TRAUMA 2019-6

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

ISSN 1306 - 696X

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

Özozan ÖV, et al. p. 545

Volume 25 | Number 6 | November 2019

Volume 25 | Number 6 | November 2019

www.tjtes.org

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi Editor-in-Chief Recep Güloğlu Editors M. Mahir Özmen Kaya Sarıbeyoğlu Osman Şimşek Publication Coordinator Mehmet Eryılmaz 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)

Orhan Alimoğlu Mehmet Eryılmaz Ali Fuat Kaan Gök Gökhan Akbulut Osman Şimşek Münevver Moran Adnan Özpek

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

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

Publisher (Yayımcı): KARE Yayıncılık (KARE Publishing) • www.kareyayincilik.com • Design (Tasarım): Ali Cangül • Graphics (Grafikler): Edibe Çomaktekin • Linguistic Editor (İngilizce Editörü): Suzan Atwood • Redaction (Redaksiyon): Erman Aytaç • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): November (Kasım) 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 0.643 (JCR 2018). 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. 2018 Journal Citation Report IF puanımız 0.643 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 6 November - Kasım 2019

Contents - İçindekiler

Deneysel Review - Çalışma Derleme - Experimental Study 535-544 Use of software in the ICU Yoğun bakımda yazılım kullanımı Bahar M, İnel EY

Experimental Studies - Deneysel Çalışma 545-554 Is tri-iodothyronine a better choice than activated protein C in sepsis treatment?

Sepsis tedavisinde triiyodotironin aktive protein C’ye göre daha iyi bir seçenek midir? Özozan ÖV, Ertorul D 555-560 An anatomical examination of iatrogenic nerve injury during inside out meniscus repair with flexion and extension of the knee Diz fleksiyon ve ekstansiyon pozisyonundayken içten-dışa menisküs tamiri sırasında iyatrojenik sinir hasarının anatomik muayenesi Atbaşı Z, Erdem Y, Neyişci Ç, Yılmaz B, Demiralp B

Original Articles - Orijinal Çalışma 561-566 Abdominal perfusion pressure is superior from intra-abdominal pressure to detect deterioration of renal perfusion in critically Ill patients Kritik hastalarda abdominal perfüzyon basıncı renal perfüzyondaki bozulmanın saptanmasında karıniçi basınçtan daha üstündür Gül F, Sayan İ, Kasapoğlu US, Erol DÖ, Arslantaş MK, Cinel İ, Aykaç Z 567-574 Factors affecting mortality in traumatic diaphragm ruptures Travmatik diyafragma yaralanmalarında mortaliteye etkili faktör Tokgöz S, Akkoca M, Uçar Y, Yılmaz KB, Sevim Ö, Gündoğan G 575-579 Abdominal cocoon syndrome: A rare cause of acute abdomen syndrome Abdominal koza sendromu: Akut karın sendromunun nadir bir neden Çolak Ş, Bektaş H 580-584 Omentopexy versus falciformopexy for peptic ulcer perforation Peptik ülser perforasyonunda omentopeksi ile falsiformopeksinin karşılaştırılması Ölmez A, Çiçek E, Aydın C, Kaplan K, Kayaalp C 585-588 Non-operative management of perforated peptic ulcer: A single-center experience Peptik ülser perforasyonunun ameliyatsız tedavisi: Tek merkez deneyimi Karabulut K, Dinçer M, Liman RK, Usta S 589-596 Evaluation of current therapeutic approach to obstructive and perforated colorectal cancers Obstrükte ve perforasyonlu kolorektal kanser hastalarına güncel tedavi yaklaşımının değerlendirilmesi Kaya S, Seker A, Altın Ö, Altuntaş YE, Kaptanoğlu L, Kement M, Bildik N, Küçük H Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

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

Number - Sayı 6 November - Kasım 2019

Contents - İçindekiler 597-602 Versatile use of the posterior interosseous flap in the reconstruction of complex upper limb defects Karmaşık üst uzuv defektlerinde ‘posterior interosseöz flebin’ çok yönlü kullanımı Barın EZ, Çinal H, Kara M, Çakmak MA, Tan Ö 603-610 Atypical femoral fractures related to bisphosphonate use: A comprehensive review of 19 patients Bifosfonat kullanımı ile ilişkili atipik femur kırıkları: 19 hastanın kapsamlı değerlendirmesi Şahin K, Ergin ÖN, Bayram S, Akgül T 611-615 Comparison of surgical techniques and results for emergency or elective femoral hernia repair Acil veya elektif uygulanmış femoral herni tamirinin cerrahi tekniği ve sonuçlarının karşılaştırılması Kunduz E, Sormaz İC, Yapalak Y, Bektaşoğlu HK, Gök AFK 616-621 Comparison of methods for closure of appendix stump during laparoscopic appendectomy using endoloops: Single surgeon experience Laparoskopik apendektomilerde endoloop ile güdük kapama tekniği karşılaştırılması: Tek hekim deneyimi Çelik Y, Erbil OA 622-627 Evaluation of the necessity of whole-body scan tomography in cases with head trauma Kafa travmalı olgularda tüm vücut tarama tomografisinin gerekliliğinin değerlendirilmesi Yaşaran İ, Karakuş A, Kuvandık G, Sebe A, Kekeç Z

Case Reports - Olgu Sunumu 628-630 Small bowel prolapse from anus: Atypical presentation of rectal perforation Anüsten ince bağırsak prolapsusu: Rektal perforasyonun atipik prezentasyonu Akbulut S, Bozkurt MA, Kabuli HA, Güneş ME 631-634 First report of traumatic scleral rupture after penetrating keratoplasty Penetran keratoplasti varlığında travmatik skleral rüptür gelişen ilk olgu Arıcı C, Hagverdiyeva S, Mergen B, Mangan MS, Arslan OŞ

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RE VI EW

Use of software in the ICU Mois Bahar, M.D.,

Emin Yalçın İnel, M.D.

Department of Intensive Care Unit, VKV American Hospital, İstanbul-Turkey

ABSTRACT In the continuum of the complex therapy process of a critically ill patient, the intensive care unit (ICU) period must be followed very meticulously because of the extremely data-intensive circumstances. Intensive care medicine is a lot more reliant on “numbers” than most of the other medical disciplines, and minor errors in the records may lead to wrong decisions, which may cause major harm to the patient. Manual records are prone to errors, inaccuracies and are time-consuming for both nurses maintaining them and physicians trying to interpret them, especially in patients with complex pathologies and long-term stays. Since the introduction of the first general-purpose computer, ENIAC (Electronic Numerical Integrator and Computer) in 1946, there have been attempts to integrate computers into medicine and in the last decades, we are witnessing the emergence of intensive care information systems (ICIS). ICIS has the potential to increase the quality and accuracy of the medical records, while also decreasing the incidence of medical errors.

They present electronic decision support and tools for quality control and performance evaluation. More importantly, they allow a medium where the physician can easily assess the current condition of the patient from different perspectives. So far, the usage of ICIS has been limited due to high costs and some other factors. Although we are in a technologically advanced position today, it is still a challenge to implement an ICIS successfully. If not planned properly, it is a process prone to significant delays in time, additional costs, poor acceptance by the staff and even total failure. In this study, we are going to evaluate the past, present and future of intensive care information systems and share our experiences in implementing them.

Keywords: Data management; ICU; information systems; quality management; software.

Critically ill patients may have many typical characteristics in their complex treatment needs, often with multiple organs affected and they are a heterogeneous group, including patients with traumatic injuries (e.g. to the skeletal system, brain, thorax, or abdomen) or burns, systemic infections, surgical complications (e.g. major blood loss or respiratory deficiencies) and multiple organ failure. However, a common feature of different critical illness pathologies is that they all give rise to severe metabolic stress often, develop systemic inflammation and multiple organ dysfunctions.

In the continuum of this complex therapy process of a critically ill patient, the intensive care unit (ICU) period must be followed very meticulously because of the extremely dataintensive circumstances. The quality of the care administered during this phase is difficult to evaluate and quantify since

there are many factors affecting the process. ICU beds are used for those patients who have the chance to survive with specific therapeutic and supportive approaches depending on an accurate collection of the real-time data measurements gathered from many different devices that are in function.

Thus, the collection of the laboratory and radiological findings are also of great importance.

A majority of the ICU’s are still using traditional paper worksheets maintained in folders. The nursing care also has its special records system based on manual records and maintains them in different sections of the folder. Meantime, the inadequacies of the paper record are observed frequently.

During long term stays, the relationship and pathological influence between the organ dysfunctions require some needs for a reevaluation of the patient; it becomes very difficult to

Cite this article as: Bahar M, İnel EY. Use of software in the ICU. Ulus Travma Acil Cerrahi Derg 2019;25:535-544.

Address for correspondence: Mois Bahar, M.D. VKV Amerikan Hastanesi, Genel Yoğun Bakım, Güzelbahçe Sk., No: 20, Nişantaşı, Şişli, 34365 İstanbul, Turkey Tel: +90 212 - 414 33 02 E-mail: bahar.mois@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(6):535-544 DOI: 10.14744/tjtes.2019.28282 Submitted: 30.11.2018 Accepted: 16.01.2019 Online: 25.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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source back the whole course through the voluminous collection of papers.

The easiest way to solve this heavy, uncomfortable and timeconsuming problem in the ICU’s is to implement Intensive Care Information System (ICIS). Between 1985–1990, some hospitals’ administration departments have started to use computers for the billing and other office purposes for the first time. Within time, the development in modern information technology influenced the daily practice in the hospitals and especially in the ICU considerably. The main reason for the ICIS implementation delay in some ICUs in the past was the high cost, and unfortunately, this problem is still remaining. Another important point is that not enough funding can be provided to have technical staff for the maintenance of these clinically integrated complex computer systems.

History The first forms of medical records dating back to ancient Egyptian papyri from 1600–3000 BC. However, until 1900– 1920, medical records were not used in a steady and organized manner.

Silent period: Since the introduction (1946) of the first general-purpose computer, ENIAC (Electronic Numerical Integrator and Computer) weighing over thirty tons, there have been attempts to integrate computers into medicine. Even in the 1950s, the National Institutes of Health started research for problems that would be suitable for computers to solve.

During that period, large hospitals began using computers for archival purposes, as well. The first mainstream experiences with information technology in healthcare started in the 1960s and were based on administrative and billing purposes.

First reports of ICIS usage in the ICU were from the 1970s and demonstrated a decrease in ICU length of stay.[1,2] Active period: Only a few early Electronic Health Records (EHRs) allowed for physician order entry and data entry through keyboard-only interfaces, and were focused mostly on laboratory results and medication review. While the computers were mostly used by scientists and engineers in the past, advances in technology allowed for smaller, more powerful and more affordable devices and after the invention of mouse, operating systems with graphic user interfaces introduced in the 1990s certainly made the computers and therefore EHRs more mainstream and open to average consumer usage. As the shortcomings of manual records were becoming more apparent in the 1990s, the Institute of Medicine suggested a transition from manual records to electronic health records. However, the widespread usage of EHRs delayed due to high costs, data entry errors and poor initial acceptance by staff. The goal of a complete transition to paperless records was not deemed financially feasible at that time, and the authors suggested that only key data should be computerised, so EHRs would complement but not replace manual records.

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The 1990s saw the networks of personal computers that were used to prescribe inpatient orders linked to EHRs. While this significantly lowered charges, it was more timeconsuming than the manual charts. After the development of patient data management systems, the EHRs were able to connect to bedside monitors so that the clinical data could be recorded and interpreted. The early forms of EHRs were developed with hierarchical or relational databases around or added to hospital scheduling and billing systems, while others, such as TMR, HELP, COSTAR, and PROMIS, were developed as clinical systems to help the physician with their patient data management systems. The EHRs were able to connect to bedside monitors, so clinical data could be recorded and interpreted. Since the laws still held physicians accountable for the accuracy and completeness of the medical orders, all the collected data had to be re-evaluated and approved by the physician. Soon, there was a significant amount of data ready for research and epidemiologic studies, but these efforts showed that the “quality” of the data should always be double-checked to prevent misinformation and patient harm.[2]

Computers in the ICU The first publications about the computer usage in the ICU date back to 1965 by Stacy et al., 1966 by Shubin et al, and to 1968 by Osborn et al., but they were used mainly to assist in calculations. After these first attempts, the first generation of commercial systems emerged between 1972–1988, enabling to connect to patient monitors and collect clinical data. The second generation of these systems between 1988 and 1994 was able to present data graphically and were easier to use with their graphical user interface after the emergence of personal computers. Since the last decade, the third generation of systems made significant progress in data collection from all the devices connected to each patient with improvements in networking technologies and the ability to deploy a personal computer for each patient.[2] Since the 1990s, computers have become an integral part of the daily routine of healthcare professionals; especially the intensivists put their challenge in the field as they worked within a digital concept in their daily life using all the modern devices. Whether we work in a paperless ICU or a completely conventional manual ICU, today, almost every clinical task is somehow dependent on computers since most of the devices we use have built-in hardware processors. Any modern device, whether they are patient monitors, ventilators, infusion pumps, pulse-wave analysis devices, blood-gas analysis, or almost all of the lab devices, hemodiafiltration machines, or ECMO devices are working with the same concept.

Their main disadvantage as of today is that most of them have the ability to store the data they produced only within limited periods of time, and more importantly, they are incapable of putting them in a meaningful context.

The problem is that this data contributes to a flood of information, overloading the physicians with over 1000 pieces Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

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of data to analyse from each of their patients.[1] It must be considered that computers have the possibility to do the synthesis of knowledge much more intelligently than professional individuals. And furthermore, more than 236 different variable categories have been reported in an ICU record and considering that humans are capable of properly analyzing only five to nine parameters at a time, this exceeds human intellectual capability by far.[3] Considering the leaps in technology happening each day, this overload only seems to grow day by day with each new ICU equipment.

The Yearbook of Medical Informatics published in 1999 gave rise to some questions as “the renewed promised of medical informatics”, which were discussed by JH van Bemmel and AT McCray in 2016. This paper demonstrates the areas with the early promises, and the authors grouped them into four main categories as follows: electronic patient records, clinical support systems, decision support systems, ethical and philosophical aspects, the evolution of the computer and model for computer applications in health care. They summarize, giving the details within a concept comparing to a building with six floors. The bottom first three levels are the most difficult levels to perform and are directly related to the implementation of an ICIS in an ICU. The other top 4th, 5th, 6th levels must be governed by professional individuals because of their dependency.[4]

Traditional Paper-based Unit (Paperwork) and Errors Medical errors are common among patients requiring intensive care. As mentioned above, intensive care medicine is a lot more reliant on “numbers” than most of the other medical disciplines and little errors in charting may lead to wrong decisions, which may cause serious harm to the patient. The ICU staff works hard to record each event, but the limits of manual records with their preset time intervals may give rise to the physician to miss the details “in-between.” Not everyone’s handwriting is perfect, so the readability is another disadvantage in manual records when reading charts and may bring about major problems in data interpretation. Although clinical observations are still very important, numerical values, such as laboratory results, fluid balance and monitor data, may influence our choice in treatment much more frequently than we imagine in intensive care medicine. Any error in transcribing these values may cause serious harm to the patient.[1] Considering the rapid advances in science nowadays, the amount of information regarding new drugs, dosing, treatment protocols and adverse effects makes the memory of a physician not a reliable tool. Manual prescription is a major source of errors, both in the choice of drugs and the appropriate dose and also in the execution of drug administration by the nurses. Long working hours and sleep deprivation are unfortunate facts in the clinician’s life and render them susceptible to fatigue-induced medical errors, as well.

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[3] Many studies have shown that the nurses’ paperwork is very loaded, which results in a long time spent in the ICU and comparatively less patient care. In a complex patient who needs more care, the reverse happens, and sometimes, the charting quality decreases considerably.

Manpower and Costs Although the idea of a paperless ICU sounds inviting, the installation, setting up and maintenance requires a considerable amount of manpower and money. The acquisition of software by itself is not the only financial burden; the regular maintenance of the software, and the payrolls of the IT staff should not be overlooked as well. There are also reports of physicians and other healthcare staff’s complaints regarding increased workload and inflexibility of EHRs and Computerized Physician Order Entry (CPOE). These complaints resulted in the use of medical scribes specialized in charting medical data and navigating the EHRs. Despite these complaints, to our knowledge, there have been no studies comparing the ICIS and manual records regarding the utilization of ICU physician’s time.[2,3] When robots entered the factories, they helped companies to decrease the size of their worker force. The ICIS may not decrease the nursing work, therefore it has no potential of reducing the nursing staff as of today, but it does improve the quality, accuracy, timely capture and recall of important clinical data, while also reducing nursing clerical work.[1] ICIS from vendors are mostly expensive, but there are reports of successful usage of open source systems in poor countries. Although these have limited capabilities, they often offer a better option than manual records, and their functionalities are getting improved each day.[2] Intensive care medicine is an extremely expensive specialty and consumes a significant amount of available healthcare resources. In the USA alone, the ICU medicine is estimated to consume 1% of the gross domestic product. The ICIS could help in the optimization of resources on the management level and lead to significant amounts of financial benefits.[3] There have been reports of fully integrated CIS to be costsaving, while also reducing hospital length of stay, morbidity and mortality. Although they may sound like an expensive investment, the improvements in quality and efficiency of care administered and the reduction in medical errors result in significant direct and indirect financial gains as well as nonfinancial gains that are impossible to measure in any currency.[1] Unfortunately, the implementation of the information technology, especially in the ICU, is not the way to decrease the workload of the medical staff. The need for the use of many devices generates more data. Thus, the amount of information will increase; and the interpretation will be facilitated, but it will consume more time. This situation may sometimes disturb 537

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medical staff, but the pool obtained from accurate and healthy data should be taken into consideration as main preference.

ICIS, and a dosing error in patients with renal failure was significantly reduced, as well.[3]

The database of an ICIS is an important tool for comparing ICU performance and costs Many commercially designed ICU software with their ability to integrate to billing software used in healthcare institutions help immensely with providing these statistical values within minutes, no matter which analysis method is used. The elimination of human error and timeframe constraints in manual data collection facilitates a much more precise way for statistical evaluation of ICU performance. Quoting Paul Batalden, “Every system is perfectly designed to achieve the results it achieves,” and considering the customization possibilities of ICU software, they may serve as an invaluable tool in the quality management of an ICU, as well.[3]

Performance Evaluation

Physician Order Entry Systems Computerized Physician Order Entry (CPOE) systems are the electronic prescription of medical orders. One of the main advantages of CPOE systems is to reduce errors that arise from handwritten readings, another advantage is its ability to help the clinician by recognizing the drug allergies and drug interactions, by showing relevant laboratory results, recommending the correct dose or dose adjustments in case of hepatic or renal failure and showing guidelines.[3] The optimal way of prescription should allow the physician to interact with three databases: (1) Patient’s drug history and current medications (2) Scientific drug information reference and guideline database (3) Patient-specific information, such as age, weight, allergies, diagnosis and laboratory results.

While the built-in computerized physician order entry (CPOE) systems in the ICIS may sound like an optimal solution and have the potential to eliminate this problem, the results of the studies conducted to evaluate its efficacy are too varied. On the one hand, there have been reports of the complete elimination of drug prescription errors and a significant reduction in adverse drug events (ADE) after the implementation of CPOEs. Bates reported a 55% decrease in non-intercepted serious medical errors after the introduction of CPOE. However, on the other hand, there are reports of consistently high rates of ADEs after the implementation of a CPOE and even higher mortality after CPOE implementation than before as well.[1] Successful implementation of CPOE with a sophisticated computerized decision support system for prescribing antibiotics was shown to significantly reduce the cost of drugs, total costs and the hospital length of stay. The effects of CPOEs in the ICU on medical errors were evaluated in a pediatric ICU, and a significant decrease in medication errors and a substantial decrease in adverse drug events was shown.

Another study showed a remarkable decrease of 26.5% vs 3.6% in medication errors after the implementation of an 538

The collection of accurately measured data is highly important and gives rise to evaluate the performance of an ICU. For many years, several scoring studies have been realized to collect scientific evidence. The ultimate aim was to develop effective and efficient treatments to reduce mortality and morbidity ratios in the ICU. In 1974, Cullen et al. created the first version of Traumatic Injury Scoring System (TISS), but in the 1980s, it was realized that the scores were decreasing each day even in non-survivors and the predicted mortality rates at their day of death was approximately 12%. Therefore, after APACHE score was introduced in 1981 by Knaus et al. and it was the first scoring system for evaluating the severity of illness applicable to most critically ill patients. Then, in 1986, Knaus et al. went on to propose the standardised mortality ratio (SMR) which is the ratio between the observed and predicted mortality.

This was an important step towards the evalution of the performance of an ICU. The APACHE Score underwent two revisions, namely APACHE II (1985 Knaus) and APACHE III (1991 Knaus). Le Gall presented the Simplified Acute Physiology Score (SAPS) in 1983 which was revised by the same author in 1993 as SAPS II. In 1985, the first version of Mortality Probability Model (MPM) was introduced by Lemeshow et al. and saw an update in 1993.

The Sequential (or Sepsis-related) organ failure assessment (SOFA) scoring system was created in a consensus meeting of the European Society of Intensive Care Medicine in 1994, and further revised in 1996.[5] SOFA is a widely used scoring system based on the number of organ failures present at the time of evaluation.

All of these scoring systems are still relevant and may be used in conjunction with SMR as a tool to evaluate how well an ICU performs based on the outcome. However, the consensus conference of European Society of Intensive Care Medicine in 1994 stated that although these systems are highly specific and may predict survival in 90% of the cases, their sensitivity is lower and may predict death in only 50–70% of the patients and therefore should not be used to predict the prognosis in individual patients.

One striking aspect is that the predicted mortality rates (PMR) in these scoring systems rise approximately 15–20% when data collection is carried out via intensive care information systems. Bosman wrote in 1998 that this might be related to the continuity of data collection with the electronic systems, whereas manual charts do the data collection within set time frames, mostly hourly and may miss abnormal physiological values, which leads to the underestimation of predicted mortality rates.[6] Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

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Risk-Adjusted Hospital Mortality Rate (RAHMR) is still an important outcome for institutions and the Joint Commission on Accreditation of Healthcare Organisations (JCAHO) since 2007 uses it to evaluate ICU performance.

In our unit, we use APACHE II, SOFA Scores to predict mortality rates (and also NUTRIC score to assess the nutritional status of the patients), and we compare these results with the realized mortality rates each month to evaluate our performance regarding mortality (Fig. 1). The introduction of the ICIS in our unit greatly improved the accuracy of the scores as well as the statistics. ICIS also facilitated a significant reduction in time spent in calculating both the scores and in the creation of the statistics.

However, since the ICU is a complex network with multiple factors affecting its quality, Elwood et al. (1988) proposed “outcome management” in 1988 with some additional endpoints. Another important aspect of the performance evaluation of an ICU is the effective utilization of its resources.

Although the ICUs in the UK receive 1–2% of the hospital budget compared to 20% in the US (Bion 1995), they perform equally well according to severity-adjusted outcomes. Economic restrictions may have a positive effect on streamlining healthcare processes and the elimination of unnecessary procedures without sacrificing the quality of care. The evaluation of cost-effectiveness is often carried out via the number of survivors, probability of survival, years of survival, or quality adjusted life years (QALYs) (Chalfin 1995). Smithies et al. in 1994 realized a cost-performance analysis based on APACHE II scores, TISS in relation to costs per survivor (CPS), costs per non-survivor (CPNS) and the effective cost per survivor (ECPS) in their ICU and while the CPS and CPNS remained in a narrow spectrum, ECPS showed an exponential rise as the predicted mortality ratios of the patients increased.[6]

Decision Support Computer Decision Support in the ICU should cover the following four basic areas:[3] • Interpretation of the collected data • Alerts (such as drug interaction, abnormal results)

• Diagnoses (such as early detection of sepsis, renal failure) • Treatment suggestions (such as the most appropriate antibiotic based on the culture results) For most of the chronic diseases, such as hypertension, cancer, or chronic obstructive pulmonary disease, the treatment may take weeks, months, or even years. In a typical ICU scenario, this cycle is reduced to days, hours, sometimes minutes and even seconds. Therefore, the clinician is constantly facing a race against time to analyse and act quickly.[3] Built-in Electronic Decision Support (EDS) systems have the potential to help the clinician to analyse the data if the customisation is done correctly, but as of today, we still need more improvements in EDS technology to replace human judgement.[7] Most of the EDS modules are focused on specific, clearly defined problems based mostly on one parameter and cannot be relied on in complex scenarios compared to a clinican’s reasoning. For example when the heart rate of a patient rises above 100 beats/min the EDS still cannot do the differentiation between agitation, seizure, fever, sepsis, electrolyte abnormalities, e.g., because to do that, it needs much more than complex algorithms: Clinical observation, physical examination and experience are still important tools in the arsenal of an intensivist.

Even though we complain of data overload in the ICU, we should consider that the computers have the potential to do the synthesis of knowledge much more intelligently then professional individuals. The human brain’s ability to connect all these dots is still far too superior to the ability of the computers. Therefore, in our unit, we do not rely on EDS modules on diagnosis and treatment, but we use some of them just as alarming tools for the staff, both nurses and physicians.

The reason for the inadequacy of the EDS modules is not only the lack of technology but also the lack of universally accepted decision support models or rules for the ICU, as well.

However, even if the EDS modules of an ICIS are not used, the ICIS itself can be identified as an EDS as well, because it helps the clinician to analyse the data faster, more accurately and in a much more organized manner than manual records and enriches the clinician’s reasoning process with trends, graphs and images in little time. A good decision requires

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Figure 1. Graph showing the difference between the predicted and realized mortality rates (%) in 2017 (American Hospital ICU Istanbul).

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good information and the ICIS, with its ability to integrate and organize the data coming from numerous devices in the ICU is a major help in this regard.

Quality Control One major disadvantage of these systems is “the artefact problem”. Measures must be in place to guarantee the accuracy of the retrieved data.[1] Otherwise, when the clinician is calculating APACHE II, a perfectly stable patient may have the minimum blood pressure showing up as 50/40 mmHg just because the nurse collects a blood sample from the arterial catheter. Considering the increase in the number of devices that are used in the ICU and the increase in the parameters they bring to the table, the possibility of more alarms increases as well. We are drowned in a flood of alarms each day and are at risk of overlooking important situations because of the “alarm fatigue”, but so far the efforts to facilitate “intelligent alarming” suffered from the loss of alarm sensitivity and resulted in an increase in the risk of missing important events. When the alarm specificity is increased, then, it becomes easier to miss potentially hazardous events, too.[8] All these alarms get recorded in the ICIS as well, since the systems cannot differentiate the artefacts from the real events, yet. Therefore, it is important to weed out these artefacts by the human hand to keep the records accurate. Otherwise, they may lead to false calculations and decisions, especially when calculating various ICU scores (e.g., APACHE II, SOFA, SAPS II, NUTRIC). To be able to differentiate the good information from the bad ones is a key factor when using ICIS. In an editorial, Purves pointed out the clinical behaviour needs and stated that the tools of “knowledge management” are more than a technical approach; they are also about human behaviours and mind-set, and the language used is not just evidence-based: it is experience-based, too.[9] The rapid technological advances in computer engineering and the research on artificial intelligence, as well as the steady increase in our knowledge in intensive care medicine, may allow significant improvements in the EDS systems in the near future.

Implementation of an ICIS The data overload we face every day in the ICU are problems for the computers, as well. It has become extremely hard and time-consuming to develop an ICIS on-site with the entire complex networking needs and the abundance of parameters needed to be implemented.

When we decided to implement an ICIS in our unit, we visited various ICUs that were using an ICIS. We believed that the most appropriate way was to experience a few days inside their unit to have the chance to analyse the first-hand experiences, understand the problems they are facing and their approaches on how to solve them. Therefore. we decided to follow the first step, which was the most viable option, to 540

buy a commercially available product that can be customised step-by-step until it suits the needs of our ICU. Finally, we understood that none of the products on the market is perfect and each has its own advantages as well as its disadvantages.

Although we are in a technologically advanced position today, it is still a challenge to implement an ICIS successfully. If not planned properly, it is a process prone to significant delays in time, additional costs, poor acceptance by the staff and even total failure.

Steps for a Successful Implementation of an ICIS (The Turkish Experience) Step 1. Decision: Our experience was mainly in line with this general approach. Our director made frequent visits to ICUs, which were using ICIS before deciding on a system. The hospital management was enthusiastic about the idea and gave total support, both by presenting the financial resources we needed and by encouraging us.

Step 2. The Build-up of the ICU Infrastructure: Although the main attention before the implementation period is usually focused on the choice of software, we would like to emphasize the importance of the equipment and infrastructure of the ICU where the ICIS is going to be implemented in. There is no advantage of using an ICIS if the equipment is not able to communicate with the software.

We decided to use an ICIS around the time of a complete renovation process, so before all the implementation period began, we made sure that the IT infrastructure of our ICU was able to handle all the data-traffic and chose only the equipment which was able to communicate with ICIS. We requested assurance from all the vendors of the devices that their devices are fully compatible with ICIS, and all the payments were made after their compatibilities with the ICIS were confirmed in real-time.

Step 3. Involvement of the Staff: Before the whole transition period began, three physicians and three nurses were designated to work cooperatively with the engineers of the software company to customise the software according to our specific needs. Physicians were mainly responsible for the translation and verification of data signals coming from the medical devices into the software, transcription of examination charts, enhancement of the drug database, and verification of the accuracy of the scoring system modules. Nurses transcribed their charts about various topics, including admission, routine care, quality management, safety protocols.

Meanwhile, two engineers from the hospital’s IT department were trained about the network needs of the software.

Step 4. Connection of the Monitor’s Data: The first step in connecting the devices with the ICIS was to make sure that the system was collecting all the relevant data from the patient monitors. We collected the data by hand and by ICIS and checked the data on multiple occasions minute-to-minute Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

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to ensure their accuracy. We created an interface window in the ICIS, identical to our main written ICU worksheet.

Step 5. Connection to the Hospital Central Laboratory Department: A direct connection to the laboratory server was created, which enabled us to see the results as soon as they were confirmed by the responsible physician in the laboratory. We ensured that each day that the routine test results were collected at 07:00 AM by the ICIS, just before the patient rounds began. The laboratory window in the ICIS was customised to group the results from the laboratory by each organ system.

Just like most of the ICUs, our ICU has its own blood gas analysis device, and we were able to connect this device to the ICIS, and all the results showed up on the blood gas screen as soon as they were compiled by the device.

Step 6. Connection to the Hospital Pharmacy Department: One of the most difficult aspects of the implementation was the CPOE system’s connection to the pharmacy.

Since all the other departments of the hospital used another CPOE system, it was a difficult task to create a coherence.

However, after many days, maybe weeks of brainstorming and negotiations, we were able to create a pharmacy interface in the ICIS in accordance with the Joint Commission International ( JCI) standards and installed a mirror in the pharmacy department for their use. Unfortunately, despite all the hard work, we were unable to connect the medication dispenser system (PYXIS MedStationTM, BD International) to our ICIS. Step 7. Preparation of the Nurse’s Worksheets: The creation of the forms which were related to nursing was one of the hardest and most time-consuming tasks. The transcription of every detail in their manual records to the electronic medium was carried out in accordance with the JCI standards.

Step 8. The Connection between ICIS and ICU Devices: Before all the ICU devices were properly introduced to the system, they required special network interface devices (terminal servers), which enabled them to send their signals to the ICIS via the network cables. The reimbursement of these network devices was a problematic process since neither the software company nor the device vendors wanted to take the responsibility at first, but it was decided that the software company should pay the additional costs. This was another setback in our endeavor, which caused a minor delay.

Step 9. Translation of the Language of the Devices: After the completion of the network, to create a common ground between the ICU devices and the ICIS, we had to translate all the signals from most of the devices, and the mechanical ventilators proved to be the most time-consuming of all since we used three different brands of ventilators for specific types of patients and each of them sends a different alphanumeric signal for each parameter. For example, Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

we saw that “EG34H” was showing 20 in the ICIS, but we did not know what “EG34H” was. We had to find out that the “EG34H” was the good old “peak inspiratory pressure” by ourselves. Translating countless parameters coming from three different ventilators was a process that took us days.

The infusion pumps were pre-loaded with presets for many standard medications, but we had to add many more to its registry to show every drug infusion properly labeled in the ICIS. Again, this required many negotiations with the vendor company and many visits from their tech-team.

Step 10. Training of the Staff: After all the preparations finished, we started with the training of the staff in the basics of the software. Only two beds were used for testing purposes during the training period, while maintaining both manual and electronic records and continuously monitoring both for errors. Once the staff got acquainted with the software, we slowly connected the remaining beds to the ICIS one by one. This period helped us to define occasional technical problems and solve them slowly and helped us to have good understanding of the technicalities of the software. When all beds were connected to the ICIS, the staff had already reached an acceptable experience level with the software.

Step 11. Before the Final Implementation: When the ICIS went live, one key difference in our implementation plan was using both the ICIS and manual records during the first six months to ensure the accuracy of the records. This of course caused an increase in the workload and was extremely time-consuming. Nevertheless, this approach caused complaints and a minor (albeit not outspoken) resistance among the staff. Providing extra staff during this period alleviated this problem to some extent.

Our aim with this approach was to double-check the records for accuracy during the patient rounds, and while we were expecting errors mostly in software data, to our surprise, most of the errors were present on the manual records, especially regarding the fluid balance. The time we spent on the infusion pumps during the preparation phase was certainly not in vain.

The patient rounds were taking double the amount of time because of the extra effort to compare both records per patient, but it had an immensely positive effect on the implementation period. It was a time for feedback, and everyone among the team contributed to some extent, giving input on how to make the software better. This way, in addition to making substantial improvements in the ICIS step-by-step each day, we created a gradual increase in the sense of ownership among the staff, as well.

Step 12. Start to Paperless ICU-Final Implementation: At the end of the sixth month, once we were absolutely 541

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sure that everything was working properly, paper and pen became obsolete. From then onwards, the process basically involved the correction of minor errors and further customisation. An interesting obstacle was the definition of the daily cycle for the software. Normally, calculations in our ICU start the day at 07:00 AM, but it took some time until we figured out that we should define the timeframe to start at 07:00 and end it at 06:59 at the following day to obtain accurate results for all of our calculations, such as fluid balance, caloric need and protein need.

of ICNUS with their calorie and protein concentrations, it is also able to calculate the amount of the calories and protein given that day automatically. This way, we can assess whether we reached our nutritional aims or not. Specific nutritional calculators for calorie and protein intake were added, so we can assess whether we will reach the calculated aims with the given nutritional therapy. We can follow the body weight changes in patients and analyse its correlation to fluid balance on this screen, as well. All of these parameters can be evaluated as graphs within seconds.

Step 13. The Cooperation between the IT Engineers and the Medical Team: The presence of the software company during the implementation period and beyond was of immense importance in fixing the errors within minutes and tailoring the software to our needs. We also built a local team among physicians, IT department and senior nurses who know the ins and outs of the software to make noncritical changes to the software on the fly to decrease the dependence on the company for basic actions.

Step 15. Secure Access via Internet Connection: Another major advantage of the ICIS is the ability to create remote connections. Our director has direct access to the system without any restrictions from his home or anywhere in the world, granted there is an internet connection. Multiple security measures were created for this process by the IT team to prevent breaches from potential outside threats.

Step 14. Tailoring of the ICIS: As stated earlier, one of the main advantages of an ICIS is to put all the collected data in context. After months of tweaking, we created many frames within the ICIS to assess the condition of the patient from different perspectives. Some examples for the most frequently used windows are as follows: • The main window is almost identical to the conventional manual charts.

• The trends window shows all the vital signs and important parameters in the last 24 hours as graphs.

• The respiration window is basically divided in three parts, where the first part shows the set parameters in the ventilator. The second part shows the measured parameters, and the third part shows the blood gas results concerning all these parameters.

• There is also a separate blood gas window for a more detailed analysis.

• The fluid balance window shows the input and output balance in detail. It has separate subsections showing the infusion.

• The infusions window shows all the continuous infusions being administered in real-time with labels, concentrations and infusion rates.

• The laboratory window groups all the test results by the organ systems they are related.

• The nutrition window is a section we have spent such a long time for and we decided to give it a separate name: Intensive Care Nutrition Software ICNUS.[10] After getting the daily caloric requirement in Kcal directly from the metabolic monitor, the ICIS automatically calculates calorie and protein needs of patients and clearly demonstrates the daily nutritional aims. Since each product on the market for enteral and parenteral nutrition is in the database 542

Current Situation ICIS’s importance is much more pronounced as a tool for scientific research. Our experience with research was limited, but we decided to evaluate the effects of nutritional therapy on mortality, and all the data from more than 800 patients, organised and grouped specifically to our design, were ready for statistical analysis within minutes. Given that more and more ICUs are adopting this technology each day, this will contribute to a significant volume of data for important multi-center studies with a high impact in the future. The only problem is ensuring the accuracy of data and facilitating the interconnectivity between these databases.

The data overload we face every day in the ICU is a problem for the computers, as well. It has become extremely hard and time-consuming to develop an ICIS on-site with all the complex networking needs and the abundance of parameters needed to be implemented. The most viable option is the successful way we follow in our unit. To buy a commercially available product and then customise it stepby-step until it suits the needs of the ICU, it is implemented.

As of today, all of the software products share two main functions: • Collection and storage of clinical data from various devices (e.g. monitors, ventilators, pumps) • A Computerized Physician Order Entry (CPOE) system to replace manual prescription In our opinion and experience, the implementation of an ideal ICIS should cover these basic areas: • Accurate collection and storage of data from medical devices in the ICU. • The ability to communicate with various systems used in the hospital (such as HIS, PACS, Pharmacy, Drug InformaUlus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

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tion Database, Clinical Guidelines Database).

• A simple but effective CPOE system (better combined with basic Computer Decision Support Systems) • Ability to sort clinical data in various ways (such as Graphs, Tables, Charts) to help in the analysis • Computer Decision Support leading to a diagnosis and optimal treatment, but today’s technology does not offer a replacement for human judgement yet.

• Quality management tools.

Given that we are still far away from these goals, especially regarding computer decision support, it must be emphasized that no ICIS is perfect as of today.

Although we are in a technologically advanced position today, it is still a challenge to implement an ICIS successfully. If not planned properly, it is a process prone to significant delays in time, additional costs, poor acceptance by the staff and even total failure (Fig. 2).

Future Trends and Conclusion The computers have been a part of our professional lives for more than three decades in the ICUs, and now, we have software to connect all the devices we use and record their data in a digital medium, having the ability to replace the conventional manual records and resulting in a paperless ICU with many benefits. However, the adoption rate of this technology is still too low (probably less than 5%), due to the high implementation costs, the complexity of the hardware and software, problems with interconnectivity between other departments of the hospital, concerns about security and the lack of significant, proven benefits.[3] As of now, we are using the third generation of ICIS, which still requires a significant amount of insight on computers.

As with every technology, early products of a newborn field are complicated to use, but as the technology rapidly ad-

vances and matures, the usability of these products becomes significantly easier for the end-user. The ICIS will not be an exception and the fourth generation of ICIS will see significant improvements in usability and connectivity. With the aid of the new generation of ICIS, the ICU physicians will hopefully be allowed to concentrate on their main mission without feeling the need for IT expertise: Caring for the critically ill!

The ICIS is only a vehicle for the intensivist to reach their destinations, so not everything should be expected from it.

There “will” be problems in data collection, no matter how well the system works and this is a completely expected sideeffect. The staff should be prepared to face them since these problems start to surface as soon as the system goes live.

We experienced a lot of them, and a solution for a problem sometimes caused another completely different problem.

This is a process that requires a lot of patience and determination. On the other hand, you may just settle with the barebones version of the software without customising it and therefore missing its full potential. As intensivists, we are already working under hard conditions, and the implementation period of an ICIS will certainly multiply the amount of workload at first. Our biggest asset in this period was the determination, dedication and experience level of the whole staff. The accuracy of computer documentation is superior to manual records, and ICIS can be beneficial only if the staff has a significant experience deriving from good intensive care medicine training based on physiology.

The meaning of “good” in medicine is certainly not only equal to “modern”. It must not be forgotten that everything once modern is getting old. In our age, the amount of time to become obsolete is getting shorter every day. We still do emphasize the importance of human factors. And what matters is not only the quality of the physicians but of the whole staff.

Conflict of interest: None declared.

Administrative Operations

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ICIS

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Patient Monitor

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CVVHDF

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Blood Gas Analysis

Figure 2. ICIS working schematics in our ICU.

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REFERENCES

Medicine. Intensive Care Med 1996;22:707–10.

1. Varon J, Marik PE. Clinical information systems and the electronic medical record in the intensive care unit. Curr Opin Crit Care 2002;8:616–24.

2. Evans RS. Electronic Health Records: Then, Now, and in the Future.

Yearb Med Inform 2016;1:S48–61.

3. Ducruyenaere J, Colpeart K. Computers in the Icu: fasten your seatbels. In: Vincent JL, editor. Yearbook of Intensive Care and Emergency Medicine. Springer Science & Business Media; 2006. p. 745–54.

4. van Bemmel J H, McCray AT. The Renewed Promise of Medical Informatics. Yearb Med Inform 2016;l1:S12–7.

5. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care

6. Vesely H, Metnitz PGH. Performance evaluation in the ICU. In: Vincent JL, editor. 2006 Yearbook of Intensive Care and Emergency Medicine.

Springer Science & Business Media; 2006. p. 399–408.

7. de Lusignan S. In this issue: Time to replace doctors’ judgement with computers. J Innov Health Inform 2015;22:3.

8. Reng M. The role of information technology in the ICU. In: Vincent JL, editor. 2005 Yearbook of Intensive Care and Emergency Medicine.

Springer Science & Business Media; 2006. p. 375–82.

9. Purves I. Where now with clinical computer systems? Br J Gen Pract 2003;835–6.

10. Bahar M. A different approach to the nutritional therapy in ıntensive care units: Nutrition software (ICNUS) Turk J Anaesthesiol Reanim 2017;45:251–9.

DERLEME - ÖZET

Yoğun bakımda yazılım kullanımı Dr. Mois Bahar, Dr. Emin Yalçın İnel VKV Amerikan Hastanesi, Genel Yoğun Bakım Ünitesi, İstanbul

Yoğun bakımdaki hastanın kompleks tedavi süreci, ciddi oranda verilere bağımlı durumlar nedeniyle dikkatle izlenmelidir. Yoğun bakım hekimliği, diğer branşlara oranla sayılarla çok daha fazla iç içe olmayı gerektirdiğinden, bu verilerdeki ufak hatalar dahi hastalar üzerinde ciddi hasarlar bırakabilecek önemli hatalara sebep olabilmektedir. Tıbbi kayıtların elle tutulması hataya eğilimi arttırdığı gibi hem bu kayıtları tutan hemşireler hem de verileri analiz eden hekimler için anlamlı ölçüde zaman alan bir durumdur. Bu durum hastalık sürecinin karmaşıklaşması ve yatış süresinin uzadığı durumlarda çok daha belirgin hale gelmektedir. ENIAC (Electronic Numerical Integrator and Computer) isimli ilk bilgisayarın 1946’da ortaya çıkmasının ardından bilgisayarları tıp pratiğine entegre etmeye yönelik birçok girişim olmuştur ve son yıllarda da yoğun bakım yazılımlarının ortaya çıkışına şahit olmaktayız. Bu yazılımlar tıbbi kayıtların doğruluğunu ve kalitesini arttırma ve medikal hataların görülme sıklığını azaltma potansiyeline sahip oldukları gibi elektronik karar desteği sunmakta; kalite kontrol ve performans değerlendirmesi gibi alanlar için de araçlar içermektedirler. Daha da önemlisi, bu sistemler hastanın anlık durumunu değerlendirme gayretindeki hekimlere farklı bakış açılarıyla yaklaşabilmesi yönünde bir ortam sunabilirler. Günümüze kadar yoğun bakım yazılımlarının kullanımı, yüksek finansal maliyetler ve diğer bir takım faktörler nedeniyle kısıtlı kalmıştır.

Günümüzde her ne kadar teknolojik yönden ileri bir konumda olsak dahi bir yoğun bakım yazılımının etkin bir şekilde kullanıma sunulması zorlu ve düzgün planlanmadığı takdirde anlamlı gecikmelere, ek finansal maliyetlere, ekip içerisinde kabullenişe yönelik zorluklara ve hatta tamamen başarısızlığa mahkum bir süreçtir. Bu yazıda, yoğun bakım yazılımlarının geçmişini, günümüzdeki halini ve geleceğini değerlendirdiğimiz gibi bu yazılımlara geçiş sürecinde kendi yaşadığımız deneyimleri de paylaşacağız.

Anahtar sözcükler: Bilgi-işlem sistemleri; data yönetimi; kalite kontrol; yoğun bakım; yazılım.

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doi: 10.14744/tjtes.2019.28282

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EXPERIMENTAL STUDY

Is tri-iodothyronine a better choice than activated protein C in sepsis treatment? Ömer Vefik Özozan, M.D.,1

Didem Ertorul, M.D.2

1

Department of General Surgery, İstinye Universtity Faculty of Medicine, İstanbul-Turkey

2

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

ABSTRACT BACKGROUND: Sepsis can be defined as a life-threatening organ dysfunction due to a dysregulated host response to infection. In sepsis, the coagulation cascade is activated and the balance shifts to the procoagulant side. Recently, the use of protein C is proposed for the treatment of sepsis. Another therapeutic agent that has been intensively studied is tri-iodothyronine.

METHODS: This study aimed to compare the effects of activated protein C and tri-iodothyronine, which are administered at a single dose to sepsis-induced rats at the late phase. Leukocyte, platelet, hemoglobin and antithrombin-III concentrations and histopathological changes in the small intestine, liver and lung were evaluated at 24 hours.

RESULTS: Single-dose intraperitoneal recombinant human APC (activated protein C) has a partial curative effect on hematological parameters in the late phase, while it is possible to state that it has significant therapeutic effects on hepatic and intestinal tissues, but more remarkably on the lung tissue. Tri-iodothyronine is also considered to be used for the treatment and has a strong potential to be a therapeutic agent.

CONCLUSION: We observed that the T3 hormone has significantly limited and reduced the sepsis-related damage to hepatic and intestinal tissues, but especially the lung tissue. Tri-iodothyronine can be a good alternative to APC, which is partially allowed due to high cost and complication of bleeding in the treatment of sepsis.

Keywords: Activated protein C; sepsis; tri-iodothyronine.

INTRODUCTION Sepsis was first defined in 1991 as the inflammatory response of the host and it has been addressed within this context until very recently. After pathophysiology of sepsis is better understood, the definition is revised as “an infection-related response of the host that is not only limited to pro- and anti-inflammatory response but also contains modifications in non-immunological pathways, such as cardiovascular, autonomic, neurological, hormonal, metabolic and coagulation systems”.[1] Sepsis was defined in the Sepsis III Conference held in 2016: A life-threatening organ dysfunction due to a dysregulated host response to infection. On the other hand, septic shock is defined as circulatory and cellular/metabolic abnormalities

that cause a severe increase in the mortality in the presence of sepsis.[1] Septic shock is accompanied by severe hypovolemia, vasodilatation and cardiac dysfunction. Septic shock is a severe hypoperfusion of tissue characterized by cytopathic hypoxia and microcirculation that are induced by systemic inflammatory response secondary to infectious etiologies.[2] The primary goal of treatment is to eliminate the infectious agent that leads to sepsis. On the other hand, the recent novel treatment options aim to support the first-line treatment of sepsis by inhibiting or eliminating the immune modulation and their adverse effects over the inflammatory cells, cytokines, antibodies, complements and coagulation cascades that play a role in the inflammation. However, no agent could

Cite this article as: Özozan ÖV, Ertorul D. Is tri-iodothyronine a better choice than activated protein C in sepsis treatment? Ulus Travma Acil Cerrahi Derg 2019;25:545-554.

Address for correspondence: Ömer Vefik Özozan, M.D. İstinye Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 444 66 23 E-mail: omerozozan2002@yahoo.com Ulus Travma Acil Cerrahi Derg 2019;25(6):545-554 DOI: 10.14744/tjtes.2019.36270 Submitted: 25.09.2019 Accepted: 05.10.2019 Online: 25.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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be invented to date, which would pose the expected effect on these pathophysiological changes, is low cost, has favorable side effect profile and can be clinically used in a larger patient population.

In sepsis, the coagulation cascade is activated, while native anticoagulant mechanisms are suppressed and the balance shifts to the procoagulant side. Protein C, Protein S and Antithrombin III are natural anticoagulants and their plasma concentrations decrease in sepsis. Recently, the use of Protein C, one of the major natural anticoagulants, is proposed for the treatment of sepsis. Protein C plays a role in the regulation of the fibrinolytic activity by converting into the activated Protein C in the presence of thrombomodulin – thrombin complex that is found in the endothelium. However, Protein C is insufficiently converted into the active form in sepsis and plasma concentrations decreased below 40% of the physiological limits. Therefore, it was considered that APC replacement in sepsis would help the fibrinolytic effects of APC and also its inhibitory effects on the production of proinflammatory cytokines from monocytes, and it had been subject to numerous clinical and experimental studies.[3] Another therapeutic agent that was intensively studied is triiodothyronine that acts in the regulation of genes, which play a role in the systemic cellular inflammatory response. Low thyroid hormone concentration is called low tri-iodothyronine (T3) syndrome. Low T2 syndrome is characterized by a reduction in concentrations of Total T3, Free T3 and Total T4. Free T4 or TSH concentrations can be low or within physiological ranges. This condition is called non-thyroidal disease syndrome that is characterized by changes in serum thyroid hormone concentrations without accompanying thyroid disease. In sepsis, low T3 concentrations are usually secondary to severe acute inflammation. The primary factor is the dysfunction of the hypothalamo-pituitary axis.[4] The changes in thyroid function tests of patients with septic shock had led to many investigators to the view whether thyroid hormone replacement would be beneficial in the treatment of sepsis.

Our study used the polymicrobial sepsis model that has signs and symptoms proven similar to intra-abdominal sepsis and is induced by caecal ligation and puncture (CLP) procedure.[5] According to this model, the early period implies two hours to ten hours after the CLP (hypodynamic phase), while the late phase is regarded as 16 to 20 hours after the procedure (hyperdynamic phase). This study aimed to compare the effects of activated protein C (Xigris) and triiodothyronine (Thyrotardin Inject), which are administered at a single dose to sepsis-induced rats at the late phase (24 hours), in the treatment of sepsis. Complete blood count and plasma AT-III concentrations are analysed, and the histopathological changes are reviewed in the lungs, liver and small intestine.

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MATERIALS AND METHODS Study Groups and Study Design Our study is approved by the Ethical Committee of Laboratory Animals at Hacettepe University and it is conducted in Laboratory Animals and Surgical Research Unit of School of Medicine at Surgical Research Unit of School of Medicine at Hacettepe University. Each study group included 30 female Sprague Dawley rats that weighed 250 to 300 gr. All rats were fed standard rat diet (chow) and tap water until the study day. They were not allowed to eat or drink at the night of the study.

Surgical Procedure Rats were anesthetized by administering Xylazin Hydrochloride (Rompun®) at dose of 5 mg/kg and Ketamine Hydrochloride (Ketalar®) at a dose of 50 mg/kg through the intraperitoneal route at the day of this study. The anterior abdominal wall was shaved and scrubbed with betadine solution. Median incision was carried out at sterile conditions and the abdominal cavity was exposed. Rats were divided into five main sub-groups. The distribution of the groups is shown below.

I. Control Group (n=6): In this group of rats, a median incision (approx. 1.5 to 2 cm) was carried out to expose the abdominal cavity. Caecum was identified and it was normal in the exploration; it was reduced to the abdominal cavity. The abdominal wall was closed with 3/0 atraumatic silk suture with non-continuous technique.

II. CLP Group (n=6): This group of rats is denominated the group of septic rats and a median incision (approx. 1.5 to 2 cm.) was made. Caecum was removed and it was tied with 4/0 free silk using the Wichterman method, such that intestinal continuity was not hindered.

Caecum was punctured at two points with 18 Gauge syringe.

Caecum was mildly milked and a certain amount of feces was discharged. Caecum was reduced into the abdominal cavity thereafter and the abdominal wall was closed with 3/0 atraumatic silk suture with non-continuous technique.

III. APC (Activated Protein C Replacement) Group (n=6): For this group of rats, caecal ligation and puncture were performed, as is the case with the CLP Group. These rats were administered Drotrecogin Alfa (Xigris®, Lilly) at a dose of 100 μg/kg through intraperitoneal route 1 hour after the procedure.

IV. Tri-iodothyronine (T3 replacement) Group (n=6): This group of rats was administered Tri-iodothyronine (Thyrotardin® Inject N Henning, Berlin GMBH, Germany) at a dose of 0.4 μg/100g through intraperitoneal route one hour after the CLP procedure.

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V. Combined Treatment (APC+T3 Replacement) Group (n=6): This group of rats was administered Drotrecogin Alfa (Xigris®, Lilly) at dose of 100 μg/kg and Tri-iodothyronine (Thyrotardin® Inject N Henning, Berlin GMBH, Germany) at dose of 0.4 μg/100g, both through intraperitoneal group, 1 hour after CLP. After surgical procedures were performed and replacement therapies were over, rats of all groups were administered 4 ml of heated isotonic sodium chloride through the subcutaneous route. Wound sites were closed with Tetracycline ointment (Terramycin®, Pfizer). They were placed in the cages, where they were allowed to eat and drink sufficiently until the sampling procedure was performed.

Analysis of Hemoglobin, Leukocyte and Platelet Counts (24 hours) Rats of all groups were sacrificed by intra-cardiac blood drawing with re-laparotomy for samplings following the anesthesia with XylazineHidroklorid (Rompun®) at the dose of 5 mg/kg and Ketamine Hydrochloride at the dose of 50 mg/kg at 24 hours. Blood samples were added to complete blood count tubes that contained 180 µl of 0.4% EDTA in 2 cc and sent to the Hematology Laboratory of Ankara Numune Teaching and Research Laboratory.

Antithrombin-III Sampling (24 Hours) Four millimetres of the intracardiac blood sampled from rats of all groups were added to the tubes that contained citrate and centrifuged (3000 rpm, 30 minutes). Blood samples were centrifuged and the plasma was taken with automated pipettes; plasma samples were added to Eppendorf tubes and sent to the Hematology Laboratory for Antithrombin III assay.

Tissue Specimens of Liver, Lung and Intestines (24 hours) After blood samples were drawn, the liver, lungs and small intestines were biopsied in all rats. For this end, the left lobe of the liver, left lobe of the lung and approximately 1.5-cm piece of the terminal ileum were biopsied with standard procedure for each rat and tissue pieces were placed in bottles that contained formol. They were sent to Pathology Laboratory Ankara Numune Teaching and Research Hospital. Specimens were stained with Haematoxylin-Eosin and examined by a pathologist who was blinded to the study groups under a light microscope.

Statistical Analysis The data were analyzed using non-parametric Kruskal Wallis and Mann-Whitney U tests using SPSS 13.0 Windows Chicago Illinois software; a p-value <0.05 was regarded significant at a 95% confidence interval.

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RESULTS Leukocyte Concentrations (24 Hours) Leukocyte concentration 24 hours after CLP was 4566/µl in the control group, 3133/µl in the septic rat group, 3266/µl in the Activated Protein C replacement group, 6083/µl in the tri-iodothyronine replacement group and 5050/µl in the combined (Activated Protein C + Tri-iodothyronine) replacement group (Fig. 1). When leukocyte concentrations of all groups were compared, the leukocyte concentrations of the septic group and the APC group were significantly lower than the leukocyte concentrations of the control group (p=0.006 and p=0.013, respectively). Leukocyte concentrations of the T3 replacement group were significantly higher than the leukocyte concentrations of the control group (p=0.003), while no significant difference was observed between the leukocyte concentrations of the combined treatment group and the control group. When replacement groups were compared with the septic group concerning leukocyte concentrations, no significant difference was observed between the APC group and the septic group, while leukocyte concentrations were significantly higher in rats of the T3 group and the combined treatment group (APC/T3) than the rats of the CLP Group (p<0.001 and p=0.001, respectively).

Platelet Concentrations (24 Hours) Platelet concentrations at 24 hours were 870.103/µl, 496.103/ µl, 357.103/µl, 291.103/µl and 328. 103/µl in control group, CLP group, APC replacement group, T3 replacement group and combined treatment group, respectively (Fig. 2). Platelet concentrations of the control group were higher than platelet concentrations of all other groups (p<0.001). Platelet concentrations of the septic group (CLP) measured significantly higher than platelet concentrations of the replacement groups (APC, T3, APC/T3) (p=0.037, p=0.005 and p=0.007, respectively). No significant difference was observed in intergroup comparisons of the replacement groups.

Hemoglobin Concentrations (24 Hours) Hemoglobin concentrations at 24 hours measured 12.72 g/dl in the control group, 14.03 g/dl in the septic rat group, 14.68 g/dl in the activated Protein C replacement group, 14.43 g/ dl in the tri-iodothyronine replacement group and 12.02 g/ dl in the combined replacement group (Fig. 3). Considering intergroup comparisons of hemoglobin concentrations, no significant difference was observed between hemoglobin concentrations of the control group and hemoglobin concentrations of all other treatment groups. Only hemoglobin concentrations of the activated Protein C replacement group were significantly higher than hemoglobin concentrations of the combined treatment group (p=0.03).

Antithrombin-III Concentrations (24 Hours) Anti-thrombin concentrations at 24 hours measured 147.08 in the control group, 111.98 in the CLP rat group, 108.92 in 547

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14.68

6003.33 6000.00

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Figure 1. Columns show the late phase (24 h) leukocyte concentrations for each group.

870.17

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Figure 3. Columns show the late phase (24 h) hemoglobin concentrations for each group.

150.00

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Figure 2. Columns show the late phase (24 h) platelet concentrations for each group

Figure 4. Columns show the late phase (24 h) antithrombin-III concentrations for each group.

the activated Protein C replacement group, 102.87 in the triiodothyronine replacement group and 91.18 in the combined replacement group (Fig. 4). Antithrombin concentrations of the control group were significantly lower than that of other groups (p<0.001). There was no significant difference between rats of activated Protein C and CLP groups concerning Antithrombin III concentrations, while antithrombin III concentrations of the CLP Group were significantly higher than antithrombin III concentrations of the tri-iodothyronine group (p=0.002) and the combined replacement group (p=0.001).

(50%), while it was accompanied by microvascular thrombosis in one of these rats (17%). Diffuse congestion was identified in intestinal tissue specimens of the other three rats (50%).

No significant change was noted in intestinal tissue specimens of the activated Protein C group, while ischemic changes were observed only in one rat in the Tri-iodothyronine group (17%). Considering rats of the combined treatment group, no significant histopathological change was observed, as is the case with rats of the control group. Figure 5 shows the histopathological changes in the small intestine.

Histopathological Changes in the Small Intestines (24 hours) In the histopathological examination of the intestinal tissue, pieces biopsied 24 hours after CLP, focal necrosis was noted in the intestinal tissue pieces of three rats in the CLP group

Histopathological Changes in Lung Tissue (24 Hours)

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When the histopathological changes were reviewed in the Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

Ă&#x2013;zozan et al. Is tri-iodothyronine a better choice than activated protein C in sepsis treatment?

Figure 5. First image shows normal intestine tissue and the second image shows congested intestine tissue, 20X, Hematoxylin and Eosin (H&E).

Figure 6. First image shows normal lung tissue and the second image shows infiltrated lung tissue by PMN, 20X, Hematoxylin and Eosin (H&E).

Figure 7. First image shows normal liver tissue and the second one shows congested liver tissue, 20X, Hematoxylin and Eosin (H&E).

lung tissue that was biopsied 24 hours after CLP, significant congestion developed in all rats of the CLP group (100%) in comparison with rats of the control group that were all normal, while the congestion was associated with polymorphonuclear leukocyte infiltration in the lung tissue of two rats (34%). Mild congestion was noted in the lung tissue of one rat in the activated Protein C group (17%), two rats in the Triiodothyronine replacement group (34%) and two rats in the combined treatment group (34%). Polymorphonuclear leukocyte infiltration was seen in none of the rats in replacement Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

groups (0%). Figure 6 shows the histopathological changes in lung tissue.

Histopathological Changes in Liver Tissue (24 Hours) When liver tissue specimens were examined, significant congestion was noted in five rats of the CLP group (85%), while congestion was associated with necrotic foci in three rats (50%). Congestion was observed only in two rats of the ac549

Ă&#x2013;zozan et al. Is tri-iodothyronine a better choice than activated protein C in sepsis treatment?

tivated Protein C group (34%), while mild congestion was identified in three rats of the tri-iodothyronine replacement group (50%) and two rats of the combined replacement group (34%). Figure 7 shows the histopathological difference between normal and congested liver tissue.

DISCUSSION Sepsis is defined as a life-threatening organ dysfunction secondary to the dysregulated host response due to the infection.[1] Although numerous measures were taken and introduced into the practice in the recent past to improve the management of sepsis and treatment outcomes, mortality is still high in patients with severe sepsis and septic shock.

A study reported that the incidence of severe sepsis is 148/100,000 and the mortality is 26 percent.[6] It was also reported that severe sepsis progressed to septic shock approximately by 25 percent and as a result, the mortality rate increased to 37.2 percent.[7] Activation of the coagulation system is the major factor that is broadly responsible for such adverse outcomes. DIC is a clinical picture that is characterized by systemic, intravascular activation of the coagulation pathways. It is reported that DIC may develop in 35% of patients with septic shock. Activation of the Protein C system poses anticoagulant, anti-inflammatory, anti-apoptotic and endothelial barrier stabilizing effects under physiological conditions.[8] After protein C, the main component, binds to endothelial protein C receptor (EPCR), it is activated by the thrombomodulin-thrombin complex.[9] Dysregulation of the Protein C system is the most important sign of the coagulopathy that is related to septic shock. Reduced protein C concentrations are linked to high morbidity and mortality.[10] Although the significant role of APC in sepsis is known, measurement of APC in patients with sepsis has not yet been specified in routine clinical practices.

Complex etiopathogenesis of sepsis leads to important problems in clinical trials and treatment-oriented investigations.

Since the physiological response of humans differs from animals, it is not easy to use agents with efficiency proven in investigational studies in the clinical practice due to comorbid pathologies and differences in duration of treatment and dosage.[11] Numerous agents with efficiency proven in investigational trials were used in the clinical practice, particularly including Antilipid, Interleukin-1 antagonists, platelet-activating factor inhibitors, immunoglobulins, ibuprofen, high-dose corticosteroids and antithrombin III, but the expected success could not be gained. Recombinant human activated Protein C was the first and the only agent with proven success that was approved by the FDA (Food and Drug Administration) for the treatment of sepsis in early 2001 and it was introduced into the clinical practice. Subsequently, early goal-directed therapy and low-dose corticosteroid replacement were started to be used in the treatment of sepsis.[12] 550

Our study used an experimental polymicrobial sepsis model that is induced by CLP and strikingly mimicking the intraabdominal sepsis secondary to intestinal perforation, a condition commonly diagnosed in surgery clinics. In the experimental sepsis model that is induced with caecal ligation and puncture, early (hyperdynamic) phase initiates 2 to 10 hours after CLP, while late (hypodynamic phase) emerges 16 to 20 hours after CLP.[13,14] Our study is conducted in the hypodynamic phase of the sepsis. However, two reasons are considered for low leukocyte counts in rats that were administered activated protein C. First, the suppressive effect of the activated protein C on the relation between leukocytes and endothelium in the early phase of the sepsis disappears in the late phase, or the other estimation is the insufficient effect of the single-dose activated Protein C replacement to maintain leukocyte concentrations.[15] Numerous studies have demonstrated that leukocyte and platelet concentrations of the host are indicators commonly used to reveal out the inflammation and coagulation abnormalities in sepsis.[8] When leukocyte concentrations were measured 24 hours after CLP, they were significantly lower in rats of CLP and APC (activated protein C) groups in comparison with the control group, while leukocyte concentrations were significantly higher in rats of tri-iodothyronine and combined replacement groups than rats of the CLP group.

When all replacement groups were taken into consideration, leukocyte concentrations were significantly higher only in rats of the tri-iodothyronine group than the rats of the control group. Given that leucopenia is among the laboratory diagnosis criteria for sepsis, low leukocyte counts in rats of the CLP group is regarded as an evidence that sepsis could be induced in this model; endothelial adhesion of leukocytes, increased endothelial permeability and migration of leukocytes into the tissue are the potential mechanisms behind the low leukocyte concentrations.

It is demonstrated that serum T3 concentrations are related to the mortality in the septic shock. YildizdaĹ&#x; et al.[16] have shown a significant reduction in plasma tT3, tT4, fT3 and fT4 concentrations in pediatric patients with septic shock and patients managed in the intensive care unit relative to adult and pediatric patients without septic shock. Similar results were revealed out in a series of 20 adult cases.[17] Higher Apache 2 scores and poorer prognosis are reported for patients with low serum fT3 and fT4 concentrations.[18] Moreover, exogenous T3 replacement may reduce the mortality in surgery patients with sepsis.[19] Thyroid hormone and immune functions are closely interlinked. Thyroid hormone plays an important role in myeloperoxidase antimicrobial system by supplying iodine. Fernandez and Videla demonstrated high NADPH and myeloperoxidase activities in rats that were fed T3.[20] On the other hand, Inan et al.[5] showed that thyroid hormone replacement increased the phagocytic activity of neutrophils in septic animal modUlus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

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els. Thyroid hormone replacement influences the activation of other immune cells in addition to neutrophils. Alamino reported that T3 replacement increased activation and expansion in cytotoxic T lymphocytes.[21] Our study also determined that leukocyte concentrations could be significantly maintained in rats of tri-iodothyronine replacement – a finding that matches the literature. We consider that the boosting effect of T3 hormone on cellular and humoral immunity is responsible for this result.[22] Reduced platelet concentration is regarded as an important parameter to prove the presence of sepsis. Thrombocytopenia that is observed in bacterial sepsis can be related with Disseminated Intravascular Coagulation, but lack of any relationship is also likely. There are two causes for thrombocytopenia that is not associated with DIC. First, bacteria or endotoxins may inhibit production of platelets; this possibility may be proven by a study conducted by Ayala et al.[23] who demonstrated the reduction of viable cell counts in the bone marrow in sepsis that is induced by CLP. The other cause is the immunological platelet damage. Increased plasma concentration of platelet-associated immunoglobulin G in patients with thrombocytopenic sepsis is the evidence for the immune damage.[24] In our study, a significant reduction was observed in platelet concentrations of all groups, excluding the control group. It is observed that the protective effect of the activated protein C and tri-iodothyronine replacement on platelet concentrations in the early phase could not be maintained in the late phase. Moreover, platelet concentrations of the replacement groups were even significantly lower than platelet concentrations of the CLP group.

We consider the potent coagulative effects of more than one factor, especially including decreased peripheral blood supply along with endothelial damage and dysfunction, for the inability to maintain platelet concentrations in the late phase of sepsis by single-dose replacements of both activated protein C and tri-iodothyronine. This fact clarifies that replacement therapies should be maintained also in the late phase.

Hemoglobin concentration is the other hematological parameter that is analyzed in this study. No significant reduction is observed in hemoglobin concentrations when septic rat and replacement groups are compared with the control group.

We can specify, in the light of these findings, that lack of reduction in hemoglobin concentrations in the control group at 24 hours is a factor, which prevents the onset of severe tissue hypoxia in the non-lethal CLP model.

AT-III concentrations were significantly low in our study groups in comparison with the control group. When compared with the replacement groups, AT-III concentrations were significantly high in the CLP group. Contrary to other results, Chapital et al.[25] conducted a study, which evidenced the therapeutic effect of tri-iodothyronine on AT-III concenUlus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

trations in sepsis; authors have reported that tri-iodothyronine was intravenously infused at a dose of 3 ng per hour for postoperative 24 hours and AT-III concentrations were measured at 24 hours. In our study, tri-iodothyronine was administered at a single dose of 0.4 µg/100 g/day, as already reported by other studies.5 We consider the differences in doses and measurement intervals for the deviation from the literature concerning therapeutic effects of activated protein C and tri-iodothyronine, alone or in combination, on AT-III concentrations in the late phase of the polymicrobial sepsis induced by CLP. A clinical study conducted by Eisele et al.[26] verifies the conclusion of our investigation study that although T3 replacement has no therapeutic effect on plasma AT-III concentrations, it has significantly limited and reduced the tissue damage caused by the sepsis over anti-inflammatory effects of APC and T3 rather than over the coagulation cascade.

Oxygen consumption decreased in the intestinal and hepatic tissues at the late phase of the sepsis and therefore, both tissues become vulnerable to hypoxia. Moreover, polymicrobial sepsis impairs the intestinal barrier, reduces the functional capillary density and leads to apoptosis of the lymphoid tissue.

Bacterial and endotoxin translocation are a result of damage to the intestinal barrier and it also triggers a humoral and cellular immune response in the host. The intestinal barrier accounts for 80% of the humoral immunity and 50% of the cellular immunity. Polymicrobial sepsis activates the release of cytokines, such as TNF-α and IL-6, from the intestinal tissue. Role of the intestinal tissue in sepsis is not confined to being an organ that can synthesize cytokines. The relation between the intestinal tissue and Kupffer cells of the liver is far more important in the systemic response to the sepsis. Kupfer cells produce 90% of macrophages in the reticuloendothelial system and it is the major source of the proinflammatory cytokines.[27] When histopathological changes are examined in the intestinal tissue specimens of rats in the CLP Group, diffuse congestion is noted in all specimens, while microvascular thrombosis or necrotic foci are identified in a significant part of them. In both activated protein C and tri-iodothyronine replacement groups, histopathological changes were significantly different from the changes identified in septic rats.

Necrotic foci or microvascular thrombosis was observed in none of the intestinal tissue specimens in rats of the replacement groups.

Healing effects of the activated protein C on the intestinal tissue may be explained with anti-apoptotic, anti-inflammatory and anti-coagulant effects in lymphoid and endothelial tissues.

A study conducted by Yang et al.[28] reported that in an experimental polymicrobial sepsis model, tri-iodothyronine replacement reduced the permeability of the intestinal tissue significantly and prevented potential structural and functional damages to the intestinal tissue secondary to the sepsis, 551

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but further studies are warranted to understand this protective mechanism better. Tri-iodothyronine probably acts by increasing the synthesis of preventive substances in the intestinal epithelial cells and boosting the endurance of the intestinal epithelium to the oxidative stress. This view is also supported by studies that demonstrated atrophy in intestinal epithelial cells and a reduction in mucosal DNA and protein in hypothyroidism.

When hepatic tissue specimens of our study groups were examined, diffuse congestion was observed in liver tissues of all rats in the CLP group, while necrotic foci were noted in a part of them; congestion was milder and there was no focal necrosis in tissue specimens of the rats in APC, T3 and APC/T3 groups. The changes in liver tissues of septic rats were matching to the findings reported in the literature.[29] Increased permeability secondary to endothelial function was considered responsible for the diffuse congestion in rats of the CLP Group, while preventive effects of the activated protein C may cover suppression of proinflammatory cytokines and limitation of microvascular coagulation.[30] As already expressed here, the preventive effects of tri-iodothyronine on the liver tissue may include the regulatory effects on cellular and humoral mechanisms.[31] An experimental study conducted by Lotková et al.[32] demonstrated that tri-iodothyronine replacement activates the mitochondrial glycerophosphate cytochrome-c reductase, which is responsible for regeneration in the liver of rats, and it increased the hepatic regeneration in rats that were undergone partial liver resection. It is possible to think that this effect may also develop in rats with sepsis and the regulatory effect of tri-iodothyronine on cellular metabolism and proliferation may play a role in the regeneration.

The most significant sepsis-related organ failure is probably ARDS that develops in the lung tissue. ARDS develops approximately in 20–40% of patients with sepsis.[33] The sepsis-related changes in the lung tissue include activation of leukocytes and monocytes along with alveolar macrophages, pulmonary edema secondary to increased permeability following the interaction of leukocytes and endothelium and the onset of microvascular thrombosis.[34] It is observed that the activity of nuclear factor kappa B (NFκB), which has a proven trigger role in the inflammatory response to the infection, increased in alveolar macrophages after experimental polymicrobial sepsis. The induction of this increase by TNF-α indicates that TNF-α may also be held responsible for the development of ARDS.[35] When the literature is reviewed, it is revealed out that these cytokines impair the synthesis of surfactant on the alveolar epithelium and decrease pulmonary compliance.

The diffuse congestion and leukocytic infiltration in rats of the septic group match the findings of the literature.[36] It is 552

observed that the histopathological changes in the lung tissue secondary to the polymicrobial sepsis are significantly limited in rats of the replacement group. We believe that the preventive effects of the activated protein C in the lung include anti-inflammatory effects and suppression of the leukocytic damage to the endothelium. On the other hand, increased pulmonary compliance, improved synthesis of surfactant and regulation of the systemic cellular response are the preventive effects of tri-iodothyronine.[31] Single-dose intraperitoneal recombinant human APC, which has a proven effect in the treatment of sepsis, has a partial curative effect on hematological parameters in the late phase, while it is possible to mention that it has significant therapeutic effects on hepatic and intestinal tissues, but more remarkably the lung tissue.[29,37] Tri-iodothyronine is also considered to be used for the treatment and has a strong potential to be a therapeutic agent, as it plays a role in the expression of genes that regulate the cellular immunity and metabolism; in our study, we observed that T3 hormone has significantly limited and reduced the sepsis-related damage to hepatic and intestinal tissues, but especially the lung tissue.

Conclusion Considering the ease of administration and low treatment cost, we believe that tri-iodothyronine will be a good alternative to APC, which is partially allowed due to high cost and complication of bleeding in treatment of sepsis. However, further studies with larger populations and different doses are warranted to have the final word, as already mentioned by all studies on sepsis.

Thanks We would like to thank all our colleagues for their support in all phases of this study.

Conflict of interest: None declared.

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2. Harrois A, Huet O, Duranteau J. Alterations of mitochondrial function in sepsis and critical illness. Curr Opin Anaesthesiol 2009;22:143–9.

3. Ranieri VM, Thompson BT, Barie PS, Dhainaut JF, Douglas IS, Finfer S, et al. Drotrecogin Alfa (Activated) in Adults with Septic Shock. N Engl J Med 2012;366:2055–64.

4. Luo B, Yu Z, Li Y. Thyroid hormone disorders and sepsis. Biomed Mater Eng 2017;28:S237–S41.

5. Inan M, Koyuncu A, Aydin C, Turan M, Gokgoz S, Sen M. Thyroid hormone supplementation in sepsis: an experimental study. Surg Today 2003;33:24–9.

6. Fleischmann C, Scherag A, Adhikari NK, Hartog CS, Tsaganos T, Schlattmann P, et al. Assessment of Global Incidence and Mortality of

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Hospital-treated Sepsis. Current Estimates and Limitations. Am J Respir Crit Care Med 2016;193:259–72.

7. Whiles BB, Deis AS, Simpson SQ. Increased Time to Initial Antimicrobial Administration Is Associated With Progression to Septic Shock in Severe Sepsis Patients. Crit care med 2017;45:623–9.

8. Levi M, van der Poll T. Coagulation and sepsis. Thromb Res 2017;149:38–44.

9. Dewitte, A, Lepreux S, Villeneuve J, Rigothier C, Combe C, Ouattara A, et al. Blood platelets and sepsis pathophysiology: A new therapeutic prospect in critical ill patients? Ann Intensive Care 2017;7:115.

10. Sapru A, Calfee CS, Liu KD, Kangelaris K, Hansen H, Pawlikowska L, et al. Plasma soluble thrombomodulin levels are associated with mortality in the acute respiratory distress syndrome. Intensive Care Med 2015;41:470–8.

11. Dyson A., Singer M. Animal models of sepsis: Why does preclinical efficacy fail to translate to the clinical setting? Crit Care Med 2009;37:S30– 7.

12. Harrison DA, Welch CA, Eddleston JM. The epidemiology of severe sepsis in England, Wales and Northern Ireland, 1996 to 2004: secondary analysis of a high quality clinical database, the ICNARC Case Mix Programme Database. Crit Care 2006;10:R42.

13. Xiao H, Siddiqui J, Remick DG. Mechanisms of mortality in early and late sepsis. Infect Immun 2006;74:5227–35.

14. Buras JA, Holzmann B, Sitkovsky M. Animal Models of sepsis: setting the stage. Nat Rev Drug Discov 2005;4:854–65.

15. Favory R, Poissy J, Alves I, Guerry MJ, Lemyze M, Parmentier-Decrucq E, et al. Activated protein C improves macrovascular and microvascular reactivity in human severe sepsis and septic shock. Shock 2013;40:512– 8.

16. Yildizdaş D, Onenli-Mungan N, Yapicioğlu H, Topaloğlu AK, Sertdemir Y, Yüksel B, et al. Thyroid hormone levels and their relationship to survival in children with bacterial sepsis and septic shock. J Pediatr Endocrinol Metab 2004;17:1435–42.

17. Meyer S, Schuetz P, Wieland M, Nusbaumer C, Mueller B, Christ-Crain M. Low triiodothyronine syndrome: a prognostic marker for outcome in sepsis? Endocrine 2011;39:167–74.

18. Tas A, Tetiker T, Beyazit Y, Celik H, Yesil Y. Thyroid hormone levels as a predictor of mortality in intensive care patients: A comparative prospective study. Wien Klin Wochenschr 2012;124:154–9.

19. Todd SR, Sim V, Moore LJ, Turner KL, Sucher JF, Moore FA. The identification of thyroid dysfunction in surgical sepsis. J Trauma Acute Care Surg 2012;73:1457–60.

20. Fernández V, Videla LA. On the mechanism of thyroid hormone-induced respiratory burst activity in rat polymorphonuclear leukocytes.

Free Radic Biol Med 1995;19:359–63.

21. Alamino VA, Montesinos MM, Rabinovich GA, Pellizas CG. The thyroid hormone triiodothyronine reinvigorates dendritic cells and potentiates anti-tumor immunity. Oncoimmunology 2015;5:e1064579.

22. Meinhold H, Gramm HJ, Meissner W, Zimmermann J, Schwander J, Dennhardt R, et al. Elevated serum diiodotyrosine (DIT) in severe infec-

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tions and sepsis: DIT, a possible new marker of leukocyte activity. J Clin Endocrinol Metab 1991;72:945–53.

23. Ayala A, Herdon CD, Lehman DL, Ayala CA, Chaudry IH. Differential induction of apoptosis in lymphoid tissues during sepsis: variation in onset, frequency, and the nature of the mediators. Blood 1996;87:4261–75.

24. Dietz S, Lautenschläger C, Müller-Werdan U, Pilz G, Fraunberger P, Päsler M, et al. Serum IgG levels and mortality in patients with severe sepsis and septic shock: The SBITS data. Med Klin Intensivmed Notfmed 2017;112:462–70.

25. Chapital AD, Hendrick SR, Lloyd L, Pieper D. The effects of triiodothyronine augmentation on antithrombin III levels in sepsis. Am Surg 2001;67:253–5.

26. Eisele B, Lamy M, Thijs LG, Keinecke HO, Schuster HP, Matthias FR, et al. Antithrombin III in patients with severe sepsis. A randomized, placebo-controlled, double-blind multicenter trial plus a meta-analysis on all randomized, placebo-controlled, double-blind trials with antithrombin III in severe sepsis. Intensive Care Med 1998;24:663–72.

27. Ding LA, Li JS, Li YS, Zhu NT, Liu FN, Tan L. Intestinal barrier damage caused by trauma and lipopolysaccharide. World J Gastroenterol 2004;10:2373–8.

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29. Dhainaut JF, Marin N, Mignon A, Vinsonneau C. Hepatic response to sepsis: interaction between coagulation and inflammatory processes. Crit Care Med 2001;29:S42–7.

30. Joyce DE, Grinnell BW. Recombinant Human Activated Protein C Attenuates The Inflammatory Response In Endothelium And Monocytes

By Modulating Nuclear Factor-kappaB. Crit Care Med 2002;30:S288– S93.

31. Shih CH, Chen SL, Yen CC, Huang YH, Chen CD, Lee YS, et al. Thyroid hormone receptor-dependent transcriptional regulation of fibrinogen and coagulation proteins. Endocrinology. 2004;145:2804–14.

32. Lotková H, Rauchová H, Drahota Z. Activation of mitochondrial glycerophosphate cytochrome c reductase in regenerating rat liver by triiodothyronine. Physiol Res 2001;50:333–6.

33. Cunningham AJ. Acute respiratory distress syndrome--two decades later.

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34. Mercer-Jones MA, Heinzelmann M, Peyton JC, Wickel DJ, Cook M, Cheadle WG. The pulmonary inflammatory response to experimental fecal peritonitis: relative roles of tumor necrosis factor-alpha and endotoxin. Inflammation 1997;21:401–17.

35. Browder W, Ha T, Chuanfu L, Kalbfleisch JH, Ferguson DA Jr, Williams DL. Early activation of pulmonary nuclear factor kappaB and nuclear factor interleukin-6 in polymicrobial sepsis. J Trauma 1999;46:590–6.

36. Stamme C, Bundschuh DS, Hartung T, Gebert U, Wollin L, Nüsing R, et al. Temporal sequence of pulmonary and systemic inflammatory responses to graded polymicrobial peritonitis in mice. Infect Immun 1999;67:5642–50.

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DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Sepsis tedavisinde triiyodotironin aktive protein C’ye göre daha iyi bir seçenek midir?

Dr. Ömer Vefik Özozan,1 Dr. Didem Ertorul2 1 2

İstinye Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul Sancaktepe Eğitim Araştırma Hastanesi, Genel Cerrahi Kliniği, İ̇stanbul

AMAÇ: Sepsis, enfeksiyona karşı konağın göstermiş olduğu disregüle yanıta bağlı gelişen hayatı tehdit edici bir organ disfonksiyonu olarak tanımlanabilir. Sepsiste, koagülasyon kaskatı aktive olur ve denge prokoagülan tarafa doğru kayar. Protein C’nin sepsis tedavisinde kullanımını araştıran yakın tarihli çalışmalar mevcuttur. Ayrıca diğer bir terapötik ajan olan triiyodotironin hakkında da çalışmalar yapılmıştır.

GEREÇ VE YÖNTEM: Çalışmamızda sepsis oluşturulmuş sıçanlarda geç dönemde tek doz aktive protein C ve triiyodotironin uygulamasının etkileri karşılaştırıldı. Uygulama sonrası 24. saatte lökosit, platelet, hemoglobin ve antitrombin-III konsantrasyonları ile ince bağırsak, karaciğer ve akciğerdeki histopatolojik değişiklikler değerlendirildi.

BULGULAR: Intraperitoneal tek doz rekombinant insan APC (aktive protein C) uygulamasının geç fazda hematolojik parametrelerde küratif etkileri olduğu ve başta akciğer olmak üzere hepatik ve ince barsak dokusunda da anlamlı terapötik etkilerinin olabileceği görülmüştür. Triiyodotironin ise sepsis tedaivisnde kullanılabilecek önemli bir terapötik ajan olarak değerlendirildi.

TARTIŞMA: Çalışmamızda T3 hormonunun özellikle akciğer dokusu olmak üzerre karaciğer ve ince bağırsak dokusu üzerinde sepsis bağlı hasarı sınırladığı veya azalttığı gözlenmiştir. Triiyodotironin daha az maliyet ve kanama riskiyle sepsis tedavisinde APC’ye iyi bir alternatif olabileceği kanaatinedeyiz.

Anahtar sözcükler: Aktive protein C; sepsis; triiyodotironin.

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doi: 10.14744/tjtes.2019.36270

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EXPERIMENTAL STUDY

An anatomical examination of iatrogenic nerve injury during inside out meniscus repair with flexion and extension of the knee Zafer Atbaşı, M.D.,1 Barış Yılmaz, M.D.,3

Yusuf Erdem, M.D.,2 Çağrı Neyişci, M.D.,2 Bahtiyar Demiralp, M.D.1

1

Department of Orthopaedics and Traumatology, Güven Hospital, Ankara-Turkey

2

Department of Orthopaedics and Traumatology, Gülhane Training and Research Hospital, Ankara-Turkey

3

Department of Orthopaedics and Traumatology, Fatih Sultan Mehmet Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: In this study, we aim to assess the safe, risky and high-risky zones by measuring the proximity of the needles to the peroneal and saphenous nerves in millimeters for the repair of tears of the anterior, middle and posterior horns of the medial and lateral menisci at flexion and extension position during inside-out repair technique.

METHODS: First, a cadaveric study was conducted on 10 cadaver knees in which both (lateral and medial) menisci were divided into anterior, corpus and posterior with the longitudinal tear simulating in each section. The next phase involved the suture of the simulated tears of the menisci while the knee was at 90° of flexion and full extension. Finally, the distance from the exit points of the K-wire being inserted through meniscal anterior, corpus and posterior tears to the aforementioned nerves was measured with a digital caliper.

RESULTS: The distance between K-wire exit points and neurovascular structures concerning corpus and anterior horn tear repair of both menisci were considered far away and not included. However, closer posterior menisci measurements were taken to avoid the risk of iatrogenic nerve injury. The measured distances for lateral meniscus posterior tears were recorded 11±5.2 mm at 90° of flexion and 8±4.5 mm at extension, whereas those recorded 17.3±5.7 mm at 90° of flexion and 13.7±4.7 mm at extension for medial meniscus. These variables were evaluated statistically using a paired t-test; the mean of t value was not considered statistically significant.

CONCLUSION: Our results show that the inside-out technique at knee flexion is safe even in the posterior meniscus tears. However, safety distance can be increased with the higher flexion degrees of the knee. Lastly, in posterior meniscal tear repair, we recommend either retractor assisted mini-open technique at knee flexion, or all-inside suture technique, to avoid nerve injury risk in this zone. Although many surgeons do not prefer inside-out techniques for posterior menisci tears, inside-out posterior meniscal repair of both menisci is as safe as an all-inside technique using retractor assisted mini-open technique with the knee at higher than 90° flexion.

Keywords: Inside-out meniscus repair; peroneal nerve injury; saphenous nerve injury.

INTRODUCTION Since Fairbank et al.’s research on knee degeneration after meniscectomy, meniscal-sparing techniques have been popularized with improved outcomes.[1–4] It is stated that subtotal or total meniscectomy increase weight-bearing on per square unit of the cartilage surface approximately three and half-

times.[5] Today, it is widely accepted that the meniscal repair indications should be expanded and that keeping menisci (even with chronical tears) as much as possible is a necessity.[6] Repair of a meniscal tear is first defined by Scottish surgeon Annandale in 1885,[7] and both open and arthroscopic repair are still being conducted. Today inside-out, outside-in or all-in-

Cite this article as: Atbaşı Z, Erdem Y, Neyişci Ç, Yılmaz B, Demiralp B. An anatomical examination of iatrogenic nerve injury during inside out meniscus repair with flexion and extension of the knee. Ulus Travma Acil Cerrahi Derg 2019;25:555-560.

Address for correspondence: Çağrı Neyişci, M.D. Gülhane Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Anabilim Dalı, 06010 Ankara, Turkey Tel: +90 312 - 304 20 00 E-mail: cagri_neyis@yahoo.com Ulus Travma Acil Cerrahi Derg 2019;25(6):555-560 DOI: 10.14744/tjtes.2019.99690 Submitted: 13.04.2019 Accepted: 09.09.2019 Online: 25.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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side techniques are used in the arthroscopic repair of meniscal tears, which was first initiated by Henning.[8] Although there are promising results on meniscal healing rates with these techniques, the gold standard remains the inside-out vertical mattress suture repair.[6,9–11] However, the inside-out repair technique may cause iatrogenic nerve and vein injury, especially in posterior horn meniscal tears. Moreover, many cases and reports about iatrogenic peroneal nerve and popliteal artery injury during lateral meniscal repair and iatrogenic nerve injury in medial meniscal repairs were reported in the literature.[12–15] To our knowledge, no reported studies have described to which extent the position of the knee (flexion and extension) can increase the neurovascular injury risk. Thus, it is crucially important to know the right knee positioning and safe zones to avoid iatrogenic nerve injury risk with patients who will have undergone inside-out meniscal repair.

The present study aims to investigate the nerve injury risk and assess the safety, risky and high-risky zones by measuring the proximity of the needles to the peroneal and saphenous nerves during the inside-out meniscal repair technique.

MATERIALS AND METHODS An anatomic study was performed by the use of 6 right and 4 left, totally 10 fresh cadaver knees (3 female, 7 male), The average cadaver age was measured as 75.1 (range 63–90 years), average weight 82.6 kg (range 41–117 kg) and average height 174.2 cm (range 152–190 cm), respectively. No previous operation scar was observed on the knee specimens. Standard medial and lateral anteroinferior arthroscopic portals were marked on the knees. The anteroinferior medial portal was marked 1 cm. medial, anteroinferior lateral portal was marked 1 cm lateral to the patellar tendon, with 1 cm proximal of tibial joint surface both. After midline skin incision, medial and lateral parapatellar arthrotomy was performed by applying sharp incisions to separate patellar tendon from tibial tuberosity (Fig. 1). Both menisci were visible. Then, medial and lateral meniscuses were divided into three equal parts as posterior, corpus and anterior by marker pen. The longitudinal tear was simulated in each part. First, 1-mm K-wire was entered from the medial portal and passed through the simulated tears at the lateral meniscus, and then, was removed from the skin

(a)

at the level of the joint line. Once the K-wire was got out of the skin, the posterior of the knees were cut between biceps femoris and iliotibial band with a 15 cm. skin incision to locate the exit point and the peroneal nerve. After blunt dissection, the peroneal nerve was observed by retracting the biceps femoris and iliotibial band. The dissection was not extended to preserve the relationship of the peroneal nerve with the surrounding soft tissue. The distance between the K-wire exit point and the peroneal nerve was then measured in millimeters with a digital caliper and recorded (Fig. 2). Measurements were performed separately while the knee was positioned at 90° of flexion and full extension for 1/3 anterior, 1/3 corpus and 1/3 posterior, respectively. Then, the medial meniscus was divided into three equal and lateral portals were used for Kwire. The saphenous nerve was viewed at posteromedial after dissecting the medial skin-subcutaneous tissue. The 1 mm Kwire was passed throughout the longitudinal tear simulated at the medial meniscus and removed from skin while the knee was positioned at 90° of flexion and full extension (Fig. 3).

The distance between the saphenous nerve and K-wire was measured in millimeters for all three parts in 90° of flexion and at full extension like lateral measurements (Fig. 4). Results, taken from both meniscuses in both positions, were transferred to Stata/SE 11.0 program and the average, minimum and maximum values and standard deviations were identified.

P<0.5 was considered as statistically significant. Furthermore, lateral and medial meniscus posterior measurements were compared, whether the flexion and extension positions of the knee made a statistical difference at this significance level. Statistical evaluation included a paired t-test.

RESULTS In one cadaver knee, K-wire was passed through the peroneal nerve during posterior lateral meniscus repair while the knee was extended. The measurements obtained between each Kwire exit point and the peroneal nerve and the saphenous nerve showed the following: The mean distance between Kwire exit point and peroneal nerve in 1/3 posterior horn tear was found to be 11±5.2 (range, 0.9–18 mm) at 90-degree

(b)

(c)

Figure 1. (a) Parapatellar arthrotomy and (b, c) posteromedial and posterolateral dissections to identify the nerves.

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Figure 2. Measurements were done by a digital caliper.

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Table 1. Measurements performed for both menisci

Anterior Middle Posterior horn horn horn

Medial meniscus (mm) 90° flexion

53.3±6.2 35.8±7.4 17.3±5.7

Extension

54.4±8.2 40.8±6.4 13.7±4.7

Lateral meniscus (mm)

90° flexion

Extension

50.6±7.2

31.3±6.4

52.5±5.4 38±5.9

11±5.2 8±4.5

are no statistically differences (p<0.5) between the K-wire exit points through the different locations studied.

DISCUSSION Figure 3. Illustration shows the distance between K-wire and the saphenous nerve. Measurements were taken at full extension and 90° of flexion.

Figure 4. Illustration shows the distance between K-wire and peroneal nerve. Measurements were taken at full extension and 90° of flexion.

knee flexion, while 8±4.5 (range, 0–12.7 mm) at extension. İt is found 31.3±6.4 (range, 22.3–40.8 mm) at 90-degree flexion and 38±5.9 (range, 26.2–49 mm) at extension for 1/3 middle horn, while 50.6±7.2 (range, 37.2–61.9 mm) at 90-degree flexion and 52.5±5.4 (range 45.2–61.8 mm) at extension was recorded for 1/3 anterior horn. Similar measurements were performed for medial meniscus. The mean distance between K-wire exit point and saphenous nerve in 1/3 posterior horn tear was found to be 17.3±5.7 (range, 5.3–24.1 mm) at 90-degree knee flexion, while 13.7±4.7 (range, 5.3–19.8 mm) at extension. İt is found 35.8±7.4 (range, 30–56 mm) at 90-degree flexion and 40.8±6.4 (range, 36.2–57.8 mm) at extension for 1/3 middle horn, while 53.3±6.2 (range, 42.8–63.6 mm) at 90-degree flexion and 54.4±8.2 (range, 42.8–70.4 mm) at extension was recorded for 1/3 anterior horn (Table 1). There Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

It is widely accepted that choosing arthroscopic meniscal repair in lieu of meniscectomy for meniscal tears is necessary when the effects of the meniscus on the knee mechanics and its chondroprotective characteristics are taken into consideration.[1–4,16–19] Today, inside-out meniscal repair technique is a preferred method with a success rate of almost 80% at isolated meniscal tears, and 90% at accompanying anterior cruciate ligament repair.[20,21] Despite that this technique requires practical experience and that takes a lot of time, it is still being used at repairable posterior and medial horn tears.

The technique requires that the suture material is transferred with the help of entering cannula and needle at a point close to the tear on the meniscus. Both the structures through which the needle passes the skin and the subcutaneous tissues that remain inside the tied knot are at risk. The most important finding of our study is the existence of the safety margin, which ensures that the higher degrees of knee flexion are not as dangerous as other ranges concerning saphenous and peroneal nerve damages.

The most probable complication after arthroscopic inside-out meniscal repair technique is a major blood vessel or nerve injury. In the literature, there are many studies indicating a high risk of neurovascular injury in posterior horn repairs.[9,12,22–25] In a study conducted on a cadaveric knee, Jurist et al.[22] reported that the K-wire used for the repair of lateral meniscus passed through the peroneal nerve. In a similar study, Anderson et al.[26] reported a common peroneal nerve neuropraxia after arthroscopic inside-out lateral meniscus repair. Raza et al.[27] reported a case with saphenous nerve damage after arthroscopic meniscus repair, and Choi et al.[28] reported in their study where inside-out and all-inside techniques were compared, resulting two patients with temporary saphenous nerve lesion after inside-out repair. In Small’s retrospective meta-analysis involving large numbers of patients, it is reported that the most frequent complication observed after a meniscal repair is nerve injury and saphenous nerves are more affected than peroneal nerve.[12] In our 557

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study, in one specimen, peroneal nerve damage occurred.

However, unless a retractor is used in posterior horn meniscal repairs, both peroneal and saphenous nerves are reported to be under high risk. In our study, in the posterior horn meniscal repair, the average distance of the needle to the peroneal nerve and saphenous nerve is noted as 8 mm and 13 mm at an extension of the knee, respectively. Moreover, the anatomical variations of the nerves may increase the risk of iatrogenic neurovascular injury. Some cadaveric studies were conducted to identify the risks. Deutsch et al.[23] emphasized that the variation of the nerve is also a risk factor causing different clinical conditions after iatrogenic neurovascular injury, by manifesting in 70 cadaveric knees that the relevant anatomy of the common peroneal nerve is divided into deep and superficial branches above, at and below the knee joint level. In a similar study, Rodeo et al.[29] stated that if the bifurcation of the peroneal nerve is 4 cm above the knee joint, exploration is inevitable for common peroneal nerve injury after knee arthroscopy. In our study, in all cadaveric knees, including the one with a peroneal nerve injury, anatomical exploration was applied to the nerve to observe whether this risk is relatively high or not, and it is observed that the nerve continued as common peroneal at knee joint level.

To prevent the nerve injury complications, the authors advise that the capsule should be viewed by placing a retractor over the gastrocnemius tendon with a small posterior incision.

Thus, the needles piercing the posterior capsule are easily deflected medially or laterally toward the surgeon. Otherwise, tying the knot without seeing the capsule may increase the risk of neurovascular injury risk because of the soft tissues trapped within the knot.[22,30,31] Espejo-Baena et al.[9] conducted a medial meniscus repair with the vertical mattress on cadaveric knees. They reported the complications as the infrapatellar branch of the saphenous nerve injury in one knee and in the other three saphenous nerve injury itself occurred after saturation. Henning et al.[32] emphasize the importance of making an exposure with 4 cm incision on the posterior for prevention of neurovascular complication risk, and for tying the knot in a safe manner. In a similar study EspejoBaena et al.[33] argued about the necessity of posterior exposure and added that the posterior incision might be smaller than that of the one made for medial meniscal repair. Mini open exposure both prevents the soft tissues from remaining in the knot and iatrogenic nerve injury. In accordance with the aforementioned studies, we are also of the opinion that using appropriate exposure and retractor in the inside-out technique for meniscal posterior horn tear may reduce the risk of nerve injury. In the medial and anterior horn repairs, due to the distance between the trace of the peroneal and saphenous nerve, inside-out technique can be applied safely without the need for any exposure.

Intraoperative knee flexion angle is another important point to be considered concerning neurovascular injuries. There is no optimal knee position to avoid nerve injury; however, the 558

optimal knee position is ranging from 90° flexion to 10-30° of flexion to full extension.[34] According to many authors, meniscal repair surgery can usually be applied at the following knee positions; varus/valgus stress in slight flexion (10–15°) or at 90–100° of flexion.[34,35] Cuéllar et al.[15] in their study, where they measured distances between the suture material used and the peroneal nerve with the knee at 90°, 45°, and 0° of flexion, reported that the 90° of flexion is the safest knee flexion angle for repairing the meniscus. With the flexion of the knee, the posterior neurovascular structures go further away from the meniscal tissue. Similar to the study of Cuéllar et al., basing on the values measured during our study, due to the millimeter proximity, the risk of nerve injury in inside-out posterior horn meniscal repairs was found significantly higher than that of the medial and anterior horn repairs. Supporting the literature, in our study, it is determined in the posterior horn repairs that the measurements taken millimetrically while the knee was in extension position, K-wire pass closer to the nerve than that of the flexion position. The results are found consistent with the literature, and it is statistically significant that placing the suture material while the knee is in flexion position reduces the risk of nerve injury (p<0.5).

While nerve symptoms have been described as the most serious complication of this technique, it has more advantages over all-inside repair technique concerning less-soft-tissue irritation, implant breakage, implant migration and implant failure.[36] Moreover, suture placement versatility, lower implant cost with lower profile needle usage for multiple suturing that allow a stable meniscal construct may be considered as the preferability of the technique.

To our knowledge, our study is the first study, concerning which both menisci are included in cadaveric knees, and mill metrical measurements of the distance between the needles used in the inside-out meniscal repair technique to the nerve are taken, and the effects of the flexion angle of the knee on the risk of nerve injury in an unwanted complication is manifested. Our study puts forward that the intraoperative preferences of the surgeons would affect the results.

Conclusion As a result, it should be well-noted that operation in a highrisk zone would take place if the inside-out meniscal repair technique is planned to be used in the posterior repair. We are in the favour of either retractor assisted mini-open technique at knee flexion, or all-inside suture technique, to avoid nerve injury risk in this zone.

The safe zones where the use of the inside-out technique is recommended are the medial and anterior horn tears, where there are no nerve injury risks. At 1/3 middle meniscal tear repairs, we consider the inside-out meniscal repair technique as the most ideal method, as it is the easiest to apply without any nerve injury risk.

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In the treatment of anterior horn tears, although the inside-out technique is safe, due to surgical technical difficulties, outside-in suture technique may also be preferred.

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

Acknowledgement: None Conflict of interest: None declared.

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5. Pasa L, Pokorný V, Kalandra S, Melichar I, Bilik A. Transplantation of deep frozen menisci. Acta Chir Orthop Traumatol Cech 2008;75:40–7.

6. Turman KA, Diduch DR. Meniscal repair: Indications and techniques. J Knee Surg 2008;21:154–62.

7. Di Matteo B, Tarabella V, Filardo G, Viganò A, Tomba P, Marcacci M. Thomas Annandale: the first meniscus repair. Knee Surg Sports Traumatol Arthrosc 2013;21:1963–6.

8. Henning CE. Arthroscopic repair of meniscus tears. Orthopedics.

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9. Espejo-Baena A, Golano P, Meschian S, Garcia-Herrera JM, Serrano Jiménez JM. Complications in medial meniscus suture: a cadaveric study.

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10. Espejo-Baena A, Figueroa-Mata A, Serrano-Fernández J, de la TorreSolís F. All-inside suture technique using anterior portals in posterior horn tears of lateral meniscus. Arthroscopy 2008;24:369.e1–4.

11. McCarty EC, Marx RG, DeHaven KE. Meniscus repair: Considerations in treatment and update of clinical results. Clin Orthop Relat Res 2002;122–34.

12. Small NC. Complications of arthroscopic meniscal surgery. Clin Sports Med 1990;9:609–17.

13. Grant JA, Wilde J, Miller BS, Bedi A. Comparison of inside-out and allinside techniques for the repair of isolated meniscal tears: a systematic review. Am J Sports Med 2012;40:459–68.

14. Rodeo SA. Arthroscopic meniscal repair with use of the outside-in technique. Instr Course Lect 2000;49:195–206.

15. Cuéllar A, Cuéllar R, Cuéllar A, Garcia-Alonso I, Ruiz-Ibán MA. The Effect of Knee Flexion Angle on the Neurovascular Safety of All-Inside Lateral Meniscus Repair: A Cadaveric Study. Arthroscopy 2015;31:2138–44.

16. Xu C, Zhao J. A meta-analysis comparing meniscal repair with meniscectomy in the treatment of meniscal tears: the more meniscus, the better outcome? Knee Surg Sports Traumatol Arthrosc 2015;23:164–70.

17. Paxton ES, Stock MV, Brophy RH. Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical

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outcomes. Arthroscopy 2011;27:1275–88.

18. Stein T, Mehling AP, Welsch F, von Eisenhart-Rothe R, Jäger A. Longterm outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears. Am J Sports Med 2010;38:1542–8.

19. Lutz C, Dalmay F, Ehkirch FP, Cucurulo T, Laporte C, Le Henaff G, et al. Meniscectomy versus meniscal repair: 10 years radiological and clinical results in vertical lesions in stable knee. Orthop Traumatol Surg Res 2015;101:S327–31.

20. Cannon WD Jr, Vittori JM. The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament-reconstructed knees versus stable knees. Am J Sports Med 1992;20:176–81.

21. Nelson CG, Bonner KF. Inside-Out Meniscus Repair. Arthrosc Tech 2013;2:e453–e60.

22. Jurist KA, Greene PW 3rd, Shirkhoda A. Peroneal nerve dysfunction as a complication of lateral meniscus repair: a case report and anatomic dissection. Arthroscopy 1989;5:141–7.

23. Deutsch A, Wyzykowski RJ, Victoroff BN. Evaluation of the anatomy of the common peroneal nerve. Defining nerve-at-risk in arthroscopically assisted lateral meniscus repair. Am J Sports Med 1999;27:10–5.

24. Small NC: Complications in arthroscopy: The knee and other joints.

Arthroscopy 1986;2:253–8.

25. Small NC, Farless BL. Avoiding complications in meniscal repair. Techn Orthop 1993;8:70–5.

26. Anderson AW, LaPrade RF. Common peroneal nerve neuropraxia after arthroscopic inside-out lateral meniscus repair. J Knee Surg 2009;22:27– 9.

27. Raza H, Abbas K, Umer M. Arthroscopic repair of meniscal tears with inside-out technique. J Pak Med Assoc 2011;61:10–4.

28. Choi NH, Kim TH, Victoroff BN. Comparison of arthroscopic medial meniscal suture repair techniques: inside-out versus all-inside repair. Am J Sports Med 2009;37:2144–50.

29. Rodeo SA, Sobel S, Weiland AJ: Deep peroneal-nerve injury as a result of arthroscopic meniscectomy. A case report and review of the literature.

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30. Warren RF. Arthroscopic meniscus repair. Arthroscopy 1985;1:170–2.

31. Morgan CD, Casscells SW. Arthroscopic meniscus repair: a safe approach to the posterior horns. Arthroscopy 1986;2:3–12.

32. Henning CE, Clark JR, Lynch MA, Stallbaumer R, Yearout KM, Vequist SW. Arthroscopic meniscus repair with a posterior incision. Instr Course Lect 1988;37:209–21.

33. Baena AE, Castilla BM, Fernandez JS, de Rota Conde AF, Reina AE, Rubio FE. Inside-out medial meniscus suture: an analysis of the risk of injury to the popliteal neurovascular bundle. Arthroscopy 2011;27:516– 21.

34. Ackmann T, Von During M, Teske W, Ackermann O, Muller P, Von Schulze Pellengahr C (2014) Anatomy of the infrapatellar branch in relation to skin incisions and as the basis to treat neuro- pathic pain by cryodenervation. Pain Physician 2014;17:E339–E48.

35. Koch G, Kling A, Ramamurthy N, Edalat F, Cazzato RL, Kahn JL, Garnon J, Clavert P. Anatomical risk evaluation of iatrogenic injury to the infrapatellar branch of the saphenous nerve during medial meniscus arthroscopic surgery. Surg Radiol Anat 2017;39:611–8.

36. Chahla J, Serra Cruz R, Cram TR, Dean CS, LaPrade RF. Inside Out Meniscal Repair: Medial and Lateral Approach. Arthrosc Tech 2016;5:163–8.

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DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Diz fleksiyon ve ekstansiyon pozisyonundayken içten-dışa menisküs tamiri sırasında iyatrojenik sinir hasarının anatomik muayenesi Dr. Zafer Atbaşı,1 Dr. Yusuf Erdem,2 Dr. Çağrı Neyişci,2 Dr. Barış Yılmaz,3 Dr. Bahtiyar Demiralp1 Güven Hastanesi, Ortopedi ve Travmatoloji Kliniği, Ankara Gülhane Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Ankara 3 Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul 1 2

AMAÇ: Diz fleksiyon ve ekstansiyon pozisyonundayken, medial ve lateral menisküslerin anterior, orta ve posterior boynuz yırtıklarının içten-dışa onarım tekniği sırasında tamir edilmesi için iğnelerin peroneal ve safen sinire milimetre cinsinden yakınlığını ölçerek güvenli, riskli ve yüksek riskli bölgeleri belirlemektir.

GEREÇ VE YÖNTEM: İlk olarak, 10 kadavra dizinde her iki (lateral ve medial) menisküste longitudinal yırtık simülasyonu ile menisküsün anterior, korpus ve posterior olarak bölündüğü kadavra çalışması yapıldı. Bir sonraki aşama, diz 90° fleksiyonda ve tam ekstansiyondayken menisküsün simüle yırtıklarının dikilmesini içeriyordu. Son olarak, anterior, gövde ve posterior meniskal yırtıklar boyunca yerleştirilen K-teli çıkış noktasının yukarıda bahsedilen sinirlerden uzaklığı bir dijital kumpas ile ölçülmüştür.

BULGULAR: Her iki menisküsün gövde ve anterior boynuz yırtıklarının tamiri sırasında K-teli çıkış noktaları ile nörovasküler yapılar arasındaki mesafe çok uzak olarak kabul edildi ve dahil edilmedi. Ancak, iyatrojenik sinir hasarı riskinden kaçınmak için daha yakın arka menisküs ölçümleri yapıldı.

Lateral menisküs posterior yırtığı için ölçülen mesafeler 90° fleksiyonda 11±5.2 mm ve ekstansiyonda 8±4.5 mm iken, medial menisküs için 90° fleksiyonda 17.3±5.7 mm ve ekstansiyonda 13.7±4.7 mm olarak kaydedildi. Bu değişkenler bağımlı örneklem t-testi kullanılarak değerlendirildi ve istatistiksel olarak anlamlı fark bulunamadı.

TARTIŞMA: Sonuçlarımız diz fleksiyondayken içten-dışa tekniğinin posterior menisküs yırtıklarında bile güvenli olduğunu göstermektedir. Bununla birlikte, güvenlik mesafesi dizin daha yüksek fleksiyon dereceleri ile arttırılabilir. Son olarak, arka menisküs yırtık tamirinde, bu bölgedeki sinir hasar riskini önlemek için diz fleksiyonda iken retraktör yardımlı mini açık tekniğini veya tamamen içeriden dikiş tekniğini öneriyoruz. Her ne kadar birçok cerrahın arka menisküs yırtıklarında içten-dışa tekniğini tercih etmediği bilinmesine rağmen, diz 90°’den daha fazla fleksiyonda iken retraktör yardımlı mini açık teknik kullanılarak her iki menisküsün içten-dışa arka menisküs tamiri tamamen içeriden dikiş tekniği kadar güvenlidir.

Anahtar sözcükler: İçten-dışa menisküs tamiri; peroneal sinir hasarı; safen sinir hasarı.

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doi: 10.14744/tjtes.2019.99690

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ORIG I N A L A R T IC L E

Abdominal perfusion pressure is superior from intra-abdominal pressure to detect deterioration of renal perfusion in critically Ill patients Fethi Gül, M.D., İsmet Sayan, M.D., Umut Sabri Kasapoğlu, M.D., Derya Özer Erol, M.D., Mustafa Kemal Arslantaş, M.D., İsmail Cinel, M.D., Zuhal Aykaç, M.D. Department of Anesthesiology and Critical Care, Marmara University Pendik Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Intra-abdominal hypertension (IAH) is a frequent cause of acute kidney injury (AKI) among critically ill patients who have risk factors. This study aimed to determine the relation between Abdominal Perfusion Pressure (APP) and AKI showed by the Doppler-based renal resistive index (RRI).

METHODS: In this study, 38 patients older than 18 years old who received mechanical ventilation and had risk factors for the development of IAH were prospectively studied. All measurements and parameters were divided into two groups according to renal dysfunction (Group I: RRI <0.72 vs Group II: RRI >0.72).

RESULTS: The mean IAPs were not significant between the groups, 11.5±6.9 mm Hg in Group I (n=35) and 13.5±5.8 in Group II (n=33), respectively. APPs were statistically higher in Group I (81.2±13.6) than Group II (66.4±9.5) (p<0.001). The AUC for the association between APP at RRI >0.72 was 0.802 (p<0.001), with the APP ≤72 mmHg having a sensitivity of the 76% (95% CI 58–89%) and a specificity of 71% (95% CI 54–85%).

CONCLUSION: Our findings suggest that an APP with a threshold of ≤72 mmHg is associated with a significant increase in renal RRI, which may be predictive of worsening of renal perfusion.

Keywords: Abdominal perfusion pressure; renal perfusion pressure; renal resistive index.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been shown to occur frequently and independently associated with morbidity and mortality among critically ill patients.[1] Given that both of them are associated with increased morbidity and mortality, identification, avoiding, or management of these conditions may improve patient outcomes.

routinely in daily follow ups of high-risk ICU patients. Normal IAP values are considered around 10 mm Hg in critically ill patients. IAH has accepted an increase in IAP ≥12 mmHg and ACS is defined elevation of IAP >20 mmHg with new onset of organ failure. Abdominal perfusion pressure (APP) is the difference between the MAP and IAP, a more accurate marker of resuscitation endpoint in patients with IAH. The APP correlates with visceral perfusion above the 60 mm Hg seems a good approach to maintain macro and microcirculation.[3]

The intra-abdominal pressure (IAP) measurement is a key point in diagnosing and managing critically ill ICU patients who have risk factors for the development of IAH and ACS. [2] IAP measurements are easy to perform and should be used

An increase of the IAP can bring on several deleterious pathophysiologic consequences, which include vascular compression that reduces perfusion and venous drainage of intra-abdominal and other organs. Although mechanisms are not yet

INTRODUCTION

Cite this article as: Gül F, Sayan İ, Kasapoğlu US, Erol DÖ, Arslantaş MK, Cinel İ, et al. Abdominal perfusion pressure is superior from intra-abdominal pressure to detect deterioration of renal perfusion in critically Ill patients. Ulus Travma Acil Cerrahi Derg 2019;25:561-566.

Address for correspondence: Zuhal Aykaç, M.D. Marmara Üniversitesi Pendik Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Yoğun Bakım Kliniği, İstanbul, Turkey Tel: +90 216 - 625 45 45 E-mail: aykaczuhal@hotmail.com Ulus Travma Acil Cerrahi Derg 2019;25(6):561-566 DOI: 10.14744/tjtes.2019.25263 Submitted: 29.06.2019 Accepted: 15.08.2019 Online: 25.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Gül et al. APP is superior from intra-abdominal pressure to detect deterioration of renal perfusion in critically Ill patients

completely understood, systemic effects of IAP may result in life-threatening for critically ill patients.[4] Increased IAP leads to many organ dysfunctions, mainly renal, cardiovascular, respiratory, gastrointestinal, and hepatic systems are affected.

The kidneys are more vulnerable to IAH than other organs due to the deleterious mechanical effects of the increased IAP in the blood supply. The etiology of renal dysfunction and probably one of the most important ones is diminished renal blood flow. Increment of renal vessel resistance occurs due to high IAP, which causes a decrease of microcirculatory flow in the renal cortex. This stimulates vasoconstriction of renal vessels with activation of the renin-angiotensin system that results in further diminished renal perfusion.[5] Little evidence is known about renal monitoring during IAH. It is a frequent cause of acute kidney injury (AKI) in ICU and not commonly recognized by an intensivist. Hence, the identification and early recognition of patients in whom renal hemodynamics deteriorate are fundamental during critical care stay for achieving good clinical outcomes.[6] Renal resistive index (RRI), measured by renal interlobar artery Doppler ultrasonography, is a successful non-invasive bedside monitoring modality which directly reveals and quantifies modifications in renal vascular resistance. This method enables repeated assessments of the renal circulation at the bedside with high diagnostic accuracy following various therapeutic interventions in critically ill patients.[7] It has been widely performed monitoring parameter that is gaining more frequent use in daily ICU practice. RRI values are usually obtained by translumbar or transabdominal Doppler approach, but measurements are also accessible with the transesophageal echocardiography.[8] RRI >0.72 allows earlier detection of AKI before other biochemical parameters increase, such as creatinine. Thus, careful fluid management and hemodynamic adjustments with avoiding the use of nephrotoxic medication are possible.[9] The primary purpose of this prospective single-center study was to investigate the relationship between APP and AKI showed by Doppler-based RRI. The secondary goal was to examine the correlation between the clinical and laboratory characteristics of the patients who had this pathologic condition.

MATERIALS AND METHODS Data Collection Age, gender, APACHE II (Acute Physiology and Chronic Health Evaluation) and SOFA (Sequential Organ Failure Assessment) scores were recorded. Simultaneous IAP, APP, Mean Arterial Pressure (MAP), cardiac output, cardiac index, heart rate, serum creatinine, lactate levels, mechanic ventilatory parameters; positive end-expiratory pressure (PEEP), Ppeak, FiO2 and PaO2 which were measured with arterial blood sampling (PaO2/FiO2 [PF] ratio) at baseline and at 24th hours were noted.

562

Patient Population This prospective study was conducted between March 2018 to March 2019 in the Intensive Care Unit of the Marmara University Pendik Education and Research Hospital. The Clinical Research Ethics Committee of the Marmara University approved the study (registration number: 09.2018.105). All participants or legal representatives signed an Informed Consent Form.

In total, 38 mechanically ventilated with deep sedation (6 points on the Ramsay scale) ICU patients (>18 years old) who had risk factors for the development of IAH and ACS and expected to stay >24 h were included in this study. Exclusion criteria consisted of pregnancy, heart failure, non-sinus cardiac rhythm that affected renal resistive index, chronic renal failure or renal artery disease (unilateral kidney, renal stone disease, renal artery stenosis or having a contraindication for intravesical pressure measurement, eg. pelvic fracture, hematuria, or neurogenic bladder).

RRI ≥0.72 has been considered as a marker of renal dysfunction and acute kidney injury.[9] We divided all measurements into two groups, according to RRI. RRI <0.72 measurements were grouped as Group I (n=35). Group II (n=33) measurements included RRI above >0.72.

According to the Consensus definitions of the WSACS (www. wsacs.org), IAH is defined by the sustained or repeated elevation of IAP >12 mmHg. Abdominal perfusion pressure (APP) was calculated by subtracting the IAP from the mean arterial pressure (MAP): APP=MAP–IAP.[3]

IAP Measurement Techniques The intra-vesicular pressure was measured through a closedsystem Foley bladder catheter. It was measured at the end of the expiration with the patient in the supine position and the transducer placed at the mid-axillary line where it crosses the iliac crest. A transducer-based needle with an interposition T-piece was used directly to canulate the urinary catheter directly. The transducer (Pressure Set, Sasan Medical Disposable Products, Ankara, Turkey) was used to connect the system to bedside monitor (IntelliVue MX550, Philips Healthcare, Inc., Andover, MA, USA). The urinary drainage tube was clamped and a maximum of 25 mL of saline was instilled into the bladder through a foley catheter. Then, zero pressure on the monitor was achieved. IAP was measured on the monitor with stopcocks open to a pressure transducer, after a one-minute equilibration period. To the extent possible, the IAP was measured twice a day (basal and then at 24 h).

RRI and Cardiac Output (CO) Measurements RRI measurements were performed using a Philips EPIQ 7 ultrasound system (Philips Healthcare, Inc., Andover, MA, USA) by a trained intensivist who is certified in ultrasonography.

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Gül et al. APP is superior from intra-abdominal pressure to detect deterioration of renal perfusion in critically Ill patients

Renal Doppler was performed on the interlobar arteries using a convex probe. Renal vasculature was identified using color Doppler, and then, the arterial waveforms were obtained by Doppler in the interlobar renal artery. RRI at the interlobular or arcuate artery near the border of the central echo complex was measured three times in the upper, middle, and lower portions of the kidney. In each patient, the following formula was used to calculate RI: (RRI = [peak systolic velocity – end-diastolic velocity]/peak systolic velocity).

Three measurements were performed and the mean value of three measurements at each kidney calculated.[8] Non-invasive Ultrasonic Cardiac Output Monitor (USCOM; USCOM Ltd., Sydney, Australia, 2005) was used to measure cardiac output transcutaneously via a probe applied to the suprasternal notch.

Table 1. Comparison of clinical and laboratory characteristics with and without acute kidney injury

Group I Group II (n=35) (n=33)

IAP (mmHg)

11.5±6.9

13.5 ±5.8

0.184

MAP (mmHg)

93±13

80±9

<0.001

APP (mmHg)

81.2±13.6

66.4±9.5

<0.001

95±18

97±14

0.692

4.9 ±1.7

4.0±1.7

0.054

Heart rate (bpm) Cardiac output (L/min)

p

Cardiac index (L/min/m2) 2.4±0.9 2.3±1.2 0.415 P/F ratio

302±99

PEEP (cmH2O)

6.6±1.8 7.2±2.1 0.173

340±189

0.309

Ppeak (cmH2O)

26.8±6.1 27.2±7.1 0.812

SpO2 (%)

97.7±1.9

98.8±1.9

0.058

1.78±1.23

0.029

Statistical Analysis

Serum creatinin (mg/dL)

1.12±0.9

Continuous parametric and nonparametric variables were presented as the mean (standard deviation) and median (25th; 75th percentiles) and were compared using the t-test and Mann–Whitney test, respectively. Categorical variables were expressed as absolute (n) and relative (%) frequency and were compared by the Chi-square test. The normality of variables was tested using the Shapiro-Wilk test for normality. Receiver operating characteristic curves were generated to test the predictive discrimination threshold of impaired renal perfusion (RRI ≥0.72) and normal renal perfusion (RRI <0.72) to APP. The area under the ROC curve (AUC) was calculated and compared using a Hanley- McNeil test. The optimal threshold value (the value that maximizes the sum of the sensitivity and specificity) was also defined for APP. The criterion associated with the Youden index is reported with its 95% CI based on bootstrapping using 1000 replications. The sensitivity and specificity values are also reported with the 95% CI. Significance was assumed for a two-sided p-value <0.05. All statistical analyses were performed using SPSS 21 (IBM SPSS Statistics, Chicago, IL, USA) and MedCalc 14 software (MedCalc, Mariakerke, Belgium). For all comparisons, a p-value of less than 0.05 was considered significant.

Ph

7.44±0.07 7.41±0.09 0.111

Lactate (mmol/L)

1.78±1.39

2.47± 2.52

0.170

Renal resistive index

0.66±0.05

0.80±0.05

<0.001

RESULTS We enrolled 38 patients (17 female) fulfilling inclusion/exclusion criteria. In total, 68 IAP and RRI measurements were performed. Heart rate, cardiac output, cardiac index, P/F ratio, PEEP, Ppeak, lactate levels, pH and SpO2 levels were comparable between the groups. The patients’ clinical and laboratory parameters are reported in Table 1. In addition to this, the characteristics and diagnosis of the patients at inclusion who had risk factors for the development of IAH and ACS are shown in Table 2.

The mean of IAPs were not significant between the groups [11.5±6.9 mmHg in Group I (n=35) vs 13.5±5.8 in Group II Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

IAP: Intrabdominal pressure; MAP: Mean arterial pressure; APP: Abdominal perfusion pressure; PEEP: Positive end-expiratory pressure.

Table 2. Characteristics and diagnosis at the inclusion of the 38 patients who had risk factors for the development of IAH and ACS Parameter Value Age, (years)

55.3±17.7

Sex, n (%)

Male

21 (55%)

Female

17 (45%)

APACHE II (inclusion)

20.3±8.4

SOFA (inclusion)

8 (5–10)

Diagnosis (n)

Intrabdominal sepsis

10

Pneumonia sepsis

7

Intracerebral hemorrhage

7

Pancreatitis

2

2

Hepatic encephalopathy

Acute myocardial infarction

3

Intraabdominal tumor

3

Others

4

The data are presented as mean±standard deviation, median [interquartile range: P25 to P75] or count (percentage). APACHE II: Acute Physiology and Chronic Health Evaluation II; SOFA: Sequential Organ Failure Assessment.

(n=33)]. MAP measurements were higher in Group I (93±13 mmHg) compared to Group II (80±9 mmHg) (p<0.001). A significant difference in APP measurements was found between 563

Gül et al. APP is superior from intra-abdominal pressure to detect deterioration of renal perfusion in critically Ill patients

100

Sensitivity

800

60

40

20 AUC = 0.802 p<0.001

0 0

20

40 60 100-Specificity

80

100

Figure 1. Receiver operating characteristic (ROC) curve for the association between the Abdominal Perfusion Pressure (APP) and an increased renal resistive index (>0.72). AUC: The area under of a ROC curve.

the groups. APPs were statistically higher in Group I than Group II (81.2±13.6 vs 66.4±9.5) (p<0.001). The AUC for the association between APP at RRI >0.72 was 0.802 (p<0.001), with the APP ≤72 mmHg having a sensitivity of 76% (95% CI 58–89%) and a specificity of 71% (95% CI 54–85%) (Fig. 1).

The serum creatinine levels were significantly higher in patients in Group II compared to Group I (1.12±0.9 vs 1.78±1.23) (p=0.029).

DISCUSSION The principal finding of this study showed that an APP with a ≤72 mmHg threshold is associated with a significant increase in renal RRI. Thus Doppler ultrasonography with RRI calculation can be a useful method in managing these patients to determine the optimal APP level for renal perfusion. Our findings also suggest that the increase of this index represents renal impairment is possible although IAP is normal. An APP value ≤72 mmHg was the best cut-off for renal dysfunction prediction and a more reliable parameter than IAP. Thus, this threshold suggests that the kidney is a potential organ for adverse physiologic effects, so prompting intervention at an earlier stage should be started. In this study, we also reported significantly elevated creatinine levels concurrently together with the increasing levels of RRI. As such, early accurate assessment of renal dysfunction radiologically with RRI is possible and maybe essential in restoring kidney perfusion during the deterioration of APP. IAH is an independent cause of mortality and very common in critically ill patients.[10] IAP exerts deleterious effects on various organs. Thus, accurate assessment and lowering of 564

IAP and establishing sufficient abdominal perfusion pressure appear essential strategies to maintain end-organ perfusion.

IAH hypothetically directly or indirectly impairs nearly every organ system and is life-threatening for the critically ill patients, but the link between IAH and organ dysfunctions are not yet completely understood. Increased pressure may lead to compromised organ perfusion. For instance, cardiac contractility and ventricular function may decrease dramatically by reducing the preload of the heart. The presence of IAH is associated with an increase of intrathoracic pressures, and proportionally peak and plateau airway pressures. Transmission of abdominal pressures to the thoracic cavity may affect mainly respiratory mechanics.[11,12] Augmented airway pressures are necessary to overcome resistance in the airway due to increased rigidity of the thoracic wall. In addition to this, it was proposed that patients having a peak airway pressure >28 cm H2O are more likely to have IAH.[13] The hypoxemia and hypercapnia may occur as a result of mechanic compression of the lungs. Impair perfusion of the liver may result in elevated serum lactate levels, and it may also give rise to the disturbance of cerebral perfusion.[14] The APP is a new parameter that shows the circulatory compromise in the abdominal cavity. The APP appears as a better resuscitation endpoint compared to other macro and microcirculatory parameters and recommended by the current literature.[15] More importantly, it is associated with visceral perfusion instead of IAP alone if feasible and has sensitivity for decision making. Evidence suggested that it is superior to IAP or other hemodynamic parameters to predict mortality.

[16] A study found that APP is better than MAP and lactate to discriminate survivors from nonsurvivors.[17] As APP <60 mmHg was considered as an indicator of abdominal hypoperfusion,[18] but at which APP early renal impairment occurs, radiologically remains unclear. In our study, the cut-off point APP ≤72 mmHg was found to be an indicator of early renal hypoperfusion because at this pressure, a significant increase in RRI was observed.

The adverse influence of IAH on renal function is often unappreciated by clinicians given that IAH is an independent cause of renal dysfunction.[19] Some new data claim that kidneys are particularly at high risk, and renal dysfunction occurs with much lower levels of IAP among critically ill patients.[20] IAH is still the cause of or contributing factor in AKI. Hence, in the early time, to find the etiology and management of critically ill patients with raised IAP should be concerned to prevent and avoid progression. IAH is associated with many negative effects on the kidneys that arise from multiple factors. It assumes that two main mechanisms during increased IAP, indirectly (systemic effects) or directly (renal effects), may affect kidney function.[21] The kidneys are physiologically at risk of IAH mainly due to its susceptibility vasculature nature, but mechanisms underlying the vulnerability are not fully known.[22] The mechanisms Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

Gül et al. APP is superior from intra-abdominal pressure to detect deterioration of renal perfusion in critically Ill patients

involved in the pathophysiology are complex, and one of the most consistently described effects is related to renal blood flow. It was suggested that renal vein compression with renal artery vasoconstriction seems to be the major cause of renal impairment.[5] In addition, direct compression of the renal cortex results in a decrease in blood flow. A large prospective observational study established IAH and low APP resulted as the best predictive factors for ARF.[23] Some studies concluded that an IAP 15–20 mmHg causes in oliguriaand anuria develops above 30 mmHg.[24] Besides, the rate of renal impairment can be raised according to the level of IAP; the incidence is doubling at 25 mmHg compared to 18 mmHg.[19] Moreover, Dalfino et al.[23] demonstrated that an association between IAH and acute kidney injury (AKI) in unselected ICU patients, IAH was a good predictor of AKI. It has also has been suggested that there is a clear link between IAH and the development of AKI in the kidney transplant patient.

Early transplant dysfunction was treated using abdominal decompression in those patients.[25] However, in our study, we showed that elevated RRI and high levels of creatinine are possible with normal IAP. Despite increasing interest in the use of ultrasound in critically ill patients, there has been a little report in the clinical examination of the patient with IAH. There are very limited data concerning aiming ideal APP to prevent acute kidney injury, and there is little evidence of radiologic measurement to show these subtle forms of organ dysfunction during IAH. RRI has been used for years in a variety of clinical settings, especially became apparent to differentiate acute and chronic obstructive renal disease. RRI provides useful information about changes in intrarenal perfusion and has been proposed to monitor renal perfusion in critically ill patients.[8,26,27] It was shown that this index might be affected by IAH and allowed earlier detection of renal impairment before the increase of other biochemical parameters.[9] In a porcine model, it was demonstrated that a linear relationship between increasing IAP and RRI and the author concluded that it might be a potential noninvasive, bedside screening tool to detect early deterioration of renal perfusion.[28] In 45 healthy volunteers, a mild increase in IAP compresses the major abdominal vessels was associated with a significant increase in RRI, suggesting that even mild IAH may affect intrarenal pressure.[5] However, in our study, the cut-off point of APP ≤72 mmHg is associated with a statistically significant increase of RRI suggesting that supporting renal function to maintain an APP >72 mmHg is to be advocated. Our findings suggest that an ideal APP determination is important and may be useful to prevent acute kidney injury.

Conclusion Kidneys seem to be the most susceptible organ to the adverse consequences of increased IAP. Increased RRI may be a useful index for objective evidence of impending kidney injury that occurs before other end-organ dysfunctions. The Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

results of our study show that an APP with a threshold of ≤72 mmHg is associated with a significant increase in renal RRI, which is predictive of worsening of renal perfusion. More importantly, our results suggest that kidneys may be particularly at risk with much higher levels of APP than believed previously. Measuring RRI using a noninvasive bedside renal Doppler ultrasound is a valuable tool to detect deterioration of renal perfusion, considering the importance of APP. In conclusion, it has an active role in helping to prevent potentially fatal complications of IAH/ACS and should be integrated while treating critically ill patients who have risk factors.

Conflict of interest: None declared.

REFERENCES 1. Balogh Z, McKinley BA, Cocanour CS, Kozar RA, Valdivia A, Sailors RM, et al. Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome. Arch Surg 2003;138:637–42.

2. Malbrain ML, De laet IE. Intra-abdominal hypertension: evolving concepts. Clin Chest Med 2009;30:45–70.

3. Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain ML, De Keulenaer B, et al. 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.

4. de Laet IE, Malbrain M. Current insights in intra-abdominal hypertension and abdominal compartment syndrome. Med Intensiva 2007;31:88–99.

5. Cavaliere F, Cina A, Biasucci D, Costa R, Soave M, Gargaruti R, et al.

Sonographic assessment of abdominal vein dimensional and hemodynamic changes induced in human volunteers by a model of abdominal hypertension. Crit Care Med 2011;39:344–8.

6. Joannidis M, Druml W, Forni LG, Groeneveld ABJ, Honore PM, Hoste E, et al. Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017 : Expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive Care Med 2017;43:730–49.

7. Barozzi L, Valentino M, Santoro A, Mancini E, Pavlica P. Renal ultrasonography in critically ill patients. Crit Care Med 2007;35:S198–205.

8. Kararmaz A, Kemal Arslantas M, Cinel I. Renal Resistive Index Measurement by Transesophageal Echocardiography: Comparison With Translumbar Ultrasonography and Relation to Acute Kidney Injury. J Cardiothorac Vasc Anesth 2015;29:875–80.

9. Marty P, Szatjnic S, Ferre F, Conil JM, Mayeur N, Fourcade O, et al.

Doppler renal resistive index for early detection of acute kidney injury after major orthopaedic surgery: a prospective observational study. Eur J Anaesthesiol 2015;32:37–43.

10. Reintam A, Parm P, Kitus R, Kern H, Starkopf J. Primary and secondary intra-abdominal hypertension--different impact on ICU outcome. Intensive Care Med 2008;34:1624–31.

11. Malbrain ML, Roberts DJ, Sugrue M, De Keulenaer BL, Ivatury R, Pelosi P, et al. The polycompartment syndrome: a concise state-of-the-art review. Anaesthesiol Intensive Ther 2014;46:433–50.

12. Regli A, Chakera J, De Keulenaer BL, Roberts B, Noffsinger B, Singh B, et al. Matching positive end-expiratory pressure to intra-abdominal pressure prevents end-expiratory lung volume decline in a pig model of intra-abdominal hypertension. Crit Care Med 2012;40:1879–86.

13. Reintam BA, Parm P, Kitus R, Starkopf J. Risk factors for intraabdom-

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14. Carr JA. Abdominal compartment syndrome: a decade of progress. J Am Coll Surg 2013;216:135–46.

15. Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, et al. Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. I. Definitions. Intensive Care Med 2006;32:1722–32.

16. Vidal MG, RuizWeisser J, Gonzalez F, Toro MA, Loudet C, Balasini C, et al. Incidence and clinical effects of intra-abdominal hypertension in critically ill patients. Crit Care Med 2008;36:1823–31.

Coll Cardiol 2008;51:300–6.

21. Cheatham ML. Abdominal compartment syndrome: Pathophysiology and definitions. Scand J Trauma Resusc Emerg Med 2009;17:10.

22. Guyton AC, editor. Formation of urine by the kidney: I. Renal blood flow, glomerular filtration, and their control. In: Textbook of Medical Physiology. 8th ed. Philadelphia:WB Saunders; 1991. p. 286–307.

23. Dalfino L, Tullo L, Donadio I, Malcangi V, Brienza N. Intra-abdominal hypertension and acute renal failure in critically ill patients. Intensive Care Med 2008;34:707–13.

24. Cheatham ML. Abdominal compartment syndrome: Pathophysiology and definitions. Scand J Trauma Resusc Emerg Med 2009;17:10.

17. Cheatham ML, White MW, Sagraves SG, Johnson JL, Block EF. Abdominal perfusion pressure: a superior parameter in the assessment of intraabdominal hypertension. J Trauma 2000;49:621–7.

25. Pertek JP, Coissard A, Lalot JM, Renoult E, Cormier L. Hypoperfused kidney following kidney transplantation associated with hyperlactatemia.

Ann Fr Anest Reanim 2001;20:282–8.

18. Rezende-Neto JB, Moore EE, Melo de Andrade MV, Teixeira MM, Lisboa FA, Arantes RM, et al. Systemic inflammatory response secondary to abdominal compartment syndrome: stage for multiple organ failure. J Trauma 2002;53:1121–8.

26. Izumi M, Sugiura T, Nakamura H, Nagatoya K, Imai E, Hori M. Differential diagnosis of prerenal azotemia from acute tubular necrosis and prediction of recovery by Doppler ultrasound. Am J Kidney Dis 2000;35:713–9.

19. Sugrue M, Jones F, Deane SA, Bishop G, Bauman A, Hillman K. Intraabdominal hypertension is an independent cause of postoperative renal impairment. Arch Surg 1999;134:1082–5.

27. Stevens PE, Gwyther SJ, Hanson ME, Boultbee JE, Kox WJ, Phillips ME. Noninvasive monitoring of renal blood flow characteristics during acute renal failure in man. Intensive Care Med 1990;16:153–8.

20. Mullens W, Abrahams Z, Skouri HN, Francis GS, Taylor DO, Starling RC, et al. Elevated intra-abdominal pressure in acute decompensated heart failure: A potential contributor to worsening renal function? J Am

28. Kirkpatrick AW, Colistro R, Laupland KB, Fox DL, Konkin DE, Kock V, et al. Renal arterial resistive index response to intraabdominal hypertension in a porcine model. Crit Care Med 2007;35:207–13.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Kritik hastalarda abdominal perfüzyon basıncı renal perfüzyondaki bozulmanın saptanmasında karıniçi basınçtan daha üstündür Dr. Fethi Gül, Dr. İsmet Sayan, Dr. Umut Sabri Kasapoğlu, Dr. Derya Özer Erol, Dr. Mustafa Kemal Arslantaş, Dr. İsmail Cinel, Dr. Zuhal Aykaç Marmara Üniversitesi Pendik Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Yoğun Bakım Kliniği, İstanbul

AMAÇ: Karıniçi hipertansiyon (KH) risk faktörü olan kritik hastalarda akut böbrek hasarının (AKI) en sık nedenlerinden biridir. Bu çalışmada abdominal perfüzyon basıncı (APP) ile Doppler temelli renal rezistif indeks (RRI) ile gösterilen AKI arasındaki ilişkiyi saptamayı amaçladık.

GEREÇ VE YÖNTEM: Bu çalışmaya KH için risk faktörü taşıyan ve mekanik ventilasyon desteği altında 18 yaşından büyük 38 hasta alındı. Tüm ölçümler ve elde edilen parametreler renal disfonksiyona göre iki gruba ayrıldı (Grup I; RRI <0.72 ve Grup II; RRI >0.72).

BULGULAR: Grupların ortalama karıniçi basınçları (IAB) Grup I’de (11.5±6.9 mmHg, n=35) ve Grup II’de (13.5±5.8, n=33) benzerdi. APP; Grup I’de (81.2±13.6) Group II’ye göre (66.4±9.5) daha yüksekti (p<0.001). RRI’ya göre renal perfüzyondaki bozulma APP’nin (≤72 mmHg) belirlemdeki duyarlılığı %76 ve seçiciliği %71’dir. ROC eğrisi altında kalan alan 0.802’dir (p<0.001).

TARTIŞMA: Çalışmamızın sonuçları APP ≤72 mmHg eşik değerinde RRI’nın anlamlı şekilde arttığını ve bunun da renal perfüzyonun bozulmasını öngörebileceğini göstermiştir.

Anahtar sözcükler: Abdominal perfüzyon basıncı; renal perfüzyon basıncı; renal resistif indeks.

Ulus Travma Acil Cerrahi Derg 2019;25(6):561-566

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doi: 10.14744/tjtes.2019.25263

Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

ORIG I N A L A R T IC L E

Factors affecting mortality in traumatic diaphragm ruptures Serhat Tokgöz, M.D., Muzaffer Akkoca, M.D., Kerim Bora Yılmaz, M.D., Özgür Sevim, M.D.,

Yasin Uçar, M.D., Görkem Gündoğan, M.D.,

Department of General Surgery, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: Traumatic diaphragm ruptures (TDR) are rarely seen. Although TDR does not cause morbidity in the acute period, undiagnosed TDR may cause clinical states, such as herniation, strangulation, pneumonia, pleural effusion, empyema, and cardiac tamponade, which have high morbidity and mortality rates in the late period. This study aims to evaluate the epidemiology, clinical characteristics, diagnosis and treatment methods of TDR encountered in thoracoabdominal trauma and to identify the factors affecting mortality.

METHODS: A retrospective examination was carried out on the patients who were operated in our clinic because of traumatic diaphragm injury between January 2012 and December 2017. Each patient operated because traumatic diaphragm injury was evaluated in respect of age, gender, manner of injury, preoperative examination findings, laboratory test results, imaging methods, time of diagnosis, operation findings, concomitant injuries to other organs, operations performed, length of stay in hospital, the development of postoperative morbidity and mortality, and the calculated Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS).

RESULTS: Between January 2012 and December 2017, a total of 1066 patients were operated in our clinic because of thoracoabdominal trauma, and of 1066 patients, 45 of the patients were determined with TDR. Of the 45 patients, surgery was applied because of penetrating trauma in 32 cases (7 firearms injuries, 25 penetrating cutting injuries), blunt trauma in nine cases, and in four cases, diaphragm rupture was seen to have developed associated with iatrogenic injury during an operation. The most common injuries concomitant to traumatic diaphragm rupture were hemopneumothorax (70%), liver (43%), spleen (32%), colon (20%), stomach (17%) injuries and rib fractures (15%), respectively. Mortality developed in seven (17%) patients; five patients were lost because of hemorrhagic shock intraoperatively or in the early postoperative hours, and two because of multiorgan failure during follow-up in the intensive care unit.

CONCLUSION: In high energy blunt and penetrating thoracoabdominal traumas, diaphragm injuries should be suspected. Factors affecting mortality were found to be the AISS, ISS, number of concomitant organ injuries and the combination with pneumohemothorax.

Keywords: Diaphragmatic rupture; diaphragmatic hernia; thoracoabdominal trauma.

INTRODUCTION Traumatic diaphragm ruptures (TDR) are rarely seen traumas with high morbidity and mortality rates due to delayed diagnosis, and for which blunt or penetrating thoracoabdominal trauma and iatrogenic injuries have a role in the etiology.

Although the actual incidence of diaphragm injuries is not known in thoracoabdominal traumas, it is known to be 0.8-

8% in high-energy blunt trauma and 10–15% in penetrating trauma.[1-4] Despite diagnostic developments, these injuries may still be overlooked at rates of 9%–41%.[5,6] This rate further increases in cases with severe multiple organ injuries.[6,7] Thorax radiographs, computed tomography (CT), ultrasonography, magnetic resonance imaging (MRI), intraperitoneal injection, diagnostic peritoneal lavage, laparoscopy

Cite this article as: Tokgöz S, Akkoca M, Uçar Y, Yılmaz KB, Sevim Ö, Gündoğan G. Factors affecting mortality in traumatic diaphragm ruptures. Ulus Travma Acil Cerrahi Derg 2019;25:567-574.

Address for correspondence: Serhat Tokgöz, M.D. Sağlık Bilimleri Üniversitesi, Dışkapı Eğitim Araştırma Hastanesi Genel Cerrahi Kliniği, Ankara, Turkey Tel: +90 505 907 96 66 E-mail: serhat.tokgoz@yahoo.com Ulus Travma Acil Cerrahi Derg 2019;25(6):567-574 DOI: 10.14744/tjtes.2019.58133 Submitted: 25.04.2019 Accepted: 02.06.2019 Online: 25.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Tokgöz et al. Traumatic diaphragm ruptures

and thoracoscopy are important in diagnosis.[3] TDR may be overlooked in patients treated conservatively and even intraoperatively at rates of 12%-66%.[8,9] Following diagnosis, repair should be made with a patch or primary repair with absorbable or non-absorbable suture material depending on the location and size of the defect. To our knowledge, to date, there have been no reports of any cases of spontaneous diaphragm healing.[10] Although TDR does not cause morbidity in the acute period, undiagnosed TDR may cause clinical states, such as herniation, strangulation, pneumonia, pleural effusion, empyema, and cardiac tamponade, which have high morbidity and mortality rates in the late period.[11,12] Early-stage mortality in thoracoabdominal traumas is generally related to the type and severity of the trauma. Especially in blunt trauma, TDR is an important indicator, which also shows the high-energy severity of the trauma.[3] Mortality rates in thoracoabdominal trauma where there is diaphragm rupture have been reported to reach 28%.[13] This study aims to evaluate the epidemiology, clinical characteristics, diagnosis and treatment methods of TDR encountered in thoracoabdominal trauma and to identify the factors affecting mortality.

MATERIALS AND METHODS Approval for this study was granted by the Local Ethics Committee. A retrospective examination was carried out on the patients who were operated in our clinic because of traumatic diaphragm injury between January 2012 and December 2017. The data related to the patients were retrieved from patient files, operation reports, and laboratory and imaging reports in the automated hospital system. Each patient who were operated because of traumatic diaphragm injury was evaluated in respect of age, gender, manner of injury, preoperative examination findings, laboratory test results, imaging methods, time of diagnosis, operation findings, concomitant injuries to other organs, operations performed, length of stay in hospital, the development of postoperative morbidity and mortality, and the calculated Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS).

Laparotomy was applied to patients with shock, as a significant finding of peritoneal irritation, organ or omentum herniation, and organ injuries confirmed by imaging methods. In patients with suspicious clinical and examination findings, diagnostic laparoscopy or laparotomy was applied.

TDR diagnosis was reached from preoperative thorax radiographs and CT findings of diaphragm elevation, loss of diaphragm integrity, or the appearance of abdominal organs in the thorax. Diaphragmatic ruptures were classified according to the organ injury classification defined by the American Association for the Surgery of Trauma (AAST).

568

Statistical Analysis Data obtained in the study were analysed statistically using SPSS vn 11.5 software (SPSS, Chicago, IL, USA). Descriptive statistics related to continuous variables were stated as mean±standard deviation, median, minimum and maximum values. In the comparison of two groups of continuous variables, the Mann-Whitney U-test was used, and in the comparison of nominal variables, the Chi-square test or Fisher’s Exact test. A value of p<0.05 was accepted as statistically significant.

RESULTS As our hospital is a tertiary level trauma centre, approximately 60.000 trauma cases present per year. Between January 2012 and December 2017, a total of 1066 patients were operated in our clinic because of thoracoabdominal trauma, and of these, 45 were determined with TDR. These patients comprised 34 male (75.5%) and 11 female (24.5%) patients with a mean age of 37.6±11.75 years. Of these 45, surgery was applied because of penetrating trauma in 32 cases (7 firearms injuries, 25 penetrating cutting injuries), blunt trauma in nine cases, and in four cases, diaphragm rupture was seen to have developed associated with iatrogenic injury during operation for intra-abdominal mass. The clinical characteristics of the patients are shown in Table 1.

The diagnosis of diaphragm injury was reached from tests applied preoperatively in the early period in nine (22%) cases, intraoperatively in 30 (73%) cases and in the late period in two (5%) cases (Table 2). The rate of diagnosis in the first 24 hours was 95%.

Following presentation at the Emergency Department, diaphragm rupture diagnosis was made in a total of nine patients in the early period from physical examination findings and examination of postero-anterior pulmonary radiograph (PAPR) and/or CT; diaphragm elevation was seen on PAPR in three patients, contrast dye administered from the thoraco-abdominal region was seen in the chest cavity and to have passed into the abdomen, the diaphragm integrity was not complete on CT, there were organ herniation, diaphragm elevation and hemopneumothorax in one patient. The preoperative diagnosis rate was determined as 22%.

CT evaluation was made of 30 patients who were hemodynamically stable. No pathology was determined in five patients. Intra-abdominal free fluid was determined in 17 patients, suspected solid organ injury in 15, loss of diaphragm integrity in two, and pneumohemothorax in 10.

Ultrasonography (USG) was applied to nine of 41 patients; no pathology was determined in two and free fluid was determined in seven patients. USG was observed not to be specific for any referral on the subject of diaphragm injury. Pulmonary Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

Tokgöz et al. Traumatic diaphragm ruptures

radiographs were taken of 39 patients; diaphragm elevation was seen in three cases and in 27, the diagnosis was made from pneumohemothorax and/or hemothorax.

The most common injuries concomitant to traumatic diaphragm rupture were hemopneumothorax (70%), liver (43%), spleen (32%), colon (20%), stomach (17%) injuries and rib fractures (15%), respectively (Table 3).

The diaphragm rupture was on the left side in 27 patients, on the right in 17 and bilateral in one patient. The mean defect

size was 9.6±5.63 cm in blunt trauma cases and 3.3±1.9 cm in penetrating trauma cases. The diaphragm rupture classifications according to the AAST and the AIS and ISS scores are shown in Table 4.

In the treatment, primary diaphragm repair with laparotomy was performed to 35 patients, laparoscopic repair under elective conditions was applied to five years after the trauma in one patient, laparoscopic repair was made during diagnostic laparoscopy in the acute period in one patient, primary repair with laparotomy and thoracotomy was applied to three

Table 1. Characteristic of the patient with diaphragmatic rupture

Penetrating

Blunt

n % n % p*

Gender

Male

27 84.4 6 66.7 0.236

Woman

5 15.6 3 33.3

Side

Right

13 40.6 2 22.2 0.563

Left

18 56.2 7 77.8

Bilateral

1

3.1

0

0

Diaphragmatic laceration

Grade 2

12 37.5 1 11.1 0.000

Grade 3

20 62.5 2 22.2

Grade 4

0

0

6

66.7

Diagnosis time

Preoperative

6 18.8 3 33.3 0.350

Intraoperative+Late period 26 81.2 6 66.7 Pneumothorax No

8

Yes

13 40.6 2 22.2

25

4

44.4

Hemothorax

3

9.4

0

0

Pneumo-hemothorax

8

25

3

33.3

No

32

100

4

44.4

Yes

0

0

5

55.6

0.576

Diaphragm elevation 0.000

Thorax tube

No

15 46.9 3 33.3 0.470

Yes

17 53.1 6 66.7

Mortality Exitus

3

9.4

4

44.4

Survive

29 90.6 5 55.6

0.031

Morbidity (n=38) No

18

62.1

3

60

Yes

11

37.9

2

40

1.000

* Chi-square test/Fisher’s Exact test

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TokgĂśz et al. Traumatic diaphragm ruptures

separating the chest and abdominal cavity.[14] TDR is generally seen in blunt trauma and more often in penetrating trauma.

It has been reported to be seen at the rate of 0.8-8% in blunt trauma and at 10-15% in penetrating trauma.[1-4] Although incidence varies according to the socio-economic region served by hospitals, the actual incidence is not known as many cases cannot be diagnosed.[13]

Table 2. Diagnosis time

Preoperative Intraoperative Delayed

(22%)

(73%)

diagnosis

Blunt (n=9)

3

5

Gunshot (n=7)

1

6

Stab wound (n=25)

5

19

(5%) 1

In the present study, the diaphragm rupture rate was determined as 4.2% in patients who were operated for thoracoabdominal trauma. Of these, in 3% of the patients, diaphragm rupture occurred following penetrating trauma and 0.8% after blunt trauma. In the literature, 75% of the TDRs have been reported to occur after blunt trauma and 25% after penetrating trauma.[15]

1

patients and repair with mesh was applied to one patient because of the large size of the defect (Table 5).

In the postoperative period, pulmonary complications developed in six patients, wound site infection in six patients, intra-abdominal abscess that was treated with percutaneous drainage in one patient and a bile fistula that regressed spontaneously with monitoring in one patient. The mean length of hospital stay was 9.48Âą8.17 days for patients with penetrating injuries and 16.80Âą13.75 days for those with blunt trauma injuries (Table 5).

Several studies have reported higher rates of TDR in males in the 4th decade of life.[16] In the present study, the median age was 37.6 years and 75.5% of the patients were male, and these rates were consistent with the findings in the literature.

Diaphragm rupture is seen on the left side approximately 10fold more, especially in blunt trauma, because the left medial and posterolateral sections of the diaphragm remain weaker during embryological development and the liver has a protective effect on the right-side.[3,17] In the present study, left -side diaphragm rupture was seen at the rate of 77.8% in blunt trauma and at 56.2% in penetrating trauma, which was consistent with data in the literature.

Mortality developed in seven (17%) patients; five patients were lost because of hemorrhagic shock intraoperatively or in the early postoperative hours, and two because of multiorgan failure during follow-up in the intensive care unit. Factors affecting mortality were found to be the AISS, ISS, number of concomitant organ injuries and the combination with pneumohemothorax (Table 6).

The rupture dimension in penetrating trauma is smaller than in blunt trauma. Therefore, it is potentially more dangerous as there is a risk that diagnosis will not be made and herniation and strangulation will develop with growth in the future.

[15,18] In this study, the mean defect diameter of 9.67 cm in

DISCUSSION The diaphragm, which plays a critical role in respiratory functions, is a layer of muscle and tendon in the form of a dome, Table 3. Frequency of associated injuries

570

Blunt n=9

%

Penetrating n=32

%

Total %

Pneumohemothorax 5 55

24 75 70

Liver laceration

3

33

15

46

44

Spleen laceration

5

55

8

25

32

Small bowel laceration

1

11

4

12

12

Colon laceration

2

22

6

19

20

Gastric perforation

0

0

7

22

17

Rib fracture

5

55

1

3

14

Vertebra fracture

1

11

1

3

4

Adrenal and kidney rupture

2

22

1

3

7

Head injury

1

11

0

0

2

Pelvic fracture

1

11

0

0

2

Pancreas injury

0

0

2

6

4

Vascular injury

0

0

2

6

4

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Tokgöz et al. Traumatic diaphragm ruptures

Table 4. Comparisons and descriptive statistics on age, Abbreviated Injury Scale, Injury Severity Score, defect size and length of stay of the patients with blunt and penetrating injuries

Penetrating (n=32)

Blunt (n=9)

Average±SD Mean Average±SD Mean p*

(Min-max) (Min-max) Age

35.41±11.28

33.5 (20-65)

41.00±12.54

40 (25-57)

0.230

Abbreviated Injury Scale

3.09±0.29

3 (3-4)

3.67±0.87

3 (3-5)

0.092

Injury Severity Score

16.72±4.87

18 (9-27)

24.00±9.11

25 (9-38)

0.024

Size of rupture (cm)

3.33±1.91

3 (1-10)

9.67±5.63

10 (2-20)

0.001

Hospital stay (day)

9.48±8.17

7 (1-42)

16.80±13.75

14 (4-40)

0.149

Number of additional organ injuries

1.62±1.24

1 (0-5)

2.112.20±

1 (0-7)

0.889

*Mann-Whitney U Test

Table 5. Clinical features of the patients

Blunt

Penetrating

n=9

n=32

Wound infection

1

5

Abscess

0 1

Fistula

0 1

Pulmonary problems

0

Morbidity

6

Mortality 4 Hemorrhagic shock

2

3

Organ failure

2

3

Transabdominal primary repair

7

28

Transabdominal mesh

1

0

Laparoscopic repair

1

1

Laparotomy and thoracotomy

0

3

Operation

blunt trauma was approximately 3-fold larger than the mean of 3.33 cm in penetrating trauma cases. The size of the defect in the diaphragm is directly proportional to the severity of the trauma but was not determined to have any effect on mortality (Table 6).

Early diagnosis of TDR remains a problem, and in this study, the early diagnosis rates were determined as 22% preoperatively and 73% intraoperatively. These rates have been reported as 34% and 88%, respectively in experienced trauma centres.[19] The most important stage in diagnosis is suspicion with accompanying clinical findings, such as dyspnea, chest pain, reduced respiratory sounds and abdominal pain.

Although thorax radiographs and thoraco-abdominal CT are the most frequently requested methods, diagnosis may not always be able to be confirmed with these two methods.

On pulmonary radiographs, signs, such as elevation of the diaphragm, a change in the shape of the curve of the diaphragm, gas and fluid shadow in the thoracic cavity, atelectasia in the inferior lobes, pleural effusion, pneumothorax, hydro-pneumothorax and mediastinal shift, can be signs of rupture.[20] CT

Table 6. Comparisons and descriptive statistics on age, Abbreviated Injury Scale, Injury Severity Score, defect size, and number of additional organ injuries in patients with exitus and survivor

Exitus(n=7)

Survive (n=34)

Average±SD Mean Average±SD Mean p*

(Min-max) (Min-max) Age

40.86±13.92

36 (25-65)

37.10±11.42

37.5 (20-57)

0.591

Abbreviated Injury Scale

4.00±0.82

4 (3-5)

3.06±0.24

3 (3-4)

0.004

Injury Severity Score

29.28±4.92

27 (25-38)

16.06±4.31

18 (9-25)

0.000

Size of rupture (cm)

6.71±6.92

5 (1-20)

4.22±3.04

3 (1-13)

0.657

Number of additional organ injuries

3.00±2.08

3 (1-7)

1.31±1.23

1 (0-5)

0.019

*Mann-Whitney U Test

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Tokgöz et al. Traumatic diaphragm ruptures

is an imaging method with high sensitivity and specificity compared to direct radiographs, especially in patients with stable vital signs. Findings, such as impairment of the integrity of the diaphragm, the observation of abdominal organs in the thorax, hemothorax, and pneumothorax, support a diagnosis of TDR. Other methods that can be used include ultrasonography, MR examination of the gastrointestinal system with barium, diagnostic peritoneal lavage, diagnostic laparoscopy and laparotomy, and diagnostic thoracoscopy and thoracotomy.

generally accompanied by other organ injuries.[28] The most frequently seen injuries are to the liver (approximately half of patients), lungs and spleen.[28] In 50-80% of cases with blunt trauma diaphragm injury, additional intra-abdominal injuries are determined. The most common concomitant organ injuries are of the spleen, liver and internal hollow organs. In this study, pneumothorax was determined most often followed by spleen injury (32%) in blunt trauma and liver injury (43%) in penetrating trauma cases.

Laparoscopy may be preferred, especially in isolated diaphragm injuries. Diagnostic laparoscopy is more sensitive and specific in TDR diagnosis compared to other methods.

However, as approximately one in three patients in the early period is operated with laparotomy or thoracotomy because of related injuries, the diagnosis of diaphragm rupture is made during surgery and the necessary treatment is applied. Diagnosis is made with physical examination in 44% of cases with penetrating diaphragm injuries and in 55% of those with blunt trauma diaphragm injuries.[21] In injuries of the lower region of the chest and the upper region of the abdomen, it must always be kept in mind that there could be TDR. As there may be no findings in the early stage, especially in small defects, taking serial pulmonary radiographs in the subsequent period may be necessary to ensure that TDR diagnosis is not overlooked. Significant findings cannot always be obtained in the physical examination and radiological evaluations carried out in the early period, especially in small defects.

Following diaphragm repair, pulmonary and wound site complications are the most frequently seen complications.

Morbidity and mortality rates vary according to the extent of concomitant organ injury, bleeding and shock status, and whether or not there are states such as hernia-related strangulation, incarceration, perforation or contamination, and damage to the respiratory or cardiovascular system. In this study, the morbidity rate following repair of diaphragm rupture was 60% in cases with blunt trauma injuries and 62.1% in those with penetrating trauma. Mortality rates for diaphragm injuries have been reported in the literature as 10-35%.[27,29,30] In the current series, mortality was determined at the rate of 17%; in 3/32 patients with penetrating injuries and in 4/9 of those with blunt trauma. In five of these cases, mortality was due to hemorrhagic shock, and in two cases, to organ failure (generally associated with concomitant injuries).

However, the diagnostic ability is reduced in right-side ruptures and small ruptures. In small injuries of the diaphragm, diagnosis is extremely difficult in the absence of herniation and when there are pleural fluid and movement artefacts.

[22-24] Of the patients who were operated in this study, synthetic graft was used in one case with a defect size of 12 cm. Laparoscopic exploration may be an appropriate option when contrast dye administered for tomography in thoracoabdominal penetrating injuries is seen within the abdomen or to have passed to the thorax, and small defects can be repaired laparoscopically.[25] As complications may develop later, a conservative approach is not recommended. The operation strategy varies according to the wound localisation, the size, manner of forming, the clinical status of the patient and additional injuries. In one patient in this study with blunt trauma who was determined in the later period and to whom explorative laparoscopy was applied, diaphragm repair was performed laparoscopically.

While small defects are repaired with non-absorbable sutures, synthetic grafts are used in large defects.[26,27] Of the operations in this study, 87% were performed with laparotomy.

TDR is a sign that the trauma was high energy and is a warning of intra-abdominal and intrathoracic organ injuries. In both penetrating and blunt trauma, diaphragm injuries are 572

The ISS and time of diagnosis were determined to affect mortality in this study, but in contrast to reports in the literature, age and the size of the defect were not found to have any effect on mortality.

This study has some limitations. This study was conducted in a single centre, was retrospective in nature and the study population was small. Patients who could not be diagnosed were not operated on and the total number of trauma patients was not known.

CONCLUSION In high-energy blunt and penetrating thoracoabdominal traumas, diaphragm injuries should be suspected. Diaphragmatic injuries are seen more often on the left side and require surgical treatment. As trauma scores and the number of additional organ injuries increase, the mortality rate also increases.

Ethics committee approval: Ethics Committee Approval has received for this study from the Ethics Committee of University of Health Sciences, Dışkapı Yıldırım Beyazıt Research and Training Hospital.

Financial disclosure: The authors declared that this study has received no financial support.

Conflict of interest: None declared.

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REFERENCES 1. Petrone P, Leppäniemi A, Inaba K, Søreide K, Asensio JA. Diaphragmatic injuries: challenges in the diagnosis and management. Trauma 2007;9:227–36.

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4. Bosanquet D, Farboud A, Luckraz H. A review diaphragmatic injury. Respir Med 2009;2:1–6.

5. Koda M, Ueki M, Maeda N, Murawaki Y. Diaphragmatic perforation and hernia after hepatic radiofrequency ablation. Am J Roentgenol 2003;180:1561–2.

6. Arıbaş OK, Tartar H. Diyafragma yaralanmaları: Defekt uzunluğunun erken tanı ve mortalitedeki rolü(Deneysel çalışma). Genel Tıp Derg 2009;19:57–64.

7. Arik MK, Tas S, Ozkul F, Sahin H, Karatağ O, Karaayvaz M. Laparoscopic repair of combined right diaphragm and liver injuries with a sharp object: a case report. Case Rep Surg 2013;2013:209494.

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9. Asensio JA, Arroyo H Jr, Veloz W, Forno W, Gambaro E, Roldan GA, et al. Penetrating thoracoabdominal injuries: ongoing dilemma-which cavity and when? World J Surg 2002;26:539–43.

10. Desir A, Ghaye B. CT of blunt diaphragmatic rupture. RadioGraphics 2012;32:477–498.

11. Bocchini G, Guida F, Sica G, Codella U, Scaglione M. Diaphragmatic injuries after blunt trauma: are they still a challenge? Reviewing CT findings and integrated imaging. Emerg Radiol 2012;19:225–35.

12. Nchimi A, Szapiro D, Ghaye B, Willems V, Khamis J, Haquet L, et al. Helical CT of blunt diaphragmatic rupture. AJR Am J Roentgenol 2005;184:24–30.

13. Shah R, Sabanathan S, Mearns AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg 1995;60:1444–9.

14. Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic injuries: spectrum of radiographic findings. Radiographics 1998;18:49–59.

15. Zeybek N, Eryılmaz M, Gözübüyük A, Peker Y, Genç O, Öner K, et al.

Diaphragmatic injuries: an analysis of 36 cases. Turkish J Thorac Cardio-

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vasc Surg 2007;15 221–5.

16. Al-Refaie RE, Awad E, Mokbel EM. Blunt traumatic diaphragmatic rupture: a retrospective observational study of 46 patients. Interact Cardiovasc Thorac Surg 2009;9:45–9.

17. Meyers BF, McCabe CJ. Traumatic diaphragmatic hernia. Occult marker of serious injury. Ann Surg 1993;218:783–90.

18. Athanassiadi K, Kalavrouziotis G, Athanassiou M, Vernikos P, Skrekas G, Poultsidi A, et al. Blunt diaphragmatic rupture. Eur J Cardiothorac Surg 1999;15:469–74.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Travmatik diyafragma yaralanmalarında mortaliteye etkili faktör Dr. Serhat Tokgöz, Dr. Muzaffer Akkoca, Dr. Yasin Uçar, Dr. Kerim Bora Yılmaz, Dr. Özgür Sevim, Dr. Görkem Gündoğan Sağlık Bilimleri Üniversitesi, Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi Genel Cerrahi Kliniği, Ankara

AMAÇ: Travmatik diyafragma rüptürleri (TDR) nadir görülür. Genellikle akut dönemde morbiditeye neden olmazlar, ancak klinik tanı konulamayan tüm TDR’ler geç dönemde herniasyon, strangülasyon, pnömoni, plevral effüzyon, ampiyem, kalp tamponadı ve solunum bozuklukları gibi morbidite ve mortalitesi yüksek klinik durumlara neden olabilir. Bu çalışmada travmatik diyafragma rüptürünün epidemiyolojisi, klinik özellikleri, tanı, tedavi yöntemleri ve mortalite üzerine etkili faktörleri değerlendirildi.

GEREÇ VE YÖNTEM: Ocak 2012-Aralık 2017 tarihleri arasında kliniğimizde travmatik diyafragma yaralanması nedeni ile ameliyat edilen hastaların kayıtları geriye dönük olarak incelendi. Travmatik diyafragma rüptürü nedeni ile ameliyat edilen hastaların; yaş, cins, yaralanma şekli, operasyon öncesi muayene bulguları, laboratuvar tetkikleri, görüntüleme yöntemleri, tanı konulma zamanları, ameliyat bulguları, eşlik eden diğer organ yaranlamaları, yapılan ameliyatlar, hastane kalış süreleri, ameliyat sonrası dönemde gelişen mortalite ve morbiditeler Abbreviated Injury Scale (AIS) ve Injury Severty Score’ları (ISS) incelendi.

BULGULAR: Ocak 2012–Aralık 2017 tarihleri arasında kliniğimizde torakoabdominal travma nedeniyle 1066 hasta ameliyat edildi ve bu hastalardan 45’ine diyafragma rüptürü tanısı konuldu. 45 hastanın 32’sinde penetran travma (7 ateşli silah 25 delici kesici alet yaralanması), 9’unda künt travma ve 4 hastada ise kariniçi kitle nedeniyle ameliyat edildiği sırada oluşan iyatrojenik yaralanma nedenli diyafragma rüptürü geliştiği görüldü. Travmatik diyafragma rüptürüne en sık eşlik eden yaralanmalar sırasıyla hemopnömotoraks (%70), karaciğer (%43), dalak (%32), kolon (%20), mide (%17), ve kot fraktürü (%15) yaralanmalarıydı. Mortalite toplamda yedi (%17) hastada görüldü; beş hasta hemorajik şok nedeniyle intraoperatif veya ameliyat sonrası erken saatlerde kaybedilirken, iki hasta yoğun bakım takiplerinde çoklu organ yetersizliği nedeniyle kaybedildi.

TARTIŞMA: Yüksek enerjili künt ve penetran torako-abdominal travmalarda diyafragma rüptüründen şüphelenmek gerekir. Mortalite üzerine etkili faktörler AIS, ISS, eşlik eden organ yaralanması sayısı ve pnömo-hemotoraks birlikteliği olarak bulundu.

Anahtar sözcükler: Diyafragma rüptürü; diyafragmatik herni; torakoabdominal travma.

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doi: 10.14744/tjtes.2019.58133

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ORIG I N A L A R T IC L E

Abdominal cocoon syndrome: A rare cause of acute abdomen syndrome Şükrü Çolak, M.D.,

Hasan Bektaş, M.D.

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

ABSTRACT BACKGROUND: A rare cause of acute abdomen or intestinal obstruction, the abdominal cocoon syndrome is also described in the literature as sclerosing peritonitis or sclerosing encapsulating peritonitis. Abdominal cocoon is characterized by the total or partial wrapping of the abdominal organs by a fibrous membrane. Although it is usually observed in young women, the etiology is unknown.

The diagnosis is usually made during laparotomy. In this case series, we aimed to present seven patients diagnosed with abdominal cocoon syndrome during operation.

METHODS: The records of patients who underwent laparotomy for abdominal pain and/or intestinal obstruction in our hospital and diagnosed as abdominal cocoon during operation between January 2012 and November 2018 were retrospectively reviewed. The demographic characteristics of the patients, etiologic factors, surgical procedures, operative findings and follow-up of the patients were recorded.

RESULTS: Four out of seven patients who were operated for abdominal cocoon were male and 3 of them were female. The median age of patients was 61 (57–63) years in male and 39.6 (28–49) years in female. Six of the patients were operated in emergency conditions with the diagnosis of an acute abdomen or ileus. One of the patients was operated with the diagnosis of an intra-abdominal mass in elective conditions. In five out of seven patients, all of the small intestines were wrapped with a fibrous collagen capsule, while two of the patient intestines were partially wrapped with a fibrous collagen capsule. Four of the patients had no underlying disease, while one of the patients had Familial Mediterranean Fever (FMF), one had Endometriosis and one had beta-blocker medication. One patient who had small bowel necrosis and septic peritonitis were observed during the operation and died post operative 6th days. Postoperative complications were not observed in the follow-up of other patients and reoperation was not required due to recurrence.

CONCLUSION: Abdominal cocoon is a condition that is usually diagnosed during operation in patients that were operated for reasons, such as the acute abdomen or intestinal obstruction. When the diagnose delayed, death can be seen due to small bowel necrosis and septic complications. High clinical suspicion and radiological imaging are important in the preoperative diagnosis. Treatment is required adhesiolysis and excision of the fibrous membranes.

Keywords: Abdominal cocoon; endometriosis; ileus; peritoneal fibrosis.

INTRODUCTION Sclerosing encapsulated peritonitis, a rare cause of acute abdomen or intestinal obstruction, was first described in 1868 and the definition of peritonitis chronica fibrosa incapsulate was used.[1] After 90 years of this identification, Foo et al.[2] used the term abdominal cocoon syndrome (ACS) for this disease, in 1978. The definition of primary sclerosing peri-

tonitis or idiopathic sclerosing peritonitis is also used synonymously for this disease.[3] ACS can be seen in primary form without any underlying cause and may be related to interventions, such as abdominal surgery, chronic peritoneal dialysis, liver transplantation, ventriculoperitoneal shunt, and some drugs.[4,5]

Cite this article as: Çolak Ş, Bektaş H. Abdominal cocoon syndrome: A rare cause of acute abdomen syndrome. Ulus Travma Acil Cerrahi Derg 2019;25:575-579.

Address for correspondence: Şükrü Çolak, M.D. İstanbul Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey.

Tel: +90 532 - 457 08 76 E-mail: sukrucolak2@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(6):575-579 DOI: 10.14744/tjtes.2019.48380 Submitted: 08.04.2019 Accepted: 23.05.2019 Online: 25.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Çolak et al. Abdominal cocoon syndrome: A rare cause of acute abdomen syndrome

Radiologically, contrast-enhanced Magnetic Resonans Imaging (MRI) can diagnose of abdominal cocoon better than computherised tomography (CT).[6] Factors affecting the clinical signs of ACS are duration and severity of the disease, underlying causes and immunological condition of patient. ACS is most commonly characterised-by recurrent intestinal obstruction attacks.[7] However, in some patients, the entero-atmospheric fistula may be associated with more rare complications, such as necrosis of small intestine due to impaired blood flow and malnutrition due to long-term nausea and vomiting of patients.[8] In most cases of ACS, is diagnosed intraoperatively. The diagnosis of ACS is very difficult with clinical evaluation.[9] Abdominal computerised tomography (CT) has a significant role in the pre-operative diagnosis of ACS.[10] Surgical intervention remains the most effective treatment option for ACS. In the surgery, excision of the fibrous capsule and adhezyolizis are performed.[11] Surgical intervention has many complications, such as iatrogenic bowel injury and recurrent ileus due to adhesions in the early period. In this study, we aimed to investigate the patients who were operated for acute abdomen or ileus between January 2012 and November 2018 and who had ACS detected during exploration.

MATERIALS AND METHODS

Figure 1. CT images of totally wrapped abdominal cocoon.

The files of the patients who were diagnosed with abdominal cocoon during the operation in our hospital were retrospectively reviewed between January 2012 and November 2018.

The demographic characteristics of the patients, etiologic factors, surgical procedures and operative findings of the patients were recorded.

The seven patients operated for abdominal cocoon, four of them were male and three of them were female. The median age of the patients was 61 (57–63) in male and 39.6 (28–49) in female. Six of the patients were admitted to the emergency department with acute abdomen and ileus. Five patients underwent CT and one patient underwent direct abdominal radiography. CT findings of patients were shown in Figure 1 and 2. The patients had a mild leucocytosis ranging from 9.900 to 12300. One of the patients underwent elective surgery with the diagnosis of intraabdominal mass localised the mesenter of intestine. Demographic characteristics, pathology and followup of patients were shown in Table 1.

Informed consent was obtained from all the patients included in this study. This study was performed, and data were collected according to the ethical principles of the Declaration of Helsinki.

Statistical Analysis Descriptive statistical methods, such as mean±standard de576

Figure 2. CT images of partially wrapped abdominal cocoon.

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Çolak et al. Abdominal cocoon syndrome: A rare cause of acute abdomen syndrome

Table 1. Demographic characteristics and histopathology of patients Sex

Age

Total capsule

Partial capsule

of intestine

of the intestine

Pathology

Etiology

Follow-up/months

Propranolol

75

–

54

M

63

(+)

Fibrous inflammatory material

M

57

(+)

Fibrous inflammation material

F

28

F

49

M

61

(+)

(+) (+)

Endometriosis

Endometriosis

45

Inflammatory peritoneum

–

36

Fibrous inflammatory material

–

36

F

42

(+)

Fibrous inflammatory material

FMF

3

E

63

(+)

Inflammatory peritoneum

–

Exitus

viation and/or median (minimum–maximum) and frequency and percentage, were used for data evaluation. The statistical analysis was performed using the Statistical Package for Social Sciences (SPSS®) software package for Windows, version 17.0 (SPSS Inc., Chicago, Illinois, USA).

RESULTS In two of the patients, all small intestines were partially wrapped with peritoneum, and there were adhesions between the small intestine. The other five patients were covered with fibrocollagenous tissue that formed on the intestines that adhered together due to inflammation. In three of these patients, fibrocollagen tissue covered all intestines, while in two patients a partial of the small intestine was covered with fibrocollagen.

All patients underwent adhesiolysis and capsule excision. In one patient, the iatrogenic injury occurred in the transverse colon during adhesiolysis and repaired primarily. One patient had underwent partial omentectomy due to necrosis of omentum, and partial small bowel resection due to small bowel necrosis. This patient developed small bowel necrosis and abdominal sepsis and died 4 days after the operation. The median duration of hospitalization was 9.5 (4–14) days.

The pathologic examination of the excised capsules revealed in two patients with peritoneal inflammation, in four with fibrozis containing fat and connective tissue and one patient with endometriosis. When the etiologic factors and past medical history of patients were evaluated four of patiets had no etiological cause, one patient had medication of betablocker, one patient had endometriosis and one patient had FMF. The median hospitalisation in our study was 9.5 (4–14) days. The follow-up period of our patients was 35.57 (3–75) months and two patients were hospitalized for follow-up because of subileus attacks, but re-operation was not required.

DISCUSSION The clinical manifestations of ACS is usually consisted of acute or subacute intestinal obstruction and sometimes acute abdomen. On physical examination, there is an increase of Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

bowel sounds with beside of abdominal distention. The small intestines covered with a fibrocollagen membrane localised anywhere in the abdomen.[12] In this case, if there is no acid in the abdomen, non-mobile intestines may cause asymmetric abdominal distension in the physical examination. There are non-specific findings, such as nausea and vomiting, which are frequently recurrent spontaneously or respond to medical treatment when questioned. Chronic constipation, loss of appetite, weight loss and intraabdominal masses, perforation, or ischemia-related necrosis is rarely seen in these patients.

Yip and Lee reported four main clinical features to standardize the preoperative diagnosis: a young female patient with intestinal obstruction with no apparent cause, having a background with similar attacks, having a bowel obstruction and bloating, and having a non-sensitive mass in the examination.

[11,13] In many studies with a high number of cases, the rate of diagnosis during operation varies between 52.3% to 100%.

On the other hand, the rate of patients diagnosed preoperatively varies between 16.7% and 48%.[9,14] In our series, the number of males was higher than female patients, whereas female patients were younger than male patients. All of the patients had similar and recurrent acute episodes, and one patient had a diagnosis of intraabdominal mass. However, we could not detect asymmetric distention in the abdomen.

The most common form of ACS is idiopathic form and its exact incidence is unknown. The secondary form occurs in various situations. These include familial Mediterranean fever (FMF), endometriosis, Peritoneal Dialysis (PD), ventriculoperitoneal or peritoneo-venous shunts, liver transplantation, recurrent peritonitis, medication of proctolol and propranolol, beta-blockers, methotrexate, protein C deficiency, exposure of asbestos, intraperitoneal chemotherapy, intraperitoneal povidone - iodine contact, liver cirrhosis, gastrointestinal malignancy, fibrogenic foreign object, systemic lupus erythematosus, abdominal tuberculosis and granulomatous peritonitis caused by parasitic infectious.[3,9,15] The incidence of ACS in patients with peritoneal dialysis has been reported to be between 1.4% and 7.3%.[6] 577

Çolak et al. Abdominal cocoon syndrome: A rare cause of acute abdomen syndrome

The case series published in recent years, ACS is seen more frequent in tropical and subtropical regions, such as in China, India and Turkey, and idiopathic ACS is reported that more common in women than men.[9,16] Preoperative diagnosis is quite difficult. Because the clinical findings are nonspecific, the most useful method for diagnosis is multislice CT. In addition, abdominal X-ray can be used and abdominal ultrasonography, but they provide very limited information for diagnosis. In x-ray examination and ultrasonography, dilated small bowel loops, air-fluid levels, intraperitoneal echogenic bands and calcifications can be seen.[4,8,11,17] Accordion pattern or cauliflower sign can be seen in abdominal CT. Delay in the passage of the contrast medium through the small intestine, collection of the dilated gut in one region, membrane formation around the intestines, wall thickening, localized fluid collection, peritoneal thickening and contrast enhancement are other features that can be seen in CT. CT is useful in preoperative diagnosis.[8,18] Evidence in the literature indicates that patients with minimal abdominal symptoms should be treated conservatively.

Intestinal resting, nasogastric decompression, and parenteral nutrition support are recommended for these patients.[3,9,19] Improving the nutritional status of these patients is of great importance as it can improve the response to conservative treatment or prevent subsequent surgical complications, such as infection and fistula. For patients not responding to conservative treatment, drugs, such as tamoxifen, steroids, colchicine, azathioprine and mycophenolic acid, can be used.

[3,9,20] Common characteristics of these drugs are anti-inflammatory and anti-fibrogenic. One of the patients in our series had a history of FMF for 15 years and the patient was using regular colchicine. ACS was present in the patient despite the anti-inflammatory and anti-fibrogenic properties of the colchicine.

If the brid ileus or internal herniation is excluded, these patients with symptoms of bowel obstruction may be candidates for surgery if not respond to conservative treatment.

The preferred method for the treatment of ACS is total or partial removal of the membrane.[3,8,9,11] Resection is rarely required, and anastomosis should be considered with caution in these patients.[3,9,21] There are a limited number of publications suggesting that mycophenolate mofetil may be useful in patients with frequent recurrent symptoms after surgery of membrane excision and adhesiolysis by laparoscopic approach in ACS.[16,22,23] Adhesiolysis and partial or full capsule excision were performed in all cases. In one patient, partial small bowel resection and end jejunostomy were performed due to the necrosis that arises from a vascular failure in the small intestine. In another patient, omentectomy was performed due to omentum necrosis. In one of the patients, colon perforation occurred during adhesiolysis and primary repair was performed. The patient was discharged without any problem.

578

CONCLUSION Abdominal cocoon is usually diagnosed during operation in patients operated for reasons such as acute abdomen or obstruction. In late diagnosed cases, death can be seen due to small bowel necrosis and septic complications. High clinical suspicion and radiological imaging are important in the preoperative diagnosis. The treatment is consisted of surgical adhesiolysis and membrane excision.

Conflict of interest: None declared.

REFERENCES 1. Cleland J. On an abnormal arrangement of the peritoneum with remarks on the developments of the mesocolon. J Anat Physiol 1868;2:201–6.

2. Foo KT, Ng KC, Rauff A, Foong WC, Sinniah R. Unusual small intestinal obstruction in adolescent girls: the abdominal cocoon. Br J Surg 1978;65:427–30.

3. Kaplan M, Atabek NM, Salman B, Durmuş O, Abbasova A, Mustafayev X. Bir olgu nedeniyle sklerozan enkapsüle peritonit. Genel Tıp Derg 2002;12:147–50.

4. Nakamoto H. Encapsulating peritoneal sclerosis-a clinican’s approach to diagnosis and medical treatment. Perit Dial Int 2005;25:S30–8.

5. Li N, Zhu W, Li Y, Gong J, Gu L, Li M, et al. Surgical treatment and perioperative management of idiopathic abdominal cocoon: single-center review of 65 cases. World J Surg 2014;38:1860–7.

6. Jovani M, Baticci F, Bonifacio C, Omodei PD, Malesci A. Abdominal cocoon or idiopathic encapsulating peritoneal sclerosis: magnetic resonance imaging. Dig Liver Dis 2014;46:192–3.

7. Zheng YB, Zhang PF, Ma S, Tong SL. Abdominal cocoon complicated with early postoperative small bowel obstruction. Ann Saudi Med 2008;28:294–6.

8. Akbulut S, Yagmur Y, Babur M. Coexistence of abdominal cocoon, intestinal perforation and incarcerated Meckel’s diverticulum in an inguinal hernia: A troublesome condition. World J Gastrointest Surg 2014;6:51–4.

9. Akbulut S. Accurate definition and management of idiopathic sclerosing encapsulating peritonitis. World J Gastroenterol 2015;21:675–87.

10. Hur J, Kim KW, Park MS, Yu JS. Abdominal cocoon: preoperative diagnostic clues from radiologic imaging with pathologic correlation. AJR Am J Roentgenol 2004;182:639–41.

11. Yeniay L1, Karaca CA, Calışkan C, Fırat O, Ersin SM, Akgün E. Abdominal cocoon syndrome as a rare cause of mechanical bowel obstruction: report of two cases. Ulus Travma Acil Cerrahi Derg 2011;17:557–60.

12. Naidoo K, Mewa Kinoo S, Singh B. Small Bowel Injury in Peritoneal Encapsulation following Penetrating Abdominal Trauma. Case Rep Surg 2013;2013:379464.

13. Yip FW, Lee SH. The abdominal cocoon. Aust N Z J Surg 1992;62:638– 42.

14. Browne LP, Patel J, Guillerman RP, Hanson IC, Cass DL. Abdominal cocoon: a unique presentation in an immunodeficient infant. Pediatr Radiol 2012;42:263–6.

15. Chew MH, Sophian Hadi I, Chan G, Ong HS, Wong WK. A problem encapsulated: the rare peritoneal encapsulation syndrome. Singapore Med J 2006;47:808–10.

16. Solak A, Solak İ. Abdominal cocoon syndrome: preoperative diagnostic criteria, good clinical outcome with medical treatment and review of the literature. Turk J Gastroenterol 2012;23:776–9.

17. Clatworthy MR, Williams P, Watson CJ, Jamieson NV. The calcified abdominal cocoon. Lancet 2008;371:1452.

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Çolak et al. Abdominal cocoon syndrome: A rare cause of acute abdomen syndrome 18. Hu D, Wang R, Xiong T, Zhang HW. Successful delivery after IVF-ET in an abdominal cocoon patient: case report and literature review. Int J Clin Exp Pathol 2013;6:994–7.

21. Da Luz MM, Barral SM, Barral CM, Bechara Cde S, Lacerda-Filho A. Idiopathic encapsulating peritonitis: report of two cases. Surg Today 2011;41:1644–8.

19. Habib SM, Betjes MG, Fieren MW, Boeschoten EW, Abrahams AC, Boer WH, et al. Management of encapsulating peritoneal sclerosis: A guideline on optimal and uniform treatment. Neth J Med 2011;69:500–7.

22. Ertem M, Ozben V, Gok H, Aksu E. An unusual case in surgical emergency: Abdominal cocoon and its laparoscopic management. J Minim Access Surg 2011;7:184–6.

20. Cornelis T, Oreopoulos DG. Update on potential medical treatments for encapsulating peritoneal sclerosis; human and experimental data. Int Urol Nephrol 2011;43:147–56.

23. Malik SA, Javed MA, Mian MA. Abdominal cocoon (sclerosingencapsulatingperitonitis): a rare cause of intestinal obstruction. J Coll Physicians Surg Pak 2012;22:171–3.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Abdominal koza sendromu: Akut karın sendromunun nadir bir nedeni Dr. Şükrü Çolak, Dr. Hasan Bektaş İstanbul Eğitim ve Araştırma Hastenesi, Genel Cerrahi Kliniği, İstanbul

AMAÇ: Literatürde nadir görülen bir akut karın veya bağırsak tıkanıklığı nedeni, abdominal koza sendromu sklerozan peritonit veya sklerozan enkapsüle peritonit olarak tanımlanmaktadır. Abdominal koza, karın organlarının lifli bir zar ile tamamen veya kısmen sarılması ile karakterizedir.

Genellikle genç kadınlarda görülmesine rağmen etiyoloji bilinmemektedir. Tanı genellikle laparotomi sırasında yapılır. Bu yazıda, operasyon sırasında abdominal koza tanısı almış yedi hasta sunuldu.

GEREÇ VE YÖNTEM: Hastanemiz genel cerrahi kliniğinde Ocak 2012 ile Kasım 2018 tarihleri arasında karın ağrısı ve/veya bağırsak tıkanıklığı nedeniyle laparotomi yapılan ve ameliyat sırasında abdominal koza tanısı alan hastaların kayıtları geriye dönük olarak incelendi. Hastaların demografik özellikleri, altta yatan etiyolojik faktörler, cerrahi işlemler, bulguları ve takipleri kaydedildi.

BULGULAR: Abdominal koza nedeniyle ameliyat edilen 7 hastadan dördü erkek, 3’ü kadındı. Ortanca yaş erkeklerde 61 (57-63), kadınlarda 39.6 (28-49) idi. Akut karın veya ileus tanısı ile altı hasta acil durumlarda ameliyat edildi. Elektif koşullarda karın içi kitle tanısı alan bir hasta ameliyat edildi. Yedi hastadan beşinde, ince bağırsakların tamamı bir fibrokollajen kapsül ile kaplıyken, 2 hastada bağırsaklar kısmen fibrokollajen kapsül ile kısmen sarıldı. Hastaların dördünde altta yatan hastalık yoktu, bir tanesinde Ailesel Akdeniz Ateşi (AAA), birinde endometriozis, birisinde betabloker kullanımı vardı. Ameliyat sırasında ince bağırsak nekrozu ve septik peritonit saptanan hasta 6 gün sonra kaybedildi. Diğer hastaların takibinde komplikasyon görülmedi ve hiçbir hasta nüks nedeniyle tekrar ameliyat edilmedi.

TARTIŞMA: Abdominal koza, akut karın veya bağırsak tıkanması gibi nedenlerle ameliyat edilen hastalarda genellikle ameliyat sırasında teşhis edilen bir durumdur. Geç tanı konulan olgularda ince bağırsak nekrozu ve septik komplikasyonlar nedeniyle ölüm görülebilir. Preoperatif tanıda yüksek klinik şüphe ve radyolojik görüntüleme önemlidir. Tedavi, fibrokollajen membranın eksizyonu ve adezyolizisdir.

Anahtar sözcükler: Abdominal koza, endometriozis; ileus; periton fibrozisi.

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doi: 10.14744/tjtes.2019.48380

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ORIG I N A L A R T IC L E

Omentopexy versus falciformopexy for peptic ulcer perforation Aydemir Ölmez, M.D.,1 Kuntay Kaplan, M.D.,2

Egemen Çiçek, M.D.,2 Cüneyt Kayaalp, M.D.2

Cemalettin Aydın, M.D.,2

1

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

2

Department of General Surgery, İnönü University Faculty of Medicine, Malatya-Turkey

ABSTRACT BACKGROUND: Open or laparoscopic Graham’s omentopexy is frequently used in the treatment of peptic ulcer perforation (PUP).

The technical difficulty of applying the omental plug, especially in patients with previous omentum resection, has led to the use of falciform ligament for the PUP, and some studies have reported that PUP may even be a more advantageous technique than omentopexy.

Here, in this study, we aimed to compare the retrospective results of patients who underwent falciformopexy or omentopexy for PUP. METHODS: Between 1999 and 2018, 303 patients who were followed-up and treated for PUP were included in this study. Patients who had malignancy, gastric resection, definitive ulcer surgery, laparoscopic surgery and nonoperative treatment were excluded from this study. In the remaining patients, either open ometopexy or falciformopexy were applied based on the surgeon’s choice. These two techniques were compared for intraoperative and postoperative outcomes.

RESULTS: Falciformopexy (n=46) and omentopexy (n=243) groups had similar demographics, but ASA scores were lower in the falciformopexy group. For ulcer size and localization, duration of operation, no difference was found between the groups. There was no significant difference between the groups concerning general postoperative morbidity and mortality. However, atelectasis was more frequently observed in the omentopexy group, whereas the pexia failure was more frequent in the falciformopexy group (2.6% and 8.7%, p=0.04).

CONCLUSION: Falciformopexy is an alternative technique that can be used in situations where it is not possible to use the omentum. Falciformopexy is not superior to omentopexy for the repair of the PUP. Keywords: Duodenal ulcer; falciform ligament; gastric ulcer; peptic ulcer; perforated; repair failure.

INTRODUCTION In peptic ulcer disease, elective surgery has lost importance today and surgical procedures are mostly applied for ulcer complications. The important complications of peptic ulcers are bleeding, stenosis and perforation. Peptic ulcer perforation (PUP) is the most important emergency pathology of a peptic ulcer due to the risk of development of preventable patient mortality. Mortality can be reduced by early diagnosis and treatment. Currently, some studies report no-mortality following PUP surgeries. However, morbidity, urgent surgical

need and hospital stay are not reduced yet.[1] Non-surgical interventions are rarely used for PUP treatment today and surgical treatment is the essential treatment modality. The standard method for PUP surgery is repairing with omentopexy, which can be applied by open or laparoscopic methods. The use of falciform ligament instead of omentum has been applied in a small number of cases. The present sudy aims to evaluate the efficacy and feasibility of falciformopexy in comparison to omentopexy.

Cite this article as: Ölmez A, Çiçek E, Aydın C, Kaplan K, Kayaalp C. Omentopexy versus falciformopexy for peptic ulcer perforation. Ulus Travma Acil Cerrahi Derg 2019;25:580-584.

Address for correspondence: Egemen Çiçek, M.D. İnönü Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Malatya, Turkey Tel: +90 422 - 377 40 01 E-mail: dregemencicek@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(6):580-584 DOI: 10.14744/tjtes.2019.11387 Submitted: 16.12.2018 Accepted: 29.01.2019 Online: 25.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Ölmez et al. Omentopexy versus falciformopexy for peptic ulcer perforation

MATERIALS AND METHODS Between 01.01.1999 and 24.04.2018, 303 patients who were diagnosed and treated for peptic ulcer perforation were retrospectively analyzed in this study. Ethical approval was obtained from the institutional review board for ethical research conduct. Patients who underwent primary repair using omentopexy or falciformopexy were included in this study.

Patients who were operated for malignancy, patients who underwent gastric resection or definitive ulcer surgery (truncal vagotomy and drainage), patients who received laparoscopic surgery or non-operative management were excluded from this study. Patients who received omentopexy and falciformopexy were evaluated for homogeneity based on age, gender, systolic and diastolic blood pressure at the time of admission, hemoglobin, white blood cell, urea, creatinine and concurrent illness (hypertension, diabetes, malignancy story, ulcer story, heart failure and coronary artery disease, chronic obstructive pulmonary disease, neuropsychiatric disease, chronic renal failure) of the patients at the time of admission.

Based on the surgeon’s preference, either open omentopexy or open falciformopexy were applied. These two techniques were investigated for its effects on postoperative mortality, repair site leakage, duration of hospitalization, the interval to oral intake, wound infection rate, evisceration, atelectasis, pneumonia and ileus rate.

Statistical Analysis Descriptive parameters were used in statistical analysis. Median and range were used for heterogeneous distributions where mean and standard deviation were used for homogeneous distributions. Student’s t-test or Mann-WhitneyU test was used to compare continuous variables, and Chi-squared or Fisher exact test was used to compare categorical variables. P<0.05 was considered significant. SPSS 17.0 was used in the analysis.

RESULTS Nine patients who underwent total gastrectomy and/or definitive surgery, one patient with medical treatment, one pa-

Table 1. Preoperative data and patient characteristics

Total

Age, years, median (range)

Omentopexy (n=243)

Falciformopexy (n=46)

p

57 (16–95)

58 (16–95)

53 (19–90)

0.19 0.78

Gender, n (%)

Male

241 (83.4)

202 (83.1)

39 (84.8)

Female

48 (16.6)

41 (16.9)

7 (15.2)

Comorbidity, n (%)

Diabetes mellitus (n=135)#

12 (8.9)

12 (9.7)

0 (0)

0.34

Hypertension (n=127)

34 (26.8)

33 (28.0)

1 (11.1)

0.25

Cardiovascular disease (n=125)Ø

15 (12.0)

13 (11.3)

2 (20.0)

0.34

&

COPD (n=136)

19 (14.0)

16 (12.9)

3 (25.0)

0.22

History of a malignancy (n=135)±

13 (9.6)

12 (9.7)

1 (9.1)

0.71

Chronic renal disease (n=17)

10 (58.8)

10 (62.5)

0 (0)

0.41 0.04

∞

µ

ASA score, n (%) (n=206)*

I

98 (47.6)

80 (44.4)

18 (69.2)

II

62 (30.1)

57 (31.7)

5 (19.2)

III

35 (17.0)

33 (18.3)

2 (7.7)

IV

10 (4.9)

9 (5.0)

1 (3.8)

V

1 (0.5)

1 (0.5)

0 (0)

Laboratory values, median (range)

White blood cell, 109/L, (n=281)

13.5 (1.3–47.8)

13.4 (1.6–34)

14.2 (1.3–47.8)

0.27

Hemoglobin, g/dL, (n=251)

14.5 (6.8–20.8)

14.7 (7.1–20.8)

15.6 (6.8–20)

0.21

Creatinine, mg/dL, (n=246)

1.0 (0.1–10.48)

1.0 (0.1–10.48)

0.96 (0.1–2.35)

0.65

Blood urea nitrogen, mg/dL, (n=245)

23.0 (5–168)

23.5 (5–168)

23.0 (10–134)

0.86

Albumin, g/dL, (n=180)

2.7 (0.7–4.6)

2.7 (0.7–4.5)

2.8 (1.2–4.6)

0.39

COPD: Chronic obstructive pulmonary disease. *Data regarding ASA scores could be obtained in 206 patients. #Data regarding diabetes mellitus could be obtained in 135 patients. &Data regarding hypertension could be obtained in 127 patients. ØData regarding cardiovascular disease could be obtained in 125 patients. ∞Data regarding COPD could be obtained in 136 patients. ±Data regarding the history of malignancy could be obtained in 135 patients. µData regarding CRD could be obtained in 17 patients.

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tient with laparoscopic repair, three patients with lack of data were excluded (in total 14 patients) from this study. Analyzes

were performed on a total of 289 patients, of whom 243 underwent omentopexy and 46 underwent falciformopexy. The

Table 2. Perioperative data of the patients included in this study

All patients

Omentopexy

Falciformopexy

p

Perforation diameter (n=276)*, cm, median (range)

0.5 (0.1–7)

0.5 (0.2–7)

0.5 (0.1–2)

0.66 0.11

Site of perforation (n=286)τ, n (%),

Duodenum

225 (78.7)

184 (76.3)

41 (91.1)

Pre-pyloric

18 (6.3)

15 (6.2)

3 (6.7)

Pyloric

9 (3.1)

8 (3.3)

1 (2.2)

Cardia, corpus

31 (10.8)

31 (12.9)

0 (0)

Gastroenterostomy site

Operative time (n=124) &, minute, median (range)

3 (1)

3 (1.2)

0 (0)

70 (30–210)

70 (30–210)

65 (45–130)

0.76

Data regarding perforation diameter could be obtained in 276 patients. τData regarding the site of perforation could be obtained in 286 patients. &Data regarding operative time could be obtained in 124 patients.

*

Table 3. Postoperative data and complications encountered in the patients

All patients

Hospital stay (n=261)*, days, median (range)

6 (1–67)

Omentopexy (n=243)

Falciformopexy (n=46)

p

7 (1–67)

6 (4–16)

0.17

Oral intake (n=225) , days, median (range)

4 (2–13)

4 (2–13)

4 (3–8)

0.32

30-day mortality (n=282)±, n (%)

29 (10.3)

25 (10.6)

4 (8.7)

0.7

Leak (n=279) , n (%)

10 (3.6)

6 (2.6)

4 (8.7)

0.04

Ileus (n=274)∞, n (%)

9 (3.3)

6 (2.6)

3 (6.7)

0.16

&

#

Evisceration (n=274) , n (%)

13 (4.7)

11 (4.8)

2 (4.5)

0.95

Atelectasis (n=276)¥, n (%)

20 (7.2)

20 (8.7)

0 (0)

0.04

Pneumoniae (n=274)µ, n (%)

28 (10.2)

26 (11.3)

2 (4.5)

0.17

Wound infection (n=273)∂, n (%)

22 (8.1)

19 (8.3)

3 (6.8)

0.74

Ø

Data regarding hospital stay could be obtained in 261 patients. &Data regarding oral intake could be obtained in 261 patients. ±Data regarding 30-day mortality could be obtained in 282 patients. #Data regarding leak could be obtained in 279 patients. ∞Data regarding ileus could be obtained in 274 patients. ØData regarding evisceration could be obtained in 274 patients. ¥Data regarding atelectasis could be obtained in 276 patients. µData regarding pneumoniae could be obtained in 274 patients. ∂Data regarding wound infection could be obtained in 273 patients. *

Table 4. Review of the literature regarding falciformopexy for peptic ulcer perforation

Article type

Fry DE., 1978[8] Costalat G., 1995[11]

Number Indication of cases

Localization and perforation size (mm)

Failure

Case

1

Thin and poor omentum

Duodenum (15)

0

Retrospective

12

New technique

Not available

0

Munro WS., 1996[13]

Case

6

New technique

Duodenum

0

Wijegoonewardene SI., 2012[15]

Case

1

Not available

Pre-pyloric

0

Bingener J., 2013[14]

Case

1

More suitable

Duodenum (4)

0

Boshnaq M., 2016[10]

Case

1

Pan-proctocolectomy

Pre-pyloric (30)

0

Calis H., 2016

Case

1

Previous gastrectomy

Gastroenterostomy (10)

0

Duodenum (5)

4 (8.7%)

[16]

This study

582

Series

46

with omentectomy New technique

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Ölmez et al. Omentopexy versus falciformopexy for peptic ulcer perforation

mean age of the patients was 54.8±20.4 (median and range 57 and 16–95) years. Two-hundred and forty-one patients (83.4%) were male. Preoperative gender, age, duration of hospitalization, laboratory values, ASA scores, comorbid factors were evaluated (Table 1). When the omentopexy and falciformopexy groups were compared preoperatively, the ASA score was higher in the omentopexy group (p=0.04). In evaluating intraoperative data, ulcer diameter, localization of perforation and duration of operation were evaluated, and there was no difference among the groups (Table 2). In the analysis of postoperative data, mortality, wound infection, pneumonia and atelectasis rate, evisceration rate, duration of hospitalization and interval to oral intake were evaluated (Table 3). Atelectasis was more frequent in omentopexy group (p=0.04).

The rate of pexia leakage was 2.6% in the omentopexy group and 8.7% in the falciformopexy group (p=0.04).

DISCUSSION Elective surgery for peptic ulcer is rarely performed due to effective medical treatment options. Bleeding, obstruction and perforation are important complications of the peptic ulcer. Perforation is the most important cause of morbidity and mortality. Although there are predictive parameters and risk factors for predicting morbidity and mortality, medical and/or surgical early intervention is the only parameter reducing mortality.[2,3] There is a relationship between patient age, admission time and mortality in PUP.[4] Among the treatment options of PUP, non-invasive management, including medical treatment and follow-up is a method that can be tried, especially in patients without an acute abdomen. In the study of Cao et al.,[5] it was emphasized that clinical features are important for radiological findings and whether APACHE scoring should be performed nonoperatively in patients. Partial gastrectomy is a preferred method, especially in the treatment of large ulcer perforations. Fortunately, due to the increasing use of H2 receptor blockers and proton pump inhibitors, the frequency of giant ulcers decreases, which results in a decrease in the use of partial gastrectomy.[6] Although surgical methods, such as resection- anastomosis and truncal vagotomy, had been used frequently in the past, Graham omentopexy is currently the most frequent technique that was first described in 1937.[7] This technique includes coverage of the perforated area with omentum using sutures. Despite the long and safe application history of this technique, there are technical difficulties in applying this technique in some patient groups. These patients include patients who have undergone previous omentectomy for several reasons, cachectic patients whose omental tissue is deficient, and cases where omentum cannot be used due to adhesions.[8–10] As there is no adequate and/or effective omentum in these patients, it has been reported that alternatively falciform ligament can be used for reinforcement of the repair site.[8] Costalat and Alquier[11] aimed to apply laparoscopic-endoscopic falciformopexy in 15 PUP cases. In their Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

study, falsiformopexy could be performed in 12 patients. In one patient, the perforation site diameter was 15mm. Thus, resection instead of the repair was performed. In the remaining two cases, falciformopexy was not preferred because generalized peritonitis was observed.[11] In the evaluation, it was argued that this technique was less aggressive than open surgery and was an alternative to non-operative treatments.

They concluded that falciformopexy could be preferred in younger patients and cases where perforation was detected early. Furthermore, it is a simple, effective, easier alternative, especially in closed perforations and in ulcers with hard or brittle edges.[12] Munro et al.[13] stated that using the falciform ligament in laparoscopic PUP repair was advantageous compared to omentopexy for falciformopexy resulted in tensionfree repair of the perforation site.[13] In a prospective study of Bingener et al.,[14] the falciform ligament in a patient who underwent transluminal PUP repair was used because it was more appropriate than omentum and no leakage occurred during follow up.[14] Wijegoonewardene et al.[15] applied laparoscopic falciformopexy for PUP of the patient with the diagnosed intraoperative. Calis et al.[16] reported the use of falciform ligament in a case of marginal ulcer perforation. The literature on falsiformopexy is mostly based on case studies, in which a small number of patients is included, and these studies generally yield positive results. In a critique of Lewis et al.[17] and Costalat et al., it was emphasized that omentum is more effective than falciform ligament due to its ability to retain leaks, adhesiveness, lymphocyte rich vascular feeding and ability to adhere to the area of inflammation and falciform ligament should be preferred in cases where omentum cannot be used. To our knowledge, there is no study comparing falciformopexy with omentopexy, which includes a large number of patients who have undergone PUP with falciformopexy/ and omentopexy in the literature (Table 4). Given that our study had a high number of pexia leakage in the group of falciformopexy indicated that falciformopexy should be an option when omentopexy cannot be performed.

Conclusion In cases with falciformopexy, it was observed that the repair failure was more common than omentopexy cases. Falciformopexy should be kept in mind as an alternative and feasible method that should be preferred when the omentum cannot be used for technical reasons.

Conflict of interest: None declared.

REFERENCES 1. Oter V, Yalcin M, Kafadar MT, Oter S. The results of perforated peptic ulcer surgery; a single center experience of 86 patients. Ann Med Res 2018;25:189–92.

2. Hut A, Tatar C, Yıldırım D, Donmez T, Unal A, Kocakusak A, et al. Is it possible to reduce the surgical mortality and morbidity of peptic ulcer perforations? Turk J Surg 2017;33:267–73.

3. Topcu A, Kıvanc AE, Kudas I, Sisik A, Ozel Y, Acar A, Basak F, et al.

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Ölmez et al. Omentopexy versus falciformopexy for peptic ulcer perforation Evaluation of mortality related factors in peptic ulcer perforation: Retrospective case-control study. Arch Clin Exp Med 2016;1:1–3.

4. Muslu U, Gokakin A, Demir A, Ureyen O, Altınel O, Tezcan E, et al.

Mortality and morbidity risk factors in the surgery of peptic ulcer perforation. Cumhur Med J 2011;34:189–93.

5. Cao F, Li J, Li A, Fang Y, Wang YJ, Li F. Nonoperative management for perforated peptic ulcer: who can benefit? Asian J Surg 2014;37:148–53.

6. Vashistha N, Singhal D, Makkar G, Chakravarty S, Raj V. Management of giant gastric ulcer perforation: report of a case and review of the literature. Case Rep Surg 2016;2016:4681989.

7. Graham RR. The treatment of perforated duodenal ulcers. Surg Gynecol Obstet 1937;64:235–38.

8. Fry DE, Richardson JD, Flint LM Jr. Closure of an acute perforated peptic ulcer with the falciform ligament. Arch Surg 1978;113:1209–10.

9. Strode JE. Utilization of the round and falciform ligaments as a peritonealizing structure in surgery of the upper abdomen. Ann Surg 1950;131:581–3.

10. Boshnaq M, Thakrar A, Martini I, Doughan S. Utilisation of the falciform ligament pedicle flap as an alternative approach for the repair of a perforated gastric ulcer. BMJ Case Rep 2016;2016.

11. Costalat G, Alquier Y. Combined laparoscopic and endoscopic treatment of perforated gastroduodenal ulcer using the ligamentum teres hepatis (LTH). Surg Endosc 1995;9:677–80.

12. Costalat G, Dravet F, Alquier Y, Noel P, Vernhet J. Treatment of perforated peptic ulcer using the round ligament under celioscopy. J Chir (Paris) 1991;128:91–3.

13. Munro WS, Bajwa F, Menzies D. Laparoscopic repair of perforated duodenal ulcers with a falciform ligament patch. Ann R Coll Surg Engl 1996;78:390–1.

14. Bingener J, Loomis EA, Gostout CJ, Zielinski MD, Buttar NS, et al.

Feasibility of NOTES omental plug repair of Perforated peptic ulcers: results from a clinical pilot trial. Surg Endosc 2013;27:2201–8.

15. Wijegoonewardene SI, Stein J, Cooke D, Tien A. Valentino’s syndrome a perforated peptic ulcer mimicking acute appendicitis. BMJ Case Rep 2012;2012.

16. Calis H, Cetin M, Sahin S, Nuraydin O, Karabeyoglu SM. Marginal ulcer perforation repair with falciform ligament: Case report. Causapedia 2016;5:144–7.

17. Lewis WI. Ligamentum teres not the ideal ulcer patch. Surg Endosc 1996;10:697.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Peptik ülser perforasyonunda omentopeksi ile falsiformopeksinin karşılaştırılması Dr. Aydemir Ölmez,1 Dr. Egemen Çiçek,2 Dr. Cemalettin Aydın,2 Dr. Kuntay Kaplan,2 Dr. Cüneyt Kayaalp2 1 2

Mersin Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Mersin İnönü Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Malatya

AMAÇ: Peptik ülser perforasyonunda (PÜP) açık veya laparoskopik Graham omentopeksi sıklıkla uygulanan tedavi şeklidir. Özellikle omentum rezeksiyon öyküsü olan hastalarda uygulanmanın teknik zorluğu, PÜP’de falsiform ligament kullanımına yol açmış olup bazı çalışmalarda omentopeksi’den daha avantajlı bir teknik olabileceği bildirilmiştir. Bu çalışmada, PÜP onarımında falsiformopeksi veya omentopeksi uygulanan hastalarımızın geriye dönük sonuçlarını karşılaştırmayı amaçladık.

GEREÇ VE YÖNTEM: 1999–2018 yılları arasında PÜP nedeniyle takip ve tedavi edilen 303 hasta çalışmaya alındı. Malignite, gastrik rezeksiyon, definitif ülser cerrahisi, laparoskopik cerrahi ve ameliyat dışı tedavi alan hastalar çalışma dışı bırakıldı. Kalan hastalara ometopeksi veya falsiformopeksi uygulandı. Bu iki teknik ameliyatta ve amaliyat sonrası sonuçlar açısından karşılaştırıldı.

BULGULAR: Falsiformopeksi (n=46) ve omentopeksi (n=243) grupları benzer demografik özelliklere sahipti, ancak ASA skorları falsiformopeksi grubunda daha düşüktü. Ülser boyutu ve lokalizasyonu, operasyon süresi açısından gruplar arasında fark saptanmadı. Genel postoperatif morbidite ve mortalite açısından gruplar arasında anlamlı fark yoktu. Bununla birlikte, omentopeksi grubunda atelektazi daha sık görülürken, peksi başarısızlığı falsiformopeksi grubunda daha sıktı (%2.6 ve %8.7, p=0.04).

TARTIŞMA: Falsiformopeksi, omentumu kullanmanın mümkün olmadığı durumlarda kullanılabilecek alternatif bir tekniktir. PÜP onarımı için omentopeksi’den daha üstün değildir.

Anahtar sözcükler: Duodenal ülser; falsiform ligaman; gastrik ülser; onarım yetmezliği; peptik ülser; perforasyon.

Ulus Travma Acil Cerrahi Derg 2019;25(6):580-584

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doi: 10.14744/tjtes.2019.11387

Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

ORIG I N A L A R T IC L E

Non-operative management of perforated peptic ulcer: A single-center experience Koray Karabulut, M.D.,1

Mürşit Dinçer, M.D.,2

Rumeysa Kevser Liman, M.D.,2

1

Department of General Surgery, Memorial Sisli Hospital, İstanbul-Turkey

2

Department of General Surgery, Fırat University Faculty of Medicine, Elazığ-Turkey

3

Department of General Surgery, İnönü University Faculty of Medicine, Malatya-Turkey

Sertaç Usta, M.D.3

ABSTRACT BACKGROUND: Perforation is a rare complication of peptic ulcer. Although the most widely accepted treatment for peptic ulcer perforation is surgery, non-operative treatment can be an option in selected patients. In this study, we aimed to present our non-surgical treatment experience in peptic ulcer perforation.

METHODS: In this study, the data of the patients who were treated due to peptic ulcer perforation between January 2012 and September 2017 in our clinic were retrospectively reviewed. The diagnosis was reached by physical examination and radiologic findings.

After obtaining the informed consent from the patients, non-operative treatment was performed to the selected patients who had normal vital parameters and did not have findings of generalized peritonitis in the abdominal examination. Oral food and fluid intake were stopped and intravenous fluid, antibiotics and pantoprazole were administered to all patients in this study.

RESULTS: A total of 41 patients were treated due to the diagnosis of peptic ulcer perforation in our clinic during the study period.

Out of 41 patients, while 35 of the patients were operated, six of them were treated non-operatively. There were peritoneal irritation signs and symptoms in the upper quadrants on physical examination in all of the patients. None of them had generalized peritonitis.

Abdominal X-ray and computed tomography were obtained from all of the patients. None of the patients in the non-operative group underwent any interventional procedure or surgery during the follow-up period. The median length of hospital stay was four days in this group. All of the patients were discharged uneventfully.

CONCLUSION: Standard treatment of peptic ulcer perforation in most of the patients is still surgical repair. Non-surgical treatment should be kept in mind as an option in the selected patients who had normal vital parameters and did not have any findings of generalized peritonitis in the abdominal examination. In this way, it may be possible to avoid unnecessary surgery and reduce the possible morbidity and mortality associated with the operation.

Keywords: Conservative treatment; non-operative treatment; peptic ulcer perforation.

INTRODUCTION

MATERIALS AND METHODS

Perforation is a rare complication of peptic ulcer. The most widely accepted treatment method for peptic ulcer perforation is surgery.[1] In a few studies in the literature, conservative treatment is also recommended in highly selected patients. In the present study, we aimed to present our nonsurgical treatment experience in the peptic ulcer perforation.

In this study, the data of the patients who were treated by hospitalizing in our clinic due to the diagnosis of peptic ulcer perforation between January 2012 and September 2017 were reviewed from the hospital database. The diagnosis was made by detecting intraperitoneal free air using direct abdominal X-ray and abdominal computed tomography in the patients with sudden onset of abdominal pain with accompanying signs

Cite this article as: Karabulut K, Dinçer M, Liman RK, Usta S. Non-operative management of perforated peptic ulcer: A single-center experience.

Ulus Travma Acil Cerrahi Derg 2019;25:585-588.

Address for correspondence: Koray Karabulut, M.D. Memorial Şişli Hastanesi, Genel Cerrahi Kliniği, Şişli, 34385 İstanbul, Turkey Tel: +90 212 - 314 66 66 E-mail: koraykarabulut@yahoo.com Ulus Travma Acil Cerrahi Derg 2019;25(6):585-588 DOI: 10.14744/tjtes.2019.31967 Submitted: 08.01.2019 Accepted: 15.01.2019 Online: 25.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Karabulut et al. Non-operative management of perforated peptic ulcer: A single-center experience

abdominal computed tomography. Intravenous contrast-enhanced abdominal tomography was obtained for all of the conservatively followed patients. Although intraperitoneal free air was present in all of the patients, perihepatic fluid was present in only three of them. Abdominal X-ray and computed tomography images of patients can be seen in Figures 2a, b, 3a, b, 4a, b.

Peptic ulcer perforation (n=41)

Surgery (n=35)

Observation (n=6)

Figure 1. Patients, according to the treatment arms.

and symptoms of peritoneal irritation on physical examination consistent with peptic ulcer perforation. Non-operative treatment was administered to the selected patients who had normal vital parameters and did not have findings of generalized peritonitis in the abdominal examination. The informed consent was obtained from each patient who participated in this study.

(a)

RESULTS A total of 41 patients were treated due to the diagnosis of peptic ulcer perforation in our clinic between January 2012 and September 2017. Out of 41 patients, while 35 (85%) of the patients were treated with laparoscopic or open surgery, six (15%) of the patients were treated non-operatively (Fig. 1). Five of the patients were male, and one patient was female. The ages of these patients ranged from 18 to 85 years.

The American Society of Anesthesiologists score (ASA) was I in four of the patients, II in one of the patients, and III in one patient of the patients. The demographic and clinical parameters of the patients are given in Table 1.

On physical examination, there was tenderness in the epigastric area in all of the patients. None of them had any signs of generalized peritonitis. All of them were hemodynamically stable. Tachycardia or hypotension was not observed in any of the patients. There was free air under the diaphragm in the direct abdominal X-ray in five of the patients. In one patient, although it can not be seen in the abdominal X-ray, there was free air around the duodenum and falciform ligament in Table 1. The demographic and clinical parameters of the patients Patient Age Gender ASA WBC no Score

Hospital stay (day)

1

18

Male

I

17430

5

2

22

Male

I

13690

4

3

29

Male

I

8580

4

4

52

Female

I

7490

4

5

63

Male

II

13900

3

6

85

Male

III

17350

4

ASA: American Society of Anesthesiologists score; WBC: White Blood Cell.

586

Oral food and fluid intake were stopped in all of the patients, intravenous fluid, antibiotics (ceftriaxone and metronidazole) and pantoprazole administered to all patients. None of the patients had nausea and vomiting. Nasogastric decompression was not used in any of the patients. They were followed up by serial physical examination. None of the patients underwent an interventional procedure or surgery during the follow-up period. All of the patients were discharged uneventfully. The median length of hospital stay was four days (3â&#x20AC;&#x201C;5). Helicobac-

(b)

Figure 2. (a, b) Abdominal X-ray and CT, showing subdiaphragmatic air.

(a)

(b)

Figure 3. (a, b) Abdominal X-ray and CT, showing subdiaphragmatic air.

(a)

(b)

Figure 4. (a) CT showing subdiaphragmatic and subhepatic air. (b) CT showing perihepatic fluid an air.

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Karabulut et al. Non-operative management of perforated peptic ulcer: A single-center experience

ter pylori eradication treatment was prescribed and a control gastroscopy appointment was scheduled for six weeks later.

DISCUSSION Many factors, such as H. pylori, non-steroidal anti-inflammatory drugs, corticosteroids, bisphosphonates, smoking, alcohol and stress, are effective in the pathogenesis of peptic ulcer disease.[2] Duodenal or gastric perforation due to peptic ulcer disease, which is seen less frequently with the use of proton pump inhibitors, is still a reason for surgical emergencies.[3,4] Perforations are more commonly seen in duodenal ulcers compared with gastric ulcers.[1] Duodenal ulcer perforations are frequently seen on the anterior surface of the duodenal bulb. Mortality rates are higher in gastric perforations than in duodenal perforations.[5] Treatment of the patients who are hemodynamically unstable and have signs of generalized peritonitis is surgical. Surgery can be performed either open or laparoscopic. During the surgery, most surgeons observe that the perforation sites are closed by the omentum, liver, or adjacent tissues. Surgeons usually remove these tissues and attachments to see the perforation area. From this point of view, the necessity of surgery has been questioned, and in some selected patient groups, these patients could be treated conservatively without any need for surgery.

A case of peptic ulcer perforation treated without surgical intervention was first presented by Redwood in 1870.[1] Wangensteen first proposed the conservative approach to peptic ulcer perforation in 1935. Taylor described broad-spectrum antibiotic therapy, intravenous fluid replacement, and Helicobacter Pylori eradication therapies as a conservative approach in peptic ulcer perforations in 1946.[6,7] In the literature, it is stated that the patients who are under 70 years of age, who are admitted to hospital within 24 hours after the onset of the symptoms, who have localized peritonitis findings and non-extensive fluid in the abdomen by imaging methods and whose peritoneal irritation symptoms are limited in the upper quadrants, can be followed-up conservatively.[8,9] The success rate of the conservative approach using this method was reported as 72% by Crofts et al.[8] In our study, all of the patients were admitted to the hospital at an early stage. Five cases were under 70 years of age. One case was 85 years old. Peritoneal irritation findings were localized in the epigastric region and in the right upper quadrant. Free air was detected in radiological imaging. The amount of fluid was few and limited in cases with free fluid in the abdomen.

They did not require an interventional procedure.

Surgical treatment is recommended for the conservatively followed patients if no clinical and imaging findings are improved within 24 hours.[3,10,11] In a study conducted on the 132 conservatively followed cases by Cao et al.,[3] it was reported that 25 patients without clinical improvement were undergone to surgery after 12 hours follow-up. In our seUlus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

ries, no clinical worsening was observed in the conservatively followed cases. Neither surgical nor radiologic interventions were required; vital signs were stable, and physical examination findings became better during the follow-up period.

In a retrospective study conducted by Devitt et al.[12] in 1967, the findings showed that the mortality rates were 72.5% in patients who did not undergo surgery and 7.5% in patients who underwent surgery. In 1971, Cohen et al.[13] reported these rates as 100% and 9%. With the increase in the use of antacid treatments, this ratio lowered.[14] In our study, although the number of patients followed was limited, there was no mortality in the patients who were followed-up conservatively or underwent surgery.

There are publications about the conservative follow-up with nasogastric drainage in peptic ulcer perforation.[15,16] In our cases, the nasogastric catheter was not inserted to the patients, so patient comfort increased, unlike non-surgical methods described in the literature. In the studies, it was reported that the length of hospital stay was longer in the conservatively followed patients compared with the patients who underwent surgery.[11] In our study, the length of hospital stay was similar to the patients who underwent surgery. In our study, another aspect differing from the literature was that the conservatively followed patients had low and medium ASA scores. While the conservative approach was generally tried in patients with high surgical risk in the literature, most of the cases in our study were followed-up with the ASA I-II score. The indication for conservative follow-up was completely based on clinical findings and physical examination in our series.

Conclusion Standard treatment of peptic ulcer perforation in most of the patients is still surgical repair. Non-surgical treatment should be considered as an option in the selected patients who had normal vital parameters and did not have findings of generalized peritonitis in the abdominal examination. In this way, it may be possible to avoid unnecessary surgery and reduce the possible morbidity and mortality associated with the operation.

Conflict of interest: None declared.

REFERENCES 1. Vijayakumar A, Mallikarjuna MN, Vijayraj P, Ajitha Naika, Shivaswamy BS. Non operative management of perforated peptic ulcer an algorithm approach. Int J Biomed Adv Res 2013;4:67–72.

2. Søreide K, Thorsen K, Harrison EM, Bingener J, Møller MH, OheneYeboah M, et al. Perforated peptic ulcer. Lancet 2015;386:1288–98.

3. Cao F, Li J, Li A, Fang Y, Wang YJ, Li F. Nonoperative management for perforated peptic ulcer: who can benefit? Asian J Surg 2014;37:148–53.

4. Thorsen K, Søreide JA, Søreide K. Scoring systems for outcome prediction in patients with perforated peptic ulcer. Scand J Trauma Resusc Emerg Med 2013;21:25.

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6. Bertleff MJ, Lange JF. Perforated Peptic Ulcer Disease: A Review of History and Treatment. Dig Surg 2010;27:161–69.

7. Hanumanthappa MB, Gopinathan S, Guruprasad RD, Dsouza N. A non-operative treatment of perforated peptic ulcer: a prospective study with 50 cases. J Clin Diagn Res 2012;6:696–99.

11. Lay PL, Huang HH, Chang WK, Hsieh TY, Huang TY, Lin HH. et al.

Outcome of nonsurgical intervention in patients with perforated peptic ulcers. Am J Emerg Med 2016;34:1556–60.

12. Devitt JE, Taylor GA. Perforated peptic ulcer. Can Med Assoc J 1967;96:519–23.

13. Cohen MM. Treatment and mortality of perforated peptic ulcer: a survey of 852 cases. Can Med Assoc J 1971;105:263–9.

8. Crofts TJ, Park KG, Steele RJ, Chung SS, Li AK. A randomized trial of nonoperative treatment for perforated peptic ulcer. N Engl J Med 1989;320:970–3.

14. Bucher P, OulhaciW, Morel P, Ris F, Huber O. Results of conservative treatment for perforated gastroduodenal ulcers in patients not eligible for surgical repair. Swiss Med Wkly 2007;137:337–40.

9. Tanaka R, Kosugi SI, Sakamoto K, Yajima K, Ishikawa T, Kanada T, et al.

Treatment for perforated gastric ulcer: a multi-institutional retrospective review. J Gastrointest Surg 2013;17:2074–81.

15. Saber A, Gad MA, Ellabban GM. Perforated duodenal ulcer in high risk patients: is percutaneous drainage justified? North Am J Med Sci 2012;4:35–9.

10. Satoh K, Yoshino J, Akamatsu T, Itoh T, Kato M, Kamada T, et al. Evidence-based clinical practice guidelines for peptic ulcer disease 2015. J Gastroenterol 2016;51:177–94.

16. Mouly C, Chati R, Scotté M, Regimbeaua JM. Therapeutic management of perforated gastro-duodenal ulcer: Literature review. J Visc Surg 2013;150:333–40.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Peptik ülser perforasyonunun ameliyatsız tedavisi: Tek merkez deneyimi Dr. Koray Karabulut,1 Dr. Mürşit Dinçer,2 Dr. Rumeysa Kevser Liman,2 Dr. Sertaç Usta3 1 2 3

Memorial Şişli Hastanesi, Genel Cerrahi Kliniği, İstanbul Fırat Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Elazığ İnönü Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Malatya

AMAÇ: Perforasyon, peptik ülserin nadir bir komplikasyonudur. Peptik ülser perforasyonunun yaygın kabul gören tedavisi cerrahi olmakla birlikte, ameliyatsız tedavi seçilmiş hastalarda bir seçenek olabilir. Bu çalışmada, peptik ülser perforasyonunda ameliyatsız tedavi tecrübemizi paylaşmayı amaçladık.

GEREÇ VE YÖNTEM: Ocak 2012 ile Eylül 2017 tarihleri arasında peptik ülser perforasyonu tanısıyla kliniğimizde tedavi edilen hastalara ait veriler geriye dönük olarak değerlendirildi. Tanı, fizik muayene ve radyoloji bulguları ile kondu. Ameliyatsız tedavi, vital parametreleri normal olup, fizik muayenede yaygın peritonit bulguları olmayan seçilmiş hastalara aydınlatılmış onamdan sonra uygulandı. Hastaların tamamında ağızdan gıda ve sıvı alımı durduruldu, intravenöz sıvı, antibiyotik ve pantoprazol başlandı.

BULGULAR: Çalışma süresince 41 hasta kliniğimize peptik ülser perforasyonu tanısı ile yatırılarak tedavi edildi. Bu hastaların 35’i ameliyat edilirken altısı konservatif olarak takip edildi. Hastaların tamamında, fizik muayenede karın üst kadranlarda periton irritasyon semptom ve bulguları vardı.

Hiçbirinde yaygın peritonit mevcut değildi. Hastaların tamamına direkt karın grafisi ve tomografi çekildi. Ameliyatsız tedavi grubundaki hastaların hiçbirine takip süresince cerrahi veya girişimsel radyolojik bir işlem yapma gerekliliği oluşmadı. Bu gruptaki hastalarda ortanca hastanede kalış süresi dört gündü. Hastaların tamamı sorunsuz olarak taburcu edildi.

TARTIŞMA: Peptik ülser perforasyonlu hastaların çoğunda standart tedavi halen cerrahidir. Ameliyatsız tedavi, vital parametreleri normal olan ve karın muayenesinde yaygın peritonit bulguları olmayan seçilmiş hastalarda bir tedavi seçeceği olarak akılda bulundurulmalıdır. Bu şekilde, gereksiz yere cerrahi yapmaktan ve cerrahinin olası morbidite ve mortalitesinden kaçınmak mümkün olabilir.

Anahtar sözcükler: Ameliyatsız tedavi; konservatif tedavi; peptik ülser perforasyonu.

Ulus Travma Acil Cerrahi Derg 2019;25(6):585-588

588

doi: 10.14744/tjtes.2019.31967

Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

ORIG I N A L A R T IC L E

Evaluation of current therapeutic approach to obstructive and perforated colorectal cancers Selçuk Kaya, M.D.,1 Ahmet Seker, M.D.,1 Önder Altın, M.D.,1 Yunus Emre Altuntaş, M.D.,1 Levent Kaptanoğlu, M.D.,2 Metin Kement, M.D.,2 Nejdet Bildik, M.D.,1 Hasan Küçük, M.D.1 1

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

2

Department of General Surgery, Bahçeşehir Univercity Faculty of Medicine, VM Medical Park Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Late diagnosis continues to be a significant problem in the treatment of colorectal cancer (CRC). Most cases require emergency surgical intervention due to acute intestinal obstruction or perforation. This retrospective study was formed from an assessment of the clinical presentation, treatment, early results, and survival of patients with CRC undergoing emergency surgery for acute obstruction or perforation.

METHODS: Between 2012 and 2017, 612 patients underwent surgery for CRC. In all, 179 patients who required emergency treatment were retrospectively evaluated according to age, gender, significant comorbidities, physiological status, surgical indications, tumor location, tumor stage, perioperative blood transfusion rate, type of surgery, and the length of the operation and hospitalization.

RESULTS: In total, 152 (85%) patients had a complete obstruction and 27 (15%) patients had a perforation. A major postoperative complication was identified nearly in half of the patients. The overall mortality rate was 12% (22 patients). Mortality was seen in 12% (18 patients) cases received surgery due to obstruction and in 15% (four patients) cases received surgery due to perforation. Perioperative blood transfusion and a high Acute Physiology and Chronic Health Evaluation II score were independent factors that predicted a major complication. Advanced age and perioperative blood transfusion were statistically independent prognostic factors for mortality.

CONCLUSION: Consisted with the findings of studies in the literature, the results of this study also revealed a high perioperative morbidity and mortality rate in patients with CRC who required urgent surgery. Our findings suggest that early detection and treatment of CRC with screening programs can be life-saving.

Keywords: Colorectal cancer; obstruction; perforation.

INTRODUCTION Colorectal cancers (CRC) are the second and third most common type of cancer among women and men in the world, respectively.[1] CRC occurs in three different forms as hereditary, sporadic, or familial. Family history, with an altered gene leads to a specific type of tumor and a younger age initially constitutes hereditary form. The familial form is seen in family members with a genetic component and as well as environmental factors. This form does not have the same direct pattern of inheritance. Sporadic CRC may occur without a

family history of the disease and is usually detected in the elderly population (60–80 years).

Neoplastic polyps, such as tubular and villous adenomas, are seen in 95% of CRC cases.[2] Despite advances in the diagnosis, treatment, and screening, CRC continues to be one of the leading causes of cancer deaths globally.[3] Early elective surgical resection is the gold standard; however, many CRC cases require urgent surgeries due to acute intestinal obstruction, perforation, or both.

Cite this article as: Kaya S, Seker A, Altın Ö, Altuntaş YE, Kaptanoğlu L, Kement M, et al. Evaluation of current therapeutic approach to obstructive and perforated colorectal cancers. Ulus Travma Acil Cerrahi Derg 2019;25:589-596.

Address for correspondence: Selçuk Kaya, M.D. Kartal Dr. Lütfi Kırdar Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey Tel: +90 216 - 458 30 00 E-mail: selcukkaya_36@hotmail.com Ulus Travma Acil Cerrahi Derg 2019;25(6):589-596 DOI: 10.14744/tjtes.2019.03828 Submitted: 04.08.2018 Accepted: 04.02.2019 Online: 25.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Kaya et al. Evaluation of current therapeutic approach to obstructive and perforated colorectal cancers

There are some reports indicating that 6–30 % of the patients with CRC show symptoms or have late complications.[4] In addition to a lessening in 5-year survival, higher mortality and morbidity rates were seen in the patients with CRC, received urgent surgeries.[5] Recently, it has been observed that the adverse effects of emergency surgery in patients with complicated colon cancer have limited perioperative turnover. The long-term survival of both emergency and elective surgery patients is similar.[6] It has been reported that in some studies, survival differences between patients undergoing emergency and elective CRC surgery are decreasing.[7] Meticulous dissection can provide considerable benefits, even in cases of urgent surgery and massive resection. The present study aims to evaluate the early results of treatment and surveillance analyzes in patients with obstruction or perforation due to colorectal cancer.

MATERIALS AND METHODS Study Design In this study, data from 612 patients who underwent surgical treatment for CRC between the years 2012–2017 were evaluated. One hundred seventy-nine patients (29.2%) required urgent surgery and are included in our study. Data were analyzed according to age, gender, significant comorbidities, physiological status, surgical indications, localization and stage of the tumor, blood transfusion requirement during surgery, surgical technique and duration of surgery and hospital stay.

Indications for emergency surgery were peritonitis, which was diagnosed by history taking and physical examination, findings of abdominal or systemic sepsis and clinical findings of obstruction. Patients with intestinal obstruction who could not be rectified by conservative methods, findings of obstruction, or perforation on radiological examinations and operated within four days of symptom onset were considered urgent. Patients who had only adenocarcinoma were included in this study. Patients, having cancer through familial adenomatous polyposis and inflammatory bowel diseases or other than adenocarcinoma, and operated in another hospital, were excluded from this study. Patients without clinical findings of obstruction and perforation were also criteria for exclusion.

Data Collection and Definitions This study was approved by our institutional Ethics committee. Patient files were reviewed for general and major morbidity and mortality as well as age, sex, major comorbidities, physiological status, surgical indications, location of the tumor, stage, transfusion requirement, type of surgery, duration of the operation and hospital stay.

At the time of the diagnosis, severe major organ dysfunction and chronic disease that required specific drug treatment were considered as co-morbidities. The American Society of 590

Anesthesiologists (ASA) classification[8] and the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system[9] were used preoperatively to investigate surgical and anesthesia risks and to group the patients according to the severity of the disease. The patients were divided into two categories: perforation and obstruction without perforation.

The perforated patient group was divided into two groups according to the position of the perforated area: adjacent perforation of the tumor and at least 2 cm of remote perforation.

The left branch of the middle colic artery was considered the border for proximal and distal tumors. The TNM Classification of Malignant Tumours (American Joint Committee on Cancer, 8th edition) was used to evaluate the tumors.

One hundred seventy-eight patients were staged by applying standard surgical techniques. Patients with no distant organ metastasis, no suspicion of residual disease after surgery, and patients with a clear surgical margin were considered cases of curative resection. Major complications were morbidities that disrupt respiratory, circulatory and excretory systems.

Deaths within the first 30 days after surgery were accepted as surgical mortality. The posthospitalized data were obtained by calling the patients or polyclinic visit charts.

Statistical Analysis Analyses were performed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, USA). Data with a normal distribution were analyzed using t-tests. Nonnormally distributed data were described using the median and interval and analyzed with the Mann-Whitney U test.

Relationships between the variables in the cross-tabulation were analyzed, if necessary, using a Chi-Square test or Fisher’s exact test. Data normality was analyzed using the Kolmogorov-Smirnov test. Univariate and multivariate analyses were performed to determine major morbidity and mortality. P<0.05 was considered significant. Kaplan-Meier survival curves were used to predict the overall survival (OS) and disease-free survival (DFS) of patients who underwent emergency CRC surgery.

RESULTS In total, 152 (85%) patients had obstruction and 27 (15%) patients had a perforation. The location of the tumor was as follows: right colon in 34 patients, transverse colon in 30 patients, splenic flexure or descending colon in 29 patients, sigmoid colon in 70 patients, and rectum in 16 patients. Left colon cancer patients had more obstruction and perforation.

Patients’ demographic details and tumor characteristics were summarized in Table 1.

The mean age of the study patients was 65.3 years (range: 31–97 years). The comorbid disease was diagnosed in 70 patients (39%). Common comorbid diseases were hypertension (38%), diabetes mellitus (22%), cardiovascular diseases (15%) and chronic obstructive pulmonary disease (7%). Male paUlus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

Kaya et al. Evaluation of current therapeutic approach to obstructive and perforated colorectal cancers

patients in the perforated colon group were 88% and 52%, respectively. 89% of the perforated patients had stoma without resection. Some cases received primary anastomosis. Patients with perforation received end stoma. Resection and anastomosis were performed in the majority of the obstructed right colon patients (74%). Bypass anastomosis was performed for one patient with advanced tumor disease. Colostomy was carried out in 18 of 128 patients with left colon carcinoma.

The only stoma was created in six patients with a stage-bystage resection plan. Permanent stoma was created in 21 patients due to inoperable disease. One hundred ten patients (86%) with left-sided tumors were resectable and resected.

Preoperatively additional procedures were applied due to various reasons. Generally, local advanced disease state, incidental findings, additional biopsies and iatrogenic causes were the main reasons. Additional treatments were administered to 33 patients (18%) for various reasons. An appendectomy

tients were predominant in obstruction cases, whereas female patients were predominant in perforation cases (p=0.027).

Advanced tumor stage (Stage III-IV) was seen in 107 of the patients (70%) with an obstructing carcinoma, and in 18 (67%) of the patients with a perforating tumor (p=0.348).

In this study, 31 patients (17%) were classified as ASA class I– II, 113 patients (63%) were ASA class III, and 35 patients (20%) were ASA class IV. The APACHE II score median average was between three and 21. The mean obstruction and perforation scores were 6.8 (SD 2.3) and 8.9 (SD 4.1), respectively (p=0.0001). In this study, 152 patients (85%) for obstruction and 27 patients (15%) for perforation were operated.

Curative surgery was applied to 95 cases (53%). The rates of general and curative resection in the patients in the obstructed colon group were 82% and 53%, respectively, while Table 1. Demographics and tumor characteristics

Obstruction n (%)

Total patients Age

Perforation n (%)

Total n (%)

152

27

179

65.1±13.2

66.5±14.8

65.3±13.4

Sex

Female

61 (40.1)

17 (63.0)

78 (43.6)

Male

91 (59.9)

10 (37.0)

101 (56.4)

Tumor stage*

I–II

44/151 (28.9)

9/27 (33.3)

53/178 (29.6)

III

45/151(29.6)

8/27 (29.6)

53/178 (29.6)

IV

62/151 (40.8)

10/27 (37.0)

72/178 (40.2)

Histologic grade**

Well differentiated

17/131 (11.2)

3/23 (11.1)

20/154 (11.2)

Moderately differentiated

86/131 (56.6)

14/23 (51.9)

100/154 (55.9)

Poorly differentiated

28/131 (18.4)

6/23(22.2)

34/154 (19.0)

Nodal status**

Negative (N0)

49/131 (37.4)

12/23 (52.2)

61/154 (39.6)

Positive (N1)

40/131 (30.5)

5/23 (21.7)

45/154 (29.2)

Positive (N2)

42/131 (32.1)

6/23 (26.1)

48/154 (31.2)

TNM**

T1–T2

3/131 (2.0)

0/23

3/154 (1.7)

T3

99/131 (65.1)

15/23 (55.6)

114/154 (63.7)

T4

29/131 (19.1)

8/23 (29.6)

37/154 (20.7)

Extramural lymphovascular invasion***

Present

68/130 (44.7)

12/23 (44.4)

80/153 (44.7)

Absent

62/130 (40.8)

11/23 (40.7)

73/153 (40.8)

Extramural perineural invasion ***

Present

71/130 (46.7)

17/23 (63.0)

88/153 (49.2)

Absent

59/130 (38.8)

6/23 (22.2)

65/153 (36.3)

*

1 missing data. **25 missing data. ***26 missing data.

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Kaya et al. Evaluation of current therapeutic approach to obstructive and perforated colorectal cancers

Table 2. Major complications after emergency surgery for colorectal cancer

Obstruction (n)

Perforation (n)

Total n (%)

p

Gastrointestinal

Ostomy-related complication

9

3

12 (6.7)

0.395

Intraabdominal abscess/peritonitis

10

18

28 (15.6)

0.000

Prolonged ileus

23

4

27 (15.1)

0.966

Anastomotic leakage

7

–

7 (3.4)

–

Intra-abdominal hemorrhage

2

–

2 (1.1)

–

Respiratory

Pneumonia

4

–

4 (2.2)

–

Respiratory failure

20

4

24 (13.4)

0.764

Pulmonary embolism

1

–

1 (0.6)

–

Renal

Acute renal failure

9

5

14 (7.8)

0.041

Cardiac

Congestive heart failure

3

–

3 (1.7)

–

Myocardial infarction

3

–

3 (1.7)

–

Other

Catheter-related sepsis

1

1

2 (1.1)

–

Deep venous thrombosis

3

–

3 (1.7)

–

was necessary for 11 patients, a cholecystectomy in seven, a hernia repair in five, a splenectomy in three, a small bowel resection in four, and a hepatic biopsy in three patients. Mortality was present in four patients (%12) who were administered an additional procedure. Two patients had an appendectomy, one case had cholecystectomy and another patient had a small bowel resection. There was no finding indicating that additional procedures may cause mortality. Besides, there was no difference between mortality rates in patients with or without additional procedures. The mean duration of operation was 137 minutes (49–285 minutes). Fifty-five patients (31%) received a perioperative blood transfusion.

Postoperative major complications occurred in 87 patients (48%) (Table 2). In patients with obstruction and perforation, the major complication rate was similar, with 48% in both cases. Digestive and respiratory system problems were common complications. 39% of the patients developed complications, such as surgical site infection, urinary infection and dehiscence, in the incision. A relaparotomy was required for 18 (10%) patients. The complication of colostomy was seen in six patients, anastomotic leak in five patients, abdominal abscess in four patients, evisceration in two patients and hemorrhage in one patient in these patients. Eighteen patients operated for obstruction and four operated for perforation died; mortality rates were 12% and 15%, respectively. The cause of death was sepsis in 12 patients, multi-organ failure in six patients, respiratory failure in three cases, and a pulmonary embolism in one case. All of the post-surgical deaths for a perforation were due to sepsis. The most frequent cause of death in patients treated for obstruction was a multi-organ failure. Among patients who underwent curative surgery, colostomy was seen with fewer complications than the primary anastomosis, with complication rates of 38% and 61%, respectively. Patients averaged 21.4 592

days in the hospital (SD 10.8 days). Obstructive patients were not statistically significant, with 23.5 days (SD 10.9 days) and 19.1 days (SD 9.2 days), respectively, with more stay at the hospital than with perforation. No statistically significant difference was found between the patients who underwent postresection anastomosis and those who had a stoma.

Univariate analyses showed that sex, age, tumor location, distant perforation from the tumor, ASA class, APACHE II score and major complications of blood transfusion did not significantly affect the risk (Table 3). Concerning mortality (Table 4), only age was a prognostic variable in univariate analysis. In multivariate analysis, perioperative blood transfusion and high APACHE II class were shown to be independent indicators of a major complication. Advanced age and perioperative blood transfusion in multivariate analysis were independent prognostic factors for mortality (Table 5).

Kaplan-Meier survival curves were used to predict the overall survival (OS) and disease-free survival (DFS) of patients who underwent emergency CRC surgery. Figure 1 displays the survival curves stratified by obstruction and perforation. As shown in Figures 1a and b, the OS and DFS were not significantly different in patients who underwent emergency surgery.

Figures 1c and d illustrate the lack of a significant difference between the OS and DFS of patients who had an emergency operation due to obstruction and the patients who had a perforation (p=0.059 and p=0.303, respectively; log-rank test).

DISCUSSION Emergency surgery for CRC is associated with a poor outcome.[5] The majority of patients who have emergency CRC surgery are operated for perforation or an obstruction. AcUlus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

Kaya et al. Evaluation of current therapeutic approach to obstructive and perforated colorectal cancers

Table 3. Univariate analysis of clinical factors in relation to major complication

Table 4. Univariate analysis of clinical factors in relation to major mortality

Categories

Categories

Major complication n (%)

p

0.256

Age

Mortality n (%)

p

Age

≤65

38/86 (44.2)

>65

49/93 (52.7)

Sex

≤65

3/86 (3.5)

>65

19/93 (20.4)

0.000

Sex

Female

33/78 (42.3)

Male

54/101 (53.5)

0.139

Tumor location

Female

11/78 (14.1)

Male

11/101 (10.9)

0.516

Tumor location

Right

20/51 (39.2)

Left

67/128 (52.3)

0.113

Tumor stage*

Right

4/51 (7.8)

Left

18/128 (14.1)

0.319 0.282

Tumor stage*

I–II

28/53 (52.8)

I–II

4/53 (7.5)

III

26/53 (49.1)

0.435

III

5/53 (9.4)

IV

32/72 (44.4)

IV

13/72 (18.1)

Indication for surgery

Indication for surgery

Obstruction

Obstruction

Cancer site perforation

74/152 (48.7) 5/14 (35.7)

0.406

Cancer site perforation

1/14 (7.1)

Proximal site perforation

8/13 (61.5)

Proximal site perforation

3/13 (23.1)

ASA class

18/152 (11.8) 0.412

ASA class

I-II

12/31 (38.7)

I–II

2/31 (6.5)

III

58/113 (51.3)

0.461

III

12/113 (10.6)

IV

17/35 (48.6)

IV

8/35 (22.9)

APACHE II score

0.086

APACHE II score

<8

31/127 (24.4)

≥8

24/52 (46.1)

0.461

Perioperative blood transfusion

<8

6/127 (4.7)

≥8

22/52 (42.3)

0.072

Perioperative blood transfusion

Yes

31/55 (56.4)

No

56/124 (45.2)

0.167

Yes

9/55 (16.4)

No

13/124 (10.5)

0.269

*1 missing data.

1 missing data.

*

cording to the literature, between 7% and 40% of CRC cases require emergency surgery.[10] Similar results were found in our study. We also observed that it was older patients who more often required emergency surgery due to CRC.[11] The CRC tumors were most commonly located in the rectosigmoid region.[12] As has been reported in the literature, the majority of our patients have had left colon and rectal tumors.

Obstructive CRC tends to progress locally. In patients with perforation, tumor staging is also seen to be more advanced than in non-emergency patients.[12] In our study, there was no statistically significant difference between obstructive and perforated tumors.

[13]

Patients undergoing emergency surgery due to right colon cancer are more likely to have locally advanced disease and Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

Table 5. Factors independently influencing the occurrence of major morbidity and mortality

Comparison

p

Major morbidity

Perioperative blood transfusion

Yes vs. no

0.034

APACHE II score

≥8 vs. <8

0.009

≤65 vs. >65

0.002

Yes vs. no

0.022

Mortality

Age

Perioperative blood transfusion

are treated more often with single-stage surgery.[12] In our study, resection-anastomosis was frequently carried out in a group of patients with resectable right colon tumors. In 593

Kaya et al. Evaluation of current therapeutic approach to obstructive and perforated colorectal cancers

(a)

(b) Survival Function Censored

0.8 0.6 0.4 0.2 0.0

0.8 0.6 0.4 0.2 0.0

0

20

40 Months

0

60

20

40 Months

60

(d) Indication Obstruction Perforation Obstruction-censored Perforation-censored

1.0 0.8 0.6 0.4 0.2 0.0

Indication Obstruction Perforation Obstruction-censored Perforation-censored

1.0 Cumulative Proportion Surviving

(c) Cumulative Proportion Surviving

Survival Function Censored

1.0 Cumulative Proportion Surviving

Cumulative Proportion Surviving

1.0

0.8 0.6 0.4 0.2 0.0

0

20

40 Months

60

0

20

40 Months

60

Figure 1. (a) Overall survival. (b) Disease-free survival. (c) Overall survival for obstructive and perforated cases. (d) Disease-free survival for obstructive and perforated cases.

resectable left colon tumors, we used the Hartmann procedure, most often in patients in the obstruction group with resection-anastomosis perforation. Several non-randomized studies have shown the Hartmannâ&#x20AC;&#x2122;s procedure does not have any benefits in mortality.[14,15] Indeed, most of the studies have shown the Hartmannâ&#x20AC;&#x2122;s procedure to be associated with a poorer prognosis, which is most likely related to selection bias, as anastomosis is avoided in high-risk patients.[16] Several studies found that the rates of morbidity and mortality in emergency colorectal surgery were 15% to 50% and 6% to 15%, respectively.[14,17] It is not clear whether the majority of these studies are partial or total obstruction.

Thus, different mortality rates are reported. In this study, the mortality rate was similar to previous study results, but we found higher morbidity rates. Comorbidities, electrolyte imbalance, dehydration, inflammatory processes due to surgery on dilated and dirty colonic segments may be attributed to high rates. In these cases, sepsis and multiorgan failure may present.

In general, incidental findings during surgery do not require additional procedures. These findings do not have any corre594

lation with the underlying disease. Clinical entities impairing patientsâ&#x20AC;&#x2122; status and iatrogenic causes may require additional procedures.[12] In our study, additional procedures did not bring on any increase in mortality and morbidity.

Postoperative morbidity affects the length of hospital stay, the likelihood of a surgical site infection and mortality rate.

One of the most feared major complications of colorectal surgery is an anastomosis leak. Some studies have shown that wound complications are higher after resection and primary anastomosis, especially in patients with left colon carcinoma.

[12] In this study, respiratory complications and intra-abdominal sepsis/abscess were more frequent.

The presentation of emergency treatment outcomes due to CRC can be used to predict pre-treatment risks and determine subsequent treatments. Predicted risks for adverse outcomes may be assessed by one or two variant analyzes of the initial diagnostic or surgical type or possible risk factors.

[12] We evaluated the possible risk factors for morbidity and mortality by conducting a multivariate analysis with a sufficient number of patient outcomes in this study.

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Kaya et al. Evaluation of current therapeutic approach to obstructive and perforated colorectal cancers

Some authors have suggested that older age does not cause worsening of prognosis in CRC patients,[10,13] but there are also authors who have shown that this factor is relevant to mortality.[12] We found that patient age is an important prognostic marker in univariate and multivariate analysis and has an independent effect on mortality in this study.

The prognosis of patients who undergo urgent surgery due to intestinal perforation is not clear. Some studies have shown that bowel perforation has a negative effect on patient outcomes.[18] A small number of retrospective studies addressing the differences between obstructive and perforated colon cancers have been published.[12,19] In addition, specific comparisons of for short and long term outcomes between cases of obstruction and perforation are not available in the literature. In most studies, emergency cases are grouped together (obstruction, bleeding, and perforation).[5] In our study, we could not statistically prove that there was a different effect as a result of obstruction or perforation on major morbidity and mortality.

Surgery for advanced disease has been reported to increase complications and the risk of surgical mortality,[20] and some publications have reported that tumor stage is not a risk factor for mortality and morbidity.[12] Although the majority of patients with major morbidity and mortality in our study were TNM stage III and IV patients, no statistical significance was found.

Some scoring systems are used in the estimation of surgical outcomes, but there are some limitations. The ASA scoring system is the most reliable and useful of these scoring systems.

A higher ASA score generally represents a poorer prognosis for the patient.[21] We could not prove the effects of the ASA score on morbidity and mortality in our study. Recent studies have also shown that APACHE II is one of the most accurate scoring systems for predicting perioperative complications in patients undergoing surgical treatment.[22] In this study, multivariate analysis, although not associated with APACHE II scores of morbidity and mortality in univariate analysis were associated with major morbidity.

In a previous study, blood transfusion in a noncardiac surgical procedure was reported to be associated with hospital mortality and increased risk of septic, wound and thromboembolic complications.[23] Another study indicated that perioperative blood transfusion increased the incidence of bacterial infection after colorectal surgery.[24] In this study, univariate analyses showed that blood transfusion did not differ significantly from morbidity and mortality when compared to those who did not transfuse. However, multivariate analyses found that perioperative blood transfusion was a risk factor for both morbidity and mortality.

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In the literature, a long-term survey analysis of patients undergoing CRC related emergency surgery was performed.

OS and DFS of the patients who underwent surgery due to CRC obstruction and perforation were worse than patients who underwent elective procedure.[25] Our results revealed no significant difference in OS and DFS between cases of perforation and obstruction.

In conclusion, as reviewed above in light of previous studies, the perioperative morbidity and mortality are still high in patients with CRC who require urgent surgery due to various complications. Given that perioperative blood transfusions are associated with more instances of a major complication or mortality, they should be avoided during surgery, if possible. In addition, the APACHE II score is associated with major complications and advanced age mortality. Thus, the surgeon should treat patients with these criteria more carefully. Considering the data we obtained and discussed in this study, we should note that the effective implementation of CRC-screening policies, which enable early detection and treatment of this disease, could be life-saving. Early diagnosis remains a major factor in the successful treatment of CRC. Conflict of interest: None declared.

REFERENCES 1. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al.

Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136:E359–86.

2. Bayar B, Yılmaz KB, Akıncı M, Şahin A, Kulaçoğlu H. An evaluation of treatment results of emergency versus elective surgery in colorectal cancer patients. Ulus Cerrahi Derg 2015;32:11–7.

3. Altobelli E, Lattanzi A, Paduano R, Varassi G, di Orio F. Colorectal cancer prevention in Europe: burden of disease and status of screening programs. Prev Med 2014;62:132–41.

4. Talebreza A, Yahaghi E, Bolvardi E, Masoumi B, Bahramian M, Darian EK, et al. Investigation of clinicopathological parameters in emergency colorectal cancer surgery: a study of 67 patients. Arch Med Sci 2017;13:1394–8.

5. McArdle CS, Hole DJ. Emergency presentation of colorectal cancer is associated with poor 5-year survival. Br J Surg 2004;91:605–9.

6. Smothers L, Hynan L, Fleming J, Turnage R, Simmang C, Anthony T. Emergency surgery for colon carcinoma. Dis Colon Rectum 2003;46:24– 30.

7. Biondo S, Martí-Ragué J, Kreisler E, Parés D, Martín A, Navarro M, et al.

A prospective study of outcomes of emergency and elective surgeries for complicated colonic cancer. Am J Surg 2005;189:377–83.

8. Owens WD, Felts JA, Spitznagel EL, Jr. ASA physical status classifications: a study of consistency of ratings. Anesthesiology 1978;49:239–43.

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

10. Jeong DS, Kim YH, Kim KJ. Surgical Outcomes and Risk Factors in Patients Who Underwent Emergency Colorectal Surgery. Ann Coloproctol 2017;33:239–44.

11. McGillicuddy EA, Schuster KM, Davis KA, Longo WE. Factors predicting morbidity and mortality in emergency colorectal procedures in elderly patients. Arch Surg 2009;144:1157–62.

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Kaya et al. Evaluation of current therapeutic approach to obstructive and perforated colorectal cancers 12. Alvarez JA, Baldonedo RF, Bear IG, Truán N, Pire G, Alvarez P. Presentation, treatment, and multivariate analysis of risk factors for obstructive and perforative colorectal carcinoma. Am J Surg 2005;190:376–82.

19. Chen HS, Sheen-Chen SM. Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends. Surgery 2000;127:370–6.

13. Garcia-Valdecasas JC, Llovera JM, deLacy AM, Reverter JC, Grande L, Fuster J, et al. Obstructing colorectal carcinomas. Prospective study. Dis Colon Rectum 1991;34759–62.

20. Payne JE, Meyer HJ. Independently predictive prognostic variables after resection for colorectal carcinoma. ANZ J Surg 1997;67:849–53.

14. Tekkis PP, Kinsman R, Thompson MR, Stamatakis JD; Association of Coloproctology of Great Britain, Ireland. The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer. Ann Surg 2004;240:76–81.

15. Biondo S, Pares D, Frago R, Marti-Rague J, Kreisler E, De Oca J, et al.

Large bowel obstruction: predictive factors for postoperative mortality.

Dis Colon Rectum. 2004;47:1889–97.

16. Trompetas V. Emergency management of malignant acute left-sided colonic obstruction. Ann R Coll Surg Engl 2008;90:181–6.

17. Gürlich R, Maruna P, Kalvach Z, Peskova M, Cermak J, Frasko R. Colon resection in elderly patients: comparison of data of a single surgical department with collective data from the Czech Republic. Arch Gerontol Geriatr 2005;41:183–90.

18. Biondo S, Kreisler E, Millan M, Fraccalvieri D, Golda T, Marti Rague J, et al. Differences in patient postoperative and long-term outcomes between obstructive and perforated colonic cancer. Am J Surg 2008;195:427–32.

21. Oh NH, Kim KJ. Outcomes and Risk Factors Affecting Mortality in Patients Who Underwent Colorectal Emergency Surgery. Ann Coloproctol 2016;32:133–8.

22. Haynes SR, Lawler PG. An assessment of the consistency of ASA physical status classification allocation. Anaesthesia 1995;50:195–9.

23. Glance LG, Dick AW, Mukamel DB, Fleming FJ, Zollo RA, Wissler R, et al. Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 2011;114:283–92 24. Houbiers JG, van de Velde CJ, van de Watering LM, Hermans J, Schreuder S, Bijnen AB, et al. Transfusion of red cells is associated with increased incidence of bacterial infection after colorectal surgery: a prospective study. Transfusion 1997;37:126–34.

25. Weixler B, Warschkow R, Ramser M, Droeser R, von Holzen U, Oertli D, et al. Urgent surgery after emergency presentation for colorectal cancer has no impact on overall and disease-free survival: a propensity score analysis. BMC Cancer 2016;16:208.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Obstrükte ve perforasyonlu kolorektal kanser hastalarına güncel tedavi yaklaşımının değerlendirilmesi Dr. Selçuk Kaya,1 Dr. Ahmet Seker,1 Dr. Önder Altın,1 Dr. Yunus Emre Altuntaş,1 Dr. Levent Kaptanoğlu,2 Dr. Metin Kement,2 Dr. Nejdet Bildik,1 Dr. Hasan Küçük1 1 2

S.B.Ü Kartal Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul Bahceşehir Üniversitesi Tıp Fakültesi Genel Cerrahi Anabilim Dalı, VM Medical Park Hastanesi, İstanbul

AMAÇ: Kolorektal kanserin (KRK) tedavisinde tanıda gecikme önemli bir sorun olmaya devam etmektedir. Birçok olgu akut bağırsak obstrüksiyonu ya da perforasyonundan ötürü acil cerrahi müdehaleyi gerektirir. Bu geriye dönük çalışma akut obstrüksiyon ya da peforasyon için acil cerrahi müdehaleye maruz kalan KRK'li hastaların sağkalımı, erken ameliyat sonrası sonuçları, tedavileri ve klinik durumlarını değerlendirmeyi amaçlamıştır.

GEREÇ VE YÖNTEM: 2012–2017 yılları arasında toplam 612 hasta KRK nedeniyle ameliyat edildi. Bu hastalar içinde acil müdehale gerektiren 179 hasta yaş, cinsiyet, komorbidite, fizyolojik durum, cerrahi endikasyon, tümör lokalizasyonu, tümör evresi, perioperatif kan transfüzyon oranı, cerrahi müdehale şekli ve hastanede kalma ve ameliyat geriye dönük olarak değerlendirildi.

BULGULAR: Toplamda 152 (%85) hastada tam obstrüksiyon, 27 hastada (%15) perforasyon vardı. Majör ameliyat sonrası komplikasyon hastaların neredeyse yarısında gözlendi. Genel mortalite oranı %12 (22 hasta) idi. Obstrüksiyon nedeniyle ameliyat edilen hastaların %12'sinde (18 hasta), perforasyon nedeniyle ameliyat edilen hastaların ise %15'inde (4 hasta) mortalite gelişti. Peroperatuvar kan transfüzyonu ve yüksek ASA skoru majör komplikasyonu öngören bağımsız prognostik faktörler olarak tespit edilirken, ileri yaş ve peroperatuvar kan transfüzyonu mortaliteyi öngören bağımsız risk faktörü olarak bulundu.

TARTIŞMA: Başka çalışmalarda da görüldüğü üzere, bizim yazımızda da acil cerrahi girişim gerektiren KRK hastalarında yüksek oranda peroperatuvar morbidite ve mortaliteye rastladık. Tarama programları yardımıyla erken tanı ve tedavi bu hastalıkta yaşam kurtarıcı rol oynamaktadır.

Anahtar sözcükler: Kolorektal kanser; obstrüksiyon; perforasyon.

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Versatile use of the posterior interosseous flap in the reconstruction of complex upper limb defects Ensar Zafer Barın, M.D.,1 Hakan Çinal, M.D.,1 Murat Kara, M.D.,2 Mehmet Akif Çakmak, M.D.,1 Önder Tan, M.D.1 1

Department of Plastic Reconstructive and Aesthetic Surgery, Ataturk University, Faculty of Medicine, Yakutiye, Erzurum-Turkey

2

Department of Plastic Reconstructive and Aesthetic Surgery, Training and Research Hospital, Yakutiye, Erzurum-Turkey

ABSTRACT BACKGROUND: Reconstruction of the complex upper extremity defects is a challenging procedure for reconstructive surgeons because of the complex anatomical and functional structure of this region. In reconstruction, local and regional flap options involving the composite tissues are restricted. The posterior interosseous flap (PIO) has been presented “in a single study” with a wide variety of uses, and in this study, the versatility of PIO has been tried to be emphasized by its multitude uses as well as its chance at adaptability to each case. Hence, due to this, the objective to highlight the versatile utility of the PIO flap in clinical practice and to present a good option for the reconstruction of complex upper limb defects for various cases have been targeted.

METHODS: We used 26 PIO flaps in 25 patients (18 male and seven female patients) with upper limb defects. The main etiological causes were burn contracture, traffic accident, firearm and acute burn injury. Twenty-two flaps were harvested as fasciocutaneous and four flaps as osteo-fasciocutaneous manner, which were applied to the metacarpal defects. In this study, 25 flaps were transferred as pedicled flaps, of which 23 and 2 flaps had reverse and antegrade blood flows, respectively, whereas one flap was used as a free flap.

RESULTS: The mean follow-up period was 14 months. All flaps except one, which had partial necrosis and secondary healed, survived completely. All patients were able to gain basic functions for daily routine activities in the late postoperative period. Patients and/ or their parents were satisfied with the postoperative functional and aesthetic improvements.

CONCLUSION: Many advantages of the PIO flap make it useful for the reconstruction of upper limb complex defects. It can be versatilely used based on changing its flow direction and enrichment of contents.

Keywords: Complex defect; flap; hand; posterior interosseous; upper extremity.

INTRODUCTION Complex upper limb defects may be particularly arise from trauma, firearm, burn and tumor resection, either exposing the vital structures, such as tendon, nerve, artery, and bone or accompanying with the defects of these structures. Thus, both circumstances necessitate flap closure. In reconstruction, local and regional flap options involving the above-mentioned composite tissues are restricted. Free flaps usually remain the unique and last option in such defects. However, these applications have also some specific and supplemental

risks, which consist of inappropriate recipient vessels for microanastomosis in traumatic limb, prolonged operative time, sophisticated equipment and procedure requirements, and bulky volumes of the transferred tissues.

The posterior interosseous (PIO) flap, which was first described by Zancolli and Angrigiani in 1986,[1,2] has been versatilely used in various styles in the literature, concerning blood flow pattern as antegrade[3] or retrograde,[4] type of transfer as pedicled[4] or free[5] and tissue content as fascial, fasciocutaneous[6] or osteo-fasciocutaneous.[4] This flap is raised

Cite this article as: Barın EZ, Çinal H, Kara M, Çakmak MA, Tan Ö. Versatile use of the posterior interosseous flap in the reconstruction of complex upper limb defects. Ulus Travma Acil Cerrahi Derg 2019;25:597-602.

Address for correspondence: Ensar Zafer Barın, M.D. Atatürk Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Erzurum, Turkey Tel: +90 442 344 66 66 E-mail: ensarzafer@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(6):597-602 DOI: 10.14744/tjtes.2019.54889 Submitted: 30.01.2018 Accepted: 08.02.2019 Online: 28.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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from the posterior aspect of the forearm and supplied by cutaneous branches of the posterior interosseous artery. The present study aims to highlight the versatile utility of the flap in clinical practice and to present a good option for the reconstruction of complex upper limb defects.

MATERIALS AND METHODS In this study, we used 26 PIO flaps in 25 patients (18 male and seven female patients) with upper limb defects. The main etiological causes were burn contracture, traffic accident, firearm and acute burn injury in eight, six, four and three patients, respectively. The age of patients ranged from three to 66 years (mean 23.2 years). The defect sites were mostly on the hand (23), and on the elbow in two patients. The flap sizes varied from 4x2.5 cm to 12x7 cm. Twenty-two flaps were harvested as fasciocutaneous and four flaps as osteo-fasciocutaneous manner, which were applied to the metacarpal defects. Twenty-five flaps were transferred as pedicled flaps, of which 23 and two flaps had reverse and antegrade blood flows, respectively, whereas one flap was used as a free flap.

The donor sites were closed primary in 19 patients and with split-thickness skin grafts in six patients.

point was marked 2 or 3 cm proximal to the distal radioulnar joint, whereas it was marked on the proximal radioulnar joint in antegrade flow PIO flap. The required length of the pedicle was then measured from the pivotal point to the proximal edge of the defect. The skin paddle was placed proximally and distally on the flap axis in reverse flow and antegrade flow PIO flaps, respectively. The dissection was started at the vascular pedicle and continued towards the skin paddle. It was important to make sure that the posterior interosseous artery and its concomitant veins existed in the septum. In case of the absence of the vascular pedicle, the procedure would be aborted, and alternate flaps would be used. At this point, the posterior interosseous nerve, which was very close to the artery, was identified and protected. The skin paddle was then raised over the deep muscle fascia in a fasciocutaneous manner. In the reconstruction of bone defects, a longitudinal ulna segment was included in the flap. The flap was transferred to the defect site through the subcutaneous tunnel, which had to be wide enough to avoid compression or torsion of the pedicle. The free PIO flap was designed and harvested in the same manner with the antegrade flow PIO flap.

RESULTS

Operative Technique The operation was performed under general anesthesia, with the arm on the side table and wrist in full pronation. A straight line was drawn from the lateral epicondyle to the distal radioulnar joint. This line represented the axis of the flap, which showed the trace of the vascular pedicle into the septum between the tendons of the extensor carpi ulnaris and extensor digiti minimi. In reverse flow PIO flap, the pivotal

(a)

(b)

(d)

(e)

The mean follow-up period was 14 months. All flaps except one, which had partial necrosis and secondary healed and survived completely. There were no additional complications, such as wound dehiscence, infection, and hematoma. We did not encounter “drop hand” deformity due to the PIO nerve injury during pedicle dissection in any patient. No patient required late surgical revision for debulking. In osteo-fasciocuta-

(c)

Figure 1. A 15-year-old male patient suffered from a complex soft tissue defect located on the right elbow due to traffic accident. (a) Preoperative view showing the ulnar nerve defect. (b) Raising of the antegrade flow PIO fap of 6x5 cm so as to pass between the radius and ulna where a penrose drain was placed. (c) Transfer of the flap to the defect site. The ulnar nerve defect was repaired with interpositional sural nerve grafts consisted of three cables. (d) Closure of the defect. (e) Late postoperative view of 11 months.

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BarÄąn et al. Versatile use of the PIO in the reconstruction of complex upper limb defects

neous flaps, there were no usual bone-related complications such as non-union, mal-union, bone resorption, or secondary fracture. The average time of bone union was three months and all donor bones (ulna) were healed with no fractures.

Recoveries of the skin donor sites were uneventful in our series. All patients were able to gain basic functions for daily

(a)

(d)

(b)

routine activities in the late postoperative period. Patients and/or their parents were satisfied with the postoperative functional and aesthetic improvements.

The case samples that presented with various complex upper extremity defects are demonstrated in Figures 1 to 3.

(c)

(e)

(f)

Figure 2. An 18-year-old male patient presented with a complex hand wound including the soft tissues and third metacarpal, caused by a firearm. The composite osteofasciocutaneous PIO flap was planned for reconstruction. (a) Preoperative dorsal aspect. A surgical clamp was easily placed through the defect from volar to dorsal side. (b) Inset of the flap in the recipient site. Metacarpal was restored with the ulna segment of the composite PIO flap. (c) Intraoperative early aspect of the defect and donor sites. (d) Postoperative comparative aspect of both hands. (e) The PIO flap provided a good contour and a thin coverage on the dorsum of the hand. (f) Postoperative radiographic aspect of the metacarpal substitution.

(a)

(b)

(c)

(d)

(e)

(f)

Figure 3. A 48-year-old male patient had a complex soft tissue defect exposing the tendons on the volar side of the hand and wrist, caused by agriculture machine. A large reverse flow PIO flap, which was 12x7 cm in size, was designed. (a) Preoperative appearance of the defect. (b) Design and marking of the flap. (c) Elevation of the flap. (d) Inset of the flap in the recipient site. (e) Late postoperative volar appearance of 2.5 years. (f) Late postoperative dorsal appearance showing the donor site which was covered with skin graft.

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DISCUSSION Reconstruction of the complex upper extremity defects is a challenging procedure for reconstructive surgeons because of the complex anatomical and functional structure of this region. Ideal repair should be performed from hard to soft tissues and from deep to surface planes in the least operative session as possible. Thus, it needs restorations of bones, tendons, nerves, and vessels, and then soft tissue coverage, depending on the requirements. Primary repair is ideal, but grafts should be used, if required, for restorations of all these components. Skin coverage is preferred to be pliable, thin and to have good colour and texture match.

Free anterolateral thigh (ALT) flap may be a good option for the reconstruction of the large and complex defects of the upper limb.[7,8] Huge skin islands can be elevated from the thigh to close the large defects exposing the tendons, nerves and bones in this region. Free ALT flap is a right versatile flap since it can be harvested with the tendon of tensor fascia lata for a vascularized tendon reconstruction,[9] with the vastus lateralis muscle to fill dead spaces,[10] or with the lateral femoral cutaneous nerve for the neurotization of the transferred skin paddle.[11] Osteocutaneous free fibular flap is another alternative for the reconstruction of the complex upper limb defects.[12] Fibula is a tubular bone and can be suitable for the reconstruction of long and large-sized bone defects as in humerus, but not for smaller bones, such as radius and ulna. On the other hand, vascular variability, short pedicle, poor nourishment of the skin paddle, difficult dissection and risk of peroneal nerve injury are disadvantages of the fibula flap.

Other free flaps, which were less used in the reconstruction of upper limb defects, were also reported in the literature.

Serratus anterior adipofascial flap and vascularized rib flaps can be elevated on the same pedicle.[13,14] Dorsalis pedis fasciocutaneous flap has been also used in the reconstruction of the hand defects[15] with poor donor scar on the foot dorsum.

The reverse flow radial forearm flap, which is known as Chinese flap, has been the main flap choice for years in complex defects of the hand.[16,17] Moderate to large defects of the hand can be successfully reconstructed with this flap.

It is thin, pliable and distally based flap and does not need microsurgical expertise. A radial bone segment can also be harvested with the flap. However, the reverse radial forearm flap has lost its popularity because it has some disadvantages, such as the sacrifice of a major artery of the hand and poor donor site scar.[18] The ulnar artery forearm flap is also not commonly used because of similar disadvantages.[19] Dorsoulnar perforator flap is another regional alternative in soft tissue reconstruction.[20,21] Although this flap does not sacrifice the ulnar artery, the limited arc of rotation confines its use to only the proximal palm and ulnar side of the dorsal hand.

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The pedicled groin and abdominal flaps have been utilized in many studies.[22] However, multi-staged procedure and bulky structure are the main disadvantages of these techniques.

Since 1986, when the PIO flap has been first reported by Zancolli and Angrigiani,[2] it has been used in several types of transfer as a right versatile flap. Park et al. have reported the free transfer of the PIO flap in their series.[5] Akın et al. treated metacarpal bone and soft tissue defects on the hand with an osteocutaneous PIO flap in five patients.[23] Mazzer used this flap based on antegrade flow in two cases.[3] We, firstly, utilized the PIO flap in all reported manners in the same series in the literature.

The PIO flap has considerable advantages when compared to the remaining regional flaps, including constant and long vascular pedicle, wide arc of rotation, good colour and texture match, thin and pliable skin paddle, versatile contents, such as skin, fascia, and bone segment, easy dissection, and short operative time. The pedicled PIO flap can be transferred on its distal and proximal bases for the coverage of hand and wrist, and elbow and distal arm defects, respectively. Moreover, the microvascular transfer is also possible for the PIO flap. Regional anesthesia alone can be mostly enough during the whole operative procedure. The main arteries of the upper limb are protected with the harvest of this flap.

The PIO flap has been proved to be quite safe in the reported studies. Necrosis rates of the PIO flap ranged between 8.8 % and 28.5%.[24-28] Büchler and Frey suggested that the main reason for the necrosis of the PIO flap was arterial ischemia,[24] whereas, Shibata blamed hypoplasia of the distal anastomosis between the posterior and the anterior interosseous arteries.[25] Tan reported no flap necrosis in his PIO flap series comprising 10 children.[4] Büchler and Frey found partial flap necrosis in 21 percent of their series and ascribed this to arterial ischemia (71 percent) or venous congestion (29 percent).[24] Costa et al. reported two patients with rim necrosis in 21 pedicled PIO flap transfers.[26] Angrigiani et al. described four total flap failures and three partial necroses (8.8 percent) in 80 consecutive patients.[27] They concluded that insufficient vascularization had resulted in flap failure. It has been reported that the planning of the flap skin island to reach the 1/3 distal of the forearm would reduce venous congestion.[29] Sonmez et al. reported an alternative solution for venous congestion in a superficial vein anastomosis added to the PIO flap.[30] Furthermore, Nikkhah et al. reported in his study that small technical manoeuvres had been conducted for the safe removal of the flap.[31] In our series, there was one partial necrosis, which healed as secondary with no intention. Partial or total necrosis rates were lower in our series compared to the literature, because of the extremely rigorous pedicle dissection and minimization of conditions such as kinging or compression that may occur in the vascular pedicle.

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The largest PIO flap reported in the literature was 16x10 cm.[32] In our series, the largest PIO flap was 12x7 cm in dimension. One of the major handicaps of the PIO flap is insufficiency in coverage of large to huge defects. Similarly, in the distal proximal interphalangeal joint (PIF), the PIO flap is also insufficient in extreme tissue defects, including the dorsal or volar faces of the fingers. In the study by Zaidenberg et al., which described the flaps planned to use the dorsal intercarpal arch (DIA) and posterior interosseous artery (PIA) anastomoses might be the solution to distal tissue defects in which the classical PIO flap is inadequate.[33] The donor site scar can also be observed as another problem in PIO flaps. The donor site scars are acceptable, particularly in primary closure. However, in some cases, a graft may be used for donor site repair. In our series of 25 patients, the donor site of six patients (24%) was closed with STSG. Although this ratio has been reported up to 50% in the literature, the closure of the donor site with the graft is directly related to the width of the flap removed.[34] As an alternative to the donor site problem, Çoban et al. has proposed a triangular design and has suggested V-Y closure[35] Jakubietz and colleagues presented the removal of the flap as a facial component, without skin, as a solution to the donor site problem.

[36] As to the donor site scar, patient and parent satisfaction is at an acceptable level in our series and to support this point; it has been reported in the literature that PIO flap is an acceptable option according to the other flap alternatives in which the forearm is used as a donor site.[29] Although there have been reports of temporal motor paralysis due to posterior interosseous nerve damage in the literature, no patient in our series had a wrist drop or similar complication due to a PIN wound.

In conclusion, many advantages of the PIO flap make it useful for the reconstruction of the upper limb complex defects.

PIO flap can be versatilely used based on its flow direction and contents. The PIO flap presents a good alternative for free flaps, particularly in the lack of microsurgical background.

Conflict of interest: We disclose that there are no financial and personal relationships with other people or organisations that could inappropriately influence (bias) this study.

REFERENCES 1. Zancolli EA, Angrigiani C. Colgajo dorsal de antebrazo (en isla); Forearm dorsal. Rev Asoc Argent Ortop Traumatol 1986;51:161–8.

2. Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg Br 1988;13:130–5.

3. Mazzer N, Barbieri CH, Cortez M. The posterior interosseous forearm island flap for skin defects in the hand and elbow. A prospective study of 51 cases. J Hand Surg Br 1996;21:237–43.

4. Tan O. Reverse posterior interosseous flap in childhood: a reliable alternative for complex hand defects. Ann Plast Surg 2008;60:618–22.

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5. Park JJ, Kim JS, Chung JI. Posterior interosseous free flap: various types.

Plast Reconstr Surg 1997;100:1186–97.

6. Goubier JN, Romana C, Masquelet AC. [The posterior interosseous flap in the child: 13 case reports]. Chir Main 2002;21:102–6.

7. Yazar S, Gideroglu K, Kilic B, Gokkaya A. Use of composite anterolateral thigh flap as double-vascularised layers for reconstruction of complex hand dorsum defect. J Plast Reconstr Aesthet Surg 2008;61:1549–50.

8. Meky M, Safoury Y. Composite anterolateral thigh perforator flaps in the management of complex hand injuries. J Hand Surg Eur Vol 2013;38:366–70.

9. Houtmeyers P, Opsomer D, Van Landuyt K, Monstrey S. Reconstruction of the Achilles tendon and overlying soft tissue by free composite anterolateral thigh flap with vascularized fascia lata. J Reconstr Microsurg 2012;28:205–9.

10. Cordova A, D’Arpa S, Di Lorenzo S, Toia F, Campisi G, Moschella F. Prophylactic chimera anterolateral thigh/vastus lateralis flap: preventing complications in high-risk head and neck reconstruction. J Oral Maxillofac Surg 2014;72:1013–22.

11. Baas M, Duraku LS, Corten EM, Mureau MA. A systematic review on the sensory reinnervation of free flaps for tongue reconstruction: Does improved sensibility imply functional benefits? J Plast Reconstr Aesthet Surg 2015;68:1025–35.

12. Momeni A, Stark GB. The free fibular flap: a useful flap for reconstruction following composite hand injuries. J Hand Surg Br 2006;31:304– 5.

13. Fassio E, Laulan J, Aboumoussa J, Senyuva C, Goga D, Ballon G. Serratus anterior free fascial flap for dorsal hand coverage. Ann Plast Surg 1999;43:77–82.

14. Siotos C, Neira PM, Lau BD, Stone JP, Page J, Rosson GD, et al. Origins of Gender Affirmation Surgery: The History of the First Gender Identity Clinic in the United States at Johns Hopkins. Ann Plast Surg 2019;83:132–6.

15. Caroli A, Adani R, Castagnetti C, Pancaldi G, Squarzina PB. Dorsalis pedis flap with vascularized extensor tendons for dorsal hand reconstruction. Plast Reconstr Surg 1993;92:1326–30.

16. Soucacos PN, Zoubos AB, Korompilias AV, Vekris MD. Versatility of the island forearm flap in the management of extensive skin defects of the hand. Injury 2008;39:S49–56.

17. Kaufman MR, Jones NF. The reverse radial forearm flap for soft tissue reconstruction of the wrist and hand. Tech Hand Up Extrem Surg 2005;9:47–51.

18. Brunelli F, Valenti P, Dumontier C, Panciera P, Gilbert A. The posterior interosseous reverse flap: experience with 113 flaps. Ann Plast Surg 2001;47:25–30.

19. Liu DX, Wang H, Li XD, Du SX. Three kinds of forearm flaps for hand skin defects: experience of 65 cases. Arch Orthop Trauma surg 2011;131:675–80.

20. Uygur F, Uygur M, Ulkur E, Sever C. Versatility of the reverse dorsoulnar fasciocutaneous flap in coverage of hand defects: clinical experience with 36 cases. J Hand Surg Am 2009;34:1327–33.

21. Tan O, Kilic M. Supercharged dorsoulnar island flap: a case report and review of the literature. Acta Orthop Traumatol Turc 2011;45:53–7.

22. Sabapathy SR, Bajantri B. Indications, selection, and use of distant pedicled flap for upper limb reconstruction. Hand Clin 2014;30:185–99.

23. Akin S, Ozgenel Y, Ozcan M. Osteocutaneous posterior interosseous flap for reconstruction of the metacarpal bone and soft-tissue defects in the hand. Plast Reconstr Surg 2002;109:982–7.

24. Büchler U, Frey HP. Retrograde posterior interosseous flap. J Hand Surg Am 1991;16:283–92.

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Barın et al. Versatile use of the PIO in the reconstruction of complex upper limb defects 25. Shibata M, Iwabuchi Y, Kubota S, Matsuzaki H. Comparison of free and reversed pedicled posterior interosseous cutaneous flaps. Plast Reconstr Surg 1997 ;99:791–802.

26. Costa H, Comba S, Martins A, Rodrigues J, Reis J, Amarante J. Further experience with the posterior interosseous flap. Br J Plast Surg 1991;44:449–55.

27. Angrigiani C, Grilli D, Dominikow D, Zancolli EA. Posterior interosseous reverse forearm flap: experience with 80 consecutive cases.

Plast Reconstr Surg 1993;92:285–93.

28. Akinci M, Ay S, Kamiloglu S, Erçetin O. The reverse posterior interosseous flap: A solution for flap necrosis based on a review of 87 cases.

J Plast Reconstr Aesthet Surg 2006;59:148–52.

29. Akdag O, Yildiran G, Sutcu M, Karameşe M. Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects. Ulus Travma Acil Cerrahi Derg 2018;24:43–8.

30. Sonmez E, Aksam E, Durgun M, Karaaslan O. Venous super-drained posterior interosseous artery flap for dorsal hand defects. Microsurgery 2018;38:876–81.

31. Nikkhah D, Pickford M. Techniques to enable identification and safe elevation of the posterior interosseous artery flap. J Plast Reconstr Aesthet Surg 2018;71:1816–34.

32. Lu L-j, Gong X, Lu X-m, Wang KL. The reverse posterior interosseous flap and its composite flap: Experience with 201 flaps. J Plast Reconstr Aesthet Surg 2007;60:876–82.

33. Zaidenberg EE, Farias-Cisneros E, Pastrana MJ, Zaidenberg CR. Extended Posterior Interosseous Artery Flap: Anatomical and Clinical Study. J Hand Surg Am 2017;42:182–9.

34. Neuwirth M, Hubmer M, Koch H. The posterior interosseous artery flap: clinical results with special emphasis on donor site morbidity. J Plast Reconstr Aesthet Surg 2013;66:623–8.

35. Coban YK, Gumus N, Cetinus E. Triangular design and V-Y closure of donor site of posterior interosseous artery flap. Plast Reconstr Surg.

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36. Jakubietz RG, Bernuth S, Schmidt K, Meffert RH, Jakubietz MG. The Fascia-Only Reverse Posterior Interosseous Artery Flap. J Hand Surg Am 2019;44:249.e1–9.e5.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Karmaşık üst uzuv defektlerinde ‘posterior interosseöz flebin’ çok yönlü kullanımı Dr. Ensar Zafer Barın,1 Dr. Hakan Çinal,1 Dr. Murat Kara,2 Dr. Mehmet Akif Çakmak,1 Dr. Önder Tan,1 1 2

Atatürk Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Erzurum Bölge Eğitim ve Araştırma Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Kliniği, Erzurum

AMAÇ: Üst ekstremitenin kompleks anatomik ve fonksiyonel yapısı, bu bölgeye ait kompleks defektlerin onarımının rekonstrüktif cerrahlar için zor bir işlem olmasına neden olmaktadır. Bu rekonstrüksiyonda kompozit dokuları içeren lokal ve bölgesel flep seçenekleri kısıtlıdır. Bu çalışmadaki amaç; posteriyor interosseöz flebinin (PİO) klinik pratikte çok yönlü kullanılabilirliğini vurgulamak ve kompleks üst ekstremite defektlerinde iyi bir seçenek olduğunu belirtmektir.

GEREÇ VE YÖNTEM: Çalışmada üst ekstremite defekti mevcut 18'i erkek, 7'si kadın toplam 25 hastaya, 26 PİO flebi uygulandı. Başlıca etyolojik faktörler, yanık kontraktürü, trafik kazası, ateşli silah yaralanması ve akut yanık yaralanması idi. 22 flep fasyokutanöz kaldırılrken, 4 flep osteofasyokutanöz şekilde kaldırılarak metakarp defektlerine uygulandı. Pediküllü transfer edilen 25 flebin, 23'ü ters, 2'si ise düz akımlı idi. Bir flep ise serbest flep olarak transfer edildi.

BULGULAR: Ortalama takip süresi 14 ay idi. Parsiyel nekroz ve sekonder iyileşme ile düzelen 1 flep hariç geri kalan fleplerin tamamı bütünüyle sorunsuz iyileşti. Tüm hastalar geç postoperatif dönemde günlük işlerini sürdürebilecek temel fonksiyonları kazandılar. Hastalar ve/veya anne babaları postoperatif fonksiyonel ve estetik gelişimden memnun kaldılar.

TARTIŞMA: PIO flebinin birçok avantajı, üst ekstremite kompleks defektlerinde kullanılabilir olmasını sağlamaktadır. Akım yönünün değiştirilebilirliği ve içeriğinin zenginleştirilebilmesi sayesinde çok yönlü olarak kullanılabilir.

Anahtar sözcükler: Flep; el; kompleks defekt; posteriyor interosseöz; üst ekstremite.

Ulus Travma Acil Cerrahi Derg 2019;25(6):597-602

602

doi: 10.14744/tjtes.2019.54889

Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

ORIG I N A L A R T IC L E

Atypical femoral fractures related to bisphosphonate use: A comprehensive review of 19 patients Koray Şahin, M.D.,

Ömer Naci Ergin, M.D.,

Serkan Bayram, M.D.,

Turgut Akgül, M.D.

Department of Orthopedics and Traumatology, Istanbul University Istanbul Medical Faculty, Istanbul-Turkey

ABSTRACT BACKGROUND: Atypical femur fracture is a rare complication of bisphosphonate treatment, which is widely used for the prevention of osteoporotic fractures. This study aims to report clinical and radiological features and outcomes of surgically treated atypical femur fractures related to bisphosphonates.

METHODS: We retrospectively reviewed patients with the diagnosis of atypical femur fracture who were under bisphosphonate treatment and who were surgically treated in our clinic between January 2009 and December 2017. Patients who met the atypical femur fracture criteria defined by the American Society for Bone and Mineral Research were included in this study. Radiological features of the fractures, bisphosphonate treatment and duration, prodromal clinical and radiological findings were evaluated. Outcome measures included perioperative results, clinical and radiological outcomes and mobilization status.

RESULTS: In this study, 19 patients were enrolled. Mean age of the patients was 69.6 years (range: 60.8-85.1) and the mean follow-up was 33.8 months (range: 13-104). Mean bisphosphonate use duration was 8.65 years (range: 3-18). Four patients had bilateral fractures.

Eight of 23 fractures were subtrochanteric and 15 were diaphyseal. Twenty-one fractures were treated with an intramedullary nail, one fracture with a locked compression plate and one fracture with cephalomedullary nail. Union was observed in 15 fractures within the first six months. There was a delayed union in four fractures and non-union in four fractures. Mean union time was 5.1 months (range: 2-9). While seven patients preserved their preoperative mobilization status, 12 patients showed regression after the fracture.

CONCLUSION: This study suggests that atypical femur fractures may have prodromal signs and that their management is complex due to high complication and nonunion rates.

Keywords: Bisphosphonates; femur fracture; fragility fracture; hip fracture; osteoporosis; stress fracture.

INTRODUCTION Osteoporosis is a chronic and progressive pathology that causes impairment of bone formation, leading to the deterioration of the bone structure and may result in fractures.[1] As the incidence of osteoporosis increases due to prolonged life expectancy, the prevention of osteoporosis-related fractures has become an important problem for the physicians.

Bisphosphonates (BP) are the most preferred drugs in this field today. BPs, which are antiresorptive agents, provide this effect by decreasing bone turnover and increasing bone mineral density.[2–4] However, studies have shown that long-term use of BPs may result in atypical femur fractures (AFF).[5–7]

The definition of an AFF suggested by the American Society for Bone and Mineral Research (ASBMR) task force in 2010 was revised in 2013. According to this, AFFs were defined as fractures located in femoral diaphysis between the distal part of the lesser trochanter and the proximal part of the supracondylar region and that meet at least four of the five major criteria (Table 1).[8] Radiologically, it can be seen that these fractures start from the lateral cortex and have transverse oblique orientation may cause spike formation in the medial cortex, or cortical thickening and periosteal reaction.[8,9] Although previous studies have reported that AFFs are associated with high complication, delayed union, and high revision

Cite this article as: Şahin K, Ergin ÖN, Bayram S, Akgül T. Atypical femoral fractures related to bisphosphonate use: A comprehensive review of 19 patients. Ulus Travma Acil Cerrahi Derg 2019;25:603-610.

Address for correspondence: Koray Şahin, M.D. İstanbul Üniversitesi İstanbul Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 414 20 00 E-mail: sahinkoray1989@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(6):603-610 DOI: 10.14744/tjtes.2019.46595 Submitted: 03.03.2019 Accepted: 02.06.2019 Online: 28.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Şahin et al. Atypical femoral fractures related to bisphosphonate use: A comprehensive review of 19 patients

surgery rates[10, 11] because of their rarity, the number of comprehensive studies on BP related AFF in the literature is limited and information on the outcome of these fractures is insufficient, which remained under-researched. The present study aims to report the radiological and clinical outcomes of the patients who were operated with the diagnosis of BP related AFF.

MATERIALS AND METHODS Between January 2009 and December 2017, the patients who were operated in our clinic with the diagnosis of AFF in the subtrochanteric or diaphyseal region were retrospectively reviewed. Patients who had at least four of the criteria defined by ASBMR and who had a history of BP use were included in this study.[8] (Table 1) Tumor-related pathological fractures and fractures that did not meet the criteria were excluded from this study. Demographic data of the patients, type of BP used and treatment duration, radiological features of fractures, duration of hospitalization, and union time of fractures and mobilization status of patients were evaluated.

Institutional review board approval was obtained before the formation of this study.

Preoperative clinical evaluation of patients, comorbidities and drug use that affect bone metabolism were noted. The patients who had prodromal pain were identified. The BP used by the patients and its duration and the changes in their medications after fracture treatment were noted. In perioperative clinical evaluation, complications, such as wound problem, infection, intraoperative fracture development, pulmonary embolism, anesthesia-related conditions and duration of hospitalization, were determined. The implant used for surgical treatment was also noted for each patient.

The mobilization of the patients was divided into five separate categories: mobilized without aid, mobilized with a sin-

gle crutch, mobilized with double crutches, mobilized with a walker and immobilized. Pre-fracture and the last follow-up mobilization status were noted for each patient. Radiological evaluation of the patients was performed with X-rays of first admission, postoperative 1st day and postoperative 1st, 2nd, 4th, 6th, 12th, 24th month X-rays. All evaluations were performed on both anteroposterior (AP) and lateral radiographs. The fractures located in the area up to 5 cm distal to the lesser trochanter were evaluated as subtrochanteric fractures and the fractures in the region extending from this point to the supracondylar area were evaluated as diaphyseal.

All patients had x-rays of the contralateral side at the time of admission and the presence of radiological findings, such as cortical thickening and periosteal reaction, were noted on these radiographs. The fractures extending up to the medial cortex were defined as complete, non-extending fractures were defined as incomplete fractures. Union was defined as the formation of bridge callus in at least three cortices in postoperative AP and lateral X-rays. Absence of radiological signs of the union until postoperative 6th month and postoperative 1st year were defined as delayed union and non-union, respectively. All radiological evaluations were performed by the first author, and then, the consistency of the measurements was confirmed by the other authors.

RESULTS In this study, 19 female patients who had 23 AFFs were included. The mean age of the patients was 69.6 years (range: 60.8-85.1). Four patients had bilateral fractures. In three of these four patients, bilateral fractures were detected at the time of admission and both femurs were treated at the same session. One of them was operated for a new fracture on the contralateral femur four years after the first fracture. Of the 15 patients with unilateral fractures, six patients had right femur fracture and nine patients had left femur fracture. The

Table 1. ASBMR Task Force 2013 revised case definition of AFFs The fracture must be located along the femoral diaphysis from just distal to the lesser trochanter to just proximal to the supracondylar flare Major features

Minor features

Associated with no trauma or minimal trauma, as in a fall from a

Generalized increase in cortical thickness of the femoral diaphysis

standing height or less The fracture line originates at the lateral cortex and is substantially

Unilateral or bilateral prodromal symptoms such as dull or aching

transverse in its orientation, although it may become oblique as it

pain in the groin or thigh

progresses medially across the femur.

Complete fractures extend through both cortices and may be

Bilateral incomplete or complete femoral diaphysis fracture

associated with a medial spike; incomplete fractures involve only the lateral cortex The fracture is noncomminuted or minimally comminuted

Delayed fracture healing

Localized periosteal or endosteal thickening of the lateral cortex is present at the fracture site (“beaking” or “flaring”)

604

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Şahin et al. Atypical femoral fractures related to bisphosphonate use: A comprehensive review of 19 patients

mean body mass index (BMI) of the patients was 27.40 (range: 20.28-34.13). The mean follow-up duration was 33.8 months (range: 13-104). The mean hospital stay was 11.6 days (range: 6-21 days) (Table 2).

(a)

(b)

(c)

(d)

Seven out of 19 patients had a comorbidity (hypothyroidism, rheumatoid arthritis, Hashimoto’s thyroiditis), which could affect bone metabolism. In the medical records of three patients, the use of drugs (corticosteroids), which could adversely affect bone metabolism, was noted. The anamnesis of the patients revealed that 12 patients had prodromal symptoms, such as thigh, groin, or hip pain before the fracture (Table 2).

In the radiographs of the patients, eight of 23 fractures were subtrochanteric and 15 were diaphyseal. Of the four patients with bilateral fractures, two had bilateral subtrochanteric and the other two patients had bilateral diaphyseal fractures (Fig. 1, 2). Five of 23 fractures were incomplete (three diaphyseal, two subtrochanteric) and 18 of them were complete fractures. At the time of presentation, four patients had radiographic findings, such as cortical thickening and periosteal reaction on the contralateral side (Fig. 3).

The mean duration of BP treatment before fracture was 8,65 years (range: 3-18). Zoledronate (ZOL) was used in three patients. Alendronate (ALE) was used in 13 patients and ibandronate (IBA) was used in three patients. BP treatment was continued in four patients and discontinued in 15 patients af-

Figure 1. Admission radiograph of a patient with a subtrochanteric transverse atypical femur fracture on the left femur (a). Early postoperative radiograph showing fixation with an intramedullary nail. A peri-operative lateral cortex fracture in the subtrochanteric region can be seen (b). Post-operative 4th month anteroposterior and lateral radiographs show a complete union (c, d).

Table 2. Demographic data and clinical features of the patients Patient no

Age

Fracture

Body mass

Hospitalization

Prodromal

Metabolic

Corticosteroids

(years)

side

index

duration (days)

symptom

disorder

use

1

76,0 Left 22.06

11

-

-

-

2

66.5 Left 34.13

10

+

-

-

3

66.1 Bilateral 27.43

12

-

-

-

4

74.8 Left 31.11

6

+

-

-

5

60.8 Bilateral 26.57

6

61.9 Left 27.76

7 8

+

Hypothyroidism

-

12

+

Hypothyroidism

-

70.0 Right 27.37

9

-

-

-

77.4 Left 26.21

14

-

-

-

9

63.7 Right 31.57

12

+

Hypothyroidism

-

10

69.1 Left 33.29

15

-

-

-

11

80.1 Left 29.90

19

+

-

-

12

75.9 Right 34.37

21

+

Hypothyroidism

-

13

85.1 Right 29.24

8

+

-

-

14

76.4

14

-

15

69.0 Left 23.12

7

-

16

69.8

6

+

17

69.6 Left 26.17

7

+

18

62.4

12

+

19

68.6 Bilateral 20.28

11

+

Right Right Bilateral

24.44 30.91 24.97

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Hashimoto’s thyroiditis - Rheumatoid arthritis - Rheumatoid arthritis -

+ + + -

605

Ĺ&#x17E;ahin et al. Atypical femoral fractures related to bisphosphonate use: A comprehensive review of 19 patients

(a)

(d)

(b)

(c)

(a)

(b)

(e)

Figure 3. Admission anteroposterior (a) and lateral (b) left femur radiographs of a patient showing cortical thickening in the diaphyseal region, which can be considered as a radiological sign of a stress reaction.

Figure 2. Admission radiograph of a patient with a diaphyseal atypical femur fracture of the right femur. A spike formation can be seen in the medial cortex (a). Early postoperative anteroposterior and lateral radiographs showing fixation with an intramedullary nail (b, c). Post-operative 4th month anteroposterior and lateral radiographs show a complete union (d, e).

ter a fracture. In the postoperative period, teriparatide (TPT) treatment was started on one patient due to nonunion and 10 patients started to have calcium (CA) and vitamin D (D3) supplementation (Table 3).

Before the fracture, only two patients were mobilized with a single crutch and the other patients did not need any support. In the post-operative period, seven patients needed a single crutch and five patients needed walkers. While seven patients preserved their preoperative mobilization status, 12 patients showed regression after fracture (Table 3).

In this study, 21 of the 23 fractures were treated with intramedullary nail (IMN), one fracture with a locked compression plate (LCP), and one fracture with cephalomedullary nail (CMN) (Table 3). Fifteen fractures were observed to unite in the first six months. Delayed union was observed in four fractures with complete union achieved after six months postoperatively. No signs of the union were detected in four fractures until the end of the follow-up period of this study and considered as nonunion. The mean union time of the fractures was 5.1 months (range: 2-9) (Table 3).

Two of the four non-united fractures belonged to a patient with bilateral subtrochanteric fractures. The patient had 606

undergone IMN operation on the left femur and LCP operation on the right femur and died on postoperative 13th month due to congestive heart failure and pneumonia. Two other fractures with nonunion were seen in a patient with bilateral diaphyseal fractures. IMN was applied bilaterally to this patient. The patient had a perioperative subtrochanteric femur fracture on the left side and had an infection that was followed-up with serial debridement. On the right side, implant failure and femoral neck fracture had developed due to a fall and the patient was treated with a long-stemmed total hip arthroplasty on postoperative 15th month (Fig. 4). One patient who was treated with IMN surgery had implant failure on 9th month and underwent revision surgery. In another patient who had undergone an IMN operation, cemented total hip arthroplasty was applied on the postoperative 4th year when a collum femoris fracture developed. However, the patient died on the 3rd postoperative day due to pulmonary embolism. In addition, two patients who had undergone IMN had perioperative lateral cortical propagation of the index fractures and two patients had irritation around the area of the distal locking screws. In another patient with IMN, acute renal failure developed in the early postoperative period, which healed without a need for dialysis (Table 3).

DISCUSSION Although BP-related AFF is a frequent subject of studies, there is a lack of prospective studies with high cohort numbers on this subject in the literature because of its rarity.

Therefore, a clear-cut causality relationship between BP use Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

Şahin et al. Atypical femoral fractures related to bisphosphonate use: A comprehensive review of 19 patients

Table 3. Union status and duration, bisphosphonates used and treatment duration, used implants and complications Patient no Union Radiological union

time (months) (years)

Used BP and

Osteoporosis

Used implant

Complication

treatment duration treatment after the fracture

1

+

3

ZOL / 5

D3

IMN

-

2

+

5

ZOL / 15

ZOL

IMN

Implant failure on 9th

month, revision surgery

3 R/L

-/-

-/-

ALE / 6

-

LCP/IMN

-

4

+

2

İBA / 10

-

IMN

-

5 R/L

+

4/6

ALE / 3

ALE

IMN/IMN

-

6

+

6

ALE / 10

CA + D3

IMN

-

7

+

3

ALE / 4

-

IMN

Collum femoris fracture on

4th year. Revision surgery

(Cemented total hip

arthroplasty). Pulmonary

embolism and death.

8

+

5

ALE / 6

CA + D3

IMN

Perioperative fracture

9

+

5

ALE / 10

D3

IMN

-

10

+

3

ALE / 6

CA + D3

IMN

Perioperative fracture

11

+

6

İBA / 6

-

IMN

-

12

+

9

ALE / 7

CA+D3

CMN

-

13

+

6

ALE / 5

-

IMN

Postoperative acute

14

+

4

ALE / 15

ALE

IMN

15

+

3

ALE / 17

16

+

9

17

+

8

18 R/L

+

7/4

-/-

locking screw

IMN

-

ALE / 7

-

IMN

-

ALE / 4

D3

IMN

-

İBA / 9

D3

IMN/IMN

Skin irritation of distal

-/-

Skin irritation of distal

ALE

19 R/L

kidney failure

ZOL / 18

CA + D3 + TPT

IMN/IMN

locking screw in the right femur Implant failure and collum

femoris fracture of the

right femur. Revision surgery

(total hip arthroplasty).

Perioperative fracture and

infection in the left femur.

BP: bisphosphonate; R: right; L: left; ZOL: zoledronate; ALE: alendronate; IBA: ibandronate; IMN: intramedullary nail; LCP: locked compression plate; CMN: cephalomedullary nail.

and AFFs has not been established yet. However, the risk of AFF is higher in the population using BP and the risk is increased in direct proportion to the duration of use.[8,12] The ASBMR task force states that the risk of development of AFF in BP users with a duration of fewer than five years is reported to be 3.2-50 per 100000 cases per year, although this risk has been shown to increase with longer use.[8] AFFs are thought to be stress fractures or insufficiency fractures. It is Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

normally expected that the micro-fracture regions formed as a result of recurrent loading in the femoral cortex will be resorbed by osteoclasts in normal individuals and then repaired. However, by the suppression of osteoclasts by BP, resorption is not possible in these micro-fracture areas, and as a result of suppressed bone turn-over and remodeling, these micro-fractures are thought to accumulate and spread to cause AFFs.[6–8,13,14] 607

Şahin et al. Atypical femoral fractures related to bisphosphonate use: A comprehensive review of 19 patients

a metabolic disorder (hypothyroidism, rheumatoid arthritis, Hashimoto’s thyroiditis). Three of these patients were under corticosteroid therapy.

(a)

As stated by ASBMR, AFFs can be seen bilaterally.[8] Even if it is not bilateral, the risk of developing AFF in the contralateral side should be known. Therefore, the contralateral femurs of all patients should be examined from the time of the first admission. In radiological imaging, even if no complete fracture is seen, stress reactions that may be considered as the precursors of fracture can be detected and preventive measures can be taken. Of the 19 patients in our study, four (21%) patients had bilateral fractures. In three of these four patients, bilateral fractures were present at the first admission and in one of the patients, a fracture developed on the contralateral side during follow-up. Excluding three patients with bilateral fractures on admission, four of the remaining 16 patients (25%) had radiological findings, such as cortical thickening and periosteal reaction on the contralateral side in X-rays. The findings in other studies also support our results. In one study, 40% of the patients with AFF have been reported to have radiological signs of stress reaction on the contralateral side.[17] In another study, this rate was 59% in the pre-fracture radiographs of the contralateral femurs.[10]

(b)

(c)

(d)

Figure 4. Pelvis (a) and right femur (b) radiographs of a patient who was treated with intramedullary nail because of bilateral atypical femur fracture. A femoral neck fracture is seen in the right hip.

The patient was treated with nail removal and long-stemmed total hip arthroplasty (c). Left femur radiographs of the same patient show a nonunion in the diaphyseal region (d).

BP-associated AFFs usually arise from minimal or no trauma.

In the majority of cases, thigh, hip or groin pain is present for some time before fracture.[8] In a study that retrospectively evaluated 12 BP-related AFFs, nine patients (75%) were reported to have prodromal pain symptoms.[15] In another multicenter retrospective study, it was reported that 34% of the patients had previously reported prodromal pain on the fracture site.[10] In our study, 12 of 19 of the patients (63%) had prodromal pain, consistent with the rates reported in the literature.

Although it is still controversial, there are some opinions that metabolic disorders and corticosteroids facilitate the development of AFF in BP users.[7,10] In a study published by Phillips et al.,[15] six out of 12 patients (50%) with BP-related AFF had a metabolic disorder (polymyalgia, rheumatica, hypothyroidism, nephritic syndrome), and two of these six patients were under corticosteroid treatment. In another case series, 25% of the patients were reported to have a metabolic disorder (rheumatoid arthritis, Addison’s disease) and corticosteroid use.[16] In our series, 36% (7/19) of the patients had 608

IMN is the recommended treatment method for AFFs in many studies. IMN is biomechanically superior in the treatment of AFF because it provides a better load distribution compared to osteosynthesis with plate-screw and causes less bending movement in the fracture area.[18] Besides, there are some opinions that IMN is more advantageous in a biological sense, as well.[19] The authors base this view on the biological basis of fracture healing. BPs do not prevent callus formation; they inhibit osteoclasts and suppress remodelling of callus to bone tissue.[20,21] Therefore, the use of BPs is thought to adversely affect bone healing in platescrew osteosynthesis in which primary bone healing is observed. Regardless of the surgical technique used, there are studies reporting that BP-related AFFs have a high rate of nonunion, delayed union, and these fractures are associated with higher complication and revision surgery rates than typical femoral fractures.[7,8,10,15,22–24] In a retrospective study, the mean union time was reported to be 24 weeks and the authors stated that union time reached up to 56 weeks for some patients.[15] In another study, it was reported that 46% of the patients with AFF who were treated with IMN had additional interventions due to lack of union.[24] The findings in our study are consistent with these results. In 23 fractures, nonunion was observed in four (17%) and delayed union was observed in four (17%) and the mean union time was 5.1 months. 17% of the fractures (4/23) required revision surgery or debridement due to various complications (collum femoris fracture, implant failure, infection). In 22% of the fractures (5/23), minor complications not requiring further interventions (intraoperative fracture, locking screw irritation) developed.

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Although they increase the risk of AFF, BPs are the preferred drugs for fracture prevention in osteoporosis. Edward et al.[25] reported that the benefits of BPs were 100 times greater than AFF development risk. In the studies, it was shown that the risk of AFF is directly proportional to the duration of BP use and the risk decreases with the cessation of treatment.

[12,26] BP treatment is a low-risk and advantageous treatment in the initial years in correctly selected patients. However, it is reported that BP treatment may increase the risk of AFF without additional benefit on the prevention of osteoporotic fractures with prolonged treatments.[27] In conclusion, AFFs may develop due to prolonged use of BPs and they are prone to high complication, nonunion, delayed union and revision surgery rates. The important point is to keep patients taking BPs under close and cooperated follow up by an endocrinologist and orthopedist to take advantage of this treatment while avoiding the risk of AFF. The retrospective nature of the presented study and the evaluation of a small group of patients constitute the weak aspects of this study, as in the majority of the studies on this subject in the literature. It is, therefore, difficult to conclude a cause-effect relationship. However, due to the comprehensive evaluation of the patients both clinically and radiologically, we believe that this study makes an important contribution to the current literature on the rarely seen AFF. Conflict of interest: None declared.

REFERENCES 1. Consensus A. Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med 1993;94:646–50.

2. Bone HG, Hosking D, Devogelaer JP, Tucci JR, Emkey RD, Tonino RP, et al. Ten years’ experience with alendronate for osteoporosis in postmenopausal women. N Eng J Med 2004;350:1189–99.

3. Hochberg MC, Greenspan S, Wasnich RD, Miller P, Thompson DE, Ross PD. Changes in Bone Density and Turnover Explain the Reductions in Incidence of Nonvertebral Fractures that Occur during Treatment with Antiresorptive Agents. J Clin Endocrinol Metab 2002;87:1586–92.

4. Wasnich RD, Miller PD. Antifracture efficacy of antiresorptive agents are related to changes in bone density. J Clin Endocrinol Metab 2000;85:231–6.

5. Saleh A, Hegde VV, Potty AG, Lane JM. Bisphosphonate therapy and atypical fractures. The Orthop Clin North Am 2013;44:137–51.

6. Gedmintas L, Solomon DH, Kim SC. Bisphosphonates and risk of subtrochanteric, femoral shaft, and atypical femur fracture: a systematic review and meta-analysis. J Bone Miner Res 2013;28:1729–37.

7. Starr J, Tay YKD, Shane E. Current Understanding of Epidemiology, Pathophysiology, and Management of Atypical Femur Fractures. Current osteoporosis reports. Curr Osteoporos Rep 2018;16:519–29.

8. Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, et al. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. Journal of bone and mineral research. J Bone Miner Res 2014;29:1–23.

9. Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG. Low-

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energy femoral shaft fractures associated with alendronate use. J Orthop Trauma 2008;22:346–50.

10. Bogdan Y, Tornetta P, 3rd, Einhorn TA, Guy P, Leveille L, Robinson J, et al. Healing Time and Complications in Operatively Treated Atypical Femur Fractures Associated With Bisphosphonate Use: A Multicenter Retrospective Cohort. J Orthop Trauma 2016;30:177–81.

11. Prasarn ML, Ahn J, Helfet DL, Lane JM, Lorich DG. Bisphosphonateassociated femur fractures have high complication rates with operative fixation. Clin Orthop Relat Res 2012;470:2295–301.

12. Schilcher J, Koeppen V, Aspenberg P, Michaelsson K. Risk of atypical femoral fracture during and after bisphosphonate use. Acta Orthop 2015;86:100–7.

13. Allen MR, Iwata K, Phipps R, Burr DB. Alterations in canine vertebral bone turnover, microdamage accumulation, and biomechanical properties following 1-year treatment with clinical treatment doses of risedronate or alendronate. Bone 2006;39:872–9.

14. Mashiba T, Hirano T, Turner CH, Forwood MR, Johnston CC, Burr DB. Suppressed bone turnover by bisphosphonates increases microdamage accumulation and reduces some biomechanical properties in dog rib.

J Bone Miner Res 2000;15:613–20.

15. Phillips HK, Harrison SJ, Akrawi H, Sidhom SA. Retrospective review of patients with atypical bisphosphonate related proximal femoral fractures. Injury 2017;48:1159–64.

16. Bhadada SK, Sridhar S, Muthukrishnan J, Mithal A, Sharma DC, Bhansali A, et al. Predictors of atypical femoral fractures during long term bisphosphonate therapy: a case series & review of literature. Indian J Med Res 2014;140:46–54.

17. Lo JC, Huang SY, Lee GA, Khandelwal S, Provus J, Ettinger B, et al.

Clinical correlates of atypical femoral fracture. Bone 2012;51:181–4.

18. Giannoudis PV, Ahmad MA, Mineo GV, Tosounidis TI, Calori GM, Kanakaris NK. Subtrochanteric fracture non-unions with implant failure managed with the “Diamond” concept. Injury 2013;44:S76–81.

19. Koh A, Guerado E, Giannoudis PV. Atypical femoral fractures related to bisphosphonate treatment: issues and controversies related to their surgical management. Bone Joint J 2017;99:295–302.

20. Amanat N, Brown R, Bilston LE, Little DG. A single systemic dose of pamidronate improves bone mineral content and accelerates restoration of strength in a rat model of fracture repair. J Orthop Res 2005;23:1029– 34.

21. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 2002;84:1093–110.

22. Thompson RN, Phillips JR, McCauley SH, Elliott JR, Moran CG. Atypical femoral fractures and bisphosphonate treatment: experience in two large United Kingdom teaching hospitals. J Bone Joint Surg Br 2012;94:385–90.

23. Meling T, Nawab A, Harboe K, Fosse L. Atypical femoral fractures in elderly women: a fracture registry-based cohort study. Bone Joint J 2014;96:1035–40.

24. Weil YA, Rivkin G, Safran O, Liebergall M, Foldes AJ. The outcome of surgically treated femur fractures associated with long-term bisphosphonate use. J Ttrauma 2011;71:186–90.

25. Edwards BJ, Bunta AD, Lane J, Odvina C, Rao DS, Raisch DW, et al. Bisphosphonates and nonhealing femoral fractures: analysis of the FDA Adverse Event Reporting System (FAERS) and international safety efforts: a systematic review from the Research on Adverse Drug Events And Reports (RADAR) project. J Bone Joint Surg Am 2013;95:297–307.

26. Dell RM, Adams AL, Greene DF, Funahashi TT, Silverman SL, Eisemon EO, et al. Incidence of atypical nontraumatic diaphyseal fractures of the femur. J Bone Miner Res 2012;27:2544–50.

27. Whitaker M, Guo J, Kehoe T, Benson G. Bisphosphonates for osteoporosis--where do we go from here? N Engl J Meda 2012;366:2048–51.

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ORİJİNAL ÇALIŞMA - ÖZET

Bifosfonat kullanımı ile ilişkili atipik femur kırıkları: 19 hastanın kapsamlı değerlendirmesi Dr. Koray Şahin, Dr. Ömer Naci Ergin, Dr. Serkan Bayram, Dr. Turgut Akgül İstanbul Üniversitesi İstanbul Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul

AMAÇ: Bifosfonatlar osteoporozlu hastalarda kırık gelişimini önlemek için sıklıkla kullanılan ilaçlardır. Ancak bifosfonat kullanımı nadiren de olsa atipik femur kırıklarına yol açabilir. Sunulan çalışma cerrahi olarak tedavi edilen bifosfonatla ilişkili atipik femur kırıklarının klinik ve radyolojik özellikleri ile tedavi sonuçlarını sunmayı amaçlamaktadır.

GEREÇ VE YÖNTEM: Kliniğimizde Ocak 2009 ile Aralık 2017 tarihleri arasında atipik femur kırığı tanısıyla ameliyat edilmiş olan ve bifosfonat kullanma öyküsü olan hastalar geriye dönük olarak incelendi. Çalışmaya Amerikan Kemik ve Mineral Araştırma Topluluğu (American Society for Bone and Mineral Research) tarafınca tanımlanmış olan atipik femur kırığı kriterlerini karşılayan hastalar dahil edildi. Dahil edilen hastaların kırıklarının radyolojik özellikleri, kullanılan bifosfonat ve kullanım süresi, prodromal klinik ve radyolojik bulguların varlığı değerlendirildi. Tedavi sonrası sonuç değerlendirmesi ise klinik değerlendirme, radyolojik kaynama durumu ve mobilizasyon durumuna göre gerçekleştirildi.

BULGULAR: Çalışmaya 19 hasta dahil edildi. Hastaların ortalama yaşı 69.6 yıl (aralık: 60.8-85.1) ve ortalama takip süresi 33.8 yıldı (aralık: 13-104).

Ortalama bifosfonat kullanım süresi 8.65 yıl (aralık: 3-18) yıl olarak bulundu. 4 hastada bilateral kırık mevcuttu. Çalışmada incelenen 23 kırıktan 8 tanesi subtrokanterik, 15 tanesi ise diafizer yerleşimliydi. 21 kırık intramedüller çivi ile, 1 kırık kilitli kompresyon plağı ile ve 1 kırık da proksimal femur çivisi ile tedavi edilmişti. 15 kırıkta ilk 6 ay içinde kaynama gözlendi. 4 kırıkta kaynama gecikmesi ve 4 kırıkta kaynamama tespit edildi. Ortalama kaynama süresi 5.1 ay (aralık: 2-9) olarak bulundu. Toplam 7 hastanın operasyon sonrasında preoperatif mobilizasyon durumunu koruğu gözlenirken 12 hastanın mobilizasyon durumunda kırık sonrasında gerileme olduğu görüldü.

TARTIŞMA: Bu çalışmanın bulguları atipik femur kırıklarının prodromal bulguları olabileceğini ve bu kırıkların yüksek komplikasyon ve kaynamama oranları ile ilişkili olduğunu göstermektedir.

Anahtar sözcükler: Bifosfonat; femur kırığı; osteoporoz, kalça kırığı; stres kırığı; yetmezlik kırığı.

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ORIG I N A L A R T IC L E

Comparison of surgical techniques and results for emergency or elective femoral hernia repair Enver Kunduz, M.D.,1 İsmail Cem Sormaz, M.D.,2 Yunus Yapalak, M.D.,1 Hüseyin Kazım Bektaşoğlu, M.D.,1 Ali Fuat Kaan Gök, M.D.2 1

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

2

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

ABSTRACT BACKGROUND: Inguinal hernia affects 3–8% of the population. Femoral hernias are only a small number of groin hernias; however, femoral hernias are very important because these operations are generally emergency procedures, and bowel resections are frequently necessary. This study aims to compare surgical outcomes of patients with femoral hernias using different techniques under emergency or elective conditions.

METHODS: Between April 2013 and November 2017, 52 patients with femoral hernias were admitted to the emergency department of the General Surgery Clinics at two university hospitals in Istanbul. The medical files of all the patients who underwent surgery with a diagnosis of a femoral hernia were retrospectively evaluated. The demographic data, hernia side information, sac contents, surgical technique, length of hospital stay, recurrence according to the last outpatient clinic and complications were retrospectively analyzed.

RESULTS: The sex distribution of the cases was as follows: 88.5% (n=46) of the patients were female, and 11.5% (n=6) were male.

The mean age was 62.9±16.49 years (31–91 years). There were no significant differences between the two groups, according to the hernia side (p=0.282). Thirteen of the elective cases (52%) were operated using open techniques, and 12 cases (48%) were operated using laparoscopic techniques.

CONCLUSION: For the comparison of surgical techniques and outcomes, prospective randomized studies should be designed to standardize broad-based surgical techniques.

Keywords: Emergency surgery; femoral hernia; laparoscopy.

INTRODUCTION Inguinal hernia affects 3–8% of the population.[1,2] Femoral hernias constitute 2–4% of all inguinal hernias.[3–5] Approximately 20 million inguinal hernia surgeries per year are carried out worldwide.[6–8] Inguinal hernia repair surgeries have been performed for many years, and many techniques have been introduced. Femoral hernias are only a small number of inguinal hernias; however, femoral hernias are very important because these operations are generally emergency procedures and bowel resections are frequently necessary.[7,8] Emergency surgeries have been reported to increase postop-

erative morbidity, but elective femoral hernia surgery does not increase morbidity, even in elderly patients.[5,9] The possibility of recurrence after femoral hernia repair is higher than that of inguinal hernia repair.[3,5] McVay repair is recommended for an emergency operation with femoral hernia incarceration before the use of synthetic patches.[10] However, repair with sutures is more likely to cause recurrence than repair with a synthetic patch.[5] Although complication rates have been reported to be over 50% in patients with intestinal resection,[10] synthetic patches are recommended for resection and anastomosis.[5,10–13] The present study aims

Cite this article as: Kunduz E, Sormaz İC, Yapalak Y, Bektaşoğlu HK, Gök AFK. Comparison of surgical techniques and results for emergency or elective femoral hernia repair. Ulus Travma Acil Cerrahi Derg 2019;25:611-615.

Address for correspondence: Enver Kunduz, M.D. Adres bilgisi: Bezmialem Hastanesi, 4. Kat, Genel Cerrahi Sekreterliği, Vatan Caddesi, Fatih, 34093 İstanbul, Turkey.

Tel: +90 212 - 453 17 00 E-mail: drkunduz@yahoo.com Ulus Travma Acil Cerrahi Derg 2019;25(6):611-615 DOI: 10.14744/tjtes.2019.04524 Submitted: 02.01.2019 Accepted: 11.02.2019 Online: 15.02.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Kunduz et al. Comparison of surgical technique and results for emergency or elective femoral hernia repair

to evaluate and compare surgical outcomes of femoral hernia cases using different techniques under emergency or elective conditions.

MATERIALS AND METHODS Between April 2013 and November 2017, 52 patients with femoral hernias were admitted to the emergency department of the General Surgery Clinics at two university hospitals in Istanbul, Turkey. The medical files of all the patients who underwent surgery with a diagnosis of femoral hernia were retrospectively evaluated. Emergency surgery patients were defined as Group 1, and elective surgery patients were defined as Group 2. The demographic data, hernia side information, sac contents, surgical technique, length of hospital stay, recurrence according to the last outpatient clinic and complications were retrospectively analyzed. Patients who had previously undergone inguinal hernia repair and/or were operated on for recurrence were excluded from this study.

Paracetamol 4x500 mg IV and narcotic analgesics (pethidine hydrochloride 4x0.5 mg/kg) were administered as pain relievers for 24 hours postoperatively in patients who were operated under elective conditions or operated under urgent conditions but without intestinal contents. Oral 4x500 mg paracetamol was administered postoperatively for at least one week. Oral fluid intake was started six hours postoperatively.

All patients with tolerance were started on a regular diet.

were performed before the operation. Lichtenstein repair was performed after the inguinal ligament was opened, and the femoral canal was visualized and turned into the groin.

Other techniques, such as synthetic patch repair (Rutkow Plug) and laparoscopic TAPP (transabdominal preperitoneal), were performed. If the intestinal segment was strangulated in the hernia pouch and ischaemia or necrosis had occurred, segmental bowel resection and functional end-to-end anastomosis were carried out.

RESULTS The sex distribution of the cases was as follows: 88.5% (n=46) of the patients were female, and 11.5% (n=6) were male. The mean age was 62.9±16.49 years (31–91 years). The number of patients was 27 and 25 in Groups 1 and 2, respectively.

There were no statistically significant differences between the two groups, according to sex, and Group 1 patients were significantly older than Group two patients (p=0.67, p=0.013). There were no significant differences between the two groups, according to the hernia side (p=0.282). Thirteen of the elective cases (52%) were operated using open techniques, and 12 cases (48%) were operated using laparoscopic techniques. In only one of the emergency cases, the operation was started laparoscopically, but due to insufficient exploration, the surgery was converted to an open technique (Table 1).

In patients undergoing emergency surgery and bowel reduction and resection anastomosis, oral feeding was started after 24 hours and followed up for at least three days in the hospital.

In Group 1, 16 patients (59.3%) had a strangulated small intestinal segment in the hernia sac, and 11 (40.7%) patients had a strangulated omentum majus in the hernia sac. In Group 2, 14 (56%) patients had no organs found in the hernia sac, and 11 (44%) patients had omentum in the hernia sac (p<0.001).

Statistical analyses were performed using the Windows SSPS 16.0 (SPSS, Chicago, IL, USA) program. The results are given as means and standard deviations. Comparisons of the groups were made with chi-squared and Mann-Whitney U tests.

Values of p<0.05 were considered statistically significant.

In Group 1, in 12 patients (85%), intestinal resection was not performed due to normalization of colour and circulation during perioperative wait and check, but four patients (15%) underwent segmental small bowel resection and functional end-to-end anastomosis.

Surgical Techniques All of the patients were informed about the surgical technique and anaesthesia before the surgery, and their consent forms were obtained. Thromboembolism and antibiotic prophylaxis

Fifteen (55%) of the patients in Group 1 underwent a modified Lichtenstein technique, and 12 patients (45%) underwent a Rutkow Plug. In two patients, small intestinal ischaemia was diagnosed, and midline laparotomy and segmental intestinal

Table 1. Findings of the emergency surgery patients in Group 1 and elective surgery patients in Group 2

Gender (male:female) Mean age in years (range) Laterality (left/right)

612

Group 1 (n=27)

Group 2 (n=25)

p

23:4

23:2

0.667

68±15.8

57.1±15.5

0.013

8:19

11:14

0.282

Average hospital stay (days)

2.8±3.4

1.08±0.26

<0.001

Follow-up average duration

16.6±16.3 months

11.76±13.73 months

=0.234

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Kunduz et al. Comparison of surgical technique and results for emergency or elective femoral hernia repair

DISCUSSION

Table 2. Distribution of surgical techniques Group Modified Rutkow Laparoscopic

Lichtenstein (n=19) TAPP

(n=19) (n=12) Group 1

15

12

0

Group 2

6

7

12

TAPP: Transabdominal preperitoneal.

Table 3. Complications ethiology Complication ethiology

Group 1 Group 2 (n=27) (n=25)

Groin hernias consist of inguinal and femoral hernias. The incidence of inguinal hernias in the United States is estimated to be between 5 and 10%, with only 4% of these being femoral hernias.[14] Although inguinal hernias are seen more frequently in all abdominal hernias (such as femoral, umbilical, and epigastric), femoral hernias also have a higher complication rate.[15] In addition, approximately 40% of femoral hernia patients are admitted to emergency departments due to incarceration or strangulation.[16,17] This study included patients who underwent emergency or elective surgery in two separate university hospitals. Over half of these patients were operated under emergency conditions, and the others were electively operated.

Seroma 4 In previous studies, the incidence of femoral hernia in women

and the need for emergency surgery were found to be significantly higher than in men.[1,5,18] Therefore, it may be considIleus 1 ered that elderly women have smaller inguinal and femoral Anastomotic leakage 1 channels than male patients. According to the Swedish hernia Pulmonary complications 1 registry, the incidence of emergency hernia repair in female Port side hernia 1 patients is 17% (53% of femoral hernias), compared with 5% Total 7 (26%) 2 (8%) (7% of femoral hernias) in male patients. In our study, the majority of women were operated on for femoral hernia according to emergency and elective operations, and there were resection with functional end-to-end anastomosis were perno significant differences between the groups concerning the formed. The other two segmental small bowel resections female/male ratio (p=0.67). All patients in Group 1 referred were performed at the groin incision after cutting the inguinal to emergency services with an irreducible hernia, and all inligament. Of the patients in Group 2, six patients (24%) uncluded small bowel or omentum majus. derwent the Lichtenstein technique, seven patients (28%) underwent a Rutkow Plug, and the remaining 12 patients In emergency femoral hernia operations, abdominal organ (48%) underwent the laparoscopic TAPP technique. The disincarcerations are found higher in sac contents than in electribution of the surgical techniques according to the groups is tive hernia operations. As a result, the rate of small bowel summarized in Table 2. resection increases, the length of hospital stay is prolonged, and the mortality rate may increase up to 10 times.[19] Early Only one groin recurrence was detected (2%). The patient diagnosis and appropriate surgical technique reduce the comwho underwent emergency modified Lichtenstein repair was plication rate.[20] re-operated with laparoscopic TAPP 1 year later. In one case (2%), a port site hernia developed after the laparoscopic reIn our study, in 59.3% of the patients in Group 1, strangulated pair. small bowel segments were found in the hernia sac. Only four patients (15%) had a segmental intestinal resection. Suppiah Postoperative complications were seen in 10 patients in this et al.[21] examined 75 femoral hernia surgeries and found the case series. Anastomotic leakage was detected after small rate of a segmental intestinal resection anastomosis to be bowel resection. The patient underwent re-operation, and 57.1% (16/28) in patients who were operated on under emera loop ileostomy was performed. One patient with aspiragency conditions. In a study conducted by Calik et al.,[22] orth tion pneumonia in Group 1 died on the 10 day in the intengan resection was shown to be a factor increasing morbidity sive care unit. Postoperative ileus occurred in one patient in during femoral hernia surgery. In this study, anastomotic leakGroup 1. There were no significant differences between the age occurred in only one patient, and a loop ileostomy was groups according to complications. Complications are sumperformed. The patient had a longer hospital stay because of marized in Table 3. this situation. One patient with femoral hernia had aspiration pneumonia because of vomiting as a result of incarceration.

The hospital stay was statistically longer for patients in Group This patient died on the 10th day in the intensive care unit.

1 than in Group 2 (p<0.001). The mean follow-up period was 16.6Âą16.3 months in emergency cases and 11.76Âą13.73 Patients were operated on using three techniques: modified months in the elective conditions (p=0.234).

Lichtenstein, Rutkow plug and Laparoscopic TAPP. Repairs of Wound infection

1

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femoral hernias with sutures bring about more recurrence than repairs with synthetic patches.[5,10] In our series, all patients were treated with a synthetic patch repair. The Rutkow plug technique was completed for 19 patients, and this technique provides untensioned repair[23] and is the main surgical technique in some series in the literature.[22,24] Recurrence was detected in one patient (2%) after the modified Lichtenstein technique. This patient was operated on under emergency conditions and then underwent repair with laparoscopic TAPP after one year. Twelve elective surgery patients (48%) underwent laparoscopic TAPP. During emergency surgery, the laparoscopic technique was preferred in only one patient but underwent open surgery because of inadequate exploration, and a Rutkow plug was performed. In a patient who was operated on using the laparoscopic technique, a port site hernia developed at 8 months postoperatively and was repaired with a patch. No other early or late complications were encountered. The laparoscopic technique is similar to open techniques using patches, whereas it is superior to repair with only sutures.[15] Although minimally invasive surgery is favourable, laparoscopy is not the preferred method in our clinics for cases of emergency surgery.

It has been reported that patients operated on in emergency conditions return for check-ups less frequently in the postoperative period than in elective conditions.[20] In our study, the patients in both groups returned for their check-ups over an average of one year, and there were no significant differences between the groups.

The most important limitation of our study is that our study is a retrospective, non-randomized study. Despite being a multi-centre study, the number of patients seems inadequate.

Thus, further research with a large number of patients can provide valuable insights.

Conclusion Although incarceration and consequential intestinal ischaemia may be riskier and more complicated to operate on under emergency conditions, there were no significant differences in our study.[5,9] It is suggested in the literature that early diagnosis of femoral hernias and elective surgery should be performed as soon as possible.[5,22] As a result, femoral hernias should be diagnosed early, and incarceration should be performed early.

Although there were no significant differences between the groups in our study, the complication rate was more frequent and more serious in elderly patients in the emergency group.

This study recommends that femoral hernias be diagnosed at an earlier age and operated under elective conditions. Thus, better surgical outcomes could be obtained.

A laparoscopic approach, such as TAPP, is recommended for femoral hernia operations for both emergency and elective 614

procedures. Laparoscopy would apply control of ischaemia in strangulated bowel segments and enable hernia repair.

This study suggests early diagnosis and surgical intervention for femoral hernia and is similar to previous studies. The contribution of this study to the literature is the encouraging laparoscopic approach for both elective and emergency femoral hernia operations.

For the comparison of surgical techniques and outcomes, prospective randomized studies should be designed to standardize broad-based surgical techniques. It was difficult for us to obtain clear and healthy results because our work is retrospective and because of the small number of patients.

Conflict of interest: None declared.

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2. Çetinkaya Z, Ayten R, Coşkun S. Kasık Fıtıklarında Etyopatogenez ve Sınıflandırma. J Surg Med Sci 2006;2:15–20.

3. Glassow F. Femoral hernia. Review of 2,105 repairs in a 17 year period.

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4. Bay-Nielsen M, Kehlet H, Strand L, Malmstrøm J, Andersen FH, Wara P, et al. Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet 2001;358:1124–8.

5. Dahlstrand U, Wollert S, Nordin P, Sandblom G, Gunnarsson U. Emergency femoral hernia repair: a study based on a national register. Ann Surg 2009;249:672–6.

6. Kingsnorth A. Treating inguinal hernias. BMJ 2004;328:59–60 .

7. Kulah B, Kulacoglu IH, Oruc MT, Duzgun AP, Moran M, Ozmen MM, et al. Presentation and outcome of incarcerated external hernias in adults.

Am J Surg 2001;181:101–4.

8. Kurt N, Oncel M, Ozkan Z, Bingul S. Risk and outcome of bowel resection in patients with incarcerated groin hernias: retrospective study.

World J Surg 2003;27:741–3.

9. Nilsson H, Stylianidis G, Haapamäki M, Nilsson E, Nordin P. Mortality after groin hernia surgery. Ann Surg 2007;245:656–60.

10. Cakir M, Savas OA, Tuzun S, Tatar C. Preperitoneal Mesh Placement with Anterior Approach in Incarcerated Femoral Hernia (Our Experiences with 23 Cases). Haseki Tıp Bülteni 2015;53:196–8.

11. Sawayama H, Kanemitsu K, Okuma T, Inoue K, Yamamoto K, Baba H. Safety of polypropylene mesh for incarcerated groin and obturator hernias: a retrospective study of 110 patients. Hernia 2014;18:399–406.

12. Atila K, Guler S, Inal A, Sokmen S, Karademir S, Bora S.Prosthetic repair of acutely incarcerated groin hernias: a prospective clinical observational cohort study. Langenbecks Arch Surg 2010;395:563–8.

13. Emir S, Sözen S, Yazar FM, Özkan Z, Çetinkünar S, Özdaş S. İnkarsere inguinal herni onarımında yama kullanımının güvenilirlik ve etkinliği: Bir klinik çalışma. Kafkas J Med Sci 2012;2:15–20.

14. Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am 1993;73:413–26.

15. Dabbas N, Adams K, Pearson K, Royle G. Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep. 2011;2:5.

16. McIntosh A, Hutchinson A, Roberts A, Withers H. Evidence-based

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Kunduz et al. Comparison of surgical technique and results for emergency or elective femoral hernia repair management of groin hernia in primary care--a systematic review. Fam Pract 2000;17:442–7.

tial for prevention of emergency surgery for femoral hernia. World J Surg 2014;38:1931–6.

17. Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults in the US population. Am J Epidemiol 2007;165:1154–61.

21. Suppiah A, Gatt M, Barandiaran J, Heng MS, Perry EP. Outcomes of emergency and elective femoral hernia surgery in four district general hospitals: a 4-year study. Hernia 2007;11:509–12.

18. Rutkow IM. A selective history of groin hernia surgery in the early 19th century. The anatomic atlases of Astley Cooper, Franz Hesselbach, Antonio Scarpa, and Jules-Germain Cloquet. Surg Clin North Am 1998;78:921–40.

19. Brittenden J, Heys SD, Eremin O. Femoral hernia: mortality and morbidity following elective and emergency surgery.J R Coll Surg Edinb 1991;36:86–8.

20. Dahlstrand U, Sandblom G, Wollert S, Gunnarsson U. Limited poten-

22. Calik B, Karaman K, Atci R, Cetindag O, Ugurlu L, Aydin C, et al. Visceral organ resection during femoral hernia surgery is a predictor of morbidity. Int Surg 2015;100:455–60.

23. Swarnkar K, Hopper N, Nelson M, Feroz A, Stephenson BM. Sutureless mesh-plug femoral hernioplasty. Am J Surg 2003;186:201–2.

24. Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg 1991;78:1171–3.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Acil veya elektif uygulanmış femoral herni tamirinin cerrahi tekniği ve sonuçlarının karşılaştırılması Dr. Enver Kunduz,1 Dr. İsmail Cem Sormaz,2 Dr. Yunus Yapalak,1 Dr. Hüseyin Kazım Bektaşoğlu,1 Dr. Ali Fuat Kaan Gök2 1 2

Bezmialem Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul İstanbul Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul

AMAÇ: Kasık fıtığı popülasyonun %3–8’ini etkiler. Femoral herniler nadiren görülmekle birlikte genellikle acil cerrahi müdehale gerektirir ve sıklıkla bağırsak rezeksiyonu gerekebilmektedir. Bu çalışmanın amacı, acil veya efektif koşullar altında farklı teknikler kullanarak femoral herni olgularının cerrahi sonuçlarını karşılaştırmaktır.

GEREÇ VE YÖNTEM: Nisan 2013 ile Kasım 2017 arasında, İstanbul’daki iki üniversite hastanesinin genel cerrahi kliniklerinin acil servisine 52 femoral herni olgusu başvurdu. Femoral herni tanısı ile ameliyat edilen tüm hastaların tıbbi dosyaları geriye dönük olarak incelendi. Demografik veriler, taraf bilgisi, kesenin içeriği, cerrahi teknik, hastanede kalış süresi, son polikliniğe göre rekürrens ve komplikasyonlar geriye dönük olarak incelendi.

BULGULAR: Olguların cinsiyet dağılımı %88.5 (n=46) idi, kadın %11.5 (n=6) idi. Ortalama yaş 62.9±16.49 yıl (31–91 yıl) idi. İki grup arasında fıtık tarafına göre anlamlı fark yoktu (p=0.282). Elektif olguların 13’ü (%52) açık teknikle, 12’si (%48) laparoskopik teknikle ameliyat edildi.

TARTIŞMA: Cerrahi tekniklerin ve sonuçların karşılaştırılması için, geniş tabanlı cerrahi teknikleri standart hale getirmek için ileriye yönelik randomize çalışmalar tasarlanmalıdır.

Anahtar sözcükler: Acil cerrahi; femoral herni; laparoskopi.

Ulus Travma Acil Cerrahi Derg 2019;25(6):611-615

doi: 10.14744/tjtes.2019.04524

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ORIG I N A L A R T IC L E

Comparison of methods for closure of appendix stump during laparoscopic appendectomy using endoloops: Single surgeon experience Yahya Çelik, M.D.,

Ozan Andaç Erbil, M.D.,

Department of General Surgery, Gebze Fatih State Hospital, Kocaeli-Turkey

ABSTRACT BACKGROUND: In this study, using single or double endoloops, with reference to the literature, we aimed to retrospectively assess the results for patients in our clinic who underwent a laparoscopic appendectomy.

METHODS: This study included 251 patients who were operated on by a single surgeon; 137 of the patients were male (54.6%) and 114 were female (45.4%). Patients were divided into two groups based on the type of endoloop procedure that was used. Group 1 included 107 patients for whom a single endoloop was used. Group II included 144 patients for whom double endoloop was used.

Age, sex, duration of operation, length of hospital stay, pathological findings, perioperative appendix findings, perioperative abdominal findings, post-operative complications requiring hospitalization and wound infections were assessed for each patient. Patients were also assessed statistically for complications.

RESULTS: There were no significant differences in the demographic characteristics, perioperative surgery findings, pathological findings or duration of hospital stays between the two groups of the patients. However, the duration of operation was shorter in Group I (54.9±16.1 min) as compared to Group II (61.2±18.8 min). The incidence of complications requiring rehospitalization was statistically significantly lower in Group I (1.9%; n=2) as compared to Group II (9%; n=13) (p=0.018). There were no complications requiring reoperation for patients in Group I. In Group II, four patients (2.8%) required re-operation; however, this difference was not statistically significant. Concerning wound infection, there was also no significant difference between Group I (7.5% n=8) and Group II (4.9% n=7).

CONCLUSION: Using a double endoloop does not decrease the risk of post-operative complications, but it does increase the cost and the duration of the operation. We have concluded that using a single endoloop in a laparoscopic appendectomy may be more appropriate.

Keywords: Appendix; closure of stump; endoloop; laparoscopic appendectomy.

INTRODUCTION Acute appendicitis is the most prevalent acute abdominal disease and the gold standard of treatment is surgical excision.[1] The laparoscopic appendectomy method was first published in the literature by Semm in 1983.[2] In addition to open and laparoscopic surgical methods, single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic appendectomy (NOTES) methods were also described for surgical treatment of acute appendicitis.[1,3–5] Clo-

sure of the appendix stump is the most controversial area in the surgical technique because most appendectomy complications are the result of stump leakage. Various methods, such as endostaplers, pre-assembled endoloops or intracorporeal knots, endoclips and Hem-o-lok, were described for laparoscopic appendectomy procedures and are still currently in use.[6–9] In this series, a double endoloop was used for some patients and a single endoloop was used for others.

Cite this article as: Çelik Y, Erbil OA. Comparison of methods for closure of appendix stump during laparoscopic appendectomy using endoloops: Single surgeon experience. Ulus Travma Acil Cerrahi Derg 2019;25:616-621.

Address for correspondence: Yahya Çelik, M.D. Gebze Fatih Devlet Hastanesi, Genel Cerrahi Kliniği, Kocaeli, Turkey Tel: +90 262 - 502 22 37 E-mail: dryahyacelik@mynet.com Ulus Travma Acil Cerrahi Derg 2019;25(6):616-621 DOI: 10.14744/tjtes.2019.63249 Submitted: 21.09.2018 Accepted: 04.02.2019 Online: 30.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

616

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Çelik et al. Comparison of methods for closure of appendix stump during laparoscopic appendectomy using endoloops

However, publications comparing the double endoloop or intracorporeal knot method with a single endoloop or intracorporeal knot method are scarce.[6] In our study, we aimed to retrospectively assess the results for the patients in our clinic who underwent a laparoscopic appendectomy using a single or double endoloop, with reference to the literature.

[10–15]

MATERIALS AND METHODS After obtaining the approval of the local ethics committee, patient charts and computer data were retrospectively assessed. Patients whose operations started laparoscopically but then switched to open surgery and patients in whom endoloop was not used due to cecal necrosis, were excluded from this study. The final series included 251 patients (137 male and 114 female) who had undergone a laparoscopic appendectomy, performed by single-surgeon (general surgeon, Y. Ç.) between July 2014 and July 2018. Endoloop was used in each of these patients, regardless of the perioperative appendix findings (phlegmonous, perforated).

Patients were assessed in concerning age, sex, duration of operation, length of hospital stay, pathological findings, perioperative appendix findings, perioperative abdominal findings, post-operative complications requiring hospitalization and wound infections. They were then divided into two groups according to the use of single or double endoloop techniques. Group I consisted of 107 patients for whom a single endoloop ligature was used. Group II consisted of 144 patients for whom a double endoloop ligature was used.

Demographic characteristics, perioperative surgical findings, pathological findings, post-operative findings and complications were statistically compared between the two groups and assessed with reference to the literature.

Surgery Pre-operative prophylactic cephazolin sodium 1 g was administered to the patients intravenously. Under general anesthesia, pneumoperitoneum was created by inserting a veres needle through the infraumbilical incision, thus enabling the 10 mm trocar to enter the abdomen. Two 5 mm trocars were inserted in the left lower quadrant and suprapubically, under direct vision. The abdomen was explorated with a 10 mm and 30 mm optic and the meso-appendix was separated using LigaSure (Medtronic). For patients in Group II, after the radix of the appendix became visible, the endoloop (Medtronic 0 vicryl) was ligated in a double endoloop, with 3–5 mm space between the ligatures. For patients in Group I, no additional procedure was carried out. The distal end was dissected by closing with the assistance of a dissector (Fig. 1). Optic 5 mm was switched with 18 cm and the appendix was removed through the 10 mm umbilical trocar or with the assistance of an endobag. If present, intraabdominal fluid or pus was Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

Figure 1. Use with single endoloop.

aspirated and then a drain was inserted. For patients with perforation, antimicrobial therapy was administered during the hospital stay and continued until 10 days after discharge.

Antimicrobial therapy was not sustained after prophylactic therapy in non-perforated patients.

Statistical Methods Statistical analysis was conducted using the SPSS version 17.0 program. The conformance of the variables to normal distribution was controlled using histogram graphics and the Kolmogorov-Smirnov test. Mean, standard deviation, median and minimum-maximum values were used for descriptive analysis. The results were compared in 2x2 cells using Pearson Chi-Square and Fisher’s Exact Test. The Mann-Whitney U test was used to assess variables without normal distribution (non-parametric) between groups. Results with a p-value <0.05 were considered statistically significant.

RESULTS The 251 patients in the series included 137 male (54.6%) and 114 female (45.4%) patients. The single endoloop technique was used in the 107 patients assigned to Group I. The double endoloop technique was used for the remaining 144 patients, who were assigned to Group II. The mean age of the patients was 32.2±11.3 years. A comparison of patient age, and duration of operation and hospital stay between the two groups found that the duration of operation was longer in Group II (61.2±18.8 min) compared to Group I (54.9±16.1 min) (p=0.001), but there was no statistically significant difference concerning patient age and length of hospital stay (p>0.05).

When pathological findings were compared for patients in each group, the incidence of acute/phlegmonous appendicitis (62.6%) was found to be higher in patients in Group I than in Group II (49.3%) (p=0.004) (Table 1).

No significant difference was found in a comparison of perioperative appendix findings (p>0.05) (Table 1), pre-operative abdominal findings or drain use (p>0.05) for patients in Group I and Group II. 617

Ă&#x2021;elik et al. Comparison of methods for closure of appendix stump during laparoscopic appendectomy using endoloops

Table 1. Pathological findings. perioperative appendix findings, perioperative appendix findings and incidence of the complications

Group I (Single endo-loop)

n

%

Group II (Double-endoloop) n

p

%

Pathological findings of the patients Appendicitis/phlegmonous

67 62.6 71 49.3 0.004

Perforated

0 0.0 3 2.1

Appendix obliterans

3

2.8

6

4.2

Phlegmonous + lymphoid hyperplasia

31

29.0

41

28.5

Pathology result non-available.

3

2.8

23

16.0

Neuroendocrine tumour

2

1.9

0

0.0

1

0.9

0

0.0

Phlegmonous + lymphoid hyperplasia + enterobius vermicularis Perioperative appendix findings

Peri-operative appendix

Normal

0

0.0

Phlegmonous acute app

80

74.8

1 111

0.7

0.488

77.1

Gangrene

8

7.5

5

3.5

Perforated

19

17.8

26

18.1

Normal

83

77.6

110

76.4

Reaction fluid

8

7.5

17

11.8

Local pus/abscess

11

10.3

14

9.7

Widespread pus/abscess

5

4.7

3

2.1

Drain

26

24.3

31

21.7

0.635

No

105

98.1

131

91.0

0.018

Yes

2

1.9

13

9.0

Subileus

2

1.9

7

4.9

Abdominal pain monitorization

0

0.0

2

1.4

Stump leakage

0

0.0

1

0.7

Trocar site hernia

0

0.0

1

0.7

Intraabdominal abscess

0

0.0

2

1.4

Requiring re-operation

0

0.0

4

2.8

0.082

Wound infection

8

7.5

7

4.9

0.387

Perioperative appendix findings of thepatients and drain use

Peri-operative abdominal 0.479

Incidence of complications requiring rehospitalization, requiring re-operation and wound infection Re-hospitalization

Complication

The incidence of wound infections or complications requiring rehospitalization or re-operation were compared. Patients in Group II required rehospitalization at a significantly higher rate (9%) than patients in Group I (1.9%) (p=0.018). There were no differences in the rate of wound infection and in the number of patients requiring re-operation between the groups (p>0.05) (Table 1).

618

0.212

In patients requiring rehospitalization, the perforated appendicitis rate (30.8%) as a perioperative appendix sign was higher than in patients that did not require rehospitalization (17.6%). The incidence of gangrene for patients requiring rehospitalization (15.4%) was also higher than in patients that did not require rehospitalization (2.3%). In patients requiring rehospitalization, the incidence of normal/phlegmonous Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

0.183 0.4% 1.9% 0.014 48 55 229 Single Endoloop Endostapler [13]

Rakić et al.

104

>0.05

0.357 1.4%

– –

1.6% 0.032

0.01 56

36.4 40.5

62 61

138 Hem-o-log

Endoloop (number non-specified) 65

Single endoloop Lucchi et al.[12]

121

Double intracorporeal knot Bali et al.[16]

3.8% 0.699

–

–

11% 9.6% 0.614

0.185 5.0% 38 40 318 1050 Endostaplaer Rossem et al. Double-endoloop

[11]

4.3%

0 0

4.3% 0.297

0.021 23.2

60 58

21.5 38

465 Single or double endoloop

Endoloop (number non-specified)

Endostapler

38 Endoclips Safavi et al.

Swank et al.[15]

571

5.1% 4.6% – – – 99 Double-endoloop Single endoloop

[14]

Beldi et al.[7]

109

Group II Group I p Group II Group I n Group II n Group I

In the study by Rakić et al.,[13] a comparison of the single proximal endoloop and endostapler techniques found that there were no differences between the two groups concerningperioperative or post-operative complications. The duration of operation, however, was shorter in endoloop patients. In their study comparing single proximal endoloop and Hem-o-lock clips, Lucchi et al.[12] found that patients in both groups experienced a similar length of hospital stay and the rate of infectious complications. Bali et al.[16] compared the use of double intracorporeal knots and endoloops and found that the duration of operation was higher when the intracorporeal knot was used, but there was no difference in the rate of complications.

In the study by Rossem et al.[11] comparing the use of double proximal endoloops and endostaplers, no significant difference was observed between the two groups about duration of operation and infectious complications. In the study by Swank et al.[15] comparing the use of double or single endoloops with endostaplers, no significant difference was found in the rate of post-operative infectious complications. The results reported by other authors are summarized in Table 2.

There were no significant differences between the two groups in our series concerning demographic characteristics, pathological findings, perioperative appendix findings and duration of hospital stay.

Used methods and number

DISCUSSION

In Group I, 2 patients requiring rehospitalization had subileus as a complication. In Group II, 13 patients requiring rehospitalization had the following complications: subileus (n=7), abdominal pain monitorization (n=2), stump leakage (n=1), trocar site hernia (n=1) and intraabdominal abscess (n=2). In Group II, four patients requiring re-operation, the complications were as follows: stump leakage (n=1), trocar site hernia (n=1) and intraabdominal abscess (n=2). Two patients diagnosed with intraabdominal abscess required open drainage.

Incisional hernia surgery was performed on a patient with a trocar site hernia diagnosis. Another patient required reoperation to re-close the appendix stump after a diagnosis of stump leakage. After draining and cleaning the abdomen, a preventive ileostomy was carried out and, three months later, the ileostomy was closed.

Table 2. Duration of operation and complication incidence in studies comparing methods for closure of appendix stump

In patients requiring re-operation, the perforated appendicitis rate (25%) was higher than in patients that did not require re-operation (18.6%). In patients requiring re-operation, the incidence of gangrene was higher (25%) when compared to patients that did not require re-operation (2.9%). In patients requiring re-operation, the rate of normal/phlegmonous acute appendicitis (50%) was lower than in patients that did not require re-operation (78.6%) (p=0.050).

Duration of operation (min)

Complication rate (%)

p

acute appendicitis (53.8%) as a perioperative appendix sign was lower than in patients that did not require rehospitalization (80.2%) (p=0.018).

>0.05

Çelik et al. Comparison of methods for closure of appendix stump during laparoscopic appendectomy using endoloops

619

Çelik et al. Comparison of methods for closure of appendix stump during laparoscopic appendectomy using endoloops

In a study of 208 patients by Beldi et al.,[7] a single endoloop was used in 109 patients, while double endoloop was used in the remaining 99 patients. Post-operative complications occurred in five patients (4.6%) in the single endoloop group and in five patients (5.1%) in the double endoloop group.

Although the rate of complication was lower in the single endoloop group, the difference was not statistically significant.

Repeat studies over a larger series were suggested. In our series, the rate of complications requiring rehospitalization was significantly lower in Group I (n=2, 1.9%) compared to Group II (n=13, 9%). There were no complications requiring re-operation in Group I, but four patients in Group II experienced complications requiring re-operation (two patients had intraabdominal abscesses, one patient had stump leakage and one patient had an incisional hernia). The difference between the two groups, however, was not significant.

In the study by Rossem et al.,[11] necrosis or perforation of the appendicitis was considered complicated appendicitis.

Complicated appendicitis was found to be a risk factor for the development of an intraabdominal abscess. In our series, there was no difference between the two groups about perioperative appendix findings. However, in the whole series, the rate of complicated appendicitis was higher in patients with complications due to surgery, as compared to patients without complications.

In our series, the mean duration of operation was shorter in Group I (54.9±16.1 min) compared to Group II (61.2±18.8 min). We think that the difference may be the result of additional time needed to insert the second loop.

In conclusion, endoloop use is as safe as other methods in laparoscopic appendectomy. Using a double endoloop does not decrease the rate of post-operative complications; however, it increases the cost and duration of the operation. Therefore, we have concluded that using a single endoloop in a laparoscopic appendectomy may be more appropriate.

Conflict of interest: None declared.

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

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3. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010;10:CD001546.

4. Cai Y-L, Xiong X-Z, Wu S-J, Cheng Y, Lu J, Zhang J, et al. Single-incision laparoscopic appendectomy vs conventional laparoscopic appendectomy: systematic review and meta-analysis. World J Gastroenterolo 2013;19:5165–73.

5. Sateesh S, Subraj H, Mahesh G, Rao PS. Comparative analysis between single incision and conventional laparoscopic appendectomy for acute appendicitis. Int J Res Med Sci 2014.2:1626–31.

6. Minutolo V, Licciardello A, Di Stefano B, Arena M, Arena G, Antonacci V. Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-years experience in a district hospital. BMC surgery 2014;14:14.

7. Beldi G, Muggli K, Helbling C, Schlumpf R. Laparoscopic appendectomy using endoloops: a prospective, randomized clinical trial. Surg Endosc 2004;18:749–50.

8. Tate JJ, Chung SC, Li AK. Laparoscopic appendicectomy: a two-handed technique. Br J Surg 1993;80:764.

9. 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.

10. Delibegović S, Matović E. Hem-o-lok plastic clips in securing of the base of the appendix during laparoscopic appendectomy. Surg Endosc 2009;23:2851–4.

11. van Rossem CC, van Geloven AA, Schreinemacher MH, Bemelman WA, snapshot appendicitis collaborative study group. Endoloops or endostapler use in laparoscopic appendectomy for acute uncomplicated and complicated appendicitis. Surg Endosc 2017;31:178–84.

12. Lucchi A, Berti P, Grassia M, Siani LM, Gabbianelli C, Garulli G. Laparoscopic appendectomy: Hem-o-lok versus Endoloop in stump closure. Updates Surg 2017;69:61–5.

13. 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.

14. Sadat-Safavi SA, Nasiri S, Shojaiefard A, Jafari M, Abdehgah AG, Notash AY Jr, et al. Comparison the effect of stump closure by endoclips versus endoloop on the duration of surgery and complications in patients under laparoscopic appendectomy: A randomized clinical trial. J Res Med Sci 2016;21:87.

15. Swank HA, van Rossem CC, van Geloven AA, Kazemier G, Meijerink WJ, Lange JF, et al. Endostapler or endoloops for securing the appendiceal stump in laparoscopic appendectomy: a retrospective cohort study.

Surg Endosc 2014;28:576–83.

16. Bali İ, Karateke F, Özyazıcı S, Kuvvetli A, Oruç C, Menekşe E, et al.

Comparison of intracorporeal knotting and endoloop for stump closure in laparoscopic appendectomy. Ulus Travma Acil Cerrahi Derg 2015;21:446–9.

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Çelik et al. Comparison of methods for closure of appendix stump during laparoscopic appendectomy using endoloops

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Laparoskopik apendektomilerde endoloop ile güdük kapama tekniği karşılaştırılması: Tek hekim deneyimi Dr. Yahya Çelik, Dr. Ozan Andaç Erbil Gebze Fatih Devlet Hastanesi, Genel Cerrahi Kliniği, Kocaeli

AMAÇ: Bu çalışmada kliniğimizde çift ya da tek endoloop kullanılarak laparoskopik apendektomi yapılan hastalarımızın sonuçlarını literatür eşliğinde geriye dönük olarak değerlendirmeyi amaçladık.

GEREÇ VE YÖNTEM: Çalışmaya 137 erkek (%54.6) ve 114 kadın (%45.4) olmak üzere tek cerrah tarafından ameliyat edilen toplam 251 hasta katıldı. Hastaların 107’si tek endoloop yönteminin kullanıldığı grup I, 144’ü çift endoloop yönteminin kullanıldığı grup II idi. Hastaların yaş cinsiyet, ameliyat süresi, hastanede yatma süresi, patoloji bulguları, perioperatif apendiks bulguları, perioperatif batın bulguları, ameliyat sonrası yatış gereken komplikasyonlar, ameliyat sonrası operasyon gereken komplikasyonlar ve yara yeri enfeksiyonuna bakıldı. Komplikasyonlar istatistiksel olarak incelendi.

BULGULAR: Her iki grup arasında demografik özellikler, perioperatif ameliyat bulguları, patoloji bulguları, ameliyat sonrası bulgular ve hastanede yatış süreleri arasında anlamlı fark izlenmedi. Ameliyat süreleri grup I’de (54.9±16,1) grup II’den (61.2±18,8) daha kısa bulundu. Tekrar yatış gerektiren komplikasyonlar grup I’de (%1,9; n=2) grup II’den (%9; n=13) anlamlı olarak az bulundu (p=0.018). Tekrar ameliyat gereken komplikasyon grup I’de olmadı. Grup II’de dört hastada (%2.8) oldu, İstatistiksel olarak anlamlı fark bulunmadı. Yara yeri enfeksiyonu grup I (%7.5 n=8) ile grup II (%4.9 n=7) arasında anlamlı fark izlenmedi.

TARTIŞMA: Çift endoloop kullanmak ameliyat sonrası komlikasyonları azaltmamakla birlikte ameliyat maliyetini artırmakta ve ameliyat süresini uzatmaktadır. Laparoskopik apendektomide loop kullanımında tek loop kullanmanın daha uygun olacağı kanaatindeyiz.

Anahtar sözcükler: Apendisit; endoloop; güdük kapama; laparoskopik apendektomi.

Ulus Travma Acil Cerrahi Derg 2019;25(6):616-621

doi: 10.14744/tjtes.2019.63249

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ORIG I N A L A R T IC L E

Evaluation of the necessity of whole-body scan tomography in cases with head trauma İffet Yaşaran, M.D.,1 Ahmet Sebe, M.D.,2

Ali Karakuş, M.D.,1 Güven Kuvandık, M.D.,1 Zeynep Kekeç, M.D.2

1

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

2

Department of Emergency Medicine, Çukurova University Faculty of Medicine, Adana-Turkey

ABSTRACT BACKGROUND: In our study, we have tried to find out how necessary whole-body computed tomography (WBCT) is to detect other body injuries that may accompany the patients, evaluating head trauma cases with WBCT. METHODS: In our study, we included 198 patients, who were referred to our hospital’s emergency service after head trauma, had brain lesions detected in brain tomography (BT), had no additional examination findings and who underwent WBCT. In this retrospective study, patients’ age, gender, type of lesion in brain CT, Glasgow Coma Scale (GCS) values and WBCT findings were examined.

RESULTS: In this study, 85.4% of the patients were male and the average age was 25.7 years. The most common cranial CT findings were fracture, followed by parenchymal bleeding. 67% of the patients’ GCS were below 8. Additional trauma was detected in 78 of the patients (39.4%). The most common additional lesion was the thoracic contusion. The mean age of the patients with cervical injuries determined in CT was significantly high (p<0.05). Statistical significance was determined between cranial fracture, foreign body incidence and thoracic injuries (p<0.05). The incidence of cervical injuries was significantly higher in patients with brain contusion detected in CT (p<0.05). Fracture frequency and presence of additional lesions in WBCT were significantly high (p<0.05). There was no correlation between other cranial lesions and additional injury areas (p>0.05).

CONCLUSION: The number of studies evaluating WBCT is high in the literature. However, our study is important concerning that to our knowledge this study is the first study to evaluate the WBCT findings in the head trauma cases without the additional lesions on their bodies. WBCT scan should be recommended in patients whose clinical evaluation could not be completed. WBCT is an important diagnostic tool for the diagnosis of many pathologies, especially for intrathoracic lesions.

Keywords: Cranial trauma; emergency department; whole-body CT.

INTRODUCTION Trauma is the most important cause of death among young adults all over the world. Early diagnoses of traumas reduce both mortality and morbidity.[1] In addition to the surgery, direct graphs, ultrasonography (USG) and contrasted-non contrast CTs are used to detect damage to the body. WBCT has been an important diagnostic tool, especially in the evaluation of the cases in the last decade.[2–4] Emergency Depart-

ments are places where anamnesis and physical examination cannot sometimes be clearly assessed. Patients presented with trauma to the hospital cannot be questioned due to reasons, such as unconsciousness, absence of their relatives, communication problems, and a complete physical examination cannot be carried out. Thus, most physicians are prone to missing the injuries associated with head trauma in the emergency department. This leads to an increased mortality and morbidity of head trauma cases. Hence, in our study, we

Cite this article as: Yaşaran İ, Karakuş A, Kuvandık G, Sebe A, Kekeç Z. Evaluation of the necessity of whole-body scan tomography in cases with head trauma. Ulus Travma Acil Cerrahi Derg 2019;25:622-627.

Address for correspondence: Ali Karakuş, M.D. Mustafa Kemal Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, 31100 Hatay, Turkey Tel: +90 326 - 229 10 00 E-mail: drkarakus@yahoo.com Ulus Travma Acil Cerrahi Derg 2019;25(6):622-627 DOI: 10.14744/tjtes.2019.42675 Submitted: 16.05.2018 Accepted: 05.02.2019 Online: 01.11.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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Yaşaran et al. Evaluation of the necessity of whole-body scan tomography in cases with head trauma

tried to determine the necessity of using WBCT to detect pathologies that may accompany head trauma cases.

MATERIALS AND METHODS The present study was carried out retrospectively at the Emergency Medicine Department after being approved by Hatay Mustafa Kemal University Faculty of Medicine ethics committee. This study was conducted in accordance with the latest version of the “Helsinki Declaration” and the “Good Clinical Practice Directive”. Patients who applied to the Emergency Department of our hospital between the dates of 2012–2016 with head trauma and who underwent WBCT were included and 2358 trauma patients applied, and 1206 of these patients had head trauma. It was determined that 567 of the patients with head trauma underwent WBCT. One hundred ninety-eight patients were included in this study. Patients diagnosed with lesion or examination findings in other organ systems, patients with organ injuries determined using USG or CT in our hospital or in another medical center, patients with a known bleeding disorder, and patients with additional trauma in their history were excluded from this study.

Patients’ age, gender, type of lesion in brain CT, GCS status and WBCT findings were evaluated. The data were analyzed in SPSS Windows version 18. Mean, median, standard deviation and frequency values were used in the descriptive statistics of the data. The distribution of the variables was checked us-

ing the Kolmogorov Smirnov Test. Mann-Whitney U test was used for numerical non-parametric data. In the analysis of qualitative data, the Pearson chi-square test and Fisher’s chi-square test were used. P<0.05 was considered statistically significant.

Patient Selection Criteria Nowadays, studies for selecting the WBCT as an indication continue, but the criteria for selecting patients has not been determined. In some trauma centers, patient selection criteria are based on vital parameters, injury mechanisms and clinical suspicion of specific injuries in a three-legged structure. The REACT-2 study is one of them and is a forwardlooking study. The REACT-2 study and the WBCT inclusion criteria are presented in Table 1. Our study is a retrospective study. Patients diagnosed with lesion or examination findings in other organ systems, patients with organ injuries determined using USG or CT in our hospital or in another medical center, patients with a known bleeding disorder, and patients with additional trauma in their history were excluded from the study. Another clinical approach scheme for the determination of WBCT as an indication has been developed (Fig. 1).

RESULTS Of the 198 patients who were included in this study, 169 (85.4%) were male, and 29 (14.6%) were female. The mean age was 25.7±13.8 (1–71). Linear fractures were the most common cranial lesions in patients (Table 2).

Table 1. REACT-2 Study inclusion and exclusion criteria[5] Inclusion criteria

Exclusion

The presence of one of the following parameters during the trauma patient’s

•

Under 18 years old

admission to the hospital

•

Known pregnancy

•

Respiratory rate ≥30/min or ≤10/min

•

Low-energy blunt trauma

•

Pulse ≥120/min

•

Stab wound in a single anatomical area

•

Systolic blood pressure ≤100 mmHg

•

Patients who were assessed as unstable

•

Estimated blood loss greater than ≥500 ml

for computed tomography in their

•

Glasgow Coma Score ≤13

clinical evaluation, patients who had

•

Abnormal pupil reaction or clinical suspicion of the following diagnoses

cardiopulmonary resuscitation or patients at

•

At least two long bone fractures

a high risk of death

•

Flail chest, open chest or multiple rib fractures

•

Severe abdominal injury

•

Pelvic Fracture

•

Unstable vertebral fracture or spinal cord pressure

or patients suffering from one of the following trauma mechanisms •

Fall from higher than 3 meters

•

Thrown from the car

•

Death in the same vehicle

•

Serious injury in the same vehicle

•

Stuck chest or abdomen

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Yaşaran et al. Evaluation of the necessity of whole-body scan tomography in cases with head trauma

(+)

Is patient conscious?

(–)

Any sign of spinal injury?

Fall from less than 1 meter

Second examination CT if necessary

(+)

Review Serial Trauma Graphs

(–)

(–) There is a respiratory dysfunction or there is a positive examination finding

(–) Clinical Findings SBP <100 mmHg/heart rate >100

+2

Respiration >24 breaths/min or Sat <93%

+3

GCS <14

+3

More than 2 affected areas

+2

Score more than 3

Trauma Mechanism Fall from higher than 5 meters

+3

In-car traffic accident

+1

Pedestrian/bicycle injury

+3

(+)

(+) Perform a WBCT

Fall from less than 5 meters

All suspicious areas are CT scanned.

Figure 1. The Manchester Trauma Imaging Protocol.[6]

When GCSs of patients are examined; 132 (66.7%) patients had severe GCS (3–8), 40 (20.2%) patients had moderate GCS (9–12), and 26 (13.1%) patients had mild GCS (13–15).

Additional lesions were detected in WBCT in 74 (37.4%) of the patients. Additional lesions were a thoracic injury in 65 (87.8%), abdominal injury in 17 (23.0%), and cervical injury in three (4.1%) patients (Table 3).

There were no significant relationship between parenchymal bleeding and cervical, thoracic and abdominal injuries (p>0.05).

A significant relationship was detected between patients with contusion and patients with cervical injuries (p<0.05-Pearson chi-square test).

There was no significant relationship between SAB and cervical, thoracic and abdominal injuries (p>0.05).

The mean age of patients with cervical injuries was significantly higher (p<0.05).

There were no statistically significant relationship between epidural bleeding and cervical, thoracic and abdominal injuries (p>0.05).

There was no statistically significant relationship between gender and additional lesions, cervical injury, thoracic injury and abdominal injury (p>0.05).

There were no statistically significant relationship between subdural bleeding and cervical, thoracic and abdominal injuries (p>0.05).

There was a significant correlation between cranial fracture incidence and patients with thoracic injuries (p<0.05).

Table 2. Cranial lesions of patients Lesion

n %

Area

Pathology

n %

Thorax Contusion

52 80

Pneumothorax

6 9.2

Thoracic fracture

4

6.2

Alveolar hemorrhage

3

4.6

Linear fracture

175

Intraparenchymal bleeding

101

51

Hemothorax

1 1.5

Subarachnoid bleeding (SAB)

77

38.9

Abdomen

Free fluid

6

35.3

Foreign body

66

33.3

Broken lumber

6

35.3

Subdural bleeding

59

29.8

Broken pelvis

5

29.4

Cerebral contusion

46

23.2

Solid-organ injury

2

11.8

Epidural bleeding

27

13.6

Cervical Fracture

624

88.4

Table 3. Additional lesion area and detected pathologies

3 100

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Yaşaran et al. Evaluation of the necessity of whole-body scan tomography in cases with head trauma

Table 4. Additional lesion presence in WBCT and

comparison of the lesion in cranial CT

Yes None p (n=74) (n=124)

n % n %

Fracture

60 81.1 115 92.7 0.013

Parenchymal bleeding

35

47.3

66

53.2

0.419

Contusion

19 25.7 27 21.8 0.529

Subarachnoid bleeding

30

40.5

47

37.9

0.713

Epidural

10 13.5 17 13.7 0.969

Subdural

27 36.5 32 25.8 0.112

Foreign body

20

27

46

37.1

0.146

*Pearson’s chi-square test.

Table 5. Comparison of the relationship between GCS score and presence of lesion in WBCT

Mild Moderate Severe p (n=26) (n=40) (n=132)

Yes, n (%)

9 (34.6)

14 (35.0)

51 (38.6)

None, n (%)

17 (64.4)

26 (65.0)

81 (61.4)

0.873

*Pearson’s chi-square test. GCS: Glaskow Coma Scale; WBCT: Whole body computed tomography.

There was a significant correlation between the probability of having thoracic trauma and the patients who had intracranial foreign bodies detected on their CT (p<0.05-Pearson chisquare test).

Patients with low GCS were found to be exposed to less cervical trauma (p<0.05).

While there was no significant relationship between additional lesions and parenchymal bleeding, contusion, (crush the underlying tissues without breaking the skin with the body of the crushing object) SAB, epidural bleeding, subdural bleeding and presence of foreign body (p>0.05), fracture frequency was significantly high (p<0.05) (Table 4).

There was no significant relationship between lesion presence in WBCT and GCS (p>0.05) (Table 5).

DISCUSSION

Trauma is the first cause of mortality in young and healthy patients.[7–10] In literature review, individuals exposed to head trauma appear to be male under 40 years old. Men are 2–3 times more likely to suffer head trauma than women.[11,12] According to the Major Trauma Outcome Study (MTOS), the average age of trauma is 28.9 years and the majority are male (71%). In our study 85.4% of the patients were male and Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

the average age was 25.7 years. The main reason for the low average age of or study may be that penetrant injuries are frequent in the second decade, there is an ongoing war in the region and there is no age restriction in this study.

Studies have shown that as the age increases in patients with trauma, more lesions are detected in WBCT. In many studies, it has been suggested that comorbid conditions may be responsible for this.[13,14] In our study, no association was found between age and the presence of additional trauma in CT. This may be because our patients are younger. The mean age of the patients with cervical injuries determined in CT was significantly high. We think that this may be due to osteoporosis that occurs in bone structures with increasing age.

When patients’ brain CTs are evaluated, it is seen that the most common lesions are in different groups. While most common CT finding was said to be cerebral edema in the study conducted by Çökük et al., in other studies, SAB and fractures were the most common findings.[15] On the other hand, in our study, the most common cranial CT findings were the fracture, followed by parenchymal bleeding. The reason for this may be the combination of penetrating and blast effect in cases of firearm injuries.

New approaches, trauma systems, diagnostic and therapeutic guidelines developed over time provide a reduction in mortality risk.[16,17] Part of this approach predicts the use of laboratory and imaging methods.[18] The precision of the CT in the diagnosis of trauma patients is 98%.[19] Thus, CT is often requested. There is evidence that WBCT scanning detects major injuries that may be missed by selective screening.[20] In a study assessing the effects of WBCT on mortality, the findings showed that patients who underwent WBCT had a lower mortality rate than the patients who had selective tomography.[21] CT is considered to be beneficial because it shortens the duration of treatment, identify incidental findings and lower the hospital expenses.[22] Despite the adverse effects of WBCT on patients concerning emergency service, WBCT is widely used because of the detection of additional lesions in patients, shortening of the follow-up time of emergency service, reduction of radiological cost and decrease of malpractice rate.[22] In a typical WBCT, the average radiation dose was measured as equivalent to 760 chest radiographs or over five years of natural background radiation acquisition.[23] It is suggested that the WBCT should be requested as an emergency necessity after a clinical examination of the emergency room physician.[24] Smith et al.[25] evaluated 400 patients with trauma to emergency room physicians and they detected that while physicians are sensitive about serious injuries, they miss many pathologies in simple traumas and were inadequate in detecting mortal pathologies in patients considered as simple trauma.

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Yaşaran et al. Evaluation of the necessity of whole-body scan tomography in cases with head trauma

In many studies, it has been shown that the percentage of pathology detected in WBCT is more than 50%, but only some of them require intervention.[26] Kroczek et al.,[27] in their study of 2440 multi-trauma patients, stated that in 8.4% of patients who underwent whole-body CT, the lesion requiring urgent intervention was detected, while in 31% of those who underwent WBCT additional lesions were detected.

In our study, additional trauma was detected in 78 patients (39.4%). We believe that the reason for this is could be that while blast-induced injuries cause mild external lesions, they cause serious damage to internal organs. It may also be due to anamnesis and inadequate physical examination.

There are differences between the most common additional pathological areas and their rates in WBCT of patients with head trauma. The incidence of the trauma of other systems ranges from 15 to 44%.[28,29] In many studies, it has been stated that in patients who underwent WBCT, the most common finding was in the abdominal and thoracic areas, and the least common lesion was in the cervical area.[11,24,27] In their study of 443 patients, Sabzghabaei et al.[30] found that the incidence of thoracic trauma detected in WBCT was significantly higher compared to selective CT. In our study, the most common additional lesion was thoracic. The reason for this may be because mild and moderate pulmonary contusions are not detected with an examination in cases with head trauma, and even mild traumas lead to contusion.

To our knowledge, there are not any studies in the literature evaluating head trauma subtype and WBCT findings. In our study, there were significant results between cranial fracture, foreign body frequency and thoracic injuries. In our study, the incidence of cervical injury was significantly higher in patients who had contusion in CT. There was no correlation between other cranial lesions and additional injury area.

Conclusion The number of studies evaluating WBCT is high in the literature. However, our study is important because to our knowledge this study is the first study to evaluate the WBCT findings in the head trauma cases without the additional lesions on the body. WBCT scan should be recommended in patients whose clinical evaluation could not be completed.

WBCT is an important diagnostic tool for the diagnosis of many pathologies, especially for intrathoracic lesions.

Conflict of interest: None declared.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Kafa travmalı olgularda tüm vücut tarama tomografisinin gerekliliğinin değerlendirilmesi Dr. İffet Yaşaran,1 Dr. Ali Karakuş,1 Dr. Güven Kuvandık,1 Dr. Ahmet Sebe,2 Dr. Zeynep Kekeç2 1 2

Mustafa Kemal Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Hatay Çukurova Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Adana

AMAÇ: Bu çalışmada, kafa travmalı olguların tüm vücut bilgisayarlı tomografi (TVBT) ile değerlendirilip, hastalarda eşlik edebilecek diğer vücut yaralanmalarının tespiti için TVBT’nin ne kadar gerekli olduğu ortaya konmaya çalışıldı.

GEREÇ VE YÖNTEM: Çalışmamıza 2012–2016 tarihleri arasında hastanemiz acil servisine kafa travması sonrasında başvurmuş, beyin tomografisinde (BT) lezyon saptanmış, ek muayene bulgusu olmayan ve TVBT çekilmiş 198 hasta alındı. Geriye dönük olarak yapılan çalışmada hastaların yaş, cinsiyet, beyin BT’deki lezyonun tipi, Glaskow Koma Skalası (GKS) değerleri ve TVBT bulguları incelendi.

BULGULAR: Hastaların %85.4’ü erkek olup, yaş ortalaması 25.7 yıldı. En sık saptanan kraniyal BT bulgusu kırık, takiben parankimal kanamaydı.

Hastaların %67’sinin GKS’si 8’in altındaydı. Hastaların 78’inde (%39.4) ek travma saptandı. En sık saptanan ek lezyon toraksta kontüzyondu. BT’de belirlenen servikal yaralanması olan hastaların yaş ortancaları anlamlı olarak yüksekti (p<0.05). Kraniyal kırık ve yabancı cisim sıklığı ile toraks yaralanması arasında anlamlılık tespit edildi (p<0.05). Beyin BT’de kontüzyon saptanan hastalarda servikal yaralanma sıklığı anlamlı olarak yüksekti (p<0.05). TVBT’de ek lezyon varlığı ile kırık sıklığı anlamlı olarak yüksekti (p<0.05). Diğer kraniyal lezyonlar ve ek yaralanma bölgesi arasında ilişki saptanmadı (p>0.05).

TARTIŞMA: Literatürde TVBT’lerin değerlendirildiği çalışma sayısı çoktur. Ancak, çalışmamız kafa travması olan ve vücudunda ek lezyon olmayıp TVBT’deki bulguların değerlendirildiği ilk çalışmadır. Klinik değerlendirilmesi tam yapılamayan hastalarda TVBT çekimi önerilmelidir. TVBT başta toraks içi lezyonlar olmak üzere, birçok patolojinin tanısında önemli bir tanı aracıdır.

Anahtar sözcükler: Acil servis; kraniyal travma; tüm vücut bilgisayarlı tomografi.

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CA S E REP OR T

Small bowel prolapse from anus: Atypical presentation of rectal perforation Sezer Akbulut, M.D., Mehmet Abdussamet Bozkurt, M.D., Hamit Ahmet Kabuli, M.D., Mehmet Emin Güneş, M.D. Department of General Surgery, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul-Turkey

ABSTRACT Non-traumatic rectum perforation is rarely seen if there is no underlying tumor formation. The perforations in the middle and lower parts of the rectum that are under the peritoneal reflex are asymptomatic unless there is intraabdominal infection or inflammation.

In this study, we aim to present a patient who referred to the emergency surgery clinic with the small bowel prolapse from the anus.

Keywords: Rectal perforation; small bowel prolapse.

INTRODUCTION Non-traumatic rectum perforation is rarely seen if there is no underlying tumor formation. In patients with rectal prolapse, prolapse of the rectum from anus and repetition of the reduction process may lead to thinning of the rectal wall and perforation. The perforations in the middle and lower parts of the rectum that are under the peritoneal reflex are asymptomatic unless there is intraabdominal infection or inflammation, which causes the perforations occurring in this region to come up with life-threatening late-stage pelvic sepsis or pelvic abscesses. In this study, we sought to present the patient who referred to the emergency surgery clinic with the small bowel prolapse from the anus.

CASE REPORT A 75-year-old female patient with known rectal prolapse applied to the Emergency Surgery Clinic with the statement that intestines were going out from her anus. The patient had rectal prolapse for three years; had gone out of the breach during the interim, and had taken it in by hand, but had not received any treatment because of prolapse. The body mass index was 25. There was no other feature in her story. The

patient’s abdominal examination revealed no features; anal exploration revealed that the small intestine was prolapsed (Fig. 1a). The small intestines were prolapsed with the mesos.

At the presentation, the WBC was 15,200 Hb and was 14.9.

An abdominal CT scan was performed to investigate whether there was an additional pathology associated with the present condition. BT showed that rectum and other intestinal parts were herniated to posterior from the anal channel, and edema of the herniated intestinal walls was detected.

An emergency operation was planned with rectal perforation preliminary diagnosis without trying reduction. The perforation area about 6–7 cm was seen on the anterior wall of the rectum (Fig. 1b), starting immediately from the pelvic reflex and extending to the proximal. It was observed that the small bowel entered the perforation area, and it was prolapsed from the anus. After the reduction of the small intestines, the rectum was closed from the distal to the perforation area. Because the patient had multiple abscesses within the abdomen, the primary repair was not performed, and anterior resection was carried out by transecting the colon 10 cm proximal to the perforation border. The anastomosis was considered very risky due to the present abscesses, and a colostomy was performed.

Cite this article as: Akbulut S, Bozkurt MA, Kabuli HA, Güneş ME. Small bowel prolapse from anus: Atypical presentation of rectal perforation.

Ulus Travma Acil Cerrahi Derg 2019;25:628-630.

Address for correspondence: Mehmet Abdussamet Bozkurt, M.D. Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey Tel: +90 212 - 414 71 59 E-mail: msametbozkurt@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(6):628-630 DOI: 10.5505/tjtes.2019.40149 Submitted: 04.07.2018 Accepted: 06.12.2018 Online: 30.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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(a)

(b)

Figure 1. (a) Preoperative on the emergency. (b) Perforation on rectum.

The patient was followed up in the service postoperatively. In the service follow-ups, the patient, who discharged gas and gaita from the stoma on the 2nd day after the surgery, was started to have oral intake. The patient was discharged on the 7th day after the operation.

The pathologic examination of the part of the colon, which was perforated, showed signs of congestion, chronic inflammation and formation of focal granular tissue, reactive epithelial changes and tissue defects. No significant finding was observed in the follow-ups of the patient.

DISCUSSION Discussions about rectal prolapse treatment algorithms are ongoing. However, as in our case, perforation secondary to rectal prolapses, together with small bowel herniation is not available in the literature. To our knowledge, in the literature, the only case in which the superficial herniation of the small intestine is observed is the result of the rectal injury that has occurred during the digitalization due to constipation.

[1–3] There is no guideline on the treatment approach to the disease. The operation in this study was planned in a relatively short time so that the patient was primarily prevented from fecal contamination due to rectum perforation. In the planned operation, primarily life-threatening rectal perforation was controlled.

The thinning of the prolapse and the reductive segment of the intestinal wall due to chronic trauma required resection to prevent another perforation that might occur in this segment. During the closure of the stoma with the removal of the prolapsed segment, it is planned that only the rectopexy operation should be sufficient.[4] As presented in our case, if prolonged prolapse herniates, it brings on thinning and perforation in the wall of the segment being reduced. This situation is emphasized as an important complication of prolonged prolapse in the literature.[5,6] Ulus Travma Acil Cerrahi Derg, November 2019, Vol. 25, No. 6

Although anastomotic repair is recommended in rectum perforation, the stoma is the preferred choice in patients with multiple abscesses as well as in our patients.

In a previously published case report, mortality due to spontaneous rectum perforation was 100% in patients with a low condition, previously untreated, or delayed onset of treatment. In the same study, mortality was 46% when only saturation was performed. When saturation was accompanied by colostomy, mortality was 23%. There was no mortality in two Hartman patients.[1] As a result, in the perforation of the rectum due to prolapse, our findings suggest that the perforation area should be intervened first, and the segment causing the pathology should be removed. Functional integrity should be considered after these steps.

Conflict of interest: None declared.

REFERENCES 1. Al-Abkari HA. Spontaneous rupture of the rectum with evisceration of omentum through the anus: a case report and review of the literature.

Ann Saudi Med 2000;20:246–7.

2. Bhat S, Azad TP, Kaur M. Spontaneous perforation of rectum with evisceration of small bowel simulating intussusception. N Am J Med Sci 2010;2:596–7.

3. Martínez Pérez A, Torres Sánchez MT, Richart Aznar JM, Martí Martínez EM, Martínez-Abad M. Transanal evisceration caused by rectal laceration. Ann Coloproctol. 2014;30:47–9.

4. Morris AM, Setty SP, Standage BA, Hansen PD. Acute transanal evisceration of the small bowel: report of a case and review of the literature.

Dis Colon Rectum 2003;46:1280–3.

5. Furuya Y, Yasuhara H, Naka S, Yamazaki K, Yanagie H, Wakahara T, et al. Intestinal evisceration through the anus caused by fragile rectal wall.

Int J Colorectal Dis 2008;23:721–2.

6. Ellul JP, Mannion S, Khoury GA. Spontaneous rupture of the rectum with evisceration of the small intestine through the anus. Eur J Surg 1995;161:925–7.

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Anüsten ince bağırsak prolapsusu: Rektal perforasyonun atipik prezentasyonu Dr. Sezer Akbulut, Dr. Mehmet Abdussamet Bozkurt, Dr. Hamit Ahmet Kabuli, Dr. Mehmet Emin Güneş Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

Non-travmatik ve altta yatan tümör olmayan rektum perforasyonları oldukça nadir olgulardır. Refleksiyon altında olan alt ve orta rektum perforasyonları batın içi apse veya enflamasyona neden olmadıkça semptomsuz olarak seyredebilir. Biz bu olgumuzda anüsten ince bağırsak prolapsusu ile acil cerrahi kliniğine başvuran bir hastayı sunmayı amaçladık.

Anahtar sözcükler: İnce bağırsak prolapsusu; rektal perforasyon.

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CAS E R EP O RT

First report of traumatic scleral rupture after penetrating keratoplasty Ceyhun Arıcı, M.D.,1 Samira Hagverdiyeva, M.D.,1 Burak Mergen, M.D.,1 Mehmet Serhat Mangan, M.D.,2 Osman Şevki Arslan, M.D.1 1

Department of Ophthalmology, İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, İstanbul-Turkey

2

Department of Ophthalmology, Okmeydanı Training and Research Hospital, İstanbul-Turkey

ABSTRACT Globe rupture is a major postoperative complication after penetrating keratoplasty (PK). Because the corneal wound is never comparable with that of healthy corneal tissue, globe rupture following blunt trauma occurs at the corneal graft-host junction. In this study, we report a case of scleral rupture that arose from blunt trauma occurring after PK. A 60-year-old female presented with loss of vision, redness and pain in the left eye, which was the consequence of blunt trauma, was our case in this study. Slit-lamp examination revealed ecchymosis on the eyelids, diffuse subconjunctival hemorrhage and total hyphema. The donor cornea was intact. The right eye showed PK, the cornea was transparent, and the sclera was blue. A 2 mm rupture behind the limbus extending from 3 o’clock to 9 o’clock in the upper half of the sclera was observed during exploratory surgery. She did not report any coexisting medical conditions except for systemic hypertension. The differential diagnosis of the bluish discoloration of her sclera was investigated. In detailed anamnesis, the patient reported that she had been treated for severe allergic eye disease during childhood.Vernal keratoconjunctivitis complication was diagnosed. It should be kept in mind that closed scleral perforation may occur in the patient with PK and blue sclera due to blunt trauma.

Keywords: Blue sclera; keratoplasty; ocular trauma; vernal keratoconjunctivitis.

INTRODUCTION

CASE REPORT

The incidence of traumatic globe dehiscence after penetrating keratoplasty (PK) has been reported to be 0.6–5.8%.[1–4] Any globe is susceptible to rupture and will do so at its weakest point if subject to sufficient force. Postoperatively, corneal scars are unlikely to regain the original preinjury strength and remain vulnerable to spontaneous and traumatic dehiscence.

This complication generally occurs within the first two years after PK.[1–5] To date, all graft dehiscences have been reported to occur at the graft-host interface.[1–5]

A 50-year-old woman was admitted to our emergency ophthalmology clinic with complaints of pain, loss of vision and redness of the left eye, which arose from a left-sided blunt trauma. She reported having had a head-to-head trauma with her grandson. The patient also reported to have used protective eyewear for the last five years regularly; unfortunately, she did not have it during the trauma. Her visual acuities were light perception without projection in the left eye and 20/40 in the right eye. The eye movements of the right eye were free in all directions, and there was only a minimal upward restriction in the left eye. Ecchymosis on the eyelids, diffuse subconjunctival hemorrhage, and total hyphema were observed in the left eye, and the donor cornea was intact.

The present study aimed to present a case of occult scleral rupture with an intact graft-host interface due to blunt trauma in a patient who had had a PK surgery 17 years earlier.

Cite this article as: Arıcı C, Hagverdiyeva S, Mergen B, Mangan MS, Arslan OŞ. First report of traumatic scleral rupture after penetrating keratoplasty.

Ulus Travma Acil Cerrahi Derg 2019;25:631-634.

Address for correspondence: Ceyhun Arıcı, M.D. İstanbul Üniversitesi-Cerrahpaşa, Cerrahpaşa Tıp Fakültesi, Göz Hastalıkları Anabilim Dalı, İstanbul, Turkey Tel: +90 532 - 340 93 51 E-mail: ceyhundr@gmail.com Ulus Travma Acil Cerrahi Derg 2019;25(6):631-634 DOI: 10.5505/tjtes.2018.55014 Submitted: 22.05.2018 Accepted: 12.11.2018 Online: 30.10.2019 Copyright 2019 Turkish Association of Trauma and Emergency Surgery

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(a)

(b)

(c)

Figure 1. (a) Penetrating keratoplasty and blue sclera in the right eye. (b) Diffuse subconjunctival hemorrhage and total hyphema in the left eye. (c) 180° sclera rupture in the lower half during emergency surgical exploration.

The right eye showed PK; the cornea was transparent, and the sclera was blue (Fig. 1a). Using the Icare Pro Tonometer (Helsinki, Finland), the intraocular pressure (IOP) was determined to be 20 mmHg in the right and hypotonic in the left.

An orbital computed tomography (CT) scan was performed under emergency conditions. The axial length was 24.0 mm on the right and 23.0 mm on the left eye. No retroorbital hemorrhage or orbital wall fracture was observed in the orbital CT, and globe integrity was reported to be intact.

Emergency exploratory surgery was planned to exclude globe rupture (Fig. 1b). A 360-degree peritomy under general anesthesia was performed in her left eye. A 2 mm scleral rupture behind the limbus extending from 3 o’clock to 9 o’clock in the upper half of the sclera was observed with some vitreous protruding into the scleral rupture area (Fig. 1c). Scleral perforation was sutured with 7.0 polyglactin, the conjunctiva was closed with 8.0 polyglactin, and the anterior chamber hyphema was cleaned with irrigation and aspiration. Iris dialysis in the upper half was detected.

Visual acuity on the 1st day postoperatively was limited to light perception. Anterior segment examination revealed donor corneal edema, diffuse conjunctival injection with recurrent hyphema. IOP was 19 mmHg. In B-scan USG, hyperechogenicity in the vitreous was observed without any retinal detachment consistent with vitreous hemorrhage. The patient was followed up by medical treatment consisting of topical moxifloxacin 0.5%, prednisolone 1%, cyclopentolate 1%, preservative-free artificial tears and hypertonic solution 5%.

Within the first week of the operation, the hyphema healed and the visual acuity improved from the light perception to hand motion (HM). B-scan USG showed diffuse vitreous opacities similar to what was seen day 1 postoperatively. At the four-week follow-up visit, visual acuity was still limited to HM. Slit-lamp examination revealed decreased corneal edema. The fundus could not be visualized because of vitreous hemorrhage. In B-scan USG, diffuse vitreous opacities were still present. The patient underwent pars plana vitrectomy (PPV) surgery. The visual acuity improved to counting fingers at 4 meters on day 1 postoperatively (Fig. 2). Mild corneal edema and conjunctival injection were present at 632

the first-month follow-up exam following PPV surgery. IOP was measured at 17 mmHg. The retina was intact, and the vitreous was clear. Visual acuity was five meters of finger counting.

The patient had undergone bilateral PK 17 years earlier, and due to graft rejection on the left eye, PK was performed again on that eye one year later. She also had had bilateral cataract surgery 15 years ago. She did not report any coexisting medical conditions except for systemic hypertension.

The differential diagnosis of the bluish discoloration of her sclera was investigated. Firstly, localized conditions, such as primary acquired melanosis, oculodermal melanocytosis, conjunctival nevus, and conjunctival melanoma, were ruled out. Secondly, toxicity from systemic medications, topical medications and argyrosis were also excluded. Thirdly, internal medicine and cardiology consultations were performed to rule out the possible causes of blue sclera, such as collagen synthesis diseases (e.g., Ehlers-Danlos syndrome, osteogenesis imperfecta and Marfan’s Syndrome), alkaptonuria and primary adrenal insufficiency (Addison’s disease). In detailed anamnesis, the patient reported that she had been treated due to severe allergic eye disease during childhood. A diagnosis of vernal keratoconjunctivitis (VKC) complication was reached.

Figure 2. One day following pars plana vitrectomy, mild donor corneal edema, conjunctival injection.

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Arıcı et al. First report of traumatic scleral rupture after penetrating keratoplasty

DISCUSSION Any trauma to the globe with proper mechanism and sufficient force would cause rupture of the globe in the weakest region. In healthy eyes, these regions are insertions of extraocular muscles or the limbal area, whereas in unhealthy eyes with previous surgery or penetrating trauma, the rupture site will be the previous corneal scar. The most prevalent cause of trauma has been reported to be accidental blunt trauma.[1,3,6] The occurrence of traumatic graft rupture has been reported from three days to 33 years after PK.[4,5] Thirty-three years is the longest reported time interval after PK, which suggests a lifetime risk of traumatic dehiscence.[6] This risk remains throughout life; laboratory experiments, histopathological studies and clinical reports showed that a corneal wound never regains the tensile strength of a normal cornea regardless of whether the wound involves the full thickness or partial thickness or has 10/0 nylon sutures in place.[6] To our knowledge, this is the first case of a scleral rupture in a patient with PK after blunt trauma.

In this study, the slit-lamp examination of the patient showed blue sclera on his right eye. After localized, systemic investigation and detailed anamnesis of the patient, the reason for the blue sclera, VKC complication was diagnosed. We hereby suggest that the scleral tissue decomposition arose from trauma might be the cause of the blue sclera.

VKC is a chronic, bilateral, conjunctival inflammatory condition. VKC typically starts before age 10 and lasts two to ten years and usually resolving during puberty. The diagnosis is relatively easily reached, based on the history and presentation of the findings. The hyperplastic epithelium of VKC patients contains eosinophils, mast cells, neutrophils, and mononuclear cells. Compared to healthy individuals, the substantia propria contains elevated numbers of mast cells.

[7] Approximately half of the mast cells in the substantia propria contain basic fibroblast growth factor, which may serve as a stimulus for fibroblast growth and production of collagen.[8] Eventually, chronic immunologic inflammation and alterations in collagen types and proteoglycans result in the abnormal connective tissue metabolism seen in VKC.[7] These biochemical and immunologic reactions may cause blue sclera, which in turn may make the sclera susceptible to blunt trauma because of its thinness and transparency. In our case, although the severity of trauma was enough to bring about hyphema and vitreous hemorrhage, the graft remained intact.

We linked the biochemical and immunologic reactions that occurred in the sclera as the possible causes of scleral rupture without affecting the graft-host interface.

CT scans of the eye may provide valuable information for further assessment of occult open globe injuries. Reported

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sensitivity and specificity of orbital CT in determining occult open globe injury varies between 56 to 68% and 79 to 100%, respectively.[9] However, in our case, orbital CT was unable to detect the globe perforation.

In conclusion, we are reporting the first case of scleral perforation after blunt trauma in a patient with PK. Although it was shown that the graft-host junction was almost always the site of dehiscence after trauma, ophthalmologists should be careful about the scleral perforations, especially in patients with the blue sclera. The risk of traumatic corneal graft or scleral rupture after PK is significant, even years after surgery, and may cause a poor visual outcome, depending upon the severity of wound dehiscence. This should be clearly emphasized during preoperative counselling. To minimize the risk of wound dehiscence after PK, thorough education of transplant candidates encouraging the use of protective eyewear and a low-risk lifestyle is warranted.

Acknowledgments: None.

Funding/Support None: Financial disclosures the authors have no financial or proprietary interest to disclose.

Conflict of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported in this study. The manuscript has been read and approved by all the authors.

REFERENCES 1. Elder MJ, Stack RR. Globe rupture following penetrating keratoplasty: how often, why, and what can we do to prevent it? Cornea 2004;23:776– 80.

2. Rohrbach JM, Weidle EG, Steuhl KP, Meilinger S, Pleyer U. Traumatic wound dehiscence after penetrating keratoplasty. Acta Ophthalmol Scand 1996;74:501–5.

3. Selver ÖB, Palamar M, Eğrilmez S, Yağcı A. Traumatic wound dehiscence after penetrating keratoplasty. Ulus Travma ve Acil Cerrahi Derg 2016;22:437–40.

4. Lam FC, Rahman MQ, Ramaesh K. Traumatic wound dehiscence after penetrating keratoplasty-a cause for concern. Eye (Lond). 2007;21:1146– 50.

5. Tran TH, Ellies P, Azan F, Assaraf E, Renard G. Traumatic globe rupture following penetrating keratoplasty. Graefes Arch Clin Exp Ophthalmol 2005;243:525–30.

6. Das S, Whiting M, Taylor HR. Corneal wound dehiscence after penetrating keratoplasty. Cornea 2007;26:526–9.

7. A Leonardi, G Abatangelo, R Cortivo, A G Secchi. Collagen types I and III in giant papillae of vernal keratoconjunctivitis. Br J Ophthalmol 1995;79:482–5.

8. Leonardi A, Borghesan F, Faggian D, Depaoli M, Secchi AG, Plebani M. Tear and serum soluble leukocyte activation markers in conjunctival allergic diseases. Am J Ophthalmol 2000;129:151–8.

9. Arey ML, Mootha VV, Whittemore AR, Chason DP, Blomquist PH. Computed Tomography in the Diagnosis of Occult Open-Globe Injuries.

Ophthalmology 2007;114:1448–52.

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Penetran keratoplasti varlığında travmatik skleral rüptür gelişen ilk olgu Dr. Ceyhun Arıcı,1 Dr. Samira Hagverdiyeva,1 Dr. Burak Mergen,1 Dr. Mehmet Serhat Mangan,2 Dr. Osman Şevki Arslan1 1 2

İstanbul Üniversitesi-Cerrahpaşa, Cerrahpaşa Tip Fakültesi, Göz Hastalıkları Anabilim Dalı, İstanbul Okmeydanı Eğitim ve Arştırma Hastanesi, Göz Hastalıkları Kliniği, İstanbul

Penetran keratoplasti (PK) sonrası glop rüptürü önemli bir ameliyat sonrası komplikasyonudur. PK sonrası kornea yarası normal kornea dokusunun sağlamlığına hiçbir zaman erişemediğinden, künt travma sonrasında glop rüptürü kornea da alıcı-donör yatağında gerçekleşir. Biz PK’li hastada künt travmaya bağlı skleral rüptürü gelişen bir hastayı sunduk. Altmış yaşında kadın hasta sol gözünde künt travmaya bağlı görme kaybı, kızarıklık ve ağrı ile başvurdu. Ön segment muayenesinde total hifema, yaygın subkonjonktival hemoraji ve kapaklarda ekimoz mevcuttu. Donör kornea sağlamdı.

Sağ göz de PK’li, kornea saydam, sklera mavi renkte idi. Limbusa 2 mm mesafede üst kadranda saat 3’ten 9’a kadar uzanan skleral rüptür cerrahi sırasında saptandı. Hastanın öyküsünde sistemik hipertansiyon dışında başka bir hastalığı yoktu. Mavi skleraya neden olan hastalıkların ayırıcı tanısı yapıldı. Ayrıntılı öyküde hasta çocukluk döneminde ciddi alerjik göz hastalığı yaşadığını belirtti. Vernal keratokonjonktivite bağlı gelişen komplikasyon tanısı kondu. PK’li ve mavi skleralı hasta da künt travmaya bağlı kapalı sklera perforasyonu gelişebileceği akılda bulundurulmalıdır.

Anahtar sözcükler: Keratoplasti; mavi sklera; oküler travma; vernal keratokonjonktivit.

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