nervous system (CNS) trauma had the highest mortality rate (43.4%), while patients with maxillofacial trauma had the lowest mortality rate (7.1%). Mortality differed significantly with respect to the primary trauma sites (p<0.001). However, no significant difference was observed according to cause of trauma (p=0.342). The data are summarized in Table 2.

Isolated thoracic trauma was present in only 30 (5.6%) trauma cases. When compared groups as patients with isolated thoracic trauma and multitrauma, there was no statistically sig-

nificant difference in demographic data (e.g., age, gender, comorbidities), hospital arrival laboratory parameters, trauma scores (ISS, RTS, and TRISS). There was no statistically significant difference between MV treatment and ICU mortality between two groups (respectively, p=0.896, p=0.891). A total of 7 (23.3%) of the 30 patients with isolated thoracic trauma were operated, and 384 (71.9%) of the 534 patients in the multitrauma group were operated. It was statistically significant (p<0.001). Evaluation according to thoracic trauma types revealed that mortality occurred in 77 of 233 (33%) patients with pulmonary contusion, 108 of 389 (27.8%) patients with rib fracture, 10 of 47 (21.3%) patients with sternum fracture, 11 of 35 (31.4%) patients with diaphragmatic rupture, 49 of 170 (28.8%) patients with hemothorax, 65 of 261 (24.9%) patients with pneumothorax, 20 of 67 (29.9%) patients with subcutaneous emphysema, 6 of 26 (23.1%) patients with mediastinal trauma, 1 of 4 (25%) patients with cardiac trauma, and 13 of 39 (33.3%) patients with flail chest.

Pulmonary contusion was seen significantly more frequently in the non-survival group (p=0.032) (Table 3). In addition, the mortality rate was significantly higher among cases with the CNS trauma (p<0.001). Other trauma types did not differ significantly in terms of mortality.

Forty-five (7.9%) patients underwent thoracic surgery due to thoracic trauma. Of these patients, 11 (24.4%) died, and 34 (75.6%) were discharged from the ICU in a healthy state (p=0.682). In addition, mortality occurred in 68 (26.6%) of the 256 (45.3%) patients who underwent tube thoracostomy (p=0.433). All patients received passive oxygen support and underwent respiratory exercises.

Mortality occurred in 61 of 88 (69.3%) patients who received inotrope/vasopressor, and mortality also occurred in 154 of 360 (42.8%) patients who were mechanically ventilated.

Among the deceased patients, the median MV length was 6.5

Table 1. Data from surviving and deceased patients at the admission of hospital Parameter

Total (n=564)

Age*

Survival (n=405)

Non-survival (n=159)

p

43 (18–87)

41 (18–87)

47 (18–86)

0.002

Sodium*

138 (125–155)

138 (126–155)

138 (125–153)

0.391

Blood urea nitrogen*

16.2 (5.3–89.4)

15.8 (5.3–45)

17.6 (6.7–89.4)

0.01

Creatinine*

0.95 (0.2–8.9)

0.93 (0.2–8.9)

1.01 (0.51–8)

<0.001

Hemoglobin** Platelet*

11.02±2.64 11.21±2.63 203.5 (16–615)

207 (19–486)

11.02±2.64 0.007 194 (16–615)

0.146

Glasgow Coma Scale

15 (3–15)

15 (3–15)

3 (3–15)

<0.001

Revised Trauma Score*

7.84 (0.73–7.84)

7.84 (0.73–7.84)

2.93 (0.73–7.84)

<0.001

*

Injury Severity Score *

Trauma and Injury Severity Score* Intensive care unit stay length*

17 (2–75)

14 (2–36)

29 (14–75)

<0.001

82.69 (0.04–99.61)

96.19 (3.77–99.61)

20.35 (0.04–98.43)

<0.001

4.5 (1–369)

4 (1–367)

6 (1–369)

0.007

*Shown as median (min-max). **Shown as mean±standard deviation. Statistically significant difference between survival and non-survival groups are shown with bold characters.

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Pehlivanlar Küçük et al. Prognostic evaluation of cases with thoracic trauma admitted to the intensive care unit

Table 2. Primary trauma site and cause of trauma among patients Parameter

Survival

Non-Survival

Total

p

n % n % n %

Primary trauma

Central nervous system

82

56.6a 63 43.4 145 100

Spinal cord

57

75a,b,c 19 25 76 100

Thorax

80

69.6a,c 35 30.4 115 100

Abdominal

94

75.8b,c 30 24.2 124 100

Orthopedic

73

88b 10 12 83 100

Cardiovascular

6

85.7a,b,c 1 14.3 7 100

Maxillofacial

13

92.9a,b,c 1 7.1 14 100 <0.001

Trauma cause

Motor vehicle accident

Fall

281 80

71 71.4

115

29

32

28.6

396

100

112

100

Penetrating trauma

28

84.8

5

15.2

33

100

Other blunt trauma

16

69.6

7

30.4

23

100

0.342

Each superscript letter denotes a subset of primary trauma categories where row proportions do not differ significantly from each other at the 0.05 level. Statistically significant difference between Survival and Non-Survival groups are shown in bold.

(1–177) days, while the median MV length among the surviving patients was 5.5 (1–161) days (p=0.200). Mortality was higher in those who received inotrope/vasopressor or MV support at any time during their ICU stay (p<0.001 for both).

Evaluation of treatments and mortality rates among the 564 patients included in this study revealed that mortality occurred in 91 of the 391 (23.3%) patients who underwent any kind of surgery, and mortality was significantly lower in the group of patients who underwent surgery when compared to patients who did not undergo surgery (p<0.001).

Although the presence of hypertension and coronary artery disease were found to be significant factors in univariate analysis, they were not significant predictors of mortality in multivariate regression analysis. In multivariate regression analysis, each age increment was associated with a 1.025-fold increase in odds of mortality, while the presence of CNS trauma was associated with a 2.147-fold increase, and the presence of pulmonary contusion was associated with a 1.752-fold increase in odds of mortality. Results are shown in Table 5.

1.0

TRISS Score ROC Analysis 0.8

Sensitivity

The AUC-ROC for mortality for TRISS was 0.922 (95% CI: 0.899–0.946). The ROC analysis using a TRISS cut-off score of 59.93 yielded a sensitivity and specificity of 0.88 and 0.87, respectively, for mortality development. With this cut-off level (59.93), the degree of agreement between TRISS and mortality was 87.4%, the positive predictive value was 72.92%, and the negative predictive value was 94.89% (Fig. 3).

ROC Curve

0.6

0.4

Mortality Predictors (Univariate and Multivariate Logistic Regression Analysis) To determine predictors of mortality, a univariate analysis including demographic data, other accompanying traumas, type of thoracic trauma, and comorbidities was performed.

Results of the univariate analysis revealed that age, presence of accompanying CNS trauma, pulmonary contusion, hypertension, and coronary artery disease were identified as significant predictors of mortality. Results are shown in Table 4.

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

0.2

0.0

Source of the curve TRISS Reference line 0.0

0.2

0.4

0.6

0.8

1.0

Specificity

Figure 3. TRISS score ROC analysis (TRISS: Trauma and injury severity score; ROC: reciever operator characteristics).

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Pehlivanlar Küçük et al. Prognostic evaluation of cases with thoracic trauma admitted to the intensive care unit

Table 3. Association between thoracic trauma type and mortality Thoracic trauma sites

Survival

Non-Survival

Total

p

n % n % n %

Pulmonary contusion No

249

75.2

82

24.8

331

100

Yes

156

67

77

33

233

100

No

124

70.9

51

29.1

175

100

Yes

281 72.2 108 27.8 389 100 0.736

0.032

Rib fracture

Sternum facture

No

368 71.2 149 28.8 517 100

Yes

37 78.7 10 21.3 47 100 0.352

Diaphragmatic rupture

No

381 72 148 28 529 100

Yes

24 68.6 11 31.4 35 100 0.806

Hemothorax

No

284 72.1 110 27.9 394 100

Yes

121

71.2

49

28.8

170

100

No

209

69

94

31

303

100

Yes

196

75.1

65

24.9

261

100

0.827

Pneumothorax 0.107

Subcutaneous emphysema

No

358 72 139 28 497 100

Yes

47 70.1 20 29.9 67 100 0.86

Mediastinal trauma

No

385 71.6 153 28.4 538 100

Yes

20

76.9

6

23.1

26

100

0.710

Cardiac trauma

No

Yes

402 71.8 158 28.2 560 100 3 75 1 25 4 100 1.000

Flail chest

No

379 72.2 146 27.8 525 100

Yes

26 66.7 13 33.3 39 100 0.579

Statistically significant differences between Survival and Non-Survival groups are shown in bold.

DISCUSSION In this study, we sought to determine whether mortality could be predicted using information that does not require any calculation and is readily available at the time of ICU admission (e.g., type of thoracic trauma, accompanying traumas, comorbid states, age, and sex). The primary goal of this study was to identify clinical data that can be used to determine prognosis upon ICU admission. Univariate analyses revealed that age, presence of accompanying CNS trauma, pulmonary contusion, hypertension, and coronary artery disease were significant predictors of mortality in patients with trauma in the ICU. With multivariate regression analysis, each age in50

crement was associated with a 1.0-fold increase in mortality risk, the presence of CNS trauma was associated with a 2.1fold increase, and the presence of pulmonary contusion was associated with a 1.7-fold increase in mortality odds.

Nearly 25% of all trauma-associated deaths are due to thoracic injuries, and thoracic injuries have the highest complication rates among all trauma types.[13] In this study, during a 10-year period, 564 (40.4%) patients admitted to the ICU had thoracic trauma, and among these, 115 (20.39%) patients had thoracic trauma as their primary indication for the ICU admission. The median age of the patients included in this study Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

Pehlivanlar Küçük et al. Prognostic evaluation of cases with thoracic trauma admitted to the intensive care unit

Table 4. Univariate logistic regression analyses

Odds ratio

95% Confidence interval

p

Demographic properties <0.001

Age

1.019

1.008–1.030

1.189

0.765–1.850

0.441

Sex (male)

Accompanying trauma

Central nervous system trauma

2.020

1.390–2.935

<0.001

Abdominal trauma

0.972

0.647–1.459

0.890

Orthopedic trauma

0.743

0.512–1.080

0.119

Aortic trauma

1.735

0.696–4.328

0.237

Spinal cord trauma

1.116

0.772–1.613

0.561

Isolated thoracic trauma

1.097

0.491–2.450

0.821

1.499

1.035–2.170

0.032

Type of thorax trauma

Pulmonary contusion

Rib fracture

0.934

0.630–1.386

0.736

Sternal fracture

0.668

0.324–1.377

0.274

Diaphragmatic rupture

1.180

0.564–2.469

0.661

1.046

0.702–1.557

0.827

Hemothorax Pneumothorax

0.737

0.509–1.069

0.108

1.096

0.627–1.916

0.748

Subcutaneous emphysema

Mediastinal injury

0.755

0.297–1.916

0.554

Cardiac injury

0.848

0.088–8.214

0.887

Flail chest

1.298

0.649–2.594

0.461

Comorbidities Hypertension

2.063

1.102–3.862

0.024

Cardiac failure

7.769

0.802–7.254

0.077

Coronary artery disease

4.351

1.027–1.425

0.046

2.557

0.159–4.129

0.508

Arrhythmia

Chronic obstructive pulmonary disease

Asthma

1.707

0.283–1.313

0.560

2.577

0.515–12.904

0.249

Chronic renal failure

5.146

0.463–57.159

0.182

Diabetes mellitus

1.714

0.831–3.535

0.145

2.567

0.358–18.381

0.348

Malignancy Statistically significant differences are shown in bold.

was 43 (min–max 18–87) years, which was consistent with the literature, and the majority of the patients were male.

[14–20] Previous reports have shown that mortality rates in patients with thoracic trauma are markedly high (up to 30%).

[21] Emircan et al.[22] reported a 22% mortality rate among patients presenting to the emergency department with thoracic trauma. However, in other studies, the mortality rate varies between 9.4% and 20%.[23] Although there are limited publications regarding ICU mortality, this study found a similar mortality rate among thoracic trauma cases (28.1%).

The severity of thoracic traumas depends on the type of trauma and on the severity of any accompanying traumas.

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

Previous studies have shown that thoracic trauma cases with accompanying head trauma had greater mortality rates than those without it.[24,25] In this study, only 30 (5.6%) cases had isolated thoracic trauma. Of the patients in this study with accompanying traumas, only those with accompanying CNS trauma had significantly higher mortality rates. Lin et al. reported that 36.3% of cases presenting to the emergency department with thoracic trauma required intensive care. As in our study, the study by Lin et al.[26] found that those thoracic trauma cases with accompanying head trauma required intensive care and had prolonged ICU stays, more so than most of the other thoracic trauma cases. However, in that same study, it was reported that the presence of hemothorax in thoracic 51

Pehlivanlar Küçük et al. Prognostic evaluation of cases with thoracic trauma admitted to the intensive care unit

Table 5. Multivariate logistic regression analyses

OR

95% CI

p

Age

1.025 1.012–1.038 <0.001

CNS trauma

2.147

1.441–3.198

<0.001

Pulmonary contusion

1.752

1.162–2.642

0.007

Hypertension

1.414 0.695–2.879 0.339

Coronary artery disease

3.274

0.720–14.879

0.125

Statistically significant differences are shown in bold.

OR: Odds ratio; CI: Confidence interval; CNS: Central nervous system.

traumas was associated with the greatest requirement for intensive care. Interestingly, in this study, which included a large patient population, only the presence of pulmonary contusion was found to be associated with mortality. Other conditions that can cause serious respiratory distress (e.g., diffuse hemothorax or flail chest) were not found to be associated with mortality. This may be due to the emergent treatment of hemothorax with surgery or chest tube drainage, and because patients with flail chest often undergo surgical stabilization in the early period. A large study by Horst et al.[19] included over 10 years of experience regarding patients with serious thoracic trauma. In that study, over those 10 years, there was a decrease in the requirement of those patients for urgent surgery, as well as in ventilation time, ICU stay length, and rate of respiratory failure development. The authors explained that these decreases were most likely due to recent advances in diagnostic methods and treatment strategies. Pulmonary contusion occurs in approximately 30%–75% of blunt thoracic traumas caused by motor vehicle accidents.[27] Pulmonary contusion requires close monitoring, as pulmonary contusion-associated mortality rates vary between 6% and 25%, and the clinical situation is often accompanied by pneumonia or acute respiratory distress syndrome.[15,17] One study reported that 5 of 16 ICU patients (31.2%) with pulmonary contusion died. Importantly, the authors of that study found that the APACHE II score, the SAPS II score, the SOFA score, the paO2/FiO2 ratio, and ventilator days were correlated with mortality.[14] It is important to note that pulmonary contusion may not manifest itself clinically or radiologically within the first few days following trauma. However, as is the case with any soft tissue contusion, the extent of injury may progress over time, and therefore, the patient should be inspected throughout his or her hospital stay for the development of respiratory failure.

In this study, thoracic injuries were most frequently caused by motor vehicle accidents (70.2%), followed by fall from height (19.8%). In developing countries, particularly rapidly developing Middle Eastern countries, mortality due to motor vehicle accidents has become a more important problem due to an increase in the number of speeding vehicles.

[28] In this study, the most frequent type of trauma associated 52

with motor vehicle accidents was rib fracture, followed by pulmonary contusion, pneumothorax, hemothorax, subcutaneous emphysema, sternum fracture, flail chest, mediastinal injuries, and cardiac injury, respectively. In the emergency department, patients must be evaluated according to the severity of their injuries. Further, admission and treatment should start as soon as possible to reduce mortality rates. In addition, the presence of comorbidities may contribute to clinical deterioration. In this study, while comorbid hypertension and coronary artery disease were found to be associated with mortality in univariate analysis, they were not found to be significant risk factors in multivariate analysis. However, our study sample mainly included young adults with a low number of comorbidities, and therefore, we believe a larger study sample is required to validate these results.

Following trauma, the ability to predict patient outcomes is important not only for clinicians, but for the patients and their families as well. Therefore, several trauma-scoring systems have been developed for this purpose. RTS is a physiological scoring system that has been proven for its accuracy in predicting mortality. It is based on GCS, SBP, and RR parameters. Next, ISS was developed for patients with multiple traumas, and is an anatomical scoring system. TRISS is based on ISS, RTS, and patient age, and is used to predict survival after trauma.[29] TRISS combines both anatomical and physiological aspects, and has been proven to be a good predictor of survival in patients with trauma. In a study that retrospectively evaluated 140 patients with thoracic trauma, Bellone et al.[16] reported that only 10 of those 140 patients (7.1%) were admitted to the ICU due to clinical and radiological deterioration. In univariate and multivariate analyses, the authors of that study found that increasing orthopnea and trauma scores could be used to predict intensive care requirement. In this study, we found a significant difference between the surviving and deceased groups of patients in terms of ISS, RTS, and TRISS scores. In this study, a TRISS cut-off score of 59.93 yielded 88% sensitivity and 87% specificity for predicting mortality, and was found to be strongly associated with mortality. Similarly, Esme et al.[18] performed a risk assessment with TRISS in 152 patients with blunt thoracic trauma, and identified that the TRISS scoring system was an independent risk factor for predicting mortality. Darbandsar Mazandarani et al.[30] evaluated patients with trauma in the emergency department with the TRISS score, and reported that the best cut-off point for TRISS mortality prediction was 13.2% (sens.=76.52%; spec.=95.65%). Another study reported that the cut-off point for TRISS was 85.[22] Although there are variations in the reported TRISS cut-off values, in general, we believe that the TRISS scoring system can be used to predict mortality in thoracic trauma.

GCS is another scoring system that has long been used to predict mortality in patients with trauma. As expected, these data revealed a significant difference in GCS between the surviving and deceased groups of patients, with surviving Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

Pehlivanlar Küçük et al. Prognostic evaluation of cases with thoracic trauma admitted to the intensive care unit

patients having significantly higher median scores (p<0.001).

Wang et al.[20] evaluated 127 patients with chest trauma, and results indicated that a lower GCS, lower oxygenation ratio, and the presence of shock were independent predictors of mortality in patients with blunt thoracic injuries.

7. Stewart RM, Corneille MG. Common complications following thoracic trauma: their prevention and treatment. Semin Thorac Cardiovasc Surg 2008;20:69–71.

As expected, in this study, we found markedly increased mortality rates among patients requiring MV or inotrope/vasopressor support (p<0.001 for both). Indeed, previous studies have shown that MV time is associated with trauma severity and the development of complications.[31,32]

9. Günay K. Thorax Traumas. In: Ertekin C, Kurdoğlu M, Taviloğlu K, editors. Book Of Trauma and Resuscitation Course. Istanbul: Logos Yayıncılık; 2006. p. 87–102.

There are several limitations associated with this study. First, this study has a retrospective and single-centered design. Second, the study sample comprised only of patients who were admitted to the Anesthesiology and Reanimation ICU. Since cardiac or major cardiovascular injuries are typically followed by cardiovascular surgery, there were no such patients in this study sample. Third, because of this study’s retrospective design, MV parameters could not be closely monitored in patients requiring MV and also APACHE II and SOFA scores were not given due to scores could not be obtained from all patients over a 10-year follow-up period.

Conclusion Mortality can be predicted in patients with thoracic trauma who are admitted to the ICU without the use of any invasive interventions or calculations; these predictions can be made by accounting only for clinical and demographic properties, trauma types, and comorbid states. The results of this study indicate that advanced age, pulmonary contusion, and accompanying CNS trauma are independent risk factors for predicting ICU mortality in patients with thoracic trauma. Our noninvasive approach is further supported with the TRISS scores, which is one of the latest scoring systems used to predict mortality in patients with trauma. Prompt diagnosis, close monitoring, and early therapeutic interventions can help to reduce mortality rates in such patients.

Conflict of interest: None declared.

REFERENCES 1. Hodgson NF, Stewart TC, Girotti MJ. Autopsies and death certification in deaths due to blunt trauma: what are we missing? Can J Surg 2000;43:130–6.

2. Arajarvi E, Santavirta S, Tolonen J. Aortic ruptures in seat belt wearers. J Thorac Cardiovasc Surg 1989;98:355–61.

3. O’Connor JV, Adamski J. The diagnosis and treatment of non-cardiac thoracic trauma. J R Army Med Corps 2010;156:5–14.

4. Santavirta S, Arajärvi E. Ruptures of the heart in seatbelt wearers. J Trauma 1992;32:275–9.

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

6. Simon BJ, Cushman J, Barraco R, Lane V, Luchette FA, Miglietta M, et al; EAST Practice Management Guidelines Work Group.. Pain manage-

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ment guidelines for blunt thoracic trauma. J Trauma 2005;59:1256–67.

8. Dimopoulou I, Anthi A, Lignos M, Boukouvalas E, Evangelou E, Routsi C, et al. Prediction of prolonged ventilatory support in blunt thoracic trauma patients. Intensive Care Med 2003;29:1101–5.

10. Greaves I, Porter K, Ryan J. Thoracic Trauma. In: Trauma Care Manuel.

New York: Oxford University Press Inc; 2001. p. 54–70.

11. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma 1987;27:370–8.

12. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma 1989;29:623–9.

13. Lancey RA, Monahan TS. Correlation of clinical characteristics and outcomes with injury scoring in blunt cardiac trauma. J Trauma 2003;54:509–15.

14. Alisha C, Gajanan G, Jyothi H. Risk Factors Affecting the Prognosis in Patients with Pulmonary Contusion Following Chest Trauma. J Clin Diagn Res 2015;9:OC17–9.

15. Allen GS, Coates NE. Pulmonary contusion: a collective review. Am Surg 1996;62:895–900.

16. Bellone A, Bossi I, Etteri M, Cantaluppi F, Pina P, Guanziroli M, et al.

Factors Associated with ICU Admission following Blunt Chest Trauma.

Can Respir J 2016;2016:3257846.

17. Cohn SM. Pulmonary contusion: review of the clinical entity. J Trauma 1997;42:973–9.

18. Esme H, Solak O, Yurumez Y, Yavuz Y, Terzi Y, Sezer M, et al. The prognostic importance of trauma scoring systems for blunt thoracic trauma.

Thorac Cardiovasc Surg 2007;55:190–5.

19. Horst K, Andruszkow H, Weber CD, Pishnamaz M, Herren C, Zhi Q, et al. Thoracic trauma now and then: A 10 year experience from 16,773 severely injured patients. PLoS One 2017;12:e0186712.

20. Wang SH, Wei TS, Chen CP. Prognostic analysis of patients with blunt chest trauma admitted to an intensive care unit. J Formos Med Assoc 2007;106:444–51.

21. Waydhas C. Thoracic trauma [Article in German]. Unfallchirurg 2000;103:871–89.

22. Emircan Ş, Özgüç H, Aydın ŞA, Özdemir F, Köksal Ö, Bulut M. Factors affecting mortality in patients with thorax trauma. Ulus Travma Acil Cerrahi Derg 2011;17:329–33.

23. Champion HR, Sarıbeyoglu K. Trauma score. In: Ertekin C, Taviloğlu K, Kurdoğlu M, Güloğlu R, editors. Trauma. 1st ed. Istanbul: Istanbul Medikal; 2005. p. 72–82.

24. Al-Koudmani I, Darwish B, Al-Kateb K, Taifour Y. Chest trauma experience over eleven-year period at al-mouassat university teaching hospital-Damascus: a retrospective review of 888 cases. J Cardiothorac Surg 2012;7:35.

25. El-Menyar A, Latifi R, AbdulRahman H, Zarour A, Tuma M, Parchani A, et al. Age and traumatic chest injury: a 3-year observational study. Eur J Trauma Emerg Surg 2013;39:397–403.

26. Lin FC, Tsai SC, Li RY, Chen HC, Tung YW, Chou MC. Factors associated with intensive care unit admission in patients with traumatic thoracic injury. J Int Med Res 2013;41:1310–7.

27. Tyburski JG, Collinge JD, Wilson RF, Eachempati SR. Pulmonary contu-

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28. Mamtani R, Al-Thani MH, Al-Thani AA, Sheikh JI, Lowenfels AB. Motor vehicle injuries in Qatar: time trends in a rapidly developing Middle Eastern nation. Inj Prev 2012;18:130–2.

29. Schluter PJ, Nathens A, Neal ML, Goble S, Cameron CM, Davey TM, et al. Trauma and Injury Severity Score (TRISS) coefficients 2009 revision.

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30. Darbandsar Mazandarani P, Heydari K, Hatamabadi H, Kashani P, Jamali Danesh Y. Acute Physiology and Chronic Health Evaluation

(APACHE) III Score compared to Trauma-Injury Severity Score (TRISS) in Predicting Mortality of Trauma Patients. Emerg (Tehran) 2016;4:88–91.

31. Huber S, Biberthaler P, Delhey P, Trentzsch H, Winter H, van Griensven M, et al; Trauma Register DGU. Predictors of poor outcomes after significant chest trauma in multiply injured patients: a retrospective analysis from the German Trauma Registry (Trauma Register DGU®). Scand J Trauma Resusc Emerg Med 2014;22:52.

32. Michelet P, Couret D, Bregeon F, Perrin G, D’Journo XB, Pequignot V, et al. Early onset pneumonia in severe chest trauma: a risk factor analysis. J Trauma 2010;68:395–400.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Yoğun bakım ünitesine başvuran toraks travmalı olguların prognostik değerlendirmesi: On yıllık sonuçlar Dr. Mehtap Pehlivanlar Küçük,1 Dr. Ahmet Oğuzhan Küçük,2 Dr. İskender Aksoy,3 Dr. Davut Aydın,1 Dr. Fatma Ülger1 1 2 3

Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, Yoğun Bakım Bilim Dalı, Samsun Karadeniz Teknik Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, Yoğun Bakım Bilim Dalı, Trabzon Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Samsun

AMAÇ: Çoklu travmalar ülkemizde ve dünyada özellikle genç erişkinlerin ölüm nedenlerinin başında gelmektedir. Bu çalışmanın amacı yoğun bakımlarda takip edilmekte olan izole ya da diğer organ yaralanmaları ile birlikte olan toraks travmalı olgularda mortalite için bağımsız prognostik faktörlerinin predikte edilmesidir.

GEREÇ VE YÖNTEM: Bu çalışmada, 2007–2016 yılları arasında yoğun bakım ünitemizde takip edilmiş olan toraks travmalı hastaların verileri geriye dönük olarak incelendi. Bu yıllar içerisinde yoğun bakım hasta kayıt sisteminde yer alan 8063 hasta arasından verilerine sağlıklı bir şekilde ulaşılan 616 toraks travma hastası saptandı. On sekiz yaş altı olgular dışlanarak kalan 564 hasta çalışma grubu hastası olarak belirlendi.

BULGULAR: Çalışmaya alınan 8063 hastanın 616’sında (%7.6) toraks travması saptandı. Çalışma kriterlerini sağlayan 564 çalışma grubu hastasının yaş ortalaması medyan (min-maks) 43 (18–87) idi. Hastaların 159’u (%28.1) mortalite ile sonlanırken 405’i (%71.8) yoğun bakım ünitesinden taburcu edildi. Travma ve Yaralanma Şiddeti Skoru’nun (TRISS) mortalite takibi için, AUC değeri: 0.922 (%95 CI: 0.899–0.946) idi. ROC analizine göre mortalite gelişme olasılığı için TRISS skoru 59.93 sınır kabul edildiğinde (Sensitivite; 0.88, Spesifisite: 0.87) olarak tespit edildi. Multivaryant lojistik regresyon analizinde mortaliteyi ön görmede her bir yaş artış mortalitede 1.025 kat, santral sinir sistemi travması varlığı mortalitede 2.147 kat, pulmoner kontüzyo varlığı mortalitede 1.752 kat artışla ilişkiliydi.

TARTIŞMA: Bu çalışmanın sonuçları ile toraks travma hastalarında ileri yaş, pulmoner kontüzyon ve eşlik eden santral sinir sistemi travması yoğun bakım mortalitesini göstermede bağımsız birer risk faktörü olarak tanımlanmıştır. Travma hastalarında en güncel skorlama sistemlerinden olan TRISS skoru da bu non-invaziv yaklaşımımızı desteklemektedir.

Anahtar sözcükler: Göğüs; hastane mortalite; toraks travma; torasik yaralanma; TRISS; yoğun bakım ünitesi.

Ulus Travma Acil Cerrahi Derg 2019;25(1):46-54

54

doi: 10.5505/tjtes.2018.97345

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No. 1

ORIG I N A L A R T IC L E

Relationship between the albumin level and the anesthesia method and the effect on clinical course in patients with major burns Müge Çakırca, M.D.,1 İsa Sözen, M.D.,2,3 Gülsüm Tozlu Bindal, M.D.,4,5 Mustafa Baydar, M.D.,1 Ahmet Çınar Yastı, M.D.2,3 Department of Anesthesiology and Reanimation, Health Sciences University Ankara Numune Training and Research Hospital, Ankara-Turkey

1 2

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

3

Department of Burn Clinic, Health Sciences University Ankara Numune Training and Research Hospital, Ankara-Turkey

4

Department of General Surgery, Ankara Akyurt State Hospital, Ankara-Turkey

5

Department of Burn Clinic, Ankara Akyurt State Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: Due to a massive increase in capillary permeability during the state of shock caused by burns, albumin and intravascular fluid rapidly move to the extravascular areas. Therefore, hypoalbuminemia is seen as an early and prolonged finding in major burns. Hypoalbuminemia leads to various problems. The aim of this study was to investigate the effect of the preoperative albumin level on perioperative morbidity and mortality in patients with major burns.

METHODS: Demographic data, preoperative albumin levels, surgical records, and clinical follow-up records of a total of 61 patients who underwent surgery for major burns in our hospital for the last 2 years were examined. Intraoperative complications were recorded, such as hypotension, bradycardia, low saturation, metabolic acidosis, reduced urine output, and hyperglycemia. Postoperative complications were recorded as intubation and the use of mechanical ventilator, sepsis, ARDS, acute renal failure, tracheotomy, hemorrhage, arrest, pneumonia, urinary tract infection, tissue infection, congestive heart failure, and pleural effusion.

RESULTS: In patients with albumin levels measured as <2 gr/dL and >2 gr/dL, intraoperative complications were determined at the rates of 31.4% and 20.8%, respectively, postoperative complications at 60.0% and 51.5%, respectively, and mortality rates at 40% and 25.8%, respectively (p=0.148, p=0.251, p=0.85, respectively). The cut-off point for the preoperative albumin level affecting postoperative morbidity was determined as ≥2.3 gr/dL (Area Under Curve=0.587; p<0.001; 95% Confidence Interval, 0.476–0.699; Cut-Off Albumin, ≥2.3).

CONCLUSION: There is as yet no consensus on the time and dosage of the delivery of albumin in patients with major burns.

Although there are studies in the literature that have shown increased morbidity and mortality rates in individuals given albumin in the intensive care, there are also reports supporting the finding that it makes a positive contribution. No useful guidelines have been obtained on the subject of hypoalbuminemia in patients with major burns. The results of this study showed that the albumin level above or below 2 gr/dL did not create any change in perioperative morbidity and mortality; however, the preoperative level above 2.3 gr/dL was the cut-off value for morbidity.

Keywords: Albumin; burn; mortality.

INTRODUCTION Albumin is an intravascular protein, 70,000 Dalton in weight,

formed from 585 amino acids, and it plays a significant role in the maintenance of capillary oncotic pressure.[1] Burns shock causes a massive increase in the capillary permeability. Thus,

Cite this article as: Çakırca M, Sözen İ, Tozlu Bindal G, Baydar M, Yastı AÇ. Relationship between the albumin level and the anesthesia method and the effect on clinical course in patients with major burns. Ulus Travma Acil Cerrahi Derg 2019;25:55-59.

Address for correspondence: Müge Çakırca, M.D. SBÜ Ankara Numune Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Ankara, Turkey.

Tel: +90 312 - 384 54 33 E-mail: mugeturkoglu81@hotmail.com Ulus Travma Acil Cerrahi Derg 2019;25(1):55-59 DOI: 10.5505/tjtes.2018.71278 Submitted: 03.05.2018 Accepted: 14.08.2018 Online: 27.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Çakırca et al. Relationship between the albumin level and the anesthesia method and the effect on clinical course in patients with major burns

albumin from plasma is rapidly released into the interstitial fluid and extracellular areas. Consequently, hypoalbuminemia emerges as an early finding and can continue in a long term.

[2,3] In addition, the albumin production is reduced, and edema forms in the interstitial tissue.[4] Thus, complications such as pulmonary edema develop, which can possibly lead to mortality, wound and soft tissue edema, and intra-abdominal edema.

In addition to the key role in the balance of the oncotic pressure, endogenous substances and drugs are transported via binding to albumin. It is also thought that it plays an antioxidant function. Due to this clinical potential, albumin replacement is applied as a volume expander in the burns shock resuscitation and to correct hypoalbuminemia in the chronic period.[3] Albumin replacement applied in the preoperative period is a controversial subject. Furthermore, a minimum albumin value desired has not been determined in patients with major burns who are to undergo surgery. As the replacement does not correct the underlying cause and does not provide permanence, there are opinions that the treatment is not effective.

[5] The aim of the current study was to determine the effect of preoperative albumin levels on perioperative morbidity and mortality in patients with major burns.

MATERIALS AND METHODS Approval for the study was granted by the Local Ethics Committee. A retrospective screening of 136 operations in 61 patients who underwent surgery for burns covering over 30% of the body surface area in our burns treatment unit for the last 2 years was conducted. Patients included in the study were those operated under general anesthesia.

A record was made of the patient demographic data, the percentage of the body surface area affected by burns, the American Society of Anesthesiology (ASA) scores, and the preoperative blood albumin and hemoglobin levels. Intraoperative pulmonary edema, hypo/hypertension, bradycardia, a decrease in peripheral oxygen saturation, the development of acidosis/alkalosis in the blood, and the development of hypo/ hyperglycemia or the development of renal failure were accepted as perioperative morbidity. In the postoperative pe-

riod, morbidity included sepsis, a need for mechanical ventilation, acute renal failure, a need for tracheostomy, pneumonia, urinary tract infection, congestive heart failure, and pleural effusion. Perioperative mortality of patients was recorded.

Statistical Analysis Descriptive statistics were calculated, and results were stated as mean±standard deviation (SD), number (n), and percentage (%) values. Non-parametric data were compared using the chi-square test. When determining the preoperative albumin level affecting postoperative morbidity, the ROC analysis was used. The Mann–Whitney U univariance analysis was applied in the determination of the effect on intraoperative morbidity of preoperative albumin, hemoglobin, ASA, and total body surface area percentage of burns. A value of p<0.05 was accepted as statistically significant.

RESULTS Throughout the study period, 136 operations were performed on 61 patients who were admitted for treatment in our clinic with burns covering over 30% of the total body surface area. There were 115 (84.6%) operations performed on male patients and 21 (15.4%) on female patients. The mean age of patients was 36.5±17.1 years, and the mean percentage of body surface area with burns was 51%±13.5% (30%–95%).

The height, weight, and preoperative albumin levels of the patients are shown in Table 1.

In the risk grouping of the patients according to the American Society of Anesthesiology (ASA) scores, a median value of 3 was determined. The ASA risk scores and the effect on intraoperative morbidity are shown in Table 2 (p=0.001).

The effects of preoperative albumin, ASA, total burned body surface area, and preoperative hemoglobin on intraoperative morbidity were determined with p-values of 0.135, 0.001, 0.714, and 0.002, respectively. According to these results, the ASA values and preoperative hemoglobin levels were found to be statistically significant, whereas the effect of the preoprative albumin level was not significant. The intraoperative and postoperative complication rates and the mortality rates of the patients are shown according to the albumin level <2 gr/dL and >2 gr/dL in Table 3.

Table 1. Height, weight, and preoperative mean albumin and hemoglobin values

Mean±SD Minimum-Maximum Median

Height (cm)

167.5±6.0

155–180

170

Weight (kg)

76.4±9.8

55–94

80

Preoperative albumin (g/dL)

2.42±0.58

1.18–4.22

2.4

Preoperative hemoglobin (g/dL)

10.9±3.3

6.5–23

10.1

SD: Standard deviation.

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Çakırca et al. Relationship between the albumin level and the anesthesia method and the effect on clinical course in patients with major burns

Table 2. American Society of Anesthesiology (ASA) scores and the effect on intraoperative morbidity of patients ASA

n

%

Intraoperative morbidity

Absent (%)

1

4

2.9

4 (100.0)

2

47

34.6

3

58

42.6

4

22

5

5

Total

p

Present (%) 0 (0)

4

45 (95.7)

2 (4.3)

47

39 (67.2)

19 (32.8)

58

16.2

13 (59.1)

9 (40.9)

22

3.7

3 (60.0)

2 (40.0)

5

0.001

Table 3. Intraoperative and postoperative complication rates and patient mortality rates according to the albumin level <2 gr/dL and >2 gr/dL

Albumin <2 g/dL

Albumin ≥2 g/dL

p

n % n %

Intraoperative complications

Absent

24 68.6 80 79.2 0.148

Present

11 31.4 21 20.8

Postoperative complications

Absent

14

Present

40

49

48.5

0.251

21 60 52 51.5

Mortality

Absent

21 60 75 74.2 0.85

Present

14 40 26 25.8

The morbidities in the intraoperative and postoperative periods of the 136 operations are shown in Table 4. Although more than one morbidity was observed in some patients, the most common intraoperative complication was hypotension (n=18, 56%) followed by low SPO2 (n=7, 22%).

As a result of the evaluation made with the ROC analysis, the albumin cut-off value was found to be ≥2.3 gr/dL for the preoperative albumin level affecting postoperative morbidity (Area Under Curve=0.587, p<0.001, 95% Confidence Interval: 0.476–0.699, Cut-Off Albumin ≥2.3).

Table 4. Intraoperative morbidities and postoperative morbidities in patients Intraoperative morbidity

n

%

Postoperative morbidity

n

%

None

104

76.5

None

63

46.3

Hypotension

10

31

Anemia and blood transfusion

23

32

Hypotension+bradycardia

5

16

Intubation and mechanical ventilator

20

27

Low SPO2

4

13

Sepsis

18

25

Hypertension

4

13

Urinary tract infection

14

19

Hypotension+low SPO2

2

6

Tissue infection

11

15

Metabolic acidosis

2

6

Impaired renal function

12

16

Low SPO2+oliguria

1 3 Arrest

7 10

Hypotension+Hyperglycaemia

1 3 ARDS

6 8

Hyperglycaemia (dextrose+insulin treatment)

1

3

2

Metabolic acidosis+hypotension+bradycardia

1

3

Tracheostomy

3

ARDS: Acute respiratory distress syndrome.

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Çakırca et al. Relationship between the albumin level and the anesthesia method and the effect on clinical course in patients with major burns

More than one postoperative morbidity was observed in some patients, and the most common morbidities were found to be anemia with blood transfusion (n=23, 32%) and intubation with the start of mechanical ventilator treatment (n=20, 27%).

In this group of patients who were admitted for treatment of extensive major burns and could be operated on, the mortality rate was 44.2% (27/61).

DISCUSSION Although serum albumin levels are affected by acute factors, such as surgical stress and trauma, they have been found to be predictive of unwanted postoperative outcomes, as a marker of malnutrition and disease, just as much as the potential protective effects through significant biological mechanisms.[6] While hypoalbuminemia in the preoperative period has been associated with an increase in postoperative morbidity and mortality following general and thoracic surgery, it has not been found as a useful preoperative risk marker in orthopedic operations.[7] However, in cases of hip fractures, an albumin level <35 g/L has been found to be related to an increase in postoperative complications and mortality, and routine measurement is therefore recommended because of this prognostic importance.[8] In radical cystectomy operations in urological surgery, a relationship has been reported between preoperative albumin <3.5 gr/dL and high ASA scores and postoperative morbidity and mortality.[9] Although there are various opinions about the preoperative evaluation of burns and the management of the perioperative process, albumin replacement in acute fluid resuscitation decreases the formation of edema and the fluid requirement, but no consensus has yet been reached about the time of albumin application, and variations are seen according to the approaches of different burns centers.[3] On the subject of albumin replacement, the use of saline and albumin for hypovolemia treatment within the first 28 days in the intensive care was not shown to make any difference to mortality in a study of 7000 patients.[10] In another report where replacement was evaluated, 15 mL/kg 5% albumin was used to help prevent hypotension by providing intravascular volume, but this was found to have no place in routine use because of the high costs.[11] In another study, it was reported that the colloid oncotic pressure was increased by 2 mmHg with the use of a mixture of 25% albumin and Ringer’s lactate.

[12] Maintaining high levels of colloid oncotic pressure reduces tissue edema by maintaining normal levels of capillary permeability. However, in the current study, these effects were not found to be related to postoperative complications.

In a study of patients with burns who were applied albumin treatment, the mortality risk was determined to be higher than that of a control group.[13] According to one group of authors, the administration of albumin to intensive care patients increases mortality; therefore, it should not be applied.[14] 58

In a previous study of children with burns covering a surface greater than 20%, for 6 weeks after the burn occurred, in one group, 25% albumin was used to keep the serum albumin level at 25–35 g/L, and in the other group, 25% albumin was administered directly to those patients with values <15 g/L. It was reported that there was no difference between these two groups of high (31–32 g/L) and low (21–24 g/L) albumin levels obtained with respect to fluid intake, urine output, subjective edema scores, requirement for mechanical ventilation, diarrhea, positivity in blood culture, the length of hospital stay, and mortality. According to these results, there was no benefit in holding the serum albumin within the recommended normal limits, and there were high costs. In our study, the ROC cutoff value was found to be 23 g/L. In our opinion, the results were not different in the studies due to the level of the albumin studied. Regarding our cut-off level, the threshold should be lower to see the difference.[15] However, in several studies, it has been reported to be an important marker of hypoalbuminemia in the evaluation of disease severity and nutritional status in intensive care patients. Thus, no useful guidelines have been obtained from literature on the subject of hypoalbuminemia in patients with burns, and chronic albumin replacement has not been shown to improve hypoalbuminemia.

[3,16] In another study, the albumin levels obtained at 72 hours after admittance were seen to affect the length of hospital stay in patients with burns.[17] In the clinical evaluations of another study, the measurement of serum albumin levels slightly increased the accuracy of mortality predictions.[18] In animal studies, while the use of albumin and other colloids in acute fluid resuscitation has been shown not to halt the edema of burns injuries, it reduces the need for resuscitation fluid by protecting the intravascular volume and does not cause an increase in extravasal fluid accumulation in the lungs as it lessens the increase in edema of soft tissues that are not burned.[3] It has been reported that if clinical studies support these findings, there could be a relationship between an increase in edema associated with extravasation in the lungs and albumin resuscitation in the first week after burns injury.[3] As a result of resuscitation with 5% albumin, cardiac output has been reported to reach pre-injury values in 6 hours.[19] Aktaş et al.[20] showed that the preoperative albumin levels were associated with wound infection in patients undergoing colorectal surgery.

In conclusion, the results of our study showed that ASA and hemoglobin levels were the markers of perioperative morbidity and mortality, and although albumin levels >2 g/dL or <2 g/dL were not observed to create any difference, the cut-off value was found to be 2.3 g/dL. Previous publications have shown variations in whether albumin replacement increases or decreases morbidity and mortality in patients with major burns. Therefore, there is a need for further studies to be able to establish a consensus on the subject of time and dose of the application of albumin in patients with major burns.

Conflict of interest: None declared.

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Çakırca et al. Relationship between the albumin level and the anesthesia method and the effect on clinical course in patients with major burns

REFERENCES 1. Chen LW, Wang JS, Hwang B, Chen JS, Hsu CM. Reversal of the effect of albumin on gut barrier function in burn by the inhibition of inducible isoform of nitric oxide synthase. Arch Surg 2003;138:1219–25.

2. O’Brien R, Murdoch J, Kuehn R, Marshall JC. The effect of albumin or crystalloid resuscitation on bacterial translocation and endotoxin absorption following experimental burn injury. J Surg Res 1992;52:161–6.

3. Cartotto R, Callum J. A review of the use of human albumin in burn patients. J Burn Care Re 2012;33:702–17.

4. Guyton AC, Granger HJ, Taylor AE. Interstitial fluid pressure. Physiol Rev 1971;51:527–63.

5. Rothschild MA, Oratz M, Schreiber SS. Serum albumin. Hepatology 1988;8:385–401.

6. Goldwasser P, Feldman J. Association of serum albumin and mortality risk. Review. J Clin Epidemiol 1997;50:693–703.

7. Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity: Results From the National VA Surgical Risk Study. Arch Surg 1999;134:36–42.

8. Pimlott BJ, Jones CA, Beaupre LA, Johnston DW, Majumdar SR.Prognostic impact of pre-operative albumin on short-term mortality and complications in patients with hip fracture. Arch Gerontol Geriatr 2011;53:90–4.

9. Djaladat H, Bruins HM, Miranda G, Cai J, Skinner EC, Daneshmand S. The association of preoperative serum albumin level and American Society of Anesthesiologists (ASA) score on early complications and survival of patients undergoing radical cystectomy for urothelial bladder cancer.

BJU Int 2014;113:887–93.

10. Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R; SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. New Engl J Med 2004;350:2247–56.

11. Mathru M, Rao TL, Kartha RK, Shanmugham M, Jacobs HK. Intravenous albumin administration for prevention of spinal hypotension during cesarean section. Anesth Analg 1980;59:655–8.

12. Ramanathan S, Masih A, Rock I, Chalon J, Turndorf H. Maternal and fetal effects of prophylactic hydration with crystalloids or colloids before epidural anesthesia. Anesth Analg 1983;62:673–8.

13. Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. BMJ 1998;317:235–40.

14. Offringa M. Excess mortality after human albumin administration in critically ill patients. Clinical and pathophysiological evidence suggests albumin is harmful. BMJ 1998;317:223–4.

15. Greenhalgh DG, Housinger TA, Kagan RJ, Rieman M, James L, Novak S, et al. Maintenance of serum albumin levels in pediatric burn patients: a prospective, randomized trial. J Trauma 1995;39:67–74.

16. Eljaiek R, Heylbroeck C, Dubois MJ. Albumin administration for fluid resuscitation in burn patients: A systematic review and meta-analysis.

Burns 2017;43:17–24.

17. Amavizca K, Yang S, Idicula A, Mata A, Dissanaike S. Lower Serum Albumin Shortly After Admission Predicts Prolonged Hospital Stay in Younger Burn Patients. J Burn Care Res 2016;37:e145–53.

18. Rafiezadeh SH, Vahedian M, Movahedi M, Bahaadinbeigy K, Hashemian M, Mirafzal A. Measuring serum albumin levels at 0 and 24h: Effect on the accuracy of clinical evaluations in the prediction of burn-related mortality. Burns 2018;44:709–17.

19. Mehrkens HH, Ahnefeld FW. Volume and fluid replacement in the early post burn period: an animal experimental study. Burns 1979;5:113–5 20. Aktaş A, Topaloğlu S, Çalık A, Arslan MK, Öncü M, Inci İ, at al. Wound surveillance with ASEPSIS in colorectal surgery [Article in Turkish].

Ulusal Cerrahi Dergisi 2012;28:175–81.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Majör yanıklı hastaların albümin düzeyinin anestezi yönetimi ile ilişkisi ve klinik gidişte etkinliği Dr. Müge Çakırca,1 Dr. İsa Sözen,2,3 Dr. Gülsüm Tozlu Bindal,4,5 Dr. Mustafa Baydar,1 Dr. Ahmet Çınar Yastı2,3 Sağlık Bilimleri Üniversitesi Ankara Numune Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Ankara Sağlık Bilimleri Üniversitesi Ankara Numune Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Yanık Kliniği, Ankara Sağlık Bilimleri Üniversitesi Ankara Numune Eğitim ve Araştırma Hastanesi, Yanık Kliniği, Ankara 4 Ankara Akyurt Devlet Hastanesi, Genel Cerrahi Kliniği, Ankara 5 Ankara Akyurt Devlet Hastanesi, Yanık Kliniği, Ankara 1 2 3

AMAÇ: Yanık şokunda, kapiller permabilitedeki masif artış sebebiyle albümin ve intravasküler sıvı hızlıca ekstravasküler alana yer değiştirir. Bu nedenle hipoalbüminemi majör yanıklarda erken ve uzamış bir bulgu olarak karşımıza çıkar. Hipoalbüminemi çeşitli sorunlara yol açmaktadır. Bu çalışmada, majör yanıklı hastaların ameliyat öncesi dönem albümin düzeylerinin ameliyattaki morbidite ve mortaliteye etkisi araştırıldı.

GEREÇ VE YÖNTEM: Hastanemizde 2011–2013 yılları arasında majör yanık nedeniyle ameliyat olmuş 61 hastanın demografik verileri, ameliyat öncesi albümin düzeyleri, ameliyat kayıtları ve servis takipleri incelendi. Ameliyat sırasında komplikasyonlar; hipotansiyon, bradikardi, satürasyon düşüklüğü, metabolik asidoz, idrar çıkımında azalma, hiperglisemi olarak kaydedildi. Ameliyat sonrası komplikasyonlar; entübasyon ve mekanik ventilatöre bağlanma, sepsis, ARDS, akut böbrek yetersizliği, trakeotomi, kanama, arrest, pnömoni, idrar yolu enfeksiyonu, doku enfeksiyon, konjektif kalp yetersizliği, plevral efüzyon olarak kaydedildi.

BULGULAR: Albümin düzeyi 2 gr/dL değerinin altında ve üstünde olan hastalar arasında ameliyat esnasında komplikasyonlar sırasıyla 31.4 ve 20.8; ameliyat sonrası komplikasyonlar %60.0 ve %51.5; mortalite oranları %40 ve %25.8 olarak bulunmuştur (p=0.148; p=0.251; p=0.85). Ameliyat sonrası morbiditeyi etkileyen ameliyat öncesi albümin düzeyi için, albümin (g/dL) değerinde ≥2.3’ün kesim noktası olduğu bulunmuştur (AUC=0.587, p<0.001, %95 GA: 0.476–0.699, cut-off albumin ≥2.3).

TARTIŞMA: Majör yanıklı hastalarda, albümin uygulaması, zamanı ve dozu konusunda görüş birliği oluşturulamamıştır. Yoğun bakım literatüründe albümin verilenlerde mortalite ve morbiditenin arttığını gösteren yayınlar olmakla beraber, olumlu katkısı olduğunu destekleyen yayınlar vardır. Majör yanıklı hastalarda hipoalbüminemi konusunda yardımcı bir rehber elde edilememiştir. Bu çalışmada, albümin düzeyinin 2 gr/dL seviyesinin altında veya üstünde olması perioperatif morbidite ve mortalitede bir değişikliğe sebep olmamıştır.

Anahtar sözcükler: Albümin; mortalite; yanık.

Ulus Travma Acil Cerrahi Derg 2019;25(1):55-59

doi: 10.5505/tjtes.2018.71278

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

59

ORIG I N A L A R T IC L E

Complicated or not complicated: Stoma site marking before emergency abdominal surgery Ali Fuat Kaan Gök, M.D.,1 İlker Özgür, M.D.,1 Meral Altunsoy, M.D.,1 Muhammed Zübeyr Üçüncü, M.D.,2 Adem Bayraktar, M.D.,1 Mehmet Türker Bulut, M.D.,1 Metin Keskin, M.D.1 1

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

2

Department of General Surgery, İstanbul Gelişim University Institute of Health Sciences, İstanbul-Turkey

ABSTRACT BACKGROUND: Marking a stoma site preoperatively decreases the possibility of experiencing later stoma-related problems and improves the quality of life of patients in the postoperative period. Those best equipped to perform this procedure are ostomy nurses and colorectal surgeons, as they receive the stoma therapy education during their training programs. The aim of this study was to compare the rate of stoma problems and quality of life of patients who underwent an operation that included stoma creation (elective or urgent) with and without preoperative stoma siting. The approach and behavior of surgical residents regarding stoma creation was also assessed.

METHODS: Patients who had undergone gastrointestinal surgery between January 2012 and December 2013 were assessed. A total of 116 of those patients who had a stoma created during the initial operation were followed by a stoma therapy nurse in the postoperative period and were enrolled in the current study. In addition, a survey of the residents was conducted to evaluate their knowledge about stoma creation and stoma care.

RESULTS: A total of 67 (58%) of the 116 patients included were male. The median age was 57±16 years (range: 17–87 years). A body mass index above 30 kg/m2 was detected in 16 patients (14%). The reason for surgery was malignant disease in 93 (80%) patients, and 97 cases (84%) were elective operations. Preoperative stoma marking was performed in 72 patients (62%). The stoma type was an ileostomy in 87 patients (75%). Stoma-related complications were observed in 40 patients (35%). Emergency surgery (p=0.020), preoperative stoma marking (p=0.000), adjuvant therapy (p=0.004), and the stoma caretaker (patient or relatives) (p=0.05) were associated with stoma-related complications. Logistic regression analysis revealed that only the type of surgery (emergency or elective), preoperative stoma marking, and the stoma caretaker increased the rate of stoma-related complications.

CONCLUSION: Marking the stoma location before surgery reduces the risk of stoma-related complications and has a positive effect on the patient’s quality of life. Multivariable analysis indicated that marking the stoma site before the operation was the only factor that affected the rate of stoma-related complications, regardless of emergency or elective surgical conditions. Since surgeons will encounter the need for a stoma procedure during their professional career and they will not always have the opportunity to work with stoma therapy nurse, stoma care education should be provided during their residency (internship) education, and ascertaining a stoma localization before surgery for all potential stoma cases should be encouraged in emergency shifts.

Keywords: Emergency surgery; stoma complications; stoma site marking.

INTRODUCTION Marking a stoma site preoperatively decreases the possibility of potential stoma problems, such as leakage, fitting chal-

lenges, skin irritation, and pain (Fig. 1a–c). It also improves the quality of life of patients in the postoperative period.

Therefore, it has been recommended that all patients be examined for stoma marking before surgical procedures.[1]

Cite this article as: Gök AFK, Özgür İ, Altunsoy M, Üçüncü MZ, Bayraktar A, Bulut MT, et al. Complicated or not complicated: Stoma site marking before emergency abdominal surgery. Ulus Travma Acil Cerrahi Derg 2019;25:60-65.

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 / 32319 E-mail: afkgok@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(1):60-65 DOI: 10.14744/tjtes.2019.48482 Submitted: 29.01.2019 Accepted: 31.01.2019 Online: 01.02.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

60

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Gök et al. Complicated or not complicated: Stoma site marking before emergency abdominal surgery

(a)

(b)

(c)

Figure 1. Examples of stoma problems such as skin irritation (a, b), leakage (b), and fitting challenges (c).

This evaluation and assessment can also provide patients and their family members with education about a stoma and stoma problems, which may help improve the patient’s quality of life in the postoperative period.[1,2] Ostomy nurses and colorectal surgeons are the best providers of this procedure since they receive stoma therapy education during their training programs.[1] However, in developing countries such as our country, there are not enough educated nurses who can provide the appropriate help in this process. Few centers have the opportunity to hire a stoma nurse. When the nurse is on vacation or when the hospital does not have a stoma nurse, only surgeons or residents who will perform the creation of the stoma are able to perform the stoma marking and provide education to the patient preoperatively.

In a study from Scotland, Macdonald et al.[3] evaluated the ability of surgeons to mark stoma locations. The authors stated that a surgeon’s skill in marking the stoma site was an important factor in the outcome. They also found that surgeons who had a subspecialty of colorectal surgery determined stoma sites better than others. The aim of this study was to compare the rate of stoma problems and quality of life of patients who underwent stoma creation procedures (elective or urgent) with and without preoperative stoma siting.

MATERIALS AND METHODS Patients who underwent gastrointestinal surgery between January 2012 and December 2013 were assessed. A total of 116 patients who had a stoma created during the initial operation and were followed up by a stoma therapy nurse in the postoperative period were enrolled in the current study.

The data were recorded using Microsoft Excel software (Microsoft Corp., Redmond, WA, USA) and were evaluated retrospectively using IBM SPSS Statistics for Windows, Version 19.0 (IBM Corp., Armonk, NY, USA).

The data collected were details of sex, age, body mass index (BMI), the reason for surgery (benign vs. malignant disease), the type of surgery (elective vs. emergency), stoma type (ileostomy vs. colostomy), the education level of patient (secondary education and above vs. below secondary education), adjuvant treatment, stoma marking data, stoma care provider Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

(patient vs. relatives), stoma-related complications, and the stoma quality of life score of the patients.

A stoma therapy nurse who has extensive experience with stoma care and coping with stoma- and wound-related complications followed up with all of the patients. The data of stoma-related complications were collected and recorded prospectively. Patient follow-up data were obtained upon readmission, by phone call, and clinical examination. The same stoma therapy nurse conducted 3 surveys (Quality Life Scale For Ostomy Patients, Ostomy Adjustment Inventory, Quality of Life-Ostomy Questionnaire) of the patients to evaluate their quality of life 3 months after they were discharged.

The residents who were working in the general surgery department during the time of the study were also evaluated regarding their practice and approach to patients who were candidates for stoma creation procedures, particularly in emergency operations.

Statistical Analysis Bivariate analysis was used to compare the data of patients who were negative and positive for stoma site marking for differences in demographics, age, sex, emergency or elective surgery, and comorbidities. A chi-square test or Fisher’s exact test was used to compare categorical variables. Student’s ttest was used to analyze normally distributed variables, and the non-parametric Mann-Whitney U test was used for the analysis of non-normally distributed values.

Variables in the bivariate analyses were entered into a forward logistic regression model to correct for selection bias and to identify independent predictors of CR. P<0.05 was considered statistically significant.

RESULTS Of 116 patients, 67 (58%) patients were male and 49 (42%) were female. The median age was 57±16 years (range: 17–87 years) and the median BMI was 26.6 kg/m2 (range: 18.1–35.2 kg/m2). A BMI greater than 30 kg/m2 was detected in 16 (14%) 61

Gök et al. Complicated or not complicated: Stoma site marking before emergency abdominal surgery

(84%) were operated on electively. The details of the surgical diagnoses are provided in Table 1.

Table 1. Surgical diagnoses Diagnoses

n

Malignant colorectal cancer

87

Inflammatory bowel disease - Benign colorectal disease

12

Benign anorectal diseases

3

Primary non-colon tumors

9

Other 5

patients. Forty-three (37%) patients had 1 or more chronic diseases, such as hypertension, ischemic heart disease, diabetes mellitus, and/or chronic obstructive pulmonary disease. Nineteen (17%) patients were smokers, and 97 (84%) patients were non-smokers. The reason for surgery was benign disease in 23 (20%) patients, whereas 93 (80%) patients underwent surgery due to malignant disease. The ratio of emergency operations was 16% (n=19), and 97 patients

Preoperative stoma marking was performed in 72 (62%) patients; however, 38% of patients (n=44) were not preoperatively evaluated for stoma marking. Analysis of the education level of the patients indicated that 29 (25%) had received elementary school education, and 87 (75%) patients had achieved a high school level education or higher. The stoma type was a colostomy in 29 (25%) patients and an ileostomy in 87 patients (75%). Stoma-related complications were observed in 40 (35%) patients, while 76 patients (65%) had no stoma-related complications (Fig. 1a).

Thirty-nine (34%) patients of the 116 managed their stoma care by themselves, whereas 77 patients (66%) had support from relatives. Fifty-six of the 93 (48%) patients who underwent surgery for malignant disease received adjuvant therapy after surgery.

Table 2. Univariate analysis of stoma-related complications

Complication (+)

n

Complication (–)

%

n

p

%

Sex

Female

15 37.5 34 44.7 0.291

Male

25 62.5 42 55.3

Concomitant chronic disease (+)

19

Body mass index <30 kg/m

36 90 64 84.2 0.288

Body mass index ≥30 kg/m2

4 10 12 15.8

Smoking (+)

7

2

47.5

24

17.5

12

31.6

15.8

0.69

0.503

Education

≥ Secondary education

31

77.5

56

73.7

< Secondary education

9

22.5

20

26.3

Tumor type

0.415

Benign

10 25 13 17.1 0.219

Malignant

30 75 63 82.9

Type of surgery Emergency

13

32.5

9

11.8

Elective

27 67.5 67 88.2

Preoperative stoma marking

12

30

60

78.9

No preoperative stoma marking

28

70

16

21.1

0.02* 0*

Stoma type

Ileostomy

28 70 59 79.7 0.247

Colostomy

12 30 15 20.3

Stoma caretaker Patient

9

Relative

31 77.5 46 60.5

Adjuvant therapy

13 32.5 43 56.6 0.004*

*

62

22.5

30

39.5

0.05*

p<0.05

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Gök et al. Complicated or not complicated: Stoma site marking before emergency abdominal surgery

Table 3a. Risk factors for patients undergoing colostomy

p

OR

Table 4. Logistic regression analysis Factor

Adjusted–OR (95% CI)

p

R2

Sex

0.16

0.286 (0.047–1.727)

Stoma marking

0.114 (0.048–0.274)

0

0.23

Chronic disease

0.637

1.020 (0.228–4.573)

Emergency surgery

3.224 (1.175–8.845)

0.02

0.048

Stoma caretaker

0.445 (0.186–1.066)

0.05

0.029

Smoking

0.329

2.500 (0.348–17.941)

Education level

0.182

0.218 (0.022–2.171)

Tumor type

0.178

5.333 (0.480–59.144)

Emergency-elective

0.295

2.33 (0.413–13.171)

*

0

0.027 (0.003–0.221)

Table 5. Patient quality of life

Patient as stoma caretaker

0.007

0.064 (0.007–0.612)

Body mass index

0.444

2.357 (0.214–25.905)

Stoma marking Non-marking

group group

Stoma marking

*p<0.05

Table 3b. Risk factors for patients undergoing ileostomy

p

OR

Sex

0.567

1.027 (0.417–2.532)

Chronic disease

*

0.047

2.471 (0.974–6.266)

Smoking

0.509

0.871 (0.232–2.874)

Education level

0.474

1.173 (0.428–3.214)

Tumor type

0.409

1.306(0.450–3.786)

Emergency-elective

0.043

3.600 (1.028–12.609)

0*

0.173 (0.065–0.460)

Stoma marking

*

Patient as stoma caretaker

0.405

0.780 (0.292–2.081)

Body mass index

0.416

1.500 (0.373–6.035)

*p<0.05

Univariate analysis that included all of the factors mentioned above revealed that emergency surgery (p=0.020), preoperative stoma marking (p<0.001), receiving adjuvant therapy (p=0.004), and the stoma caretaker (patient or relative) (p=0.05) were associated with stoma-related complications, whereas sex (p=0.291), BMI (p=0.288), smoking (p=0.503), patient level of education (p=0.415), concomitant chronic disease (p=0.690), reason for surgery (benign or malignant) (p=0.219), and stoma type (ileostomy or colostomy) (p=0.247) had no effect on stoma-related complications (Table 2). A separate evaluation of colostomy and ileostomy patients in terms of stoma-related complications indicated that the stoma caretaker and preoperative stoma marking were risk factors in patients undergoing a colostomy, and concomitant chronic disease, emergency surgery, and preoperative stoma marking were detected as risk factors for patients undergoing an ileostomy (Table 3a and b). However, logistic regression analysis revealed that only the type of surgery (emergency or elective), preoperative stoma marking, and the stoma caretaker increased stoma-related complications (Table 4).

Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

*

p<0.05

p

Survey 1

46.29±12.61

38±15.18

0.002*

Survey 2

54.53±5.75

57.34±6.33

0.016*

Survey 3

57.26±16.15

39.04±17.15

0*

*

p<0.05

To evaluate patient quality of life, 3 different surveys were administered to the patients. Each indicated that preoperative stoma marking decreased stoma-related complications and also improved the patients’ quality of life (Table 5).

In the present study, it was determined that preoperative stoma marking was performed statistically more frequently in patients undergoing elective surgery than in patients who underwent emergency surgery [11% (n=2/19) vs. 72% (n=70/97); p<0.001]. This result prompted a re-evaluation of the insufficient level of importance given to stoma marking before emergency surgeries.

DISCUSSION The results of our retrospective study indicated that no stoma siting before surgery, stoma creation during an emergency surgical intervention, and stoma care undertaken by patients themselves increased the frequency of stoma-related complications. Upon separately evaluating the patients who had a colostomy or an ileostomy, we found that more often patients with a colostomy had risk factors regarding stoma siting before surgery and a stoma caretaker, and patients with an ileostomy more frequently had risk factors for stoma-related complications associated with stoma citing before surgery, concomitant diseases, and emergency surgical interventions. Stoma siting before surgery was a risk factor for stoma-related complications regardless of the type of a stoma (ileostomy or colostomy). In addition, it was also found that the rate of stoma site marking before surgery was lower in cases of an emergency surgical intervention than an elective surgery in our clinic.

The American Colorectal Surgeons and Wound Ostomy Continence Nurses Association recommends that all patients who are candidates for ostomy surgery should be evaluated 63

Gök et al. Complicated or not complicated: Stoma site marking before emergency abdominal surgery

for stoma site marking before surgery by physicians who are educated and experienced in this field.[1] The gold standard is for care and education to be provided by stoma care nurse.

[4] Also, during this assessment, patients and their relatives should receive education about stomas and stoma care.[1] However, earlier studies have indicated that the majority of patients were provided with care and education services postoperatively (following stoma creation) during their stay in the hospital.[5] If the hospitalization period after the operation is short, this limits the education given by the stoma care nurses.[6] Therefore, in such cases stoma care education should be provided during out-patient follow-up visits and/ or at home.[4] However, determining the stoma site and providing education to the patient and relatives before surgery reduces postoperative visits to the hospital due to leakage, adaptor siting problems, stoma bag changing problems, using more adaptors and bags because of frequent changing, pain, dressing issues, and other stoma-related complications. Inappropriate location of a stoma increases the frequency of the complications listed above and the likelihood of patient dissatisfaction, as these problems negatively affect the quality of life of both patients and caretakers of the stoma.[2,4] Determining a stoma site before surgery during a clinical examination is possible in a sitting, standing, or supine position, and enables detection of the ideal location for the stoma. Person et al.[7] established that stoma site determination before surgery reduced complications after surgery and increased the patients’ quality of life. The authors used a quality of life scale that consists of 20 parameters; 18 of those parameters were statistically positively affected by determining the stoma site before the operation. In the same study, it was reported that the permanent or temporary nature of a stoma did not affect quality of life. Moreover, it was observed that patients could move more freely and that their quality of life was greater when their stoma site had been marked preoperatively.[7] In our study, consistent with the literature, statistical analysis indicated that marking the stoma site before surgery reduced stoma-related complications in cases of both ileostomy and colostomy. We also observed that marking before surgery statistically increased the quality of life scores based on 3 different quality of life scales.

Another result that was clear in our study was that the rate of stoma site determination performed before surgery was lower in emergency surgical interventions than in elective surgeries conducted in our clinic (16% vs. 84%; p=0.02). In addition, it was discovered in the multivariable analysis that emergency surgical intervention was a parameter that affected stoma-related complications. In a Spanish study of 270 patients, 75% of the patients underwent elective surgery and 25% underwent emergency procedures. The rate of stoma site marking in patients who underwent elective surgeries was 58.8%, whereas no patients who underwent emergency interventions were marked; the occurrence rate of early skin irritation and dermatitis was statistically higher in patients who underwent 64

emergency intervention than those who had elective surgery.

The authors stated that stoma site marking was neglected before surgery even in specific colorectal surgery centers, especially in emergency interventions. Furthermore, it was found that the effect of educating patients about stoma care before the operation was disregarded by the surgical team even though patients wanted to be a part of the effort to participate in their cure and care-taking process.[8] The stoma creation process is the last part of long and difficult operations and is followed by the completion of critical elements (resection +/- anastomosis). Stoma creation is most often performed by candidate surgeons, who are less experienced with stoma site determination and the stoma creation procedure. This suggests that surgeons give importance to saving patients’ lives, but they do not care much about their quality of life.[9] The stoma creation procedure is the most important factor that affects patients’ lives for 3 months after the surgery, though this is often not given much consideration during the operation.[9] Considering the data, we conducted a simple survey of our 23 residents who had completed one year of education at our clinic to evaluate their knowledge of and experience with stoma site marking. All of the residents stated that they had created a stoma in the previous 6 months and that they had participated in stoma creation interventions during their emergency surgery shifts. All of the residents who participated in the survey remarked that stoma site marking before surgery would reduce stoma-related complications and that this would positively affect the patient’s quality of life. However, only 4 (17%) stated that they marked the stoma site before the operation on emergency surgery shifts and only 8 (34%) residents reported that the on-call specialist physician or senior assistant surgeons wanted the stoma site to be determined before emergency gastrointestinal interventions. Although the vast majority of residents (91%, n=21/23) claimed that they knew the criteria for determining stoma sites, only 3 could correctly define how the stoma site was determined. In addition, only 8 (34%) residents followed up with patients for whom they had created a stoma during their shifts and stated that they relied on insights from the associated stoma therapy nurses. These data correspond with our findings that the high rate of complications encountered in stomas created during emergency surgeries is related to the low level of stoma site determination before these emergency interventions.

Conclusion The results of our retrospective study demonstrated that stoma site marking before surgery reduces the risk of stoma-related complications (ileostomy or colostomy) and has a positive effect on patients’ quality of life. Multivariable analysis indicated that preoperative stoma site marking was the only factor that affected stoma-related complications, whether it Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

Gök et al. Complicated or not complicated: Stoma site marking before emergency abdominal surgery

was performed in an emergency or elective surgery. Stoma sites are rarely determined before an emergency surgical intervention. Even though residents on emergency shifts were aware of the importance of marking the stoma site, they were not provided with enough education to properly determine the stoma location and they neglected the necessity of the procedure. Therefore, since residents will encounter the need to perform stoma procedures during their professional careers and they will not always have the opportunity to work with stoma therapy nurse, additional stoma care education should be provided during their internship education, and they must be encouraged to determine stoma sites before surgery for all potential stoma cases.

Conflict of interest: None declared.

REFERENCES 1. American Society of Colon and Rectal Surgeons Committee Members; Wound Ostomy Continence Nurses Society Committee Members.

ASCRS and WOCN joint position statement on the value of preoperative stoma marking for patients undergoing fecal ostomy surgery. J Wound Ostomy Continence Nurs 2007;34:627–8.

2. AUA and WOCN Society joint position statement on the value of preoperative stoma marking for patients undergoing creation of an incontinent urostomy. J Wound Ostomy Continence Nurs 2009;36:267–8.

3. Macdonald A, Chung D, Fell S, Pickford I. An assessment of surgeons’ abilites to site colostomies accurately. Surgeon 2003;1:347–9.

4. Colwell JC, Gray M. Does preoperative teaching and stoma site marking affect surgical outcomes in patients undergoing ostomy surgery? J Wound Ostomy Continence Nurs 2007;34:492–6.

5. Dudas S. Postoperative considerations. In: Broadwell DC, Jackson BS, editors. Principles of Ostomy Care. St Louis: Mosby; 1982. p. 340–68.

6. Carmel JE, Goldberg MT. Preoperative and Postoperative Management.

In: Colwell JC, Goldberg MT, Carmel JE, editors. Fecal &Urinary Diversions: Management Principles .St.Louis: Mosby; 2004. p. 207–39.

7. Person B, Ifargan R, Lachter J, Duek SD, Kluger Y, Assalia A. The impact of preoperative stoma site marking on the incidence of complications, quality of life, and patient’s independence. Dis Colon Rectum 2012;55:783–7.

8. Millan M, Tegido M, Biondo S, García-Granero E. Preoperative stoma siting and education by stomatherapists of colorectal cancer patients: a descriptive study in twelve Spanish colorectal surgical units. Colorectal Dis 2010;12:e88–92.

9. Cataldo PA. Technical tips for stoma creation in the challenging patient.

Clin Colon Rectal Surg 2008;21:17–22.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Komplike ya da değil: Acil abdominal cerrahi öncesinde stoma yeri işaretlenmesi Dr. Ali Fuat Kaan Gök,1 Dr. İlker Özgür,1 Dr. Meral Altunsoy,1 Dr. Muhammed Zübeyr Üçüncü,2 Dr. Adem Bayraktar,1 Dr. Mehmet Türker Bulut,1 Dr. Metin Keskin1 1 2

İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul İstanbul Gelişim Üniversitesi Sağlık Bilimleri Enstitüsü, Genel Cerrahi Anabilim Dalı, İstanbul

AMAÇ: Stoma bölgesinin ameliyat öncesi işaretlenmesi stomada problem olma olasılığını azaltır ve ameliyat sonrası dönemde hastaların yaşam kalitesini arttırır. Bu prosedür için en iyi uygulayıcılar ostomi hemşireleri ve kolorektal cerrahlardır, çünkü eğitim programları sırasında stoma tedavisi alırlar. Bu çalışmada, stoma oluşturulan hastalarda (elektif veya acil) ameliyat öncesi stoma yeri işaretlemesi yapılan ve yapılmayan hastalar arasındaki stoma problemi oranını ve ameliyat sonrası yaşam kalitesini karşılaştırmayı amaçladık. Ayrıca cerrahi asistanlarının nöbet şartlarında stoma oluşturma konusundaki yaklaşım ve davranışlarını değerlendirdik.

GEREÇ VE YÖNTEM: Ocak 2012–Aralık 2013 tarihleri arasında gastrointestinal cerrahi geçiren hastalar değerlendirildi. Ameliyat sonrası stoma oluşturulan toplam 116 hasta ameliyat sonrası dönemde stoma tedavisi hemşiresi tarafından takip edildi ve bu çalışmaya alındı. Ayrıca asistanlara stoma oluşturma ve stoma bakımı hakkındaki bilgilerini değerlendirmek üzere bir anket yapıldı.

BULGULAR: Yüz on altı hastanın 67’si (%58) erkekti. Ortanca yaş 57±16 yıldı (dağılım 17–87). On altı hastada (%14) beden kitle indeksi 30 kg/ m2’nin üzerinde tespit edildi. Ameliyat nedeni 93 hastada (%80) malign hastalık idi. Doksan yedi hasta (%84) elektif olarak ameliyat edildi. Ameliyat öncesi stoma işareti 72 hastaya (%62) yapıldı. Stoma 87 hastada (%75) ileostomi idi. Stoma ile ilgili komplikasyonlar 40 hastada (%35) gözlendi. Acil cerrahi (p=0.020), ameliyat öncesi stoma işaretlenmesi (p=0.000), adjuvan tedavi (p=0.004) ve stoma bakımını yapan kişi ya da kişiler (hastanın kendisi veya akrabaları) (p=0.05) stomaya bağlı komplikasyonlarla ilişkiliydi. Lojistik regresyon analizinde sadece cerrahi tip (acil veya elektif ), ameliyat öncesi stoma işaretlemesi ve stoma bakımını yapan kişinin stomaya bağlı komplikasyonları arttırdığını ortaya koydu.

TARTIŞMA: Stoma yerinin ameliyattan önce işaretlenmesi, stomaya bağlı komplikasyon riskini azaltır ve hastaların yaşam kalitesini olumlu yönde etkiler. Çok değişkenli analiz, stoma bölgesini ameliyattan önce işaretlemenin, acil bir durumda veya elektif bir ameliyatta yapılmasına rağmen stomaya bağlı komplikasyonları değiştirebilecek tek faktör olduğunu göstermektedir. Cerrahların profesyonel kariyerleri sırasında her zaman stoma prosedürü ile karşılaşacakları ve stoma terapi hemşiresi ile çalışma fırsatlarına her zaman sahip olamayacakları göz önüne alındığında, asistanlık eğitimi sırasında stoma bakım eğitimi verilmeli ve teşvik edilmelidir. Nöbetlerde tüm potansiyel stoma vakalarının ameliyat öncesi stoma lokalizasyonunun belirlenmesi için asistanlar teşvik edilmelidirler.

Anahtar sözcükler: Acil cerrahi; stoma komplikasyonları; stoma yeri işaretleme.

Ulus Travma Acil Cerrahi Derg 2019;25(1):60-65

doi: 10.14744/tjtes.2019.48482

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ORIG I N A L A R T IC L E

Efficacy and cost-effectiveness of the cell saver system in instrumented posterior fusion with thoracic and lumbar vertebral fractures Serdar Hakan Başaran, M.D.,1 Alkan Bayrak, M.D.,1 Emrah Sayit, M.D.,2 Halil Nadir Öneş, M.D.,1 Kadir Gözügöl, M.D.,3 Cemal Kural, M.D.1 1

Department of Orthopaedics and Traumatology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul-Turkey

2

Department of Orthopaedics and Traumatology, Samsun Training and Research Hospital, Samsun-Turkey

3

Department of Orthopaedics and Traumatology, Istanbul University Cerrahpaşa Faculty of Medicine, İstanbul-Turkey

ABSTRACT BACKGROUND: The aim of our study was to determine the efficacy and cost-effectiveness of intraoperative autotransfusion that uses the cell saver system (CSS) in patients undergoing posterior instrumentation and fusion of thoracic and lumbar vertebral fractures.

METHODS: We divided 121 patients who were to undergo posterior instrumentation and fusion due to thoracic and lumbar vertebral fractures into two groups: 59 patients (23 males and 36 females) were in the cell saver group, and 62 patients (22 males and 40 females) were in the control group. Hemoglobin, hematocrit, and red blood cell (RBC) values were recorded for all patients preoperatively, on the postoperative first, second, and third days, and on the hospital discharge day. Transfusion rates and numbers of allogeneic erythrocyte transfusions, as well as the costs of transfused total auto- and allogeneic transfusions were compared.

RESULTS: The numbers of erythrocyte suspensions transfused perioperatively were 0.2±0.6 units in the cell saver group and 0.7±1.4 units in the control group (p=0.01). Statistically significant differences were noted between the two groups on the postoperative first, second, and third days in terms of hemoglobin, hematocrit, and RBC values. These differences had disappeared by the hospital discharge day. The average cost of perioperative blood transfusions was $431±27.4 in the cell saver group and $34.5±66.25 in the control group (p<0.001).

CONCLUSION: The use of the CSS was not cost-effective, but it was particularly successful at reducing the rate and the number of units of postoperative allogenic blood transfusions.

Keywords: Blood transfusion; cell saver system; cost effectiveness; spinal surgery.

INTRODUCTION Intraoperative blood loss is a common problem, especially in the procedures of multi-level posterior instrumentation and spinal fusion.[1] Consequently, major spinal surgery procedures usually require allogeneic erythrocytes transfusions (AETs) during and after the operation.[2] Despite the availability of modern screening methods, AETs still carry a risk of infectious diseases such as HIV, CMV, and hepatitis.[3,4] More-

over, AETs may cause allergic reactions, graft versus host disease, isoimmunization, and hemolytic reactions.[5] Alternative methods have been developed to obtain safer blood loss management in major spinal surgery procedures because of these risks. These include controlled hypotensive anesthesia, the use of patient positioning devices to reduce abdominal compression, provision of acute normovolemic hemodilution, the use of topical hemostatic agents, pharma-

Cite this article as: Başaran SH, Bayrak A, Sayit E, Öneş HN, Gözügöl K, Kural C. Efficacy and cost-effectiveness of the cell saver system in instrumented posterior fusion with thoracic and lumbar vertebral fractures. Ulus Travma Acil Cerrahi Derg 2019;25:66-70.

Address for correspondence: Serdar Hakan Başaran, M.D. Adres bilgisi: Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul, Turkey.

Tel: +90 212 - 414 71 70 E-mail: drserdarhakan@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(1):66-70 DOI: 10.5505/tjtes.2018.77823 Submitted: 24.01.2018 Accepted: 14.08.2018 Online: 27.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Başaran et al. The cell saver system in instrumented posterior fusion with vertebral fractures

cologic stimulation of erythropoiesis, preoperative autologous blood donation, and intraoperative and/or postoperative CSS-mediated autotransfusion, which can all reduce the AET requirements during and after major spinal surgery.[1,3,6–9] Intraoperative use of the CSS reduces the need for AETs; thus, this system may prevent AET complications.[10–11] The purpose of present study was to determine the efficacy and cost-effectiveness of intraoperative autotransfusion using the CSS in patients undergoing posterior instrumentation and fusion for the treatment of thoracic and lumbar vertebral fractures.

MATERIALS AND METHODS Approval for the study was granted by the Local Ethics Committee. The patients who underwent posterior instrumentation and fusion due to thoracic and lumbar vertebral fractures were reviewed retrospectively. An intraoperative autotransfusion system was used in operations due to surgeons’ demand and randomly. Patients older than 18 years and who had no previous spinal surgery were included. Those without full medical records or who underwent procedures including anterior approach and laminectomy were excluded. Patients who had coagulopathy, postoperative myocardial infarction, pulmonary embolism, or gastrointestinal bleeding and who had different surgery due to any fracture were also excluded.

In total, 121 patients were divided into two groups: 59 patients (23 males and 36 females) were in the cell saver group, and 62 patients (22 males and 40 females) were in the control group. All surgeries were performed by the same surgeons.

Demographic features of the patients are given in Table 1.

The AutoLog Autotransfusion System (Medtronic, USA) was used intraoperatively in the cell saver group, but this system was not continued postoperatively. Perioperative blood loss management was performed for both groups.

All surgical procedures were performed under hypotensive anesthesia and intraoperative hemodilution. The iliac crest graft was not harvested in any patients. A hemovac drain with a positive pressure set to continuous suction was used in all patients, and the postoperative blood loss values were

recorded. Low-molecular-weight heparin and anti-thromboembolic stockings were used for the prophylaxis of deep vein thrombosis. Our indications for AET were hemoglobin <8 mg/dl with tachycardia and hypotension. The intraoperative and postoperative numbers of transfused allogeneic erythrocyte suspension units were recorded. The costs of the CSS and the AET were also recorded in both groups. No major complications were observed in any patient.

The hemoglobin, hematocrit, and red blood cell (RBC) values were recorded preoperatively, then again on the postoperative first, second, and third days, and on the day of hospital discharge.

The cell saver group was compared with the control group. We also analyzed the costs of both transfusion strategies.

The SPSS software (SPSS 20.0 for Macintosh, SPSS, Chicago, IL) was used for the statistical analysis. The data were evaluated with descriptive statistical methods (mean±standard deviation). An independent samples t-test was used for the analysis of independent groups of quantitative data showing normal distribution. A crude analysis of independent groups of qualitative data was obtained with the chi-square test. A 95% confidence interval and significance at p<0.05 were accepted.

RESULTS No statistically significant differences were noted with regard to age, gender, body mass index, fusion levels, surgical duration, or intraoperative and postoperative bleeding between the two groups (Table 1). The intraoperative bleeding amount was 553.7±393.7 ml in the cell saver group and 479.7±166.3 ml in the control group; postoperative bleeding was 292.8±135.1 ml in the cell saver group and 284.2±146.8 ml in the control group. No statistical difference was found between the two groups (p>0.05).

The two groups were also similar in terms of preoperative hemoglobin, hematocrit, and RBC values. However, statistically significant differences were noted between the two groups on the postoperative first, second, and third days in terms of the hemoglobin, hematocrit, and RBC values. These differences had disappeared by the hospital discharge day (Table 2).

Table 1. Clinical characteristics of the patient groups

Cell saver group (n=59)

Gender (male/female) Age (year) Body mass index Surgical duration (minute) Levels of fusion

Control group (n=62)

p

23/36

22/40

0.691

42.9±14.6

38.6±14.7

0.113

25.6±3.2

25.7±3.1

0.880

153.1±69.4

141.3±53.1

0.293

3.6±1.4

3.7±1.4

0.739

Intraoperative bleeding (mL)

553.7±393.7

479.7±166.3

0.177

Postoperative bleeding (mL)

292.8±135.1

284.2±146.8

0.738

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Başaran et al. The cell saver system in instrumented posterior fusion with vertebral fractures

We compared the averages of transfused allogeneic erythrocyte suspension units intraoperatively, postoperatively, and perioperatively in both groups (Table 3). We also compared the rates and numbers of patients transfused with allogeneic erythrocyte suspensions in both groups (Table 4).

The average cost of perioperative blood transfusions was $431±27.4 (distribution, $421–560.5) in the cell saver group and $34.5±66.25 (distribution, $0–279) in the control group.

The average cost of the perioperative blood transfusions was significantly higher for the cell saver group than for the con-

Table 2. Comparison of the hemoglobin, hematocrit, and red blood cell values for the cell saver and

control groups

Cell saver group (n=59)

Control group (n=62)

p

Preoperative Hemoglobin

12.6±1.8

12.6±2

0.904

Hematocrit Rbc

38.3±4.8

37±5.7

0.193

4.5±0.8

4.2±0.7

0.077

Hemoglobin

11.3±1.8

10.5±1.7

0.009

Hematocrit

34.3±5.2

31.4±5.4

0.002

3.9±0.7

3.6±0.7

0.006

Hemoglobin

10.7±1.6

10±1.7

0.025

Hematocrit

32.2±4.6

29.9±5.4

0.012

3.7±0.6

3.4±0.6

0.009

Hemoglobin

10.4±2.2

9.6±1.4

0.041

Hematocrit

31.5±6.2

28.5±4.3

0.007

3.6±0.8

3.3±0.6

0.014

Hemoglobin

10.6±1.9

10.3±1.2

0.234

Hematocrit

32.2±5.4

30.5±4.6

0.068

3.7±0.7

3.5±0.5

0.116

Postoperative day 1

Red blood cell

Postoperative day 2

Red blood cell

Postoperative day 3

Red blood cell

Discharge day

Red blood cell

Table 3. Average numbers of transfused allogeneic erythrocyte suspension units

Cell saver group (n=59)

Control group (n=62)

Mean±SD (range)

Mean±SD (range)

Intraoperative

0.02±0.13 (0–1)

0.05±0.28 (0–2)

0.437

Postoperative

0.2±0.5 (0–2)

0.7±1.3 (0–5)

0.007

Perioperative

0.2±0.6 (0–3)

0.7±1.4 (0–6)

0.010

p

Table 4. Rates and number of patients transfused with allogeneic erythrocyte suspensions

68

Cell saver group (n=59)

Control group (n=62)

p

Yes

No

Yes

No

Intraoperative

1 (1.7%)

58 (98.3%)

2 (3.2%)

60 (96.8%)

1.000

Postoperative

9 (15.3%)

50 (84.7%)

20 (32.3%)

42 (67.7%)

0.029

Perioperative

9 (15.3%)

50 (84.7%)

20 (32.3%)

42 (67.7%)

0.029

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Başaran et al. The cell saver system in instrumented posterior fusion with vertebral fractures

trol group (p<0.001). The average cost was calculated based on the blood transfusion and hospital stay, and other parameters were same for both groups.

DISCUSSION Perioperative blood loss still represents a common problem for spinal surgeons in posterior spinal fusion and instrumentation.[1] Multi-level posterior spinal fusion procedures usually involve major blood loss, and these procedures increase the requirement for AETs.[12] The present study showed that the use of the CSS successfully reduced the rates and numbers of patients transfused with allogeneic erythrocyte suspensions, both postoperatively and perioperatively, but not intraoperatively. The CSS method also successfully decreased the numbers of allogeneic erythrocyte suspension units used postoperatively and perioperatively. These findings are not compatible with some studies in literature,[3,10,13,14] but they agree with others.[15,16] The findings of the present study also showed that the protection of the hemoglobin, hematocrit, and RBC values until hospital discharge was more successful in the CSS group than in the control group. The blood recovery rate using the CSS was 45.3%, which compared favorably with the results of Reitman et al.[3] Some authors have indicated that the intraoperative use of the CSS did not diminish the rates of AET in spinal surgery, despite predonated autologous blood transfusions.[2,3,17,18] Our study, as well as that of Owens et al.[16] also found no decrease in the intraoperative numbers of allogeneic erythrocyte suspension units with the use of the CSS, but this number did decrease postoperatively.

Determining which patients would benefit from the CSS use remains a controversial issue. The use of the CSS is suggested especially in multi-level posterior spinal surgery with an estimated prolonged surgery time and excessive blood loss.[10,16,19] In addition, some authors have stated that even if this system reduces the AET requirements, it is not necessary, especially for single-level or double-level posterior lumbar fusion.[3,7,18] Other authors have also stated that the AES requirements of many spinal surgery patients can be provided by predonated blood transfusions.[3,17] Nevertheless, other researches have shown that the patients in which the CSS was not used generally had greater requirements for autologous and the allogeneic blood transfusions when compared to the patients in which the CSS was used.[3,13,17] The cost-effectiveness of the CSS is another important issue.

The CSS use is not cost-effective in many posterior spinal instrumentation and fusion procedures,[18,20] as we also determined here. One important reason for the cost increase of the CSS is its fixed cost regardless of the amount of salvaged or transfused blood. However, the efficacy of this system Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

can be increased by also using it in the postoperative period.

The advantage of the CSS is that it can be used safely along with other blood conservation techniques.[21] This system also can be chosen for patients with traumatic vertebral fractures, because autologous blood donation cannot be reserved in these patients.

[20]

Most of the previous studies indicated that the rates and numbers of allogeneic erythrocyte suspensions may be affected by the CSS use, because the blood transfusions were performed by autotransfusion with intraoperative collected and predonated blood.[2,3,17,18] In addition, preoperative autologous blood donation may cause a reduction in patient’s preoperative hemoglobin, hematocrit, and RBC values. None of our patients was able to undergo preoperative autologous blood donation.

One strength of the present study is that it included an investigation of the efficiency and cost-effectiveness of the CSS in traumatic vertebral fractures, a feature that is absent from the current literature. A weakness of our study was its retrospective nature.

Conclusion Intraoperative autotransfusion using the CSS is a safe and effective method for lumbar and thoracic vertebral fracture surgery by posterior instrumentation and fusion. In addition, this method successfully reduced the numbers of allogeneic erythrocytes a suspension unit required, especially postoperatively. This method was also successful in decreasing the postoperative rates and numbers of patients transfused with allogeneic erythrocyte suspensions. The major disadvantage of this system seems to be its cost. In light of our study, we suggest the use of the CSS for surgical treatment of acute vertebral fractures.

Informed consent: Informed consent was obtained from all individual participants included in the study.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Conflict of interest: None declared.

REFERENCES 1. Elgafy H, Bransford RJ, McGuire RA, Dettori JR, Fischer D. Blood loss in major spine surgery: are there effective measures to decrease massive hemorrhage in major spine fusion surgery? Spine (Phila Pa 1976) 2010;35:S47–56 2. Gause PR, Siska PA, Westrick ER, Zavatsky J, Irrgang JJ, Kang JD. Efficacy of intraoperative cell saver in decreasing postoperative blood transfusions in instrumented posterior lumbar fusion patients. Spine (Phila Pa 1976) 2008;33:571–5.

3. Reitman CA, Watters WC, Sassard WR. The Cell Saver in adult lumbar fusion surgery: a cost-benefit outcomes study. Spine (Phila Pa 1976)

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Başaran et al. The cell saver system in instrumented posterior fusion with vertebral fractures 2004;29:1580–3.

4. Sharma S, Sharma P, Tyler LN. Transfusion of blood and blood products: indications and complications. Am Fam Phys 2011;83:719–24.

5. Cha CW, Deible C, Muzzonigro T, Lopez-Plaza I, Vogt M, Kang JD. Allogeneic transfusion requirements after autologous donations in posterior lumbar surgeries. Spine (Phila Pa 1976) 2002;27:99–104.

6. Bess RS, Lenke LG, Bridwell KH, Steger-May K, Hensley M. Wasting of preoperatively donated autologous blood in the surgical treatment of adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2006;31:2375–80.

7. Florentino-Pineda I, Blakemore LC, Thompson GH, Poe-Kochert C, Adler P, Tripi P. The Effect of epsilon-aminocaproic acid on perioperative blood loss in patients with idiopathic scoliosis undergoing posterior spinal fusion: a preliminary prospective study. Spine (Phila Pa 1976) 2001;26:1147–51.

8. McNeill TW, DeWald RL, Kuo KN, Bennett EJ, Salem MR. Controlled hypotensive anesthesia in scoliosis surgery. J Bone Joint Surg Am 1974;56:1167–72.

9. Relton JE, Hall JE. An operation frame for spinal fusion. A new apparatus designed to reduce haemorrhage during operation. J Bone Joint Surg Br 1967;49:327–32.

10. Bowen RE, Gardner S, Scaduto AA, Eagan M, Beckstead J. Efficacy of intraoperative cell salvage systems in pediatric idiopathic scoliosis patients undergoing posterior spinal fusion with segmental spinal instrumentation. Spine (Phila Pa 1976). 2010;35:246–51.

11. Carless PA, Henry DA, Moxey AJ, O’Connell D, Brown T, Fergusson DA. Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2010;4:CD001888.

12. Guay J, Haig M, Lortie L, Guertin MC, Poitras B. Predicting blood loss in surgery for idiopathic scoliosis. Can J Anaesth 1994;41:775–81.

13. Lennon RL, Hosking MP, Gray JR, Klassen RA, Popovsky MA, Warner

MA. The effects of intraoperative blood salvage and induced hypotension on transfusion requirements during spinal surgical procedures. Mayo Clin Proc 1987;62:1090–4.

14. Savvidou C, Chatziioannou SN, Pilichou A, Pneumaticos SG. Efficacy and cost-effectiveness of cell saving blood autotransfusion in adult lumbar fusion. Transfus Med 2009;19:202–6.

15. Ersen O, Ekıncı S, Bılgıc S, Kose O, Oguz E, Sehırlıoglu A. Posterior spinal fusion in adolescent idiopathic scoliosis with or without intraoperative cell salvage system: a retrospective comparison. Musculoskelet Surg 2012;96:107–10.

16. Owens RK 2nd, Crawford CH 3rd, Djurasovic M, Canan CE, Burke LO, Bratcher KR, et al. Predictive factors for the use of autologous cell saver transfusion in lumbar spinal surgery. Spine (Phila Pa 1976) 2013;38:E217–22.

17. Siller TA, Dickson JH, Erwin WD. Efficacy and cost considerations of intraoperative autologous transfusion in spinal fusion for idiopathic scoliosis with predeposited blood. Spine (Phila Pa 1976) 1996;21:848–52.

18. Canan CE, Myers JA, Owens RK, Crawford CH 3rd, Djurasovic M, Burke LO, et al. Blood salvage produces higher total blood product costs in single-level lumbar spine surgery. Spine (Phila Pa 1976) 2013;38:703– 8.

19. Chanda A, Smith DR, Nanda A. Autotransfusion by cell saver technique in surgery of lumbar and thoracic spinal fusion with instrumentation. J Neurosurg 2002;96:298–303.

20. Behrman MJ, Keim HA. Perioperative red blood cell salvage in spine surgery. A prospective analysis. Clin Orthop Relat Res 1992;278:51–7.

21. Joseph SA Jr, Berekashvili K, Mariller MM, Rivlin M, Sharma K, Casden A, et al. Blood conservation techniques in spinal deformity surgery: a retrospective review of patients refusing blood transfusion. Spine (Phila Pa 1976) 2008;33:2310–5.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Torakal ve lomber vertebra kırıklarında enstrümentasyon ve posterior füzyon uygulanmış hastalarda maliyet ve hücre koruyucu sistemin etkinliği Dr. Serdar Hakan Başaran,1 Dr. Alkan Bayrak,1 Dr. Emrah Sayit,2 Dr. Halil Nadir Öneş,1 Dr. Kadir Gözügöl,3 Dr. Cemal Kural1 1 2 3

Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanei, Ortopedi ve Travmatoloji Kliniği, İstanbul Samsun Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Samsun İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul

AMAÇ: Çalışmamızın amacı torakal ve lomber vertebra kırıkları nedeniyle posterior enstrümantasyon ve füzyon yapılan ve ameliyatta ototransfüzyon yapılan hastalarda hücre koruyucu sistemin etkinliğini ve maliyet etkinliğini belirlemektir.

GEREÇ VE YÖNTEM: Torakal ve lomber vertebra kırıkları nedeniyle posteriyor enstrümentasyon ve füzyon uygulanmış 121 hasta iki guruba ayrıldı: 59 hasta (23 erkek ve 36 kadın) hücre koruyucu gurup, 62 hasta (22 erkek ve 40 kadın) kontrol gurubuna dahil edildi. Hastaların hemoglobin, hemotokrit ve kırmızı hücre sayısı (KHS) ameliyat öncesi ve sonrası birinci, ikinci, üçüncü gün ve taburculuk esnasındaki değerleri değerlendirildi.

Transfüzyon oranları ve allojenik eritrosit transfüzyonlarının (AET’ler) yanı sıra, transfüzyona tabi tutulan toplam oto ve allojenik transfüzyonların maliyetleri karşılaştırıldı.

BULGULAR: Perioperatif kan transfüzyonu hücre koruyucu grupta 0.2±0.6 ünite, kontrol grubunda 0.7±1.4 ünite olarak tespit edildi (p=0.01).

Ameliyat sonrası birinci, ikinci ve üçüncü günde hemoglobin, hemotokrit ve KHS arasında istatistiksel olarak anlamlı fark tespit edildi. Taburculuk hemoglobin, hemotokrit ve KHS arasında anlamlı farklılık saptanmadı. Perioperatif kan transfüzyonu ortalama maliyeti hücre koruyucu grupta $431±27.4, kontrol grubunda $34.5±66.25 olarak belirlendi (p<0.001).

TARTIŞMA: Hücre koruma sisteminin kullanımı maliyet açısından uygun değildi, ancak özellikle ameliyat sonrası allojenik kan transfüzyonlarının oranını ve sayısını azaltmada başarılıydı.

Anahtar sözcükler: Hücre koruyucu sistem; kan transfüzyonu; maliyet etkinliği; omurga cerrahisi.

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ORIG I N A L A R T IC L E

Admission neutrophil-to-lymphocyte ratio and postoperative mortality in elderly patients with hip fracture Aytun Temiz, M.D.,1

Salim Ersözlü, M.D.2

1

Department of Orthopedics and Traumatology, Balıkesir Edremit State Hospital, Balıkesir-Turkey

2

Department of Orthopedics and Traumatology, İstinye University Faculty of Medicine, İstanbul-Turkey

ABSTRACT BACKGROUND: Hip fractures in elderly patients are associated with a high mortality rate. Most deaths associated with hip fracture result from complications after surgery. Recent studies suggest that the neutrophil-to-lymphocyte ratio (NLR), which is a laboratory marker used to evaluate systemic inflammation, may be useful to estimate excess mortality. This study aimed to investigate the prognostic value of admission NLR in elderly patients with hip fracture.

METHODS: We evaluated patients admitted to the Orthopaedic Surgery Department of Balikesir-Edremit State Hospital. Inclusion criteria were female gender, age between 65 and 80 years, ASA score of 3, unstable intertrochanteric fracture treated with hemiarthroplasty, and time between fracture and surgery less than 72 h. Patients with multiple fracture, previous same side or other side hip surgery, pathological fracture, such as fracture caused by tumor or metabolic bone disease (e.g., Paget’s disease), and malignancies were excluded from this study (purposive sampling technique). Finally, “case” (group 1) was defined as patients who died within 1 year after surgery, whereas “control” (group 2) was defined as patients who survived. Patients in group 1 and 2 were statistically compared in terms of NLR value on hospital admission. A total of 22 patients (44%) were included in group 1, and 28 (56%) were included in group 2.

RESULTS: We found that the admission NLR values of patients in the mortality group were significantly higher than those of patients in the control group (p<0.001). The cutoff value of NLR was calculated as 4.7 on ROC analysis.

CONCLUSION: We believe that the NLR value at admission could be used for risk stratification of mortality in elderly patients with hip fracture.

Keywords: Elderly; hip fracture; neutrophil-to-lymphocyte ratio.

INTRODUCTION Hip fractures in the elderly are associated with high postoperative complications and mortality.[1] It was previously reported that 1-year mortality ranges from 8.4% to 36%.[2] Most deaths result from cardiovascular events and inflammatory complications, such as pneumonia, cardiac failure, myocardial infarction, and pulmonary embolism.[1,3] Studies indicated that some laboratory findings, such as high potassium, low hemoglobin, and low albumin could be associated with increased risk of mortality in patients with hip

fracture.[4] Serum inflammation markers such as C-reactive protein (CRP) could also be a predictor of excess mortality.

[5] Recent studies suggest that the neutrophil-to-lymphocyte ratio (NLR), which is a laboratory marker used to evaluate systemic inflammation, may be useful to estimate excess mortality and poor prognosis in clinical conditions such as breast cancer, colorectal-gastric cancer, and coronary heart disease.[6–8] The preoperative NLR also reflects patients’ survival in lung and liver cancer.[8] In orthopedic literature, the relationship between high NLR and excess mortality has been scarcely studied. Therefore, we aimed to investigate the prognostic value of preoperative NLR in elderly patients with hip

Cite this article as: Temiz A, Ersözlü S. Admission neutrophil-to-lymphocyte ratio and postoperative mortality in elderly patients with hip fracture.

Ulus Travma Acil Cerrahi Derg 2019;25:71-74.

Address for correspondence: Aytun Temiz, M.D. Balıkesir Edremit Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Balıkesir, Turkey.

Tel: +90 266 - 243 06 08 E-mail: aytuntemiz@hotmail.com Ulus Travma Acil Cerrahi Derg 2019;25(1):71-74 DOI: 10.5505/tjtes.2018.94572 Submitted: 18.02.2017 Accepted: 30.05.2018 Online: 26.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Temiz et al. Admission NLR and postoperative mortality in elderly patients with hip fracture

fracture. We hypothesized that if an elderly patient with hip fracture had a high NLR value on admission, the postoperative 1-year mortality risk increases.

Population (elderly patients with hip fracture) (n=296)

MATERIALS AND METHODS Study Design This retrospective case control study was approved by the ethics committee of Balikesir University Faculty of Medicine University, School of Medicine. We evaluated elderly patients with hip fracture admitted to the Orthopaedic Surgery Department of Edremit State Hospital between January 2008 and March 2014. Because age, gender, fracture type, ASA score, and time between fracture and surgery have been reported as risk factors for mortality in patients with hip fracture,[1] a purposive sampling design was used to better evaluate the prognostic value of high NLR. Inclusion criteria were female gender, age between 65 and 80 years, ASA score of 3, unstable intertrochanteric fracture treated with hemiarthroplasty, and time between fracture and surgery less than 72 h.

Patients with multiple fracture, previous same side or other side hip surgery, pathological fracture, such as fracture caused by tumor or metabolic bone disease (e.g., Paget’s disease), and malignancies were excluded. Patients with a history of another surgery or infectious disease in the last 30 days prior to admission and current use of immunosuppressants such as corticosteroids were also excluded. The postoperative mortality status of the study population was detected by phone call. Finally, “case” (group 1) was defined as patients who died within 1 year after surgery, whereas “control”(group 2) was defined as patients who survived (Fig. 1).

Patients and Care All patients were operated under local anesthesia. Calcar replacement, cemented stem was used via posterior exposure in all patients. A second-generation cementing technique was utilized. A similar postoperative protocol comprising early ambulation with weight bearing was performed. Enoxaparin sodium 0.4 ml once a day was initiated on admission and continued for 4 weeks postoperatively. Cefazolin sodium 1 g was intravenously administered three times a day only on postoperative day 1. Clinical follow-up was conducted by a multidisciplinary medical team that included orthopedic surgeons, anesthesiologists, a general internist, and physiotherapists.

Laboratory Measurements NLR on admission was established as the main variable in this study. In each patient, venous blood samples were obtained, and complete blood cell count (CBC) was assessed at our biochemical laboratory. An automated blood cell counter was used for CBC measurement (Beckman Coulter® LH 780, California, USA). NLR was calculated as the simple ratio between absolute neutrophil and absolute lymphocyte counts on admission.

72

Non-probability (purposive) sampling Inclusion Criteria: Unstable intertrochanteric fracture, Cemented hemiarthroplasty, Follow-up more than one year, Female gender, Age between 65 and 80 years, ASA score 3, Operated within 72 h Exclusion Criteria:Multiple fracture, Pathological fracture, Previous hip surgery, Methabolic bone disease, Malignancy, Immunosuppressant usage, Lost to follow-up

Study group (n=50)

Case (n=22)

Control (n=28)

Patients who died within

Patients who lived more than

1 year period

1 year

Mean age = 73.81

Mean age = 72.71

Mean NLR = 8.11

Mean NLR = 4.14

Analysis SPSS v 21, MEDCALC v 13, level of significance = 0.05, ShapiroWilk test, Mann-Whitney U test, ROC analysis, Youden index

Results Admission NLR value of case group patients were significantly higher than those of the control group (p<0.001).

Figure 1. Diagram showing the study design and results.

Statistical Analysis Group 1 and 2 patients were statistically compared in terms of NLR value on hospital admission. Statistical analysis was performed using SPSS v.21 and MEDCALC v.13 package. The level of significance was defined as ∝=0.05. The normal distribution of data was tested using Shapiro–Wilk test. The Mann–Whitney U-test was used to compare the groups. The ROC analysis and Youden index were used to determine the cutoff value.

RESULTS Of 296 patients with hip fracture who were treated during this time period, 50 patients who met the inclusion and exclusion criteria were defined as the study group. A total of 22 patients (44%) were included in group 1, and 28 (56%) patients were included in group 2. The mean age of patients was 73.81 (65–80) for group 1 and 72.71 (67–80) for group 2 (p>0.05). The mean NLR value was calculated as 8.11 for group 1 and 4.14 for group 2 (Table 1).

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Temiz et al. Admission NLR and postoperative mortality in elderly patients with hip fracture

Table 1. The neutrophil-to-lymphocyte ratio value of each group Group

n

Median

Minimum

Standard deviation 1.9744177

Mortality 22 7.51500 1.8500 22.0000 8.118182

4.9131501

Total

4.0584509

50 4.740000 1.0000 22.0000 5.890800

DISCUSSION The most important result of our study is that patients who died within 1 year after hip fracture surgery have a higher admission NLR value than those in the control group. As a new risk factor for mortality in patients with hip fracture, NLR was first evaluated by Forget et al.[2] in 2015. In their study, NLR was investigated at admission and at postoperative days 2 and 5. They reported that if postoperative day 5 NLR >5, excess mortality can be expected, but preoperative NLR is not predictive of postoperative mortality. Fisher et al.[9] assessed the prognostic value of admission NLR for short-term outcomes in ortho-geriatric patients. They found that high NLR on admission is a significant risk factor of postoperative myocardial injury, high inflammatory response, and in-hospital death.

Inflammatory changes induced by hip trauma and surgery can affect survival.[10] It has been suggested that acute inflammaNeutrophil-to-lymphocyte ratio 100

Specificity: 78.6 Criterion: >4.7

60

40

20

0 20

40 60 Specificity

tory response assessed by some inflammatory markers, such as tumor necrosis factor-∝ (TNF-∝), interleukin-6 (IL-6), and IL-10 can predict the 12-month outcome of patients with hip fracture.[11] NLR is also described as a new potential marker of systemic inflammation.[12] Therefore, it can be associated with the prognosis of patients with hip fracture. Forget et al.[2] reported that the prognostic value of NLR is more prominent after surgery. They reported that this finding can be explained by the cumulative effect of persistent acute inflammatory response and persisting stress status in frail older patients.[2] However, acute inflammatory response during the postoperative period can be affected by different factors, such as type of surgery. Sedlár et al.[13] reported that elevation of CRP, WBC, and IL-6 levels was highest in patients treated with hemiarthroplasty compared with patients treated with osteosynthesis. Del Prete et al.[14] found that secretion of inflammatory markers, especially IL-6, is less marked when minimally invasive techniques are used compared with traditional surgery for the fixation of pertrochanteric fracture via dynamic hip screw. Accordingly, we focused on the evaluation of the prognostic value of admission NLR rather than postoperative NLR. Preoperative estimation of excess mortality risk may be more useful for determining the treatment modality. If the patient has high admission NLR, less invasive surgical techniques can be selected to prevent excess postoperative inflammatory response. Hypothetically, to reduce systemic inflammation, some pharmacological agents, such as statins and aspirin, can be used in the postoperative treatment of patients with hip fracture with high NLR value. Further investigations are needed in this subject.

Our study is a retrospective analysis of single-center patients, and it has all the inherent limitations of a retrospective study.

We used a non-probability, purposive sampling technique to construct a study group, and this technique has some advantages and disadvantages. We believe that the primary advantage of purposive sampling in this study is to reduce the confounding effect of previously reported risk factors of mortality (age, gender, fracture type, surgical time, and ASA score). Additionally, malignancies and recent steroid therapies can affect the inflammatory status and NLR value of patients. The primary disadvantages of purposive sampling are the high probability of selection bias and sampling error. For this reason, the generalizability of our findings is low.

Sensitivity: 86.4

80

Sensitivity

Mean

Control 28 3.730000 1.0000 11.7000 4.140714

We found that the admission NLR values of the mortality group patients were significantly higher than those of the control group (p<0.001). The cutoff value of NLR was calculated as 4.7 on ROC analysis (area under the curve: 0.839, standard error: 0.0635, 95% confidence interval: 0.708–0.928, z statistic: 5.345, p<0.0001, sensitivity: 86.4, specificity: 78.6, and Youden index J: 0.65) (Fig. 2).

0

Maximum

80

Figure 2. Graphics of ROC analysis.

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Despite these limitations, we conclude that high NLR value on admission can be a risk factor for excess 1-year mortality in elderly patients with hip fracture. We believe that this sim73

Temiz et al. Admission NLR and postoperative mortality in elderly patients with hip fracture

ple and inexpensive biomarker could be used for risk stratification of mortality in this patient population.

Conflict of interest: None declared.

7. Malietzis G, Giacometti M, Askari A, Nachiappan S, Kennedy RH, Faiz OD, et al. A preoperative neutrophil to lymphocyte ratio of 3 predicts disease-free survival after curative elective colorectal cancer surgery. Ann Surg 2014;260:287–92.

8. Shimada H, Takiguchi N, Kainuma O, Soda H, Ikeda A, Cho A, et al.

High preoperative neutrophil-lymphocyte ratio predicts poor survival in patients with gastric cancer. Gastric Cancer 2010;13:170–6.

REFERENCES 1. Fahy AS, Wong F, Kunasingam K, Neen D, Dockery DNF, Ajuied A, Back DL. A Review of Hip Fracture Mortality—Why and How Does Such a Large Proportion of These Elderly Patients Die? Surgical Science 2014;5:227–32.

2. Forget P, Moreau N, Engel H, Cornu O, Boland B, De Kock M, et al.

The neutrophil-to-lymphocyte ratio (NLR) after surgery for hip fracture (HF). Arch Gerontol Geriatr 2015;60:366–71.

3. Hu F, Jiang C, Shen J, Tang P, Wang Y. Preoperative predictors for mortality following hip fracture surgery: A systematic review and meta-analysis. Injury 2012;43:676–85.

4. Mosfeldt M, Pedersen OB, Riis T, Worm HO, Mark Sv, Jørgensen HL, et al. Value of routine blood tests for prediction of mortality risk in hip fracture patients. Acta Orthop 2012;83:31–5.

5. Forasassi C, Golmard JL, Pautas E, Piette F, Myara I, Raynaud-Simon A. Inflammation and disability as risk factors for mortality in elderly acute care patients. Arch Gerontol Geriatr 2009;48:406–10.

6. Azab B, Bhatt VR, Phookan J, Murukutla S, Kohn N, Terjanian T, et al. Usefulness of the neutrophil-to-lymphocyte ratio in predicting shortand long-term mortality in breast cancer patients. Ann Surg Oncol 2012;19:217–24.

9. Fisher A, Srikusalanukul W, Fisher L, Smith P. The Neutrophil to Lymphocyte Ratio on Admission and Short-Term Outcomes in Orthogeriatric Patients. Int J Med Sci 2016;13:588–602.

10. Sedlář M, Kvasnička J, Krška Z, Tománková T, Linhart A. Early and subacute inflammatory response and long-term survival after hip trauma and surgery. Arch Gerontol Geriatr 2015;60:431–6.

11. Sun T, Wang X, Liu Z, Chen X, Zhang J. Plasma concentrations of proand anti-inflammatory cytokines and outcome prediction in elderly hip fracture patients. Injury 2011;42:707–13.

12. Ahsen A, Ulu MS, Yuksel S, Demir K, Uysal M, Erdogan M, Acarturk G. As a new inflammatory marker for familial Mediterranean fever: neutrophil-to-lymphocyte ratio. Inflammation 2013;36:1357–62.

13. Sedlár M, Kudrnová Z, Erhart D, Trca S, Kvasnicka J, Krska Z, et al.

Older age and type of surgery predict the early inflammatory response to hip trauma mediated by interleukin-6 (IL-6). Arch Gerontol Geriatr 2010;51:e1–6.

14. Del Prete F, Nizegorodcew T, Regazzoni P. Quantification of surgical trauma: comparison of conventional and minimally invasive surgical techniques for pertrochanteric fracture surgery based on markers of inflammation (interleukins). J Orthopaed Traumatol 2012;13:125–30.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Kalça kırıklı yaşlı hastalarda nötrofil-lenfosit oranı ve ameliyat sonrası mortalite Dr. Aytun Temiz,1 Dr. Salim Ersözlü2 1 2

Balıkesir Edremit Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Balıkesir İstinye Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul

AMAÇ: Kalça kırıklı yaşlı hastalarda ameliyat sonrası mortalitenin yüksek olduğu bildirilmiştir. Bunun nedeni genellikle ameliyat sonrası gelişen komplikasyonlardır. Güncel çalışmalarda nötrofil-lenfosit oranının (NLR), yüksek mortalite oranı ile ilişkili olduğu belirtilmektedir. Çalışmamızda amaç, kalça kırıklı yaşlı hastalarda, hastaneye yatış esnasındaki NLR’nin, ameliyat sonrası mortalite ile ilişkisi olup olmadığını araştırmak idi.

GEREÇ VE YÖNTEM: Balıkesir Edremit Devlet Hastanesi Ortopedi ve Travmatoloji Kliniği’nde 65–80 yaş arası, ASA puanı 3 olan, stabil olmayan trokanterik kırık nedeniyle çimentolu bipolar kalça protezi uygulanan kadın hastalar çalışmaya dahil edildi. Tüm hastalar kırık sonrası ilk 72 saat içinde ameliyat edilmiş idi (amaca yönelik örnekleme tekniği). Grup 1 hastalar ameliyat sonrası birinci yıl içinde ölenler (n=22, %44), grup 2 hastalar (n=28, %56) ise yaşayanlar idi. Her iki grup ameliyat öncesi NLR değerleri açısından istatistiksel olarak karşılaştırıldı.

BULGULAR: Gruplar arasında ameliyat öncesi NLR değeri açısından anlamlı fark tespit edildi (p<0.001). ROC analizinde kesim değeri 4.7 bulundu.

TARTIŞMA: Buna göre ameliyat öncesi NLR değerinin kalça kırıklı yaşlı hastalarda mortalite ile ilişkili olduğu kanaatindeyiz.

Anahtar sözcükler: Kalça kırığı; nötrfil-lenfosit oranı; yaşlı hasta.

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ORIG I N A L A R T IC L E

The ANK nail treatment of lateral malleolar fractures with syndesmosis injury: Clinical outcomes at 10 years of follow-up Sinan Kahraman, M.D.,1 Hasan Hüseyin Ceylan, M.D.,2 Mehmet Mesut Sönmez, M.D.,3 Ayhan Nedim Kara, M.D.1 1

Department of Orthopaedics and Traumatology, İstanbul Bilim University Şişli Florence Nightingale Hospital, İstanbul-Turkey

2

Department of Orthopaedics and Traumatology, İstanbul Lütfiye Nuri Burat State Hospital, İstanbul-Turkey

3

Department of Orthopaedics and Traumatology, Hamidiye Şişli Etfal Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Lateral malleolar fractures associated with syndesmotic injuries are common. Various surgical implants may be used for the management of syndesmosis injury. One of these is ANK nail. The aim of the present study was to assess the clinical and radiological outcomes of patients treated with ANK nail.

METHODS: Forty-eight patients who were followed up for a minimum of 10 years were reviewed retrospectively using American Orthopedic Foot and Ankle Society (AOFAS) score, radiological evaluation, and development of posttraumatic arthritis. Final data were collected at the last follow-up.

RESULTS: The mean age of the patients was 37.3 (17–69) years. The mean follow-up was 129.9 (123–150) months. Twenty-two patients had Weber type B fracture, and their mean AOFAS score was 93.36 points. The remaining 26 patients had Weber type C fracture, and their mean AOFAS score was 97.66 points. There was no relationship between the type of fracture and the clinical outcome.

There was a significant correlation between shortening of the fibula and posttraumatic arthritis.

CONCLUSION: The ANK nail used for the management of ankle fractures may provide both fracture and syndesmosis stabilities in selected cases and is also a cost effective method as cheap as a cortical screw and a Kirschner wire.

Keywords: ANK nail; ankle fracture; syndesmosis injury.

INTRODUCTION The distal tibiofibular syndesmosis is essential for the stability of the ankle mortise. The function of the syndesmosis ligament group is to maintain a balanced relationship between the tibia, fibula, and talus during ankle movements.

Syndesmosis injury and widening of the ankle joint mortise may result in poor function and osteoarthritis. The incidence of ankle fractures has increased significantly due to an increase in sports activities. Its prevalence is approximately 1-2 per 1000 people.[1–7] Weber type B fractures[8] and Lauge– Hansen[9] supination external rotation injuries are the most

common of all indirect fractures, and distal tibiofibular diastasis, also known as syndesmosis injury, is reported to occur in approximately 30% of these fractures. This is the most common clinical condition when evaluation and treatment of syndesmosis injury must be considered. The static fixation with one or multiple screws through three or four cortices is the conventional treatment in syndesmosis repair.[10,11] The syndesmosis screw should be removed after the procedure, otherwise local symptoms and complications may occur due to fixation. Removal of the screw is another surgical procedure exposing the patient to the disadvantage for a second surgical intervention.[11,12]

Cite this article as: Kahraman S, Ceylan HH, Sönmez MM, Kara AN. The ANK nail treatment of lateral malleolar fractures with syndesmosis injury: Clinical outcomes at 10 years of follow-up. Ulus Travma Acil Cerrahi Derg 2019;25:75-79.

Address for correspondence: Sinan Kahraman, M.D. Hamidiye Şişli Etfal Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul, Turkey.

Tel: +90 212 - 373 50 00 E-mail: mdmesutsonmez@yahoo.com Ulus Travma Acil Cerrahi Derg 2019;25(1):75-79 DOI: 10.5505/tjtes.2018.91679 Submitted: 04.02.2016 Accepted: 16.07.2018 Online: 27.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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In 1980, Dr. Kara designed an implant that enables elastic fixation, enabling a small degree of movement is accepted as a more physiological method.[13–15] The aim of the present study was to investigate the radiological and functional outcomes in the long-term follow-up (≥10 years) of patients who were treated with ANK nail for lateral malleolar fractures.

MATERIALS AND METHODS The medical records of 163 patients with ankle fractures who had undergone surgical treatment with ANK nail in our clinic between January 1996 and January 1999 were retrospectively evaluated. Patients with multiple traumas, neuropathic arthropathy, and associated pilon fracture were excluded from the study. A total of 48 patients who underwent last evaluation were included in the study.

All patients were evaluated with respect to the etiology and type of fracture, time elapsed before surgery, and postoperative length of follow-up. The American Orthopedic Foot and Ankle Society (AOFAS) ankle/hind foot score was chosen as the primary outcome measure. Radiological assessment was done with weight bearing anteroposterior, lateral, and mortise views of the ankle obtained at the last followup. The grading system described by Morrey and Wiedemann was used to detect the presence of postoperative osteoarthritis.[16] Statistical analysis of the data was performed using the Statistical Package for the Social Sciences software, version 13 (IBM Corp., Chicago, IL, USA).

(a)

(b)

Characteristics of the ANK Nail The ANK nail (Hipokrat, Izmir, Turkey) is made from stainless steel and has a diameter of 2.5 mm. It consists of a straight section that is applied intramedullary into the fibula. This is neither an expandable nor a press-fit implant. Therefore, the ANK nail is not suitable for long oblique and segmented distal fibular fractures. The implant has a curved distal section that is used to fix the fibula to the tibia and a screw hole at the distal tip of the curved section (Fig. 1a). Another piece that completes the instrument is the malleolar screw. The ANK nails for the right and left ankles are different.

Surgical Technique The operations were performed under general or regional anesthesia, with the patient in supine position and a padding inserted under the ipsilateral hip. A 2.5–4 cm curved incision is made on the lateral aspect of the ankle under pneumatic tourniquet control, taking care not to injure the superficial peroneal nerve. The fibular fracture is exposed and reduced anatomically. The lateral cortex of the fibula is drilled with either a 2.2 mm drill or a 2.5 mm Kirschner wire, which are then advanced intramedullary and proximal to the fracture.

Under fluoroscopic guidance, an ANK nail is inserted and advanced until its corner rests on the tip of the fibula. The widening of the syndesmosis is confirmed with the observation of the tibiofibular diastasis when the fibula is pulled laterally with a hook (Cotton test). The end of the ANK nail bearing the screw hole is placed on the tibia, and while keeping the foot in neutral flexion, the nail is fixed onto the anterior or anterolateral corner of the tibia with a malleolar screw.

When the posterior malleolus is also fractured, the malleolar

(c)

Figure 1. (a) ANK devices for the right and left ankles. A simple, 2.5 mm in diameter Kirschner wire that is curved distally is used. (b) Early postoperative anteroposterior X-ray. (c) Postoperative lateral view after ANK nail application.

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screw is inserted in a manner to include this fragment as well.

The stability is reassessed using the traction test after fixation. A below knee cast splint, with the ankle at 90°, is applied after skin closure (Fig. 1b and c).

Postoperative Care The operated extremity is elevated for a few days and kept in a cast splint for 2 weeks to decrease the pain. The splint is removed after 2 weeks, and full active range of motion exercises is initiated. Partial weight bearing is allowed after 6 weeks, and active flexion and extension movements are continued.

RESULTS The study included 16 female and 32 male patients. The mean age of the patients was 37.3 (17–69) years. The mean length of postoperative follow-up was 129.9 (123–150) months. The cause of injury was a result of low-energy trauma (simple ankle sprain) in 24 patients and high-energy trauma (motor vehicle accident and fall from height). All fractures were classified according to the Denis–Weber classification, in which 22 patients were Weber type B, and 26 patients were Weber type C. Four patients had open fracture (Gustilo–Anderson type 1 in three patients and 2 in one patient). Of the patients, 26 (54.16%) had bimalleolar fractures, 16 (33.33%) had trimalleolar, and 6 (12.5%) had isolated lateral malleolar fractures associated with syndesmosis injury.

There was a significant relationship between the presence of comorbidity (diabetes, hypertension, and vascular disease) and the development of posttraumatic arthritis, and arthritic changes were more common in these patients (Fisher’s exact test, p=0.011).

There were no relationships between the AOFAS score, extension losses, and radiological osteoarthritis degrees (p>0.05). There was a significant relationship between the loss of flexion and AOFAS score (p=0.048).

Twenty-two patients had Weber type B fracture, and their mean AOFAS score was 93.36 points. The remaining 26 patients had Weber type C fracture, and their mean AOFAS score was 97.66 points. There was no relationship between the type of fracture and the clinical outcome (p>0.05). The mean grades of osteoarthritis were 0.68 in type B fractures and 0.57 in type C fractures. There was no significant relationship between the type of fracture and the development of osteoarthritis (p>0.05).

Four patients had >2 mm (mean 3.85 mm) shortening of the fibula compared with the contralateral side, and their mean AOFAS score was 83.75 (80–90) points.

DISCUSSION Distal tibiofibular syndesmosis injuries associated with anUlus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

kle fractures may result from low-energy trauma, including sports injuries, simple falls, or sprain, or high-energy trauma, including traffic accidents or falling from height.

A body weight of 80–90% is transferred to the talar dome through the tibial articular surface at the ankle during weight bearing. The remaining load is transferred through the fibular side by the syndesmosis ligaments and the lateral collateral ligaments.[17] The fibula plays an important role in ankle stability, and the best outcomes in the management of its fractures can be achieved only with anatomic reduction to prevent the development of arthrosis.[18] Transfixion of the fibula to the tibia is often necessary in tibiofibular syndesmosis injuries. It can be performed with a screw that holds three or four cortices, screw over a plate, button suture technique, or a bolt nail.[19,20] Screw fixation is the most commonly preferred method. The distance of the screw to the ankle joint, whether ankle movement in the presence of the screw is allowed or not, and weight bearing in the presence of the screw are the major controversial aspects of this method. Micromotion and reactional loosening around the screw occurs in time. The possibility of breakage in an unremoved screw reaches 10–29% and is caused by the physiological longitudinal movement that occurs during loading.[21] ANK nail allows an elastic fixation in contrast to that of the rigid fixation of a screw. Therefore, the movements of the ankle and fibula are not restricted. In addition, it does not require removal due to its elasticity. Kabukcuoglu et al.[14] reported excellent and good results, and early weight bearing was allowed.

The ANK nail makes an intramedullary fixation for the fractured fibula. The rotational stability in this method is provided by the screw applied to the tibia, as well as the contact of the implant with the fibular tip. The distal aspect of the ANK nail has a curvature that conforms to the fibular valgus. In addition to its contribution to rotational stability, this prevents any narrowing in the malleolar space. A distal crural computerized tomography (CT) assessment of all patients may be useful for the accurate assessment of residual rotation. We did not perform a CT scan in our study.

Fibular shortening has great significance with respect to the depth of the ankle mortise and, related to that, its balance.

This significance is greater during weight bearing.[5] The most important problem related to the ANK nail is the development of fibular shortness. Previous studies on the ANK nail performed in Turkey emphasized the possible development of fibular shortness due to intramedullary fixation.[13–15] Kabukcuoglu et al.[14] stated that they do not prefer the ANK nail in comminuted and long oblique fibula fractures and advocated that if the ANK nail will be used in such fractures, then cerclage wire support will be necessary. Comminuted fibula fractures were reported to result in collapse and shortness. In one of these previous studies, three fibular shorten77

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ing was reported among 42 patients operated with the ANK nail.[14] In our study, four patients had a fibular shortening >2 mm (mean 3.85 mm) compared with the contralateral side.

In comparison to these patients with those without shortness, there was a significant difference with respect to the AOFAS scores and the development of osteoarthritis. The indications of ANK should be carefully determined, and the technique should be applied meticulously. In our study, we observed that the ANK nail was applied commonly in short oblique fractures. Reduction loss and fibular shortening appear inevitable when the ANK nail is used in long oblique fractures and segmented-comminuted metaphyseal fractures.

Kara et al.[13] reported that early weight bearing can lead to reduction loss in these types of fractures. The ANK nail appears to be inadequate for providing a rotational stability in the distal fibula. These two causes narrow the indications for the implant.[13–15] Our study has several limitations. First, this is a retrospective study. Second, the results could have been more accurate with a randomized, prospective, controlled study. Finally, the results of fractures operated with the ANK nail were not compared with today’s more popular methods, such as plate osteosynthesis.

Our study and others have shown that the ANK nail method does not yield very poor results in the management of ankle fractures associated with distal tibiofibular ligament injuries.

[13–15] Its main advantage is the lack of any need for implant removal. The cost is approximately equal to that of a single cortical screw. Fixation with the ANK nail is an appropriate method that can be applied in selected lateral malleolar fractures associated with syndesmosis injury.

Ethical Standard All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the 1975 Declaration of Helsinki, as revised in 2008. Informed consent was obtained from all the patients included in the study.

Conflict of interest: None declared.

REFERENCES 1. Wuest TK. Injuries to the distal lower extremity syndesmosis. J Am Acad Orthop Surg 1997;5:172–81.

2. Daly PJ, Fitzgerald RH Jr, Melton LJ, Ilstrup DM. Epidemiology of ankle fractures in Rochester, Minnesota. Acta Orthop Scand 1987;58:539–44.

3. Jensen SL, Andresen BK, Mencke S, Nielsen PT. Epidemiology of ankle fractures. A prospective population-based study of 212 cases in Aalborg,

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Denmark. Acta Orthop Scand 1998;69:48–50.

4. Yilmaz E, Karakurt L, Serin E, Bulut M. The results of surgical treatment in ankle fractures. Acta Orthop Traumatol Turc 2002;36:242–7.

5. Ovaska M. Complications in ankle fracture surgery. Acta Orthop Suppl 2015;86:1–32.

6. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures-an increasing problem? Acta Orthop Scand 1998;69:43–7.

7. Regan DK, Gould S, Manoli A 3rd, Egol KA. Outcomes over a decade after surgery for unstable ankle fracture: functional recovery seen 1 year postoperatively does not decay with time. J Orthop Trauma 2016;30:236–41.

8. van den Bekerom MP, Lamme B, Hogervorst M, Bolhuis HW. Which Ankle Fractures Require Syndesmotic Stabilization? J Foot Ankle Surg 2007;46:456–63.

9. Lauge-Hansen N. Fractures of the ankle. II. Combined experimentalsurgical and experimental-roentgenologic investigations. Arch Surg 1950;60:957–85.

10. Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Ortho Trauma 2005;19:102–8.

11. Manjoo A, Sanders DW, Tieszer C, MacLeod MD. Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma 2010;24:2–6.

12. van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, et al. Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines Knee Surg Sports Traumatol Arthrosc 2016;24:1217–27.

13. Kara AN, Esenyel CZ, Sener BT, Merih E. A different approach to the treatment of the lateral malleolar fractures with syndesmosis injury: the ANK nail. J Foot Ankle Surg 1999;38:394–402.

14. Kabukcuoglu Y, Kucukkaya M, Eren T, Gorgec M, Kuzgun U. The ANK device: a new approach in the treatment of the fractures of the lateral malleolus associated with the rupture of the syndesmosis. Foot Ankle Int 2000;21:753–8.

15. Xie B, Jing Y, Xiang L, Zhou D, Tian J. A modified technique for fixation of chronic instability of the distal tibiofibular syndesmosis using a wire and button. J Foot Ankle Surg 2014;53:813–6.

16. Morrey BF, Wiedeman GP Jr. Complications and long-term results of ankle arthrodeses following trauma. J Bone Joint Surg Am 1980;62:777– 84.

17. Kapandji IA. The physiology of the joints. 6th ed. New York: Churchill Livingstone; 2007. p.1–2.

18. Yablon IG, Segal D, Leach RE. Ankle injuries. New York: Churchill Livingstone; 1983. p. 268.

19. Campbell WC, Canale ST, Beaty JH. Campbell’s operative orthopaedics.

11th ed. Philadelphia: Mosby/Elsevier; 2008.

20. Cottom JM, Hyer CF, Philbin TM, Berlet GC. Transosseous fixation of the distal tibiofibular syndesmosis: comparison of an interosseous suture and endobutton to traditional screw fixation in 50 cases. J Foot Ankle Surg 2009;48:620–30.

21. Bell DP, Wong MK. Syndesmotic screw fixation in Weber C ankle injuries--should the screw be removed before weight bearing? Injury 2006;37:891–8.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Synesmoz yaralanmasının eşlik ettiği lateral malleol kırıklarının ANK çivisi ile tedavisi: On yıllık tedavi sonuçları Dr. Sinan Kahraman,1 Dr. Hasan Hüseyin Ceylan,2 Dr. Mehmet Mesut Sönmez,3 Dr. Ayhan Nedim Kara1 İstanbul Bilim Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Kliniği, İstanbul İstanbul Lütfiye Nuri Burat Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul 3 Hamidiye Şişli Etfal Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul 1 2

AMAÇ: Syndesmoz yaralanmasının eşlik ettiği lateral malleol kırıkları oldukça sıktır. Syndesmoz yaralanmaları için birçok çeşit implant kullanılmaktadır. Bunlardan birisi de ANK çivisidir. Çalışmamızın amacı syndesmoz yaralanmasının eşli ettiği ayak bileği kırıklarında ANK çivisi ile tedavinin uzun dönem klinik ve radyolojik sonuçlarını değerlendirmektir.

GEREÇ VE YÖNTEM: En az 10 yıllık takibi yapılabilen 48 hastanın son kontrollerinde AOFAS (American Orthopaedic and Foot Society) klinik değerlendirme formu kullanılarak klinik sonuçları ve radyolojik değerlendirme kriterleri ile artroz varlığı araştırıldı.

BULGULAR: Hastaların ortalama yaşı 37.3 idi (17–69). Hastalar ortalama 129.9 ay (123–150) takip edildi. Weber B kırığa sahip 22 hastada ortalama AOFAS skoru 93.36 idi. Weber C kırığa sahip 22 hastada ortalama AOFAS skoru 97.66 idi. Kırık tipi ile AOFAS skoru arasında istatiksel olarak anlamlı fark saptanmadı. Travma sonrası artroz gelişimi ile fibula kısalığı arasında anlamlı fark saptandı.

TARTIŞMA: ANK çivisi özellikle seçilmiş olgularda; syndesmoz yaralanmasının eşlik ettiği ayak bileği kırıklarında başarılı şekilde uygulanabilir. Özellikle maliyet açısından oldukça avantaja sahiptir.

Anahtar sözcükler: ANK çivisi; ayak bileği kırıkları; syndesmoz yaralanması.

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CA S E REP OR T

Management of enteroatmospheric fistula thanks to new isolation technique Seracettin Eğin, M.D., Berk Gökçek, M.D., Fazıl Sağlam, M.D., Burak Güney M.D.

Metin Yeşiltas, M.D.,

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

ABSTRACT We aimed to present our method called as new isolation technique with stopper (NITS) to manage enteroatmospheric fistula (EAF) in an open abdomen (OA). The patient was a 71-year-old male with Hartmann colostomy and incisional hernia. A dual mesh was used for incisional hernia repair after colorectal anastomosis.The patient was urgently re-admitted to hospital due to EAF on the postoperative 30th day. The NITS application was performed twice at different times. General anesthesia was not required for the applications, but sterile conditions in operation room were provided. A Penrose drain was sutured with 5/0 polydioxanone onto the mucosa of EAF orifice. A small pool was created to protect enteric content from leakage. The leak test was performed by spilling saline into this pool.

The sponge with visceral organ protector around the pool was adhered by adhesive sterile drape, and one opening was performed on drape. Negative pressure therapy was launched with -75 mmHg in continuous form. EAF was isolated from the OA wound and sponge with the help of stopper performed with adaptable and obstacle ring paste. After these two applications, EAF was converted to stoma.

The anastomosis of small intestine was performed 45 days later. In our NITS system, control of EAF may be successfully provided besides prevention of loss of enteric fluid and electrolyte. Advantages of NITS: 1) Successful control in all types of EAF is possible with NITS. 2) The required material for NITS system can be found easily. 3) All types of EAF can be converted into stoma in a short time.

Consequently, the therapy of EAF in Björck 4 OA patients may be carried out successfully with NITS method.

Keywords: Enteroatmospheric fistula; negative pressure therapy; open abdomen; penrose drain.

INTRODUCTION The enteroatmospheric fistula (EAF) has been described as a fistula that directly opens the gastrointestinal tract to the atmosphere without any canal.[1,2] Open abdomen (OA) practice provides the survival in cases such as severe generalized peritonitis, severe pancreatitis, abdominal aortic aneurysm rupture, acute mesenteric ischemia, damage-control surgery after trauma, and abdominal compartment syndrome, but its application is a challenging strategy. EAF in an OA is a feared complication that can cause death. If EAF takes place, therapy of the patients with OA gets harder, and the likelihood of mortality and morbidity also increases.[1] The identified treatment methods for EAF are biological dressings, vacuum-as-

sisted closure (VAC), application of fibrin glue, sump drainage, primary suturing, and fistula VAC technique. It is essential to control the enteric effluent of EAF. The uncontrolled flow of EAF makes it difficult to heal the wound with irritation of the surrounding skin due to persistent contamination.[2] EAF associated with frozen OA is classified as Björck 4 OA.[1] It may not always be possible to prevent persistent contamination and chemical irritation caused by EAF in the patients with Björck 4 OA. If the isolation of the EAF is not fully achieved in these patients, their death is usually the clear outcome due to sepsis.

This case report describes our experience with negative pressure therapy (NPT) in the management of EAF in an OA.

Cite this article as: Eğin S, Gökçek B, Yeşiltas M, Sağlam F, Güney B. Management of enteroatmospheric fistula thanks to new isolation technique.

Ulus Travma Acil Cerrahi Derg 2019;25:80-82.

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 2019;25(1):80-82 DOI: 10.5505/tjtes.2018.45267 Submitted: 11.11.2018 Accepted: 17.12.2018 Online: 25.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Eğin et al. Management of enteroatmospheric fistula thanks to new isolation technique

We aimed to present our method called as new isolation technique with stopper (NITS), performed by modifying “fistula isolation by suturing the Penrose drain to the mucosa of orifice of EAF” (FISPME) method. In a short time, condition of our patient with EAF in Björck 4 OA improved thanks to this method without excessive fluid losses, electrolyte and acid-base disturbances, and septic complications.

CASE REPORT The patient, a 71-year-old male, was operated 13 months after his first surgery for the closure of the previous Hartmann colostomy and incisional hernia. A dual mesh was used for incisional hernia repair after colorectal anastomosis. After discharge, the patient was urgently re-admitted to hospital due to EAF 30 days after surgery (Fig. 1a). Informed consent was obtained from the patient, and he was operated 32 days after surgery for the first NITS application. The application was

(a)

(b)

performed twice at different times. The second NITS was performed 55 days after surgery. The second NITS was performed when the first NITS broke down. General anesthesia was not required for the applications, but sterile conditions in operation room were provided. A Penrose drain was sutured with 5/0 polydioxanone onto the mucosa of EAF orifice (Fig. 1b). A small volume pool was created by suturing the Penrose drain to avoid leakage of enteric content. The leak test was performed by spilling saline into this pool. A pool area was created on the sponge of NPT. The sponge with visceral organ protector around the pool was applied according to OA wound, and sutured to the top edge of Penrose. A small dry gauze was placed in this pool. The gauze in this pool and the sponge with visceral organ protector around of the pool was adhered by adhesive sterile drape, and one opening was performed on drape. The collecting system channel of NPT was affixed to this opening. NPT was launched with −75 mmHg in continuous form. The drape on this pool was opened by

(c)

Figure 1. (a) EAF at the small intestine. (b) A Penrose drain was sutured with 5/0 polydioxanone onto the mucosa of EAF orifice. (c) EAF was isolated from the OA wound and sponge with the help of stopper performed with adaptable and obstacle ring paste.

(a)

(b)

Figure 2. (a) Releasing the afferent and efferent small intestine loops of the stoma. (b) The patient fully recovered.

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cutting, and the gauze was removed. EAF was isolated from the OA wound and sponge with the help of stopper performed with adaptable and obstacle ring paste (Fig. 1c). After these two applications, EAF was converted to stoma 58 days after surgery. Stoma bag was applied to enterostomy, and the patient was discharged 75 days after surgery. After 58 days of discharge, side-to-side anastomosis was performed with the linear cutter by releasing the afferent and efferent small intestine loops of the stoma (Fig. 2a). The patient was discharged 12 days after last surgery as fully recovered (Fig. 2b).

DISCUSSION When NPT was introduced, some considered the usage of vacuum therapy for fistula improvement a contraindication.

However, nowadays the use of NPT has been reported in several case report and case series with excellent results.[3] In 2017, Yetisir et al.[4] described an innovative technique called FISPME that is applied with VAC to treat EAF in Björck 4 OA patients. Our technique is a modification of the technique described by Yetisir et al., but there are significant differences in both application technique and post-application nutrition.

Because we isolated EAF with stopper, a stoma bag did not need to stick around the EAF orifice. Thus, there was no loss of excess fluid and electrolyte from EAF. The patients with EAF are hypercatabolic, and their health rapidly deteriorate.

Nutritional support for these patients is an important predictor for survival. We preferred total parenteral nutrition support for short time although enteral nutrition was preferred

by Yetisir et al.

In Björck 4 OA patients, proximal diversion of enteric contents is not possible. However, isolation techniques of the enteric contents are possible for control of the EAF in these patients. These techniques were described by D’Hondt and Jannasch in 2011.[3,5] Afterwards, some techniques such as floating stoma, fistula VAC, tube VAC, nipple VAC, ring and

silo VAC were described by Marinis et al.[2] in 2013. Applications of these techniques are not easy for EAF. The leak from EAF to surface of the OA wound is an important problem for all these EAF control systems. The leak always occurs because isolation of the enteric contents may not be successfully performed. These control systems fail every time.

In our NITS system, control of EAF may be successfully provided besides prevention of loss of enteric fluid and electrolyte. Advantages of NITS: 1) Successful control in all types of EAF is possible with NITS. 2) The required material for NITS system can be found easily. 3) All types of EAF can be converted into stoma in a short time. Consequently, the therapy of EAF in Björck 4 OA patients may be carried out successfully with NITS method.

Conflict of interest: None declared.

REFERENCES 1. Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain ML, De Keulenaer B, et al; Pediatric Guidelines Sub-Committee for the World Society of the Abdominal Compartment Syndrome. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013;39:1190–206.

2. Marinis A, Gkiokas G, Argyra E, Fragulidis G, Polymeneas G, Voros D. “Enteroatmospheric fistulae”--gastrointestinal openings in the open abdomen: a review and recent proposal of a surgical technique. Scand J Surg 2013;102:61–8.

3. D’Hondt M, Devriendt D, Van Rooy F, Vansteenkiste F, D’Hoore A, Penninckx F, et al. Treatment of small-bowel fistulae in the open abdomen with topical negative-pressure therapy. Am J Surg 2011;202:e20–4.

4. Yetisir F, Sarer AE, Aldan M. New isolation technique for enteroatmospheric fistula in Björck 4 open abdomen. Hernia 2017;21:809–12.

5. Jannasch O, Lippert H, Tautenhahn J. A novel device for treating enteroatmospheric fistulae in the open abdomen. [Article in German]. Zentralbl Chir 2011;136:585–9.

OLGU SUNUMU - ÖZET

Yeni izolasyon tekniği ile enteroatmosferik fistülün yönetimi Dr. Seracettin Eğin, Dr. Berk Gökçek, Dr. Metin Yeşiltas, Dr. Fazıl Sağlam, Dr. Burak Güney Sağlık Bilimleri Üniversitesi, Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

Açık karında enteroatmosferik fistül (EAF) yönetiminde tıkaçla yeni izolasyon tekniği olarak adlandırılan yöntemimizi sunmayı amaçladık. Hasta, Hartmann kolostomi ve insizyonel herni olan 71 yaşında bir erkek hastaydı. Kolorektal anastomoz sonrası insizyonel fıtık onarımı için dual meç kullanıldı. Hasta, acil olarak EAF nedeniyle ameliyat sonrası otuzuncu günde hastaneye tekrar başvurdu. Yeni izolasyon tekniği uygulaması iki kez farklı zamanlarda yapıldı. Genel anestezi gerekli değildi, ancak ameliyat odasında steril koşullar sağlandı. Bir penroz dren, 5/0 polidioksanon ile EAF mukozasına dikildi. Enterik içeriği sızdırmayan küçük bir havuz oluşturuldu. Sızıntı testi, bu havuza serum fizyolojik dökülerek yapıldı. Havuzun etrafındaki açık karın alanı organ koruyuculu süngerle ve steril dreple örtüldü. Örtü üzerinde bir açıklık yapıldı ve sürekli formda -75 mmHg ile negatif basınç tedavisi başlatıldı. EAF, açık karın yarasından ve süngerden, el ile şekil verilebilen ve sızdırmaz halka macunu ile yapılan tıkaç yardımıyla izole edildi. Bu iki uygulamadan sonra, EAF stomaya dönüştürüldü. İnce bağırsağın anastomozu 45 gün sonra yapıldı. Tıkaçla yeni izolasyon tekniği sistemimizde, enterik sıvı ve elektrolit kaybını önlemenin yanı sıra EAF’nin kontrolü de sağlanabilir. Tıkaçla yeni izolasyon tekniğinin üstünlükleri: 1.

Her türlü EAF’de başarılı kontrol mümkün olabilir. 2. Sistemimiz için gerekli materyal kolayca bulunabilir. 3. Tüm EAF tipleri kısa sürede stomaya dönüştürülebilir. Sonuç olarak, Björck 4 açık karın hastalarında EAF tedavisi tıkaçla yeni izolasyon tekniğiyle başarılı şekilde gerçekleştirilebilir.

Anahtar sözcükler: Açık karın; enteroatmosferik fistül; negatif basınç tedavisi; penroz dren.

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Gastrointestinal stromal tumor leading to acute abdomen and hypovolemic shock in a trauma patient Aylin Hande Gökçe, M.D. Department of General Surgery, İstanbul Medicine Hospital, İstanbul-Turkey

ABSTRACT Gastrointestinal stromal tumors (GISTs) are among the rare tumors of gastrointestinal (GI) tract. GISTs occur respectively in the stomach, small intestines, colon and rectum, omentum and mesentery, esophagus, retroperitoneal space, and abdominal cavity. However, they may occur anywhere along the GI tract. Typically, these tumors generally do not cause symptoms; however symptomatic patients may show stomach pain, GI bleeding, and palpable abdominal masses.These patients usually undergo surgery for obstruction symptoms or some other diagnosis. Our patient was admitted to the emergency department with acute abdomen and hypovolemic shock due to fall. The patient underwent emergency surgery, which revealed active bleeding from a stomach tumor showing an exophytic pattern of growth.This patient was a 32-year-old male, and blood tests revealed a white blood cell count of 23.500/mm³ and a hemoglobin level of 7.9 gr/dL. The heart rate was 110 beats/minute. The chest radiograph showed no subdiaphragmatic free air, and abdominal ultrasound showed impression of a mass that could not be distinguished from the liver, along with closed perforation or hemangioma. During the surgical procedure, 1200 cc of blood was suctioned, and the exophytic tumor was removed completely. Histological analysis of the tumor showed GIST, and it was considered to be a ruptured tumor by the oncology consultant. The patient was applied imatinib for 3 years after the surgery, and the disease did not re-occur during this period. Our goal in this case study is to emphasize that trauma may not be necessarily the cause of acute abdomen for emergency patients but that it also may be caused by hypotension-associated hypovolemic shock or other causes, bleeding from a GIST along with tumor torsion.

Keywords: Acute abdomen; gastrointestinal stromal tumor; hypovolemic shock.

INTRODUCTION Gastrointestinal stromal tumors (GISTs) are among the rare tumors of gastrointestinal (GI) tract.[1] GISTs occur respectively in the stomach, small intestines, colon and rectum, omentum and mesentery, esophagus, retroperitoneal space, and abdominal cavity. However, they may occur anywhere along the GI tract.[2,3] Typically, these tumors do not cause symptoms; however symptomatic patients may show stomach pain, GI bleeding, and palpable abdominal masses.[4,5] These patients usually undergo surgery for obstruction symptoms or some other diagnosis.

Our patient was admitted to the emergency department with acute abdomen and hypovolemic shock due to fall. Here, we

will be presenting the case in which the patient underwent acute GIST surgery.

CASE REPORT A 32-year-old male patient was seen in the emergency room after a fall. A physical examination of the patient revealed a blood pressure of 80/40 mmHg and a heart rate of 110 beats/minute, diffuse abdominal tenderness upon palpation, and rebound tenderness. Blood tests at the emergency laboratory revealed a white blood cell count of 23.500/mm³, a hemoglobin level of 7.9 gr/dL, and a hematocrit value of 22.8%. The chest radiograph did not show subdiaphragmatic free air, and abdominal radiograph in standing position was unremarkable.

Cite this article as: Gökçe AH. Gastrointestinal stromal tumor leading to acute abdomen and hypovolemic shock in a trauma patient. Ulus Travma Acil Cerrahi Derg 2019;25:83-85.

Address for correspondence: Aylin Hande Gökçe, M.D. İstanbul Medicine Hastanesi, Genel Cerrahi Kiliniği, İstanbul, Turkey.

Tel: +90 212 - 489 08 00 E-mail: ahgokce79@hotmail.com Ulus Travma Acil Cerrahi Derg 2019;25(1):83-85 DOI: 10.5505/tjtes.2018.35005 Submitted: 07.05.2018 Accepted: 03.09.2018 Online: 05.09.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Emergency ultrasound showed a 72 mm epigastric lesion, undistinguishable from the left lobe of the liver and surrounded with fluid. Based on ultrasound findings suggesting a hemangioma or closed perforation, the patient was diagnosed with intra-abdominal bleeding and acute abdomen, and he underwent emergency surgery. A mass arising from the body of the stomach was detected during the surgery. The mass was 9x7x6 cm in size and showed an exophytic growth pattern (Fig. 1a, b). Approximately 1200 cc of blood was suctioned from the abdominal cavity. The tumor was totally removed along with the part of the stomach where the tumor was connected with the body of the stomach. The body of the stomach was repaired as double layers. Other intra-abdominal organs were intact. During the post-operative period, the patient was stable and did not develop any complications until he was discharged from the hospital.

A low-grade GIST was reported based on the histological findings. Mitotic count was less than 5 per 50 high-power fields. The tumor was positive for CD 117 (c-kit) and DOG-1 and focally positive for CD 34, while it was negative for S-10 and SMA. Ki-67 proliferation index was less than 5%. Histologic examination revealed torsion-related hemorrhagic necrosis and edema, which might explain large dimensions of the tumor. The tumor stage was reported as pT3.

The patient was referred to the Department of Oncology after the surgery. The tumor was accepted as ruptured in the Department of Oncology, and the patient received imatinib therapy for 3 years. The disease did not recur during this period of time.

DISCUSSION GISTs are mesenchymal tumors arising from interstitial cells, and they may occur in the gastrointestinal canal anywhere

(a)

from esophagus to anus along with omentum, mesentery, and retroperitoneal space.[6] GISTs usually occur after the fourth decade of life, and the mean age of occurrence is approximately 60s.[7] The patient presented in this paper was 32 year old, and considering the age range reported in the literature, he was relatively younger. GISTs are usually asymptomatic or may cause non-specific symptoms such as abdominal pain, anemia, abdominal masses, and dyspepsia.

These tumors are usually detected incidentally during a surgical, radiological, or endoscopic procedure that is done for any other reasons.[8,9] With the patient presented here, GIST bleeding into the abdominal cavity led to symptoms of hypovolemic shock, and tumor torsion led to acute abdomen.

The patient was not hematologically stable, and he needed an emergency laparotomy. Pre-operative differential diagnosis of gastrointestinal stromal tumors may present challenges. Based on an emergency ultrasound scan, preliminary diagnoses in this patient include bleeding hemangioma and closed perforation.

Prognostic factors in GIST are mitotic activity, size, location of the tumor, and the feasibility of performing optimum surgery.

[10] GISTs are divided into risk groups based on tumor size: tumors less than 2 cm in diameter are classified as the low-risk group, and tumors larger than 5 cm in diameter are classified as the high-risk group. Higher Ki-67 proliferation index values further increase the risk for metastasis and recurrences. In the case of GIST presented here, the Ki-67 proliferation index value was less than 5%, although the tumor was 9×7×6 cm in size. Even though the tumor was larger than 2 cm in diameter, it was considered a low-grade tumor by pathologists. Torsion-related hemorrhagic necrosis and edema were the reported underlying causes of the increase in tumor size.

It was concluded that hypovolemic shock was the result of bleeding from the stomach tumor with exophytic extension and subsequently tumor-torsion-caused symptoms of acute abdomen.

(b)

Figure 1. (a) Gastrointestinal stromal tumors showing an exophytic pattern of growth, from the corpus of stomach. (b) A piece of the gastrointestinal stromal tumors.

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A carefully obtained medical history and a meticulous physical examination are of paramount importance in trauma patients admitted to emergency services. We believe that trauma patients are best managed by adequate pre-operative preparations to the extent of hematological stability and optimum surgery. Post-operative diagnosis may differ from pre-operative diagnosis in some of the emergency patients as with our patient. In such cases, a rapid planning of the management is essential to perform the optimum goal-oriented surgery. In addition, next to common causes of acute abdomen, there are also rare causes of acute abdomen as with our patient, and one should be prepared for such circumstances.

Conclusion In this case report, we aimed to emphasize the findings of acute abdomen exposure to the torsion of GISTs and bleeding shock. Trauma may not be necessarily the cause of acute abdomen for an emergency patient, but it may also be caused by hypotension-associated hypovolemic shock or other causes, bleeding from a GIST, along with tumor torsion.

Conflict of interest: None declared.

REFERENCES 1. Kim CJ, Day S, Yeh KA. Gastrointestinal stromal tumors: analysis of clinical and pathologic factors. Am Surg 2001;67:135–7.

2. Gold JS, Dematteo RP. Combined surgical and molecular therapy: the gastrointestinal stromal tumor model. Ann Surg 2006;244:176–84.

3. Engin G, Asoglu O, Kapran Y, Mert G. A gastrointestinal stromal tumor with mesenteric and retroperitoneal invasion. World J Surg Oncol 2007;5:121.

4. Pidhorecky I, Cheney RT, Kraybill WG, Gibbs JF. Gastrointestinal stromal tumors: current diagnosis, biologic behavior, and management. Ann Surg Oncol 2000;7:705–12.

5. Lehnert T. Gastrointestinal sarcoma (GIST)-a review of surgical management. Ann Chir Gynaecol 1998;87:297–305.

6. Duffaud F, Blay JY. Gastrointestinal stromal tumors: biology and treatment. Oncology 2003;65:187–97.

7. Sturgeon C, Chejfec G, Espat NJ. Gastrointestinal stromal tumors: a spectrum of disease. Surg Oncol 2003;12:21–6.

8. Pierie JP, Choudry U, Muzikansky A, Yeap BY, Souba WW, Ott MJ. The effect of surgery and grade on outcome of gastrointestinal stromal tumors. Arch Surg 2001;136:383–9.

9. Levine MS, Buck JL, Pantongrag-Brown L, Buetow PC, Hallman JR, Sobin LH. Leiomyosarcoma of the esophagus: radiographic findings in 10 patients. AJR Am J Roentgenol 1996;167:27–32.

10. Dougherty MJ, Compton C, Talbert M, Wood WC. Sarcomas of the gastrointestinal tract. Separation into favorable and unfavorable prognostic groups by mitotic count. Ann Surg 1991;214:569–74.

OLGU SUNUMU - ÖZET

Travmalı hastada akut batın ve hipovolemik şok yapan gastrointestinal stromal tümör Dr. Aylin Hande Gökçe İstanbul Medicine Hastanesi, Genel Cerrahi Kliniği, İstanbul

Gastrointestinal stromal tümör (GİST), gastrointestinal sistemin nadir görülen tümörlerinden biridir. Gastrointestinal sistemin her yerinde olabilir ama en sık sırasıyla görüldüğü yerler mide, ince bağırsaklar, kolorektal, omentum/mezenter, özefagus ve nadiren gastrointestinal sistem ile bağlantısız olarak retroperiton veya abdomendir. Genelde semptomsuz seyreder. Semptomlu olursa karın ağrısı, gastrointestinal sistem kanaması, elle muayenede ele gelen kitle gibi bulgular verebilir. Hastalar genellikle obstrüksiyon bulguları ve başka tanılarla ameliyata alınmaktadır. Sunacağımız olgu acil kliniğe düşme sonrası akut karın ve hipovolemik şok bulgularıyla getirilen, acil şartlarda operasyona alınan ve operasyonda mideden kaynaklı eksofitik büyümüş tümör kanaması olduğu saptanan olgudur. Olgu 32 yaşında, erkek hasta ve yapılan kan incelemelerinde lökosit sayımı 23.500/ mm3, hemoglobin değeri 7.9 gr/dL, nabız 110/dk idi. Akciğer grafisinde diafragma altı serbest hava saptanmayan, ultrasonografisinde karaciğerden ayırt edilemeyen kitlesel görünüm arzeden ve kapalı perforasyon – hemanjiom ayrımı yapılamayan hasta ameliyata alındı. Ameliyatta yaklaşık 1200 cc kan aspire edildi ve mideden ekzofitik uzanım gösteren kitle total olarak çıkarıldı. Patoloji sonucu GİST olarak gelen hasta onkoloji bölümü tarafından rüptüre kabul edildi. Ameliyat sonrası üç yıl imatinib tedavisi verildi ve bu süre içinde nüks saptanmadı. Travma sonucu acile başvuran hastalarda akut karın nedeninin her zaman travmayla ilgili olmayabileceği, hipovolemik şok veya başka nedenlerden dolayı tansiyon düşmesi sonucu travmanın gerçekleşebileceğini vurgulamak ve GİST’nin kanayıp hipovolemik şoka ve torsiyona uğrayıp akut batın bulgularına yol açabileceğini sunmak istedik.

Anahtar sözcükler: Akut karın; gastrointestinal stromal tümör; hipovolemik şok.

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Airbag cover impact: a rarely seen reason for mandibular defects Ersin Akşam, M.D.,

Erhan Sönmez, M.D.,

Önder Karaaslan, M.D.,

Mustafa Durgun, M.D.

Department of Plastic, Reconstructive and Aesthetic Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir-Turkey

ABSTRACT Airbags and seatbelts are among the primary means of preventing severe injuries after motor vehicle accidents. Nonetheless, many studies have examined injuries that were related to airbag deployment. To our knowledge, this is the first case report of multiple mandible fractures caused by impact with the airbag cover. Removal of non-viable bone fragments was performed and the resulting hemi-mandible defect was reconstructed with a free iliac crest flap. A radial forearm free flap was used to reconstruct the mucosal defect.Airbags can prevent deadly injuries; however, they can also cause serious harm to the maxillofacial bones at the time of deployment.

Keywords: Accidents; air bags; free tissue flaps; motor vehicles; traffic.

INTRODUCTION Many people get injured or die in car crash accidents every day around the world. Airbags are one of the most important inventions of the 20th century that save lives and decrease car crash-related morbidity.[1] However, airbags can cause injury or death when used without paying attention to precautions.

In this report, we present a case of mandibular defect caused by high-energy crash of airbag cover that needed two consecutive free-flap surgeries for reconstruction. Although the car velocity was low, the impact pressure of the airbag deployment was very high due to the absence of a seatbelt.

CASE REPORT All procedures in this study were performed in accordance with the ethical standards of the institutional research committee and the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The patient signed a written informed consent.

A 38-year-old male patient requiring microsurgical mandibular reconstruction was referred to our department from a state hospital. He was injured in a car crash due to the collision of the cover of the airbag with the steering wheel (Fig

1a). A surgery was performed in the first admitted hospital to excise the airbag cover and to debride small pieces of the fractured mandible. The resulting mandibular defect was reconstructed with plate and screws to avoid its collapse. The patient had a near hemi-mandibular defect when he was referred to our hospital (Fig. 1b). An osteocutaneous iliac free flap was used in the first stage to reconstruct the mandibular defect. The left facial artery and vein were used as first recipient vessels. The cutaneous component was added for monitoring of the flap viability. Hematoma formation was observed on the first postoperative day; the hematoma was drained in the operating room, and the vascular anastomoses were seen as patent. On the seventh postoperative day, the cutaneous component of the iliac flap was excised and the defect was primarily repaired. In the early postoperative period, intraoral wound dehiscence and mucosal defect were observed. A second surgery was performed, and a radial forearm free flap was used to reconstruct the intraoral defect on the 14th postoperative day. The right facial artery and vein were used as recipient vessels for radial forearm flap. The tracheostomy defect was closed in the second postoperative month; debulking of the radial forearm flap was done in the eighth postoperative month. No late postoperative complications were seen. The jaw movements were evaluated as mod-

Cite this article as: Akşam E, Sönmez E, Karaaslan Ö, Durgun M. Airbag cover impact: a rarely seen reason for mandibular defects. Ulus Travma Acil Cerrahi Derg 2019;25:86-88.

Address for correspondence: Ersin Akşam, M.D. İzmir Katip Çelebi Üniv. Atatürk Eğit. ve Araşt. Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Kliniği, İzmir, Turkey.

Tel: +90 232 - 243 43 43 E-mail: ersinaksam@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(1):86-88 DOI: 10.5505/tjtes.2018.50494 Submitted: 21.07.2018 Accepted: 15.10.2018 Online: 25.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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(a)

(b)

Figure 1. (a) Anterior and lateral oblique view of the three-dimensional computed tomography of the patient. The cover of the steering wheel was embedded into the mandible causing a multi-segment fracture. (b) After excision of the airbag cover and removal of necrotic bone segments, left hemi-mandibular defect was temporarily repaired with plate and screws to prevent its collapse.

erate-good in the late postoperative period (Fig. 2a-c). Both the patient and the surgeons were satisfied with the result.

DISCUSSION Maxillofacial bone fractures usually occur in motor vehicle accidents; these fractures can occur either as an isolated injury or can be accompanied by other injuries including those to extremities as well as cranial and spinal injuries. Airbags are lifesaving technologic devices; however, some mandatory rules need to be followed for the beneficial use of these devices. Simoni et al.[2] have found significant benefits

(a)

(b)

of using together airbags and seatbelts on the occurrence of facial fractures. Airbag deployment usually causes minor injuries including abrasions, contusions, and lacerations.[3] In the presented case, the patient was driving without wearing a seatbelt. A relatively low-velocity motor vehicle crash (at 40 km/h) occurred when the patient was paying attention to his new carâ&#x20AC;&#x2122;s music system. To our knowledge, this is the first report of a multi-segment mandible fracture caused by the embedding of an airbag cover on the steering wheel into the mandible. Aggressive debridement and removal of the necrotic bone segment had been performed in another city hospital, resulting in a hemi-mandibular defect. We planned

(c)

Figure 2. (a-c) Postoperative radiograph and view of the patient. The iliac crest free flap was properly incorporated to the defect. The occlusion and mouth opening was very good.

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free iliac bone-skin flap for reconstruction of defects involving the corpus-angulus regions of the mandible. The greatest advantage of the iliac flap was that it did not require an extra osteotomy because the mandible shape was similar to the original shape of iliac bone, and thus, flap viability was more reliable. Wound dehiscence has been seen in the intraoral side of the closure in the follow-up period; thus, we had to perform a second reconstructive procedure. The radial forearm free flap was chosen for the reconstruction of intraoral defect because of its pliable nature.

In conclusion, this is the first report of a multi-segment mandibular fracture caused by the collision of the airbag cover. There is no reported data on the biomechanical effect of steering wheel-airbag cover impact at the time of motor

vehicle accidents. The case presented here is an example of an unexpected significant mandibular defect caused by embedding of airbag cover into the mandible that needed complex reconstructive procedures.

Conflict of interest: None declared.

REFERENCES 1. Zador PL, Ciccone MA. Automobile driver fatalities in frontal impacts: air bags compared with manual belts. Am J Public Health 1993;83:661– 6.

2. Simoni P, Ostendorf R, Cox AJ 3rd. Effect of air bags and restraining devices on the pattern of facialfractures in motor vehicle crashes. Arch Facial Plast Surg 2003;5:113–5.

3. Antosia RE, Partridge RA, Virk AS. Air bag safety. Ann Emerg Med 1995;25:794–8.

OLGU SUNUMU - ÖZET

Hava yastığı kapağı çarpması: Mandibula defektinin nadir görülen bir sebebi Dr. Ersin Akşam, Dr. Erhan Sönmez, Dr. Önder Karaaslan, Dr. Mustafa Durgun İzmir Katip Çelebi Üniversitesi Atatürk Eğitim ve Araştırma Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İzmir

Motorlu taşıt kazalarından sonra ağır yaralanmalar için hava yastıkları ve emniyet kemerleri ana koruma yöntemidir. Hava yastığının açılması sonucu meydana gelen yaralanmalar hakkında birçok çalışma bildirilmiştir. Bu olgu sunumu, hava yastığı kapağının çarpmasından kaynaklanan çoklu mandibula kırığı ile sonuçlanan ilk olgu sunumudur. Canlı olmayan kemik parçaları debride edildi ve ortaya çıkan hemi-mandibula defekti serbest iliak krest flebi ile rekonstrükte edildi. Mukozal defekti yeniden oluşturmak için radyal ön kol serbest flebi yapıldı. Hava yastıkları, önlemlere göre kullanıldığında ölümcül yaralanmaları önler. Bununla birlikte, açılma sırasında maksillofasiyal kemiklere ciddi şekilde zarar verebilirler.

Anahtar sözcükler: Hava yastıkları; kazalar; motorlu taşıtlar; serbest flepler; trafik.

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CAS E R EP O RT

Improvement of a duodenal leak: Two-way vacuum-assisted closure Seracettin Eğin, M.D., Berk Gökçek, M.D., Metin Yeşiltaş, M.D., Semih Hot, M.D., Dursun Özgür Karakaş, M.D. Department of General Surgery, Health Sciences University, Okmeydanı Training and Research Hospital, İstanbul-Turkey

ABSTRACT A 55-year-old male patient developed a duodenal re-leak, which caused severe peritonitis, on the second postoperative day after surgery to treat an acutely perforated duodenal ulcer. Relaparotomy was performed 2 days after surgery for the re-leak after omentoplasty. The necrotic omentum was dissociated from the bulbus duodeni. Viable omentum for reinsertion of the omental patch was not found. The turned-outward duodenal mucosa was excised and the duodenal perforation was sutured. Two-way vacuum-assisted closure (VAC) was carried out by taking a liquid culture of the abdomen and washing the abdomen. The two-way VAC exchange procedures were continued every 3 days until the re-leak was terminated. The whole treatment process occurred in the intensive care unit. The duodenal leak was completely stopped by 41 days after surgery. The subcutaneous layer was dissected from the fascial layer of the anterior wall of the abdomen; thus, the abdominal skin was closed without tension and the patient was subsequently discharged.

In conclusion, since primary source control is often difficult when treating duodenal leaks, the two-way VAC system is a convenient solution for localizing the source of the peritonitis and removing toxic peritoneal material.

Keywords: Duodenal leak following omentoplasty; duodenal ulcer perforation; vacuum-assisted closure.

INTRODUCTION Re-leak following omentoplasty for acute duodenal ulcer perforation is a well-known clinical issue with a high mortality rate. The incidence of re-leak following omentoplasty ranges between 4 and 16% in various studies.[1–3] Kumar et al.[4] cited the following risk factors for re-leak after surgical closure of a perforated duodenal ulcer by Graham’s Patch: age >60 years, pulse rate >110/minute, blood pressure <90 mmHg, hemoglobin <10 g/dL, serum albumin <2.5 g/dL, total lymphocyte count <1800 cells/mm³, and perforation size >5 mm. The size of the peptic duodenal ulcer and the serum albumin and hemoglobin levels were independent risk factors in a multivariate analysis.

The presently described case had severe peritonitis due to re-leak after a Roscoe-Graham operation for an acute per-

forated duodenal ulcer, which was managed by implementing two-way VAC.

CASE REPORT The patient, a fifty-five-year-old male, had severe and diffuse abdominal pain, loss of appetite, nausea, and vomiting for the previous 24 hours. Abdominal rigidity and rebound was determined in the physical examination, and subdiaphragmatic free air was seen in a plain x-ray. In the preoperative stage, the pulse rate was 120 beats/minute, blood pressure was 80/40 mmHg, hemoglobin was 17.3 g/dL, total lymphocyte count was 880 cells/mm³, and serum albumin was 2.1 g/dL. The patient was operated on using the Roscoe-Graham technique for acute duodenal ulcer perforation. The size of the perforation on the front wall of the bulbus duodeni was 10 mm. Re-leak following omentoplasty was diagnosed 2 days

Cite this article as: Eğin S, Gökçek B, Yeşiltaş M, Hot S, Karakaş DÖ. Improvement of a duodenal leak: Two-way vacuum-assisted closure. Ulus Travma Acil Cerrahi Derg 2019;25:89-92.

Address for correspondence: Seracettin Eğin, M.D. SBÜ 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 2019;25(1):89-92 DOI: 10.5505/tjtes.2018.22934 Submitted: 26.11.2018 Accepted: 27.12.2018 Online: 29.12.2018 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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EÄ&#x;in et al. Improvement of a duodenal leak: Two-way vacuum-assisted closure

after surgery as soon as the tube drainage was observed to have bilious content and relaparotomy was performed immediately (Fig. 1a). Abundant bile fluid was detected in the abdomen. Necrotic omentum was dissociated from the bulbus duodeni and viable omentum for reinsertion of an omental patch was not found. The duodenal mucosa had turned outward. After taking the sample for culture, the bile fluid was aspirated, and the peritoneal cavity was irrigated with 12 liters of warm sterile saline. The turned-outward duodenal mucosa was excised, and the duodenal perforation was closed by suturing with a 2/0 vicryl. At the time of re-suturing, a two-way VAC management system was applied because of the increased risk of continuous re-leak in the following period (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 with six additional sponge extensions. One tip of the extracted additional sponge extension was placed next to the duodenal perforation and the other tip was taken out of the upper-right quadrant. Five additional sponge extensions were carried out in the abdominal cav-

(a)

(c)

ity. The two sets of sponge extensions were separately connected to 2 vacuum devices with 75 mmHg of pressure. The external appearance of the first VAC application can be seen in Figure 1b. Total parenteral nutrition was initiated for the patientâ&#x20AC;&#x2122;s feeding and sustained until the abdomen was closed.

Nasogastric tube application was also continued until definitive abdomen closure. The two-way VAC procedures were carried out at 3-day intervals and included taking a liquid culture from the abdomen and washing the abdomen. It was constantly observed that the leak from the sutured duodenal perforation continued during the two-way VAC change applications. Acinetobacter baumannii was observed in the liquid culture of the abdomen, and therefore the patient was treated with meropenem and tazobactam. All treatment processes were sustained in the intensive care unit after VAC exchange applications. Forty days after surgery, no more bile leaked into the VAC liquid collection canister and only serous fluid was seen. Abdominal computerized tomography (CT) with double contrast (oral and intravenous) was performed in the same day. No contrast leak was detected by abdominal CT; therefore, we concluded that the abdominal was defini-

(b)

(d)

(e)

Figure 1. (a) Peritonitis due to duodenal leak following omentoplasty. (b) The external appearance of the two-way vacuum-assisted closure technique. (c) No bile leakage is present, and the inside of the abdomen is completely clean. (d) The abdominal skin was closed after dissecting the subcutaneous layer from the fascial layer of the abdomen. (e) External image of the abdomen six months after discharge.

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tively sealed. The next day, it was observed that the duodenal leak was completely stopped. Figure 1c shows that no bile leakage was present, and the inside of the abdomen was completely clean. The subcutaneous layer was dissected from the fascial layer of the anterior wall of the abdomen. Thus, the OA was closed by skin without tension (Fig. 1d) and the patient was discharged. The external image of the abdomen six months after discharge is shown in Figure 1e.

ulcer perforation. This strategy was also successfully carried out in three cases with anastomotic leak following upper gastrointestinal system surgery and esophagojejunostomy; the first of these three cases was previously reported.[8] The twoway VAC technique should encourage surgeons to remedy both a re-leak following Roscoe-Graham omentoplasty and an anastomotic leak following upper gastrointestinal system surgery.

DISCUSSION

The three separate additional surgical techniques applied by Maghsoudi and Ghaffari also included continuous intra-abdominal irrigation and long-term hospitalization[3] and, overall, had a 70.6% success rate. The number of re-leak cases following omentoplasty (17 patients) was low, particularly when considering the study performed by Saurabh et al.[3,5] The additional surgical procedures performed in two studies were dissimilar except for the jejunal patch. The numbers of patients treated using the jejunal patch technique were 1/17 and 7/41 in the first and second studies, respectively. In the second study, the mortality rate increased as the variety and number of additional surgical procedures was augmented. In the second study, 13 patients treated conservatively died.

In both first and second study, it was thought that primary source control was not sufficiently provided in mortal patients. The most common cause of mortality in these studies was sepsis.[3,5]

Until today, various studies have recommended multiple surgical and conservative methods for the management of re-leak following omentoplasty. Maghsoudi and Ghaffari suggested sub-hepatic drainage and re-insertion of the omental patch, only sub-hepatic drainage, and a jejunal serosal patch.

[3] Saurabh et al.[5] recommended cholecystoduodenoplasty, a jejunal patch, triple-tube-ostomy, T-tube duodenostomy, and conservative methods. The incidence of mortality in these two studies was 5/17 (29.4%) and 32/41 (78%), respectively.

The rate of success in stopping the leak was observed as high (12/17, 70.6%) in the first study but rather low (9/41, 22%) in the second study.[3,5] The second study stated that 26 of 32 mortality patients died due to sepsis.[5] In severe abdominal sepsis, the open abdomen (OA) may allow control of any persistent source of infection and the effective removal of infected or cytokine-loaded peritoneal fluid. Vacuum-assisted closure (VAC) techniques have a history of safety as the most extensively used methods for temporary abdominal wall closure.[6] In cases with a persistent source of peritonitis (unsuccessful source control), the OA is an option for emergency surgery patients with severe peritonitis and severe sepsis or septic shock (grade of recommendation 2C).[7] The additional surgical procedures recommended in various studies for the management of re-leak following omentoplasty are not always successful. These surgical procedures have very low success rates. The sutures that enter into the abdomen are contaminated by the bile leak and therefore are not safe. Infected and edematous tissues are usually cut by the applied suture. All types of anastomosis in the contaminated abdomen may be resulted in failure. Additional surgical procedures in patients with severe peritonitis always increase the risks of morbidity and mortality. It is not always possible to control the primary source in patients with duodenal leakage; in these patients, it is necessary to localize the duodenal leakage completely. The two-way VAC system is well-suited to localize the duodenal leakage completely and discharge the toxic liquids that accumulate in the abdomen. In addition, the VAC system accelerates the formation of granulation tissue; for this reason, the duodenal perforation closes early with the granulation tissue. The reason for applying the low pressure of 75 mmHg is to avoid increasing the duodenal leakage with an excessive negative pressure effect. This patient was our first case using the two-way VAC system for re-leak management following omentoplasty due to an acute duodenal Ulus Travma Acil Cerrahi Derg, January 2019, Vol. 25, No.1

In conclusion, since primary source control is often difficult when treating duodenal re-leaks, the two-way VAC technique is a convenient solution for localizing the peritonitis source and removing toxic peritoneal material. Moreover, intraabdominal sepsis in duodenal re-leaks may be treated without additional surgical procedures via the two-way VAC technique.

Conflict of interest: None declared.

REFERENCES 1. Chalya PL, Mabula JB, Koy M, Mchembe MD, Jaka HM, Kabangila R, et al. Clinical profile and outcome of surgical treatment of perforated peptic ulcers in Northwestern Tanzania: A tertiary hospital experience. World J Emerg Surg 2011;6:31.

2. Gupta S, Kaushik R, Sharma R, Attri A. The management of large perforations of duodenal ulcers. BMC Surg 2005;5:15.

3. Maghsoudi H1, Ghaffari A. Generalized peritonitis requiring re-operation after leakage of omental patch repair of perforated peptic ulcer. Saudi J Gastroenterol 2011;17:124–8.

4. Kumar K, Pai D, Srinivasan K, Jagdish S, Ananthakrishnan N. Factors contributing to releak after surgical closure of perforated duodenal ulcer

by Graham’s Patch. Trop Gastroenterol 2002;23:190–2.

5. Saurabh S. Sanjanwala, Vinaykumar N. Thati1, Omprakash S. Rohondia, Samir U. Rambhia. Comparison of operative procedures for re-leaks duodenal perforation: a cross-sectional analysis from a tertiary care hospital in a developing country. Int Surg J 2016;3:1314–7.

6. Sartelli M, Abu-Zidan FM, Ansaloni L, Bala M, Beltrán MA, Biffl WL, et al. The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper. World J Emerg Surg 2015;10:35.

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Eğin et al. Improvement of a duodenal leak: Two-way vacuum-assisted closure 7. Coccolini F, Roberts D, Ansaloni L, Ivatury R, Gamberini E, Kluger Y, et al. The open abdomen in trauma and non-trauma patients: WSES guidelines. World J Emerg Surg 2018;13:7.

8. 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;24:601–3.

OLGU SUNUMU - ÖZET

Duodenal kaçağın iyileştirilmesi: İki yönlü vakum yardımlı kapama Dr. Seracettin Eğin, Dr. Berk Gökçek, Dr. Metin Yeşiltaş, Dr. Semih Hot, Dr. Dursun Özgür Karakaş Sağlık Bilimleri Üniversitesi, Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

Elli beş yaşında erkek hastada, perfore duodenal ülserin tedavisi için yapılan ameliyattan sonraki ikinci günde ciddi peritonite neden olan duodenal kaçak gelişti. Omentoplasti sonrası tekrar sızıntı nedeniyle ameliyattan iki gün sonra relaparotomi yapıldı. Nekrotik omentum, bulbus duodeniden ayrılmıştı. Omental yamanın yeniden yerleştirilmesi için canlı omentum bulunamadı. Dışa dönmüş duodenum mukozası kesildi ve duodenum perforasyonu dikildi. İki yönlü vakum yardımlı kapama (VYK), karın sıvı kültürü alınarak ve karın yıkanarak yapıldı. İki yönlü VYK değişim işlemleri, sızıntı sonlandırılana kadar her üç günde bir sürdürüldü. Tüm tedavi süreci yoğun bakımda gerçekleşti. Duodenal sızıntı ameliyattan 41 gün sonra tamamen durdu. Cilt altı tabakası karın ön duvarının fasiyal tabakasından ayrıştırıldı; böylece, karın cildi gergin olmadan kapatıldı ve hasta daha sonra taburcu edildi. Sonuç olarak, primer kaynak kontrolü duodenal sızıntıları tedavi ederken sıklıkla zor olduğu için, iki yönlü VYK sistemi, peritonit kaynağını lokalize etmek ve toksik peritoneal materyali uzaklaştırmak için uygun bir çözümdür.

Anahtar sözcükler: Duodenal ülser perforasyonu; omentoplasti sonrası duodenal kaçak; vakum yardımlı kapama.

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doi: 10.5505/tjtes.2018.22934

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