TJTES 2020-2

ISSN 1306 - 696X

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

Volume 26 | Number 2 | March 2020

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TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi Editor-in-Chief Mehmet Kurtoğlu Editors M. Mahir Özmen Mehmet Eryılmaz Publication Coordinator Mehmet Eryılmaz Former Editors Ömer Türel, Cemalettin Ertekin, Korhan Taviloğlu, Recep Güloğlu 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, Ali Erşen Plastic and Reconstructive Surgery Figen Özgür, Atakan Aydın Pediatric Surgery Aydın Yagmurlu, Ebru Yeşildağ Thoracic Surgery Alper Toker, Akif Turna Urology Ali Atan, Öner Şanlı Vascular Surgery Cüneyt Köksoy, Mehmet Kurtoğlu Emergency Medicine Burak Katipoğlu, Bülent Erbil

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)

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

p-ISSN 1306-696x • e-ISSN 1307-7945 • Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), DOAJ, EBSCO, and Turkish Medical Index (Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), 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 • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): March (Mart) 2020 • 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

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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.

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.

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 2019). It is cited as ‘Ulus Travma Acil Cerrahi Derg’ in PubMed.

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” section, called “Upload Your Files”.

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.

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.

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. Submission Fee: In order to further improve the quality and accessibility of the journal, a fee will be charged as a contribution to the cost of production. This fee will be charged during the process of application of submitted articles and will be charged regardless of eventual acceptance/rejection of the manuscript. Foreign authors can complete the article submission process after depositing USD 100.- to the USD account below. The article number released at the last stage of the article upload process must be written in the bank shipment description section. Recipient: ULUSAL TRAVMA VE ACIL CERRAHI DERNEGI IKTISADI ISLETMESI IBAN: TR02 0006 4000 0021 0490 9277 35 (USD) Turkish authors can complete the article submission process after depositing 500.- TL to the account below. The article number released at the last stage of the article upload process must be written in the bank shipment description section. Alıcı: ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ İKTİSADİ İŞLETMESİ IBAN: TR37 0006 4000 0021 0491 5103 66 (Türk Lirası Hesabı) Open Access Policy: Full text access is free. There is no charge for 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,

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. 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. Makale Gönderim Ücreti (Submission Fee): Dergimizin maliyetine katkı olarak, gönderilen makalelerde “başvurusu sırasında; kabul/red şartına bağlı olmaksızın” ücretlendirme yapılacaktır. Türk yazarlar aşağıdaki hesaba 500.- TL yatırdıktan sonra makale gönderim işlemini tamamlayabilirler. Alıcı: Ulusal Travma ve Acil Cerrahi Derneği IBAN: TR37 0006 4000 0021 0491 5103 66 (T. İş Bankası) (Banka gönderisi açıklama kısmına, makale yükleme işlemi sırasında son aşamadaki çıkacak makale numarası mutlaka yazılmalıdır). 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 26

Number - Sayı 2 March - Mart 2020

Contents - İçindekiler Experimental Studies - Deneysel Çalışma 153-162 Ischemia-modified albumin and the IMA/albumin ratio in the diagnosis and staging of hemorrhagic shock: A randomized controlled experimental study Hemorajik şok tanısında ve evrelemesinde iskemi modifiye albumin (IMA) ve IMA/albumin oranı: Randomize kontrollü deneysel çalışma Türedi S, Şahin A, Akça M, Demir S, Reis Köse GD, Çekiç AB, Yıldırım M, Yuluğ E, Menteşe A, Türkmen S, Acar S 163-170 A novel hemostatic scaffold material and the importance of scaffold formation on ending hemorrhage: An experimental rat study Yeni bir hemostatik scaffold materyali ve kanama durdurmada fibrin çatı oluşumunun önemi: Deneysel sıçan çalışması Altıntop İ, Tatlı M, Soyer Z, Yay AH, Öztürk A, Karakükçü Ç 171-177 The effects of nitroglycerin in the zone of stasis in a rat burn model Sıçanlarda deneysel yanık modelinde oluşan staz zonunda nitrogliserinin etkisi Gündüz M, Sekmenli T, Uğurluoğlu C, Çiftçi İ

Original Articles - Orijinal Çalışma 178-185 A new technique in the evaluation of strangulated and incarcerated hernias: Near-infrared spectroscopy Strangüle ve inkarsere hernilerin değerlendirilmesinde yeni bir teknik: Near infrared spectroscopy Ziyan M, Kalkan A, Bilir Ö, Ersunan G, Özel D, Uzun Ö, Korku S 186-190 Should percutaneous cholecystostomy be used in all cases difficult to manage? Perkütan kolesistostomi yönetimi zor olan tüm olgularda yapılmalı mıdır? Cartı EB, Kutlutürk K 191-196 Diagnostic value of GCP-2/CXCL-6 and hs-CRP in the diagnosis of acute appendicitis Akut apandisit tanısında GCP-2/CXCL-6 ve hs-CRP’nin tanısal değeri Yücel Ç, Fırat Oğuz E, Er S, Balamir İ, Turhan T, Tez M 197-202 An updated analysis of the surgical and urological complications of 789 living-related donor kidney transplantations: Experience of a single center Canlı donörden böbrek transplantasyonunda cerrahi ve ürolojik komplikasyonların 789 olguda güncellenmiş analizi: Tek bir merkez tecrübesi Oktar T, Koçak T, Tefik T, Erdem S, Şanlı Ö, Ziylan HO, Nane İ 203-211 Endoscopic and surgical management of iatrogenic biliary tract injuries İyatrojenik safra yolu yaralanmalarının endoskopik ve cerrahi yönetimi Acar T, Acar N, Güngör F, Alper E, Gür Ö, Çamyar H, Hacıyanlı M, Dilek ON 212-221 Correlation between optic nerve sheath diameter and Rotterdam computer tomography scoring in pediatric brain injury Pediatrik beyin hasarında optik sinir kılıf çapı ile Rotterdam bilgisayarlı tomografi skorlama arasındaki korelasyon Kayadibi Y, Ülgen Tekerek N, Yeşilbaş O, Tekerek S, Üre E, Kayadibi T, Tekcan Şanlı DE 222-226 Electrical burns and complications: Data of a tertiary burn center intensive care unit Elektrik yanıkları ve komplikasyonları: Üçüncü basamak yanık merkezi yoğun bakım ünitesi verileri Başaran A, Gürbüz K, Özlü Ö, Demir M, Eroğlu O, Daş K 227-234 Non-operative management of civilian abdominal gunshot wounds Sivil nedenli abdominal ateşli silah yaralanmalarında non-operatif tedavi Özpek A, Canbak T 235-241 Fournier’s gangrene: Five years’ experience from a single center in Turkey Fournier gangreni: Türkiye’deki tek bir merkezden beş yıllık deneyimlerimiz Hatipoğlu E, Demiryas S, Şimşek O, Sarıbeyoğlu K, Pekmezci S 242-246 The importance of the injury severity scores and revised trauma scores for moderate traumas: A state hospital experience Yaralanma ciddiyeti skorları ve revize edilmiş travma skorlarının orta dereceli travmalar için önemi: Bir devlet hastanesi tecrübesi Yıldırım Aydın F, Dülger D 247-254 Ingested foreign bodies in children: Do they really pass spontaneously from the gastrointestinal tract? A single-centre experience with 1000 cases Çocuklarda yutulan yabancı cisimler: Gerçekten gastrointestinal sistemden kendiliğinden geçiyorlar mı? 1000 olgu ile tek merkezli deneyim Gezer HÖ, Serin Ezer S, Temiz A, İnce E, Hiçsönmez A

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TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 26

Number - Sayı 2 March - Mart 2020

Contents - İçindekiler 255-259 Reversal of Hartmann’s procedure is still a high-morbid surgery? Hartmann kapatılması prosedürü hâlâ yüksek morbiditeli bir cerrahi midir? Akıncı O, Yurdacan M, Turgut BC, Uludağ SS, Şimşek O 260-264 Results of acromioclavicular joint reconstruction using a novel minimally invasive technique Minimal invaziv teknik ile akromioklaviküler eklem rekonstrüksiyonunun sonuçları Huri G, Özdemir E, Ziroğlu N, Costouros J, McFarland E 265-273 Acetabular fractures treated surgically: Which of the parameters affect prognosis Cerrahi olarak tedavi edilen asetabulum kırıkları: Prognozu hangi parametreler etkiler? Bilekdemir U, Civan O, Cavit A, Özdemir H 274-279 Comparison of caspase-8, granzyme B and cytochrome C apoptosis biomarker levels in orthopedic trauma patients Ortopedik travma hastalarında kaspas-8, granzim B ve sitokrom C apoptoz biyobelirteçlerin düzeylerinin karşılaştırılması Pazarcı Ö, Aydın H, Kılınç S 280-286 Is electromagnetic guidance system superior to a free-hand technique for distal locking in intramedullary nailing of tibial fractures? A prospective comparative study Tibia kırıklarının intramedüller çivilemesinde, distal kilitleme için elektromanyetik yönlendirme sistemi, serbest el tekniğinden üstün müdür? İleriye yönelik karşılaştırmalı bir çalışma Aslan A, Konya MN, Gülcü A, Sargın S 287-295 A bibliometric analysis of publications on trauma in critical care medicine during 1980–2018: A holistic view Yoğun bakım alanında travma konusunda 1980–2018 yılları arasında yapılan yayınların bibliyometrik analizi: Bütünsel yaklaşım Karaca O, Güldoğan CE 296-300 Evaluation of the patients admitted to the pediatric emergency service: Cross-sectional analysis of the pediatric emergency and trauma clinic of a tertiary training hospital in Turkey Çocuk acil servise başvuran hastaların gözden geçirilmesi: Türkiye’deki bir üçüncü basamak hastane çocuk acil eğitim kliniğinin kesitsel analizi Pakdemirli A, Orbatu D, Berksoy E. 301-305 Assessment of firearm injuries undergoing advanced airway management: Role II hospital experience İleri hava yolu yönetimi uygulanan ateşli silah yaralanmalarının değerlendirilmesi: Role II hastane deneyimi Eksert S, Aşık MB, Kaya M 306-313 Diagnostic accuracy of ultrasonography and scoring systems: The effects on the negative appendectomy rate and gender Skorlama sistemleri ve ultrasonografinin tanısal doğruluğunun negatif apandektomi oranı ve cinsiyet üzerine etkisi Şenocak R, Kaymak Ş 314-319 Comparison of tandir burns and other flame burns Tandır yanıkları ve diğer alev yanıklarının karşılaştırılması Çinal H, Barın EZ

Case Series - Olgu Serisi 320-324 Endovascular embolisation treatment in a rare acute abdomen spontaneous rectus sheath haematoma Nadir bir akut batın nedeni olan spontan rektus hematomunda endovasküler embolizasyon tedavisi Çakır Ç

Case Reports - Olgu Sunumu 325-327 Posterior reversible encephalopathy syndrome as an underlying cause for encephalopathy in a sepsis patient in the intensive care unit: A case report Yoğun bakım ünitesinde sepsisli bir hastada ensefalopatinin altında yatan bir neden olarak posterior reversible ensefalopati sendromu: Olgu sunumu Orhun G 328-330 A rare case report: Cervical subcutaneous and mediastinal emphysema due to mastoid fracture Nadir bir olgu sunumu: Mastoid kırığı nedeniyle oluşan servikal subkutan ve mediastinal amfizem Gök H, Şeker S, Peker HO, Çal MA, Altay T, Çelik S 331-333 Successful treatment of a combined bronchial and aortic trauma Bronş ve aortun müşterek yaralanmasının başarılı tedavisi Sarıçam M, Özkan B, Toker A

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EXPERIMENTAL STUDY

Ischemia-modified albumin and the IMA/albumin ratio in the diagnosis and staging of hemorrhagic shock: A randomized controlled experimental study Süleyman Türedi, M.D.,1 Aynur Şahin, M.D.,1 Metehan Akça, M.D.,2 Selim Demir, M.D.,3 Gökçen Derya Reis Köse, M.D.,4 Arif Burak Çekiç, M.D.,5 Mehmet Yıldırım, M.D.,2 Ersin Yuluğ, M.D.,4 Ahmet Menteşe, M.D.,6 Süha Türkmen, M.D.,7 Sami Acar, M.D.8 1

Department of Emergency Medicine, Karadeniz Technical University Faculty of Medicine, Trabzon-Turkey

2

Department of Physiology, University of Health Science Faculty of Medicine, İstanbul-Turkey

3

Department of Nutrition and Dietetics, Karadeniz Technical University Faculty of of Health Sciences, Trabzon-Turkey

4

Department of Histology, Karadeniz Technical University Faculty of Medicine, Trabzon-Turkey

5

Department of General Surgery, Karadeniz Technical University Faculty of Medicine, Trabzon-Turkey

6

Department of Medical Laboratory Techniques, Karadeniz Technical University Faculty of of Health Sciences, Trabzon-Turkey

7

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

8

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

ABSTRACT BACKGROUND: To determine the value of ischemia-modified albumin (IMA) and IMA/albumin ratio (IMAR) in the diagnosis and staging of hemorrhagic shock (HS). METHODS: A pressure-targeted HS model was established in this study. The control and shock groups were monitored for 30 min and 60 min to simulate varying durations of exposure to HS. All subjects underwent invasive arterial monitoring during the experiment and were further divided into mild and severe shock groups based on decreases in mean arterial pressure (MAP). Biochemical and histologic comparisons were performed between the groups. RESULTS: Our results revealed higher IMA, IMAR, lactate, total oxidant status (TOS) and oxidative stress index (OSI) levels in both the 30- and 60-min shock groups compared to the control group. Concerning MAP-based shock staging, IMA, IMAR, lactate, TOS and OSI levels in the 30-min and 60-min mild and severe shock groups were higher than those of the controls. However, there was no significant difference between the mild and severe shock groups. A significant correlation was determined between all the biomarkers evaluated and HS-induced damage in various organs. This correlation was highest in lactate and IMAR levels. CONCLUSION: IMA and IMAR levels may be used in the early diagnosis of HS and also have the potential for use in determining the severity of HS. IMA and IMAR measurement may also be considered as an alternative or in addition to lactate measurement in the diagnosis of HS. Keywords: Albumin; hemorrhage; ischemia modified albumin; hemorrhagic shock; lactate; trauma.

INTRODUCTION Background Trauma and trauma-related hemorrhage are one of the main causes of mortality and morbidity in young people world-

wide.[1] Significant hemorrhage following trauma progresses rapidly within a few hours, resulting in hemorrhagic shock (HS). The majority of trauma-related mortality is associated with uncontrolled hemorrhage and HS.[2]

Cite this article as: Türedi S, Şahin A, Akça M, Demir S, Reis Köse GD, Çekiç AB, et al. Ischemia-modified albumin (IMA) and the IMA/albumin ratio in the diagnosis and staging of hemorrhagic shock: A randomized controlled experimental study. Ulus Travma Acil Cerrahi Derg 2020;26:153-162. Address for correspondence: Süleyman Türedi, M.D. Karadeniz Teknik Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, 61080 Trabzon, Turkey Tel: +90 462 - 377 11 61 E-mail: suleymanturedi@hotmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):153-162 DOI: 10.14744/tjtes.2019.32754 Submitted: 28.08.2018 Accepted: 14.05.2019 Online: 26.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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Türedi et al. IMA and IMAR in the diagnosis of hemorrhagic shock

Importance The identification of hypoperfusion and assessing the degree thereof are of major importance in predicting adverse clinical events that may develop in association with HS and in planning appropriate treatment. Traditional parameters, such as blood pressure (BP), heart rate (HR), and respiration rate (RR), have been used for many years and are still employed as guides for trauma team activation and trauma management.[3,4] The physiological response to hemorrhage is quite variable. Vital parameters alone may be inadequate in the management of HS due to the insidious course of HS from the compensated phase to the decompensated phase and eventually to the irreversible phase, and due to the variation in the physiological response observed during this progression. In addition, more frequent comorbid disease, particularly in elderly patients, use of drugs, such as B-blockers, other accompanying injuries and physiological changes emerging in association with pain, may also lead to confusion in the diagnosis of HS.[5] In the light of the foregoing, there is a need for more objective criteria or biomarkers that can be used in the early diagnosis of HS, and that are capable of predicting its severity and subsequent prognosis, and of guiding treatment. Lactate, a product of anaerobic metabolism emerging during and after tissue hypoperfusion, is recommended as the most useful biochemical marker in several hypoperfusion states.[6,7] However, various factors affecting lactate levels other than hypoperfusion restrict the diagnostic use of lactate by itself. Under acute ischemic and hypoxic conditions, the binding capacity of albumin to the metal in the N-terminus region decreases and gives rise to the metabolic protein ischemiamodified albumin (IMA). Previous studies have shown that IMA levels increase rapidly from the onset of ischemic and hypoxic states and are determined at high levels in the blood so long as ischemia is maintained.[8–11]

Objectives of This Investigation This study aims to determine the value of IMA and IMAR levels in diagnosis and in determining the severity of HS in an experimentally induced model and to examine the relation with lactate levels.

MATERIALS AND METHODS Study Design This randomized, controlled, non-blinded experimental study was approved by the Karadeniz Technical University Animal Care and Ethics Committee.

Setting and Selection of the Participants The experiments were carried out in the Karadeniz Technical University Experimental Research and Application Center laboratory. Thirty-two mature female Wistar rats weighing 154

350±25 g were kept in steel cages until the day of the study at a room temperature of 22 ºC and were given water and standard rat chow. For the last 12 hours before the experiment, they were given only water.

Intervention HS model: Our review of the literature revealed various different, widely-accepted experimental HS models. The pressure-targeted HS model involves the induction of blood loss until a predetermined pressure is reached.[12–14] In the blood pressure-targeted model, blood loss cannot be standardized, and targeted blood pressure levels may be reached with different amounts of blood loss. The study groups in this study were classified into a control group with no blood loss and HS groups with target blood pressure. The groups were assessed after 30- and 60-min observation. To induce HS, general anesthesia was first applied with the intramuscular injection of 90 mg/kg ketamine and 10 mg/kg xylazine. The left femoral artery was then cannulated with a 26 G iv cannula under a microscope, under aseptic conditions and with an aseptic technique. All rats were subjected to hemodynamic monitoring throughout the study, and hemodynamic parameters were recorded dynamically. Exsanguination was then performed at a rate of 0.5 cc/100 mg/2 min until the desired blood pressure was achieved. Following these recordings, we observed varying hemodynamic responses despite rats being exposed to similar amounts of blood loss. On the basis of these responses, the shock groups were classified based on the amount of decrease in mean arterial pressure (MAP) levels. Rats with a decrease in MAP ≤30% during this study were classified as the mild shock group and those with a decrease in MAP >30% as the severe shock group. Following this classification, our study groups consisted of 30-min control, 30-min mild shock, 30-min severe shock, 60-min control, 60-min mild shock, and 60-min severe shock groups. All rats were euthanized by decapitation under anesthesia after the prescribed period. Six groups were established based on hemodynamic responses after blood loss and decreases in MAP levels as follows: The 30-min control group (Group I): Undergoing anesthesia and iv cannulation, but receiving continuous 30-min hemodynamic monitoring without blood loss, and with blood specimens collected for IMA, albumin and lactate measurement at the end of 30 min. The 30-min mild shock group (Group II): Exposed to blood loss after anesthesia and iv cannulation. Continuous hemodynamic monitoring was performed for 30 min, with a decrease in MAP ≤30% compared to the initial level. Blood Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Türedi et al. IMA and IMAR in the diagnosis of hemorrhagic shock

specimens were taken for IMA, albumin and lactate measurements after 30 min. The 30-min severe shock group (Group III): Exposed to blood loss after anesthesia and iv cannulation. Continuous hemodynamic monitoring was performed for 30 min, with a decrease in MAP >30% compared to the initial level. Blood specimens were taken for IMA, albumin and lactate measurements after 30 min. The 60-min control group (Group IV): Undergoing anesthesia and iv cannulation, but receiving continuous 60min hemodynamic monitoring without blood loss, and with blood specimens collected for IMA, albumin and lactate measurement at the end of 30 min. The 60-min mild shock group (Group V): Exposed to blood loss after anesthesia and iv cannulation. Continuous hemodynamic monitoring was performed for 60 min, with a decrease in MAP ≤30% compared to the initial level. Blood specimens were taken for IMA, albumin and lactate measurements after 60 min. The 60-min severe shock group (Group VI): Exposed to blood loss after anesthesia and iv cannulation. Continuous hemodynamic monitoring was performed for 60 min, with a decrease in MAP >30% compared to the initial level. Blood specimens were taken for IMA, albumin and lactate measurements after 60 min.

Monitoring and Recording of Hemodynamic Parameters Following the completion of femoral artery cannulation, the tip of the 26 Giv cannula was attached to a pressure transducer (Reusable BP Transducer, ADInstruments, Castle Hill, Australia) to measure blood pressure. Once the animals had been placed onto the experimental platform on which physiological parameters were to be recorded, the BP transducer was attached to a blood pressure amplifier (Quad Bridge Amp, ADInstruments, Castle Hill, Australia) with a data acquisition unit (PowerLab 26T, ADInstruments, Castle Hill, Australia), and monitoring and recording were carried out with the help of the computer by which the system was controlled. For ECG recording, ECG gel was applied to the animal’s front legs and left rear leg, and ECG Clip electrodes (ADInstruments, Castle Hill, Australia) were then attached. These electrodes were then connected to the data acquisition unit via the amplifier (ADInstruments, Castle Hill, Australia). Respiratory rate was recorded with the help of a piezoelectric transducer (Piezo Electric Pulse Transducer, ADInstruments, Castle Hill, Australia) attached to an elastic strap on the animal’s chest. Animals’ body temperatures were monitored with a probe throughout the experiments and were maintained at 37 °C with a homoeothermic blanket system (Harvard Homoeothermic Blanket, Harvard InstruUlus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

ments, South Natick, MA, USA). ECG, blood pressure, heart rate and respiratory rate were recorded from rats attached to the electrophysiological data acquisition unit for the time periods determined in the different groups. All parameters were monitored and recorded using LabChart software (v8.1, ADInstruments, Castle Hill, Australia). During the recording, baseline ECG, blood pressure and respiratory data were first collected for 10 min, and the hemorrhagic shock model was then established without interrupting the recording. Once the model had been established, data recording was carried out for the specified 30- or 60-min periods. At the end of the experiment, the ECG, blood pressure and respiratory rate data obtained were converted into numerical values with the help of LabChart software modules.

Biochemical Measurements At the end of this study, IMA, albumin and lactate measurements were carried out with blood collection from the femoral artery to induce HS. In addition to serum IMA, IMAR and lactate levels, we also evaluated TAS, TOS and OSI levels, which play roles in ischemic-hypoxic pathophysiology and reflect oxidant and antioxidant status. All parameters were measured by a biochemist blinded to the different animal group. IMA and IMAR measurement: Serum and plasma samples were prepared with 15 min of centrifugation at 3000 rpm. The specimens were pipetted into Eppendorf tubes and stored at –80 °C. Reduced cobalt to albumin binding capacity (IMA level) was analyzed using the rapid and colorimetric method and the results were reported as absorbance units (ABSUs) (8). Serum albumin levels were estimated using an automated analyzer, Cobas 6000 (Roche, Germany). IMAR levels were calculated as a ratio of IMA to albumin, and the results were expressed as µg/per g albumin. Lactate measurement: Lactate measurement was performed using a Roche vitreous chemistry 950 autoanalyzer. TAS, TOS, and OSI measurement: TAS in tissue was measured using an automated colorimetric measurement method.[15] TOS was determined using an automated measurement method.[16] Serum TAS levels were calculated in mmol Trolox equivalent/L. Serum TOS levels were calculated in µmol H2O2 equivalent/L. The TOS/TAS ratio was used as the oxidative stress index (OSI). To perform that calculation, the TAS unit, mmol Trolox equivalent/L, was converted to mmol Trolox equivalent/L, and OSI was calculated as follows using the formula OSI=[(TOS, µmol H2O2 equivalent/L)/ (TAS, µmol Trolox equivalent/L)×100].

Histopathological Examination Following blood sampling and euthanasia by decapitation, heart, brain, small bowel, liver and striated muscle specimens 155

Türedi et al. IMA and IMAR in the diagnosis of hemorrhagic shock

were collected for histopathological examination. All samples were macro- and microscopically evaluated by a histologist blinded to which groups animals belonged. At brain damage analysis, all layers of the cortex were assessed concerning general histological architecture. The cortex regions of both hemispheres were classified histologically about neuronal changes: Grade 1; mildly shrunken neurons with/without cytoplasmic vacuolization, Grade 2; moderately shrunken neurons (eosinophilic cytoplasm), and increased nuclear basophilia or vacuolated cytoplasm and vesicular nuclei, Grade 3; severely shrunken neurons (eosinophilic cytoplasm), pyknotic nuclei. In addition, the percentage of degenerative pyramidal neurons was calculated by counting 100 pyramidal cells in the cortex at x200 magnification on Analysis 5 Research software (OlympusSoftImaging Solutions, Münster, Germany).[8] At heart damage analysis, myocardial cell degeneration in heart tissue myocardial fibrosis and vascular damage were assessed using a semi-quantitative method. Myocardial cell degeneration was scored between 0 and 3; 0 (normal): no degeneration in myocytes, 1 (mild): A few degenerated myocytes, 2 (moderate): approximately 50% myocyte degeneration, and 3 (severe): myocyte degeneration exceeding 50%.[17] Kidney damage was assessed using the semi-quantitative method concerning degeneration in tubular cells and intertubular vascular congestion, scored between 0 and 3 as follows; 0: none, 1: mild, 2: moderate, and 3: severe. For scoring, preparates were evaluated by inspecting 20 different areas at x200 magnification. Damage assessment was based on the cortex and extramedullary areas. Degeneration in tubular cells was assessed concerning dilatation, shedding and vacuolization in tubular epithelial cells, and scored.[18] At examination of bowel damage, the ilium was sampled, and each area was scored between 0 and 3 using the semi-quantitative method concerning inflammatory cell infiltration, hemorrhage, villus conglomeration, and epithelial degeneration in the apical surface of the villus; 0: none; 1: mild; 2: moderate, and 3: severe.[11] At the analysis of liver damage, five randomly selected different areas in preparates from all groups were assessed concerning general histological architecture. Every tissue specimen was assessed semi-quantitatively in hepatocyte degeneration, vascular congestion, sinusoidal dilatation and congestion in vacuolated sinusoids using the scale 0: none; 1: mild, 2: moderate, and 3: severe.[19] At striated muscle evaluation, disorganization in muscle fibers was assessed semi-quantitatively concerning inflammatory cell infiltration using scale 0: normal, 1: mild, 2: moderate, and 3: severe.[20] 156

Outcome Measures The primary outcome was the determination of any differences concerning serum IMA, IMAR, lactate, TOS, TAS and OSI values in the groups exposed to HS of varying severity according to scores based on decreases in MAP, and of correlation between lactate levels and IMA and IMAR levels, the most frequently used biochemical parameters in the monitoring and treatment of HS in clinical practice, and between HS-related histological damage and IMA, lactate and IMAR values.

Statistical Analysis Statistical analysis was performed using SPSS 23.0 (IBM SPSS Statistics, IBM Corporation, Armonk, NY) and MedCalc 12.3 (MedCalc Software, Mariakerke, Belgium). Results were expressed as median and 25–75 percentiles. Multiple group comparisons between groups with mild and severe shock based on decreases in MAP and the control groups were performed using Kruskal Wallis analysis of variance (Mann-Whitney U test with Bonferroni correction as post hoc). Spearman’s correlation analysis was used to assess the relationship between biochemical parameters and histopathological damage scores. Statistical significance was set at p<0.05.

RESULTS i. Biochemical Parameters Serum IMA, lactate and IMAR levels determined in the different groups at the analysis of the mild and severe shock groups based on decreases in MAP and comparisons between the groups are shown in Table 1. As shown in Table 1, IMA, IMAR, lactate, TOS and OSI values in the mild and severe shock groups constituted on the basis of MAP were higher than those in the control groups. However, no significant difference was determined between the mild and severe shock groups concerning IMA, IMAR, lactate, TOS, or OSI. Only TOS values were significantly higher in the severe shock group compared to the mild shock group.

ii. Histopathological Examination Histopathological findings of organ damage determined in the mild and severe shock groups established on the basis of decreases in MAP levels and comparisons between the groups are shown in Table 2. As shown in Table 2, damage in the control group was lower than in the mild and severe shock groups classified according to MAP. However, damage levels in the mild and severe shock groups were similar.

iii. Correlation Results Correlation results between the biomarkers assessed and HSrelated histopathological damage in different organs are shown Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Türedi et al. IMA and IMAR in the diagnosis of hemorrhagic shock

Table 1. A comparison of biochemical measurements between the mild and severe HS groups based on decreases in MAP, and the control group

30-min observation

Parameters

Group I 30 min control (n=5)

Group II 30 min mild shock (n=5)

60-min observation

Group III 30 min severe shock (n=5)

Group IV 60 min control (n=5)

Group V 60 min mild shock (n=5)

p*

Group VI 60 min severe shock (n=7)

IMA (ABSU) Median

Percentiles (25–75)

0.681

0.747

0.746

0.614–0.708 0.688–0.763

0.728–0.796

0.644a,b 0.755a 0.739b =0.026a 0.610–0.688

0.695–0.806

0.700-0.826

IMAR (mg/per g albumin) Median

Percentiles (25–75)

=0.012b =0.016a,b

0.25a 0.34a 0.35b 0.23c,d 0.30c 0.32d =0.009c 0.264–0.30

0.31–0.38

0.33–0.41

0.22–0.27

0.29–0.37

0.30-0.38

=0.004d

Lactate (mg/dl) =0.009a Median

Percentiles (25–75)

8.65a 22.49 23.99a 7.49b 23.92 27.74b =0.004b 4.98–10.48

13.59–26.82

18.64–28.42

6.68–15.37

13.94–53.04

23.03–34.02

TAS (mmoltrolox equivalent/L) Median Percentiles (25–75)

=0.009a

1.26a,b 0.67a 0.40b 1.07c 0.56 0.59c =0.016b 1.10–1.58 0.43–0.76 0.35–0.83 0.94–1.28 0.55–0.91 0.38–0.71 =0.004c

TOS (µmol H2O2 equivalent/L) Median

Percentiles (25–75)

=0.009a,b,c

2.66 8.63 8.71 3.44 8.41 9.40 =0.004d a,b

2.49–3.38

a

8.16–8.92

b

8.17-9.07

c,d

2.23–5.36

c,e

8.17–8.68

d,e

8.89–9.60

=0.007e

OSI =0.009a,b,c Median

Percentiles (25–75)

0.22a,b 1.23a 2.01b 0.32c,d 1.49c 1.61d =0.004d 0.16–0.29

1.11–2.54

1.13-2.42

0.24–0.41

0.99–1.51

1.26–2.33

IMA: Ischemia modified albumin; IMAR: IMA/albumin ratio; TAS: Total antioxidant status; TOS: Total oxidant status; OSI: Oxidative stress index. *According to Kruskal Wallis variance analysis (the Mann-Whitney U test with Bonferroni correction as post hoc).

in Table 3. Our findings revealed a significant correlation between all the markers investigated (IMA, IMAR, lactate, TOS, TAS and OSI) and HS-related damage in different tissues. This correlation was highest in lactate and IMAR values. Correlations within biochemical parameters are shown in Table 4. Our findings revealed a moderately significant positive correlation between lactate values and IMA and IMAR.

DISCUSSION Early determination and appropriate treatment of trauma-related hemorrhage and HS represent the fundamental principle of HS management. To our knowledge, our study is the first study to examine the value of levels of the novel biomarkers IMA and IMAR, already shown to increase in blood under acute ischemic and hypoxic conditions, in the diagnosis of HS and the determination of its severity. According to the results of this preliminary study, IMA and IMAR values follow a similar course to those of lactate, which is still used in the diagnosis and management of treatment of HS and other form of shock, particularly septic shock. From that perspective, IMA and IMAR levels have the potential for use in the Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

early diagnosis of HS, in determining the severity of HS and as a prognostic marker. The first step in the management of shock in trauma, one of the leading causes of death in young people, is to identify the presence of shock. The probable cause of shock then needs to be determined and treated accordingly. Trauma management guidelines today still recommend the use of scoring based on the physiological response to hemorrhage and the clinical findings that result in the diagnosis of HS and in staging its severity. Although this physiological classification system assists the diagnosis and management of HS, several factors may nevertheless cause variations in the physiological response, and can, therefore, lead to errors in the diagnosis and classification of HS based on it.[3] This is because these traditional hemodynamic parameters, such as blood pressure, heart rate and urine output, are inadequate indicators of end-organ hypoperfusion. Classic parameters, such as blood pressure and saturation, have been determined as normal in approximately 20% of the patients with HS. Vital signs are insufficient in the decision to safely conclude resuscitation of patients with HS, as they are in the diagnosis of shock and determining its depth. 157

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Table 2. A comparison of histopathological measurements between the mild and severe HS groups based on decreases in MAP, and the control group

30–min observation

Parameters

Group I 30 min control (n=5)

Group II 30 min Mild shock (n=5)

60–min observation

Group III 30 min Severe shock (n=5)

Group IV 60 min control (n=5)

Group V 60 min Mild shock (n=5)

p*

Group VI 60 min Severe shock (n=7)

Degenerative neuron percentage (%) Median Percentiles (25–75)

12.0a,b 43.0a 39.0b 12.0c,d 42.0c 48.0d =0.009a,b,c 9.5–14.0 38.5–58.0 35.0–60.0 11.0–13.5 22.5–50.0 35.0–55.0 =0.004d

Total cerebral damage (point) Median Percentiles (25–75)

1.0 2.0 1.0 1.0 2.0 2.0 0.0–1.0 1.0–2.0 1.0–2.5 0.0–1.0 1.0–2.0 1.0–2.0

Total cardiac damage (point)

=0.011a

Median

=0.007b

Percentiles (25–75)

0.0a,b 5.0a 4.0b 0.0c,d 4.0c 4.0d

0.0–1.5 2.5–5.5 3.5–5.0 0.0–1.5 4.0–4.0 3.0–4.0 =0.005c =0.004d

Total liver damage (point) Median Percentiles (25–75)

1.0

4.0

4.0

1.0a,b 6.0a 5.0b =0.012a

0.5–2.5 1.0–7.5 2.0–4.0 0.5–3.0 4.5–7.5 3.0–6.0 =0.014b

Total kidney damage (point) Median

Percentiles (25–75)

=0.013a

0.0 3.0 5.0 1.0 3.0 3.5 =0.007b a,b

0.0–2.0

a

3.0–6.0

b

3.5–5.0

c,d

0.0–2.0

c

2.5–4.5

d

2.75–4.0

=0.014c

=0.009d Total striated muscle damage (point) =0.007a Median Percentiles (25–75)

0.0a,b 3.0a 5.0b 1.0c,d 5.0c 5.0d =0.008b,c 0.0–2.0 3.0–5.5 4.0–5.5 0.0–2.0 4.5–6.0 5.0–7.0 =0.004d

Total intestinal damage (point) Median

Percentiles (25–75)

1.0 0.5–2.0

3.0 0.5–6.0

3.0 2.0–4.0

2.0a,b 6.0a 10.0b =0.007a 1.5–2.5

6.0–9.5

8.0–10.0

=0.004b

*According to Kruskal Wallis variance analysis (the Mann-Whitney U test with Bonferroni correction as post hoc). HS: Hemorrhagic shock; MAP: Mean arterial pressure.

Inadequate tissue hypoperfusion may be present despite normal physiological parameters. This occult shock is known as cryptic shock and is associated with increased mortality.[22] The majority of trauma patients may maintain normal physiology despite being in critical hypovolemic shock associated with blood loss, and classic hemodynamic parameters may be within normal limits.[23] More sensitive indicators are therefore needed. It has been suggested that biochemical parameters, such as pH, PO2, PCO2, and alkali deficit with arterial blood gas measurements in addition to physiological evaluations, can provide more objective diagnostic data, although the most widely employed metabolic parameter is lactate.[24–27] [21]

Lactate is a biomarker resulting from oxygen delivery being inadequate to meet metabolic needs and is used as a marker 158

of tissue hypoxia.[28] When a decrease in oxygen delivery due to hypoxia or hypoperfusion exceeds the critical threshold, aerobic metabolism is replaced by anaerobic metabolism, which manifests with lower ATP production and increased lactate. Lactate levels are therefore described as a guide in the diagnosis and treatment of HS, marked by tissue hypoperfusion and hypoxia. Evaluations performed in the light of the current data have shown that both lactate and the normalization of lactate can be used as an indicator of appropriate resuscitation of shock patients in the emergency department.[6,23] Although increased lactate levels and lactic acidosis most commonly derive from hypoxia and hypovolemia and tissue hypoperfusion resulting from these (type A lactate producUlus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Türedi et al. IMA and IMAR in the diagnosis of hemorrhagic shock

Table 3. Correlation results between biochemical parameters and histological damage Degenerative Cerebral Cardiac Liver Kidney Muscle Intestinal neuron damage damage damage damage damage damage percentage

r p r p r p r p r p r p r p

IMA

0.495 0.004 0.471 0.007 0.618 <0.001 0.208 0.254 0.469 0.008 0.491 0.004 0.243 0.181

IMAR 0.663 <0.001 0.591 <0.001 0.635 <0.001 0.357 0.045 0.648 <0.001 0.580 <0.001 0.275 0.127 Lactate 0.727 <0.001 0.602 <0.001 0.590 <0.001 0.566 <0.001 0.635 <0.001 0.716 <0.001 0.511 <0.001 TAS

-0.550 <0.001 -0.406 0.02 -0.602 <0.001 -0.451 0.01 -0.563 <0.001 -0.764 <0.001 -0.515 <0.001

TOS

0.658 <0.001 0.490 0.004 0.575 <0.001 0.560 <0.001 0.537 0.002 0.693 <0.001 0.703 <0.001

OSI

0.660 <0.001 0.503 0.003 0.633 <0.001 0.521 0.002 0.591 <0.001 0.808 <0.001 0.591 <0.001

IMA: Ischemia modified albumin; IMAR: IMA/albumin ratio; TAS: Total antioxidant status; TOS: Total oxidant status; OSI: Oxidative stress index. According to Spearman’s correlation analysis.

Table 4. Correlation results among biochemical parameters IMAR Lactate TAS

TOS

OSI

r p r p r p r p r p

IMA

0.794 0.004 0.496 0.004 -0.415 0.018 0.452 0.009 0.445 0.011

IMAR

0.560 <0.001 -0.575 <0.001 0.506 0.003 0.581 <0.001

Lactate

-0.606 <0.001 0.643 <0.001 0.682 <0.001

TAS

-0.585 <0.001 -0.941 <0.001

TOS 0.745 <0.001 IMA: Ischemia modified albumin; IMAR: IMA/albumin ratio; TAS: Total antioxidant status; TOS: Total oxidant status; OSI: Oxidative stress index. According to Spearman’s correlation analysis.

tion), there are many other causes of lactate elevation that do not involve tissue hypoxia (type B lactate production). Diabetes and drugs, such as metformin used in the treatment of diabetes, leukemia, neoplastic conditions, such as lymphoma or, rarely, some solid tumors, alcohol consumption and chronic alcoholism frequently seen in traffic accident victims, HIV infections and the use of drugs, such as B adrenergic agonists, can all increase lactate levels and cause lactic acidosis.[28] Clinicians managing HS patients should, therefore, consider several conditions capable of resulting in increased lactate levels and must evaluate various potential causes of lactate elevation other than HS. Although lactate is a very useful biomarker from that perspective, new biomarkers capable of use with it are needed in the management of trauma patients. The present study, therefore, considered the novel biomarkers IMA and IMAR for that purpose. On the basis of our findings, the course of IMA and IMAR values in rats exposed to HS is similar to that of lactate. A significant increase was observed, similar to that in lactase, in the first 30 min in rats subjected to HS. This increase is Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

significantly positively correlated with HS-related damage occurring in different organs. To our knowledge, this is the first study to reveal an association between IMA and IMAR and HS, and we think that it will serve as a guide for future studies on the subject. Our findings indicate a significant correlation between serum IMA and IMAR values and lactate levels. From that perspective, these may be considered as a novel biomarker capable of use in the diagnosis and measurement of HS together with lactate, or as an alternative to lactate in conditions that may have an effect on lactate levels and in which lactate levels cannot, therefore, be used safely. During acute ischemic and hypoxic conditions, the metal binding capacity of albumin is modified and reduces transition metal binding, generating a metabolic variant of protein. This change is quantifiable and commonly known as IMA. IMA levels can be affected by serum albumin levels. Recent studies involving IMA have, therefore, reported the use of IMA levels, not alone, but in combination with serum albumin levels, or IMAR levels alone are used instead of serum IMA levels.[29] IMA and IMAR levels increase in several conditions involving exposure to hypoxia or ischemia independently of the organ affected. An increase in IMA levels has previously 159

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been reported in conditions, particularly involving myocardial ischemia, such as acute coronary syndromes, ischemic conditions, such as acute mesenteric ischemia and stroke, and in conditions involving hypoxia, rather than ischemia, such as pulmonary embolism and carbon monoxide intoxication, and evidence exists that this increase can be used for diagnostic and prognostic purposes.[8–11] HS is one of the conditions in which ischemic pathogenesis is most prominent due to decreasing blood volume and also hypoxic pathogenesis in which oxygen delivery is affected by decreasing hemoglobin concentrations. From that perspective, it is logical to expect serum IMA and IMAR values to rise in patients with HS, and it may be concluded that this elevation may potentially be used for diagnostic purposes and has the same potential as lactate clearance in evaluating response to treatment and screening prognosis. Although we did not have the opportunity to perform a full assessment in this study, in order for lactate to increase secondary to HS and for lactic acidosis to develop, anaerobic metabolism has to replace aerobic metabolism, and lactate must emerge as the resulting end product. This is a multistage process, and relatively more advanced stages of HS or longer exposure to this ischemic-hypoxic state will be required in order for it to occur and for high lactate levels to be capable of being determined in blood. Serum albumin is the most abundant protein in human blood. Albumin, which plays an important role in the regulation of oncotic pressure, also serves as a buffer in the regulation of blood pH. Studies have shown that albumin undergoes modification within minutes in ischemic-hypoxic states.[11] From that perspective, HS-related increases in IMA and IMAR may be expected to appear before an increase in lactate and before blood becomes acidotic, and these increases may be expected to be detected earlier, and in milder cases of HS. This is a subject that definitely requires investigation. Our study, to our knowledge, the first to assess IMA and IMAR values in HS cases, is not capable of solving all these questions that need to be answered and that will contribute to the management of HS. However, it will serve as a guide to future studies on this subject.

Limitations The main limitation of our study is that although the experimental protocol was scrupulously applied and no additional procedure was performed in the sham groups other than anesthesia and femoral artery cannulation, some degree of damage appears to have developed in almost all organs. This damage is probably associated with the anesthesia administered or with surgical stress. Although similar experimental procedures were applied in the control groups and the shock groups, it should not be forgotten that this damage might have affected serum IMA and lactate levels, and the IMAR values calculated. 160

Second, of the various biomarkers recommended by current trauma management guidelines in the diagnosis and management of HS, only lactate was used for comparison in this study. Blood gas measurements were not performed, and other parameters recommended by the ATLS in the diagnosis and management of HS, such as pH and base deficit, was not evaluated. Our research was an experimental study planned to simulate HS. Two subgroups, mild and severe HS, were established based on decreases in MAP, for that simulation. This shock severity scoring performed solely on the basis of a decrease in MAP does not exactly reflect the four-stage classification based on physiological parameters and used in clinical practice.

Conclusion Our study findings suggest that IMA and IMAR values follow a similar course to those of lactate, which is still used in the diagnosis and management of HS. From that perspective, IMA and IMAR values have the potential to be used in the early diagnosis of HS and as a prognostic marker. IMA and IMAR measurement may be considered in the early diagnosis of HS as an alternative to lactate under conditions affecting lactate levels. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: S.T., A.S., M.Y., E.Y., A.M.: substantial contributions to conception and design, experimentation, acquisition of data, analysis and interpretation of data, drafting the article or revising it critically for important intellectual content and final approval of the version to be published; M.A., S.D., G.D.R.K., Sh.T., S.A.: Experimentation, acquisition of data, interpretation of data, drafting the article or revising it critically for important intellectual content and final approval of the version to be published (ST*: Suha Turkmen). Conflict of Interest: None declared. Financial Disclosure: This study was supported by the scientific and technical research fund of Karadeniz Technical University (THD-2015-5306).

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Türedi et al. IMA and IMAR in the diagnosis of hemorrhagic shock ditional vital signs, shock index, and age-based markers in predicting trauma mortality. J Trauma Acute Care Surg 2013;74:1432–7. 5. Schiller AM, Howard JT, Convertino VA. The physiology of blood loss and shock: New insights from a human laboratory model of hemorrhage. Exp Biol Med (Maywood) 2017;242:874–83. 6. Johnson MC, Alarhayem A, Convertino V, Carter R 3rd, Chung K, Stewart R, et al. Comparison of compensatory reserve and arterial lactate as markers of shock and resuscitation. J Trauma Acute Care Surg 2017;83:603–8. 7. Sarıaydın T, Çorbacıoğlu ŞK, Çevik Y, Emektar E. Effect of initial lactate level on short-term survival in patients with out-of-hospital cardiac arrest. Turk J Emerg Med 2017;17:123–7. 8. Turedi S, Yilmaz SE, Mentese A, Turkmen S, Karaca Y, Sen O, et al. The diagnostic value of serum ischemia-modified albumin levels in experimentally induced carbon monoxide poisoning and their correlation with poisoning severity. Acad Emerg Med 2013;20:652−8. 9. Türedi S, Karahan SC, Menteşe A, Gündüz A, Topbaş M, Koşucu P, et al. Investigation of relationship between the D-dimer and ischemiamodified albumin levels with the radiological imaging-based pulmonary embolism severity score in acute pulmonary embolism. Anadolu Kardiyol Derg 2010;10:346−52. 10. Turedi S, Gunduz A, Mentese A, Dasdibi B, Karahan SC, Sahin A, et al. Investigation of the possibility of using ischemia-modified albumin as a novel and early prognostic marker in cardiac arrest patients after cardiopulmonary resuscitation. Resuscitation 2009;80:994−9. 11. Gunduz A, Turkmen S, Turedi S, Mentese A, Yulug E, Ulusoy H, et al. Time-dependent variations in ischemia-modified albumin levels in mesenteric ischemia. Acad Emerg Med 2009;16:539−43. 12. Lu YQ, Cai XJ, Gu LH, Wang Q, Huang WD, Bao DG. Experimental study of controlled fluid resuscitation in the treatment of severe and uncontrolled hemorrhagic shock. J Trauma 2007;63:798−804. 13. Lee JH, Kim K, Jo YH, Kim MA, Lee KB, Rhee JE, et al. Blood pressuretargeted stepwise resuscitation for hemorrhagic shock in rats. J Trauma Acute Care Surg 2014;76:771−8. 14. Takasu A, Prueckner S, Tisherman SA, Stezoski SW, Stezoski J, Safar P. Effects of increased oxygen breathing in a volume controlled hemorrhagic shock outcome model in rats. Resuscitation 2000;45:209–20. 15. Erel O. A novel automated method to measure total antioxidant response against potent free radical reactions. Clin Biochem 2004;37:112–19. 16. Erel O. A new automated colorimetric method for measuring total oxidant status. Clin Biochem 2005;38:1103–11. 17. Tokatli F, Uzal C, Doganay L, Kocak Z, Kaya M, Ture M, et al. The po-

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tential cardioprotective effects of amifostine in irradiated rats. Int J Radiat Oncol Biol Phys 2004;58:1228−34. 18. Karahan SC, Türkmen S, Menteşe A, Zengin A, Gündüz A, Türedi S, et al. Ischemia-modified albumin as an early diagnostic marker for acute renal ischemia and infarction. Turkiye Klinikleri J Med Sci 2010;30:1230−5. 19. Yıldız O, Can Z, Saral O, Yuluğ E, Oztürk F, Aliyazıcıoğlu R, et al. Hepatoprotective potential of chestnut bee pollen on carbon tetrachloride-induced hepatic damages in rats. Evid Based Complement Alternat Med 2013;2013:461478. 20. Erkanli K, Kayalar N, Erkanli G, Ercan F, Sener G, Kirali K. Melatonin protects against ischemia/reperfusion injury in skeletal muscle. J Pineal Res 2005;39:238−42. 21. Furmaga W, Cohn S, Prihoda TJ, Muir MT, Mikhailov V, McCarthy J, et al. Novel markers predict death and organ failure following hemorrhagic shock. Clin Chim Acta 2015;440:87−92. 22. Meregalli A, Oliveira RP, Friedman G. Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients. Crit Care 2004;8:R60–5. 23. Baxter J, Cranfield KR, Clark G, Harris T, Bloom B, Gray AJ. Do lactate levels in the emergency department predict outcome in adult trauma patients? A systematic review. J Trauma Acute Care Surg 2016;81:555–66. 24. Batra P, Dwivedi AK, Thakur N. Bedside ABG, electrolytes, lactate and procalcitonin in emergency pediatrics. Int J Crit Illn Inj Sci 2014;4:247– 52. 25. Choi SB, Park JS, Chung JW, Kim SW, Kim DW. Prediction of ATLS hypovolemic shock class in rats using the perfusion index and lactate concentration. Shock 2015;43:361–8. 26. Soller B, Zou F, Prince MD, Dubick MA, Sondeen JL. Comparison of Noninvasive pH and Blood Lactate as Predictors of Mortality in a Swine Hemorrhagic Shock with Restricted Volume Resuscitation Model. Shock 2015;44:90–5. 27. Saad S, Mohamed N, Moghazy A, Ellabban G, El-Kamash S. Venous glucose, serum lactate and base deficit as biochemical predictors of mortality in patients with polytrauma. Ulus Travma Acil Cerrahi Derg 2016;22:29–33. 28. Andersen LW, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc 2013;88:1127−40. 29. Cakir M, Karahan SC, Mentese A, Sag E, Cobanoglu U, Polat TB, et al. Ischemia-modified albumin levels in children with chronic liver disease. Gut Liver 2012;6:92−7.

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DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Hemorajik şok tanısında ve evrelemesinde iskemi modifiye albümin ve IMA/albümin oranı: Randomize kontrollü deneysel çalışma Dr. Süleyman Türedi,1 Dr. Aynur Şahin,1 Dr. Metehan Akça,2 Dr. Selim Demir,3 Dr. Gökçen Derya Reis Köse,4 Dr. Arif Burak Çekiç,5 Dr. Mehmet Yıldırım,2 Dr. Ersin Yuluğ,4 Dr. Ahmet Menteşe,6 Dr. Süha Türkmen,7 Dr. Sami Acar8 Karadeniz Teknik Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Trabzon Sağlık Bilimleri Üniversitesi Tıp Fakültesi, Fizyoloji Anabilim Dalı, İstanbul Karadeniz Teknik Üniversitesi Sağlık Bilimleri Fakültesi, Beslenme ve Dieyetetik Bölümü, Trabzon 4 Karadeniz Teknik Üniversitesi Tıp Fakültesi, Histoloji Anabilim Dalı, Trabzon 5 Karadeniz Teknik Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Trabzon 6 Karadeniz Teknik Üniversitesi Sağlık Bilimleri Fakültesi, Medikal Laboratuvar Teknikleri Bölümü, Trabzon 7 Acıbadem Üniversitesi, Tıp Fakültesi Acil Tıp Anabilim Dalı, İstanbul 8 Acıbadem Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul 1 2 3

AMAÇ: Hemorajik şokun (HS) tanı ve evrelemesinde iskemi modifiye albümin (IMA) ve IMA/albümin oranının (IMAR) değerini belirlemek. GEREÇ VE YÖNTEM: Basınç hedefli bir HS modeli oluşturuldu. Kontrol ve şok grupları, HS’ye çeşitli maruz kalma sürelerini simüle etmek için 30 dakika ve 60 dakika boyunca izlendi. Deneyler sırasında tüm deneklere invaziv arter muayenesi yapıldı ve ayrıca ortalama arter basıncı (MAP) azalışlarına dayanarak hafif ve şiddetli şok gruplarına ayrıldı. Gruplar arasında biyokimyasal ve histolojik karşılaştırmalar yapıldı. BULGULAR: Sonuçlarımız kontrol grubuna göre hem 30 hem de 60 dakikalık şok gruplarında IMA, IMAR, laktat, total oksidan durumu (TOS), total antioksidan durumu (TAS) ve oksidatif stres indeksi (OSI) düzeylerini ortaya koydu. MAP bazlı şok evrelemesi açısından, 30 dakikalık ve 60 dakikalık hafif ve şiddetli şok gruplarındaki IMA, IMAR, laktat, TOS ve OSI düzeyleri kontrol grubundan daha yüksekti. Ancak, hafif ve şiddetli şok grupları arasında anlamlı fark yoktu. Değerlendirilen tüm biyobelirteçler ile çeşitli organlarda HS kaynaklı hasar arasında anlamlı korelasyon tespit edildi. Bu korelasyon laktat ve IMAR düzeylerinde en yüksekti. TARTIŞMA: İskemi modifiye albumin ve IMAR düzeyleri HS’nin erken tanısında kullanılabilir ve ayrıca HS’nin şiddetini belirlemede kullanım potansiyeline sahiptir. IMA ve IMAR ölçümü alternatif olarak veya HS tanısında laktat ölçümüne ek olarak düşünülebilir. Anahtar sözcükler: Albümin; hemoraji; hemorajik şok; iskemi modifiye albümin; laktat; travma. Ulus Travma Acil Cerrahi Derg 2020;26(2):153-162

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doi: 10.14744/tjtes.2019.32754

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EXPERIMENTAL STUDY

A novel hemostatic scaffold material and the importance of scaffold formation on ending hemorrhage: An experimental rat study İsmail Altıntop, M.D.,1 Mehmet Tatlı, M.D.,1 Zeynep Soyer, M.D.,4 Arzu Hanım Yay, M.D.,5 Ahmet Öztürk, M.D.,3 Çiğdem Karakükçü, M.D.2 1

Department of Emergency Medicine, University of Health Science, Kayseri Training and Research Hospital, Kayseri-Turkey

2

Department of Biochemistry, University of Health Science, Kayseri Training and Research Hospital, Kayseri-Turkey

3

Department of Biostatistics, Erciyes University Faculty of Medicine, Kayseri-Turkey

4

Erciyes University, Hakan Çetinsaya Experimantal Animal Center, Kayseri-Turkey

5

Department of Histology and Embryology, Erciyes University Faculty of Medicine, Kayseri-Turkey

ABSTRACT BACKGROUND: Different pharmacological agents are developed to control bleeding. However, it is critical for these agents to induce thrombin formation and have an effect on vasoconstriction, coagulation, and scaffold. In this study, we aimed to demonstrate the agents’ ability to stop bleeding properties on minor and major open bleedings after skin clefts, extracorporal injuries, traumatic cuts, spontaneous or surgical intervention besides scaffold properties. For this purpose, a new and authentic hemostatic agent, processed diatomite (PD) and the most preferred chitosan in the medical area were used to test blood stopping and scaffold effects in a rat femoral bleeding model. The samples were examined by scanning electron microscopy (SEM), and the results on blood stopping were shared. METHODS: The current experimental study was conducted on rats. The effects of hemostatic agents on our femoral bleeding model were determined. In this study, 22 male Wistar albino rats weighing 158–215 g, were used. The rats were assigned randomly to three groups: control group (n=6), chitosan group (n=8), and PD group (n=8). Bleeding time, scaffold formation, weight differences, histopathological effect and scanning electron microscope (SEM) analyses were performed. RESULTS: In our experimental model, weight loss was 5.0±1.3 g for the control group, 2.9±1.1 g for the chitosan group, and 2.7±1.0 g for the PD group, respectively. When weighed before and after the experiment, there was a significant change in weights of rats in chitosan, and PD groups regarding scaffold formation: it was complete for six rats (75%) and weak for two (25%) rats in chitosan group; however, it was complete for seven rats (87.5%) and weak for one (12.5%) rat in the PD group. Scaffold formation was significant for the chitosan and PD groups versus the control group (p=0.002). CONCLUSION: In our study, the scaffold formed by PD exerts appropriate porousness and contributes to fibrin formation and prevent re-bleeding. PD had a strong and significant scaffold effect. The effectiveness of PD to stop bleeding was equal to chitosan. Besides being natural, hemostatic agents should not induce cellular damage. We histopathologically demonstrated that PD was harmless for the natural structure of cells and vessels in the femoral site. Keywords: Chitosan; diatomite; hemostatic agent; scaffold.

INTRODUCTION Uncontrolled hemorrhages constitute nearly half of the deaths in the military zone and also are the second cause of

deaths due to trauma in the field of health.[1,2] Hemorrhages are composed of injury owing to trauma, war and disaster injuries, stab injuries, nose hemorrhages and post-burn hemorrhages.[2,3] Regardless of the dimension and type, it is crucial

Cite this article as: Altıntop İ, Tatlı M, Soyer Z, Yay AH, Öztürk A, Karakükçü Ç. A novel hemostatic scaffold material and the importance of scaffold formation on ending hemorrhage: An experimental rat study. Ulus Travma Acil Cerrahi Derg 2020;26:163-170. Address for correspondence: İsmail Altintop, M.D. Sağlık Bilimleri Üniversitesi Kayseri Eğitim ve Araştırma Hastanesi, Acil Tıp Anabilim Dalı, Kayseri, Turkey Tel: +90 352 - 336 88 84 E-mail: draltintop1@hotmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):163-170 DOI: 10.14744/tjtes.2019.34359 Submitted: 01.07.2018 Accepted: 12.03.2019 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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to stop the hemorrhage in early states. Similarly, bleedings due to surgical procedures should be intervened immediately. The insufficiency in homeostasis may induce different hemorrhagic complications.[3,4] Bleedings may represent a wide spectrum: from a leakage type hemorrhage and the surgical incision site to hemorrhages with a requirement of transfusion and even disturbing organ functions with a hemorrhagic shock, which ultimately cause the patient’s death.[3,4] The most common hemorrhages are the extracorporeal ones.[5,6] In the USA, nearly 1/3 of 6 million deaths due to trauma depend on hemorrhages.[6] Of those, half of the cases could not reach a hospital setting and died of uncontrolled hemorrhage.[6] It is critical to intervene in the hemorrhages owing to trauma in health and military fields properly and correctly. Hemostatic agents are used widely in the world not only to stop hemorrhage but also to form a scab on the wound as well. In recent years, the most preferred local hemostatic agent was chitosan. Chitosan is a biomaterial produced from the salts found in fossils of oyster shells in oceans.[7,8] The term “scaffold” is used in many medical areas. It is especially defined as a fibrin structure, fibrin matrix in closing the wound site.[9,10] After the cessation of hemorrhage, the scab is called scaffold.[10,11] The scaffold structure is composed of blood elements, thrombocytes and the applied hemostatic agent.[10–13] The pore dimension of the scaffold, surface area and porousness are accepted as important parameters in tissue engineering.[12] In the scaffold structure, the morphology of pore wall, the connection between the pores, cell culture, migration, volume transfer, growth, gene expression and new tissue formation in three dimensions are the most studied issues in recent years.[11,13] The clinical use of biological scaffold materials becomes widespread. Scaffold surgical mesh materials are primarily used to construct extracellular matrix integrity. In the current study, we used processed diatomite (PD). Diatomite is a fossil-type sedimentary rock formed by the accumulation of the crusts, including silica of diatoms, the aquatic creatures belonging to the algae genus.[14,15] Diatom is a very little protoplasm living in its own crust or shell made up of silica provided from the water. In nature, it becomes fossil by natural processes. The natural product is obtained by only the drying of crude diatomite and removing foreign materials. The diatomite used in this study is processed diatomite (PD), and it is used as a hemostatic agent after pre-treatment. Besides the hemostatic trait of PD, we searched its effects on blood stopping by forming scaffold’s continuity. For this purpose, we compared the effects of chitosan and PD in the femoral hemorrhage model in rats to contribute to the current literature.

MATERIALS AND METHODS All the procedures with animals in this study were approved by the local Ethical Committee of Erciyes University Experimental Research and Application Center-HADYEK (Approval date: 14.12.2016 and number: 16/52). By obtaining additional 164

ethical approval, we evaluated the scaffold structures. In this study, 22 male Wistar albino rats weighing 158–215 g, were used. After their first controls, the animals were accommodated under standard experimental animal housing conditions with controlled temperature (21±2° C), humidity (50±5%), air change (12 air change per hour), 12 hours of light and darkness and ad libitum feed. Each cage contained three rats and provided coarse sawdust bedding. The rats were assigned randomly to three groups: control group (n=6), chitosan group (n=8), and PD group (n=8). For the control group (n=6), the hemorrhage site was directly compressed with gauze without any hemostatic agent. For the chitosan group (n=8), direct pressing was applied with chitosan. For the PD group, direct pressing was applied with PD. Before the experiments, ketamine and xylazine hydrochloride were prepared for anesthesia. The inguinal site of the rat was trimmed and cleaned with octenisept® for the femoral artery and vein hemorrhage model. Skin and subcutaneous tissue were dissected to demonstrate the femoral artery and vein. Hemorrhage was performed by the entire incision of the femoral artery and vein. The hemorrhage was stopped by the concurrent application of the hemostatic material with gauze dressing (Celox® or PD). For all the applications, a standard weight of 200 g was used as pressure on the hemorrhage site. First, hemorrhage control was performed at 60 seconds and controlled every 30 seconds. Hemorrhage time was recorded (BST), and the pressure was terminated. The scaffold structures on the hemorrhage site were collected in sterile containers. The surface morphology of microparticles related to scaffold structures (PD, chitosan) was observed by a scanning electron microscope (SEM). The aluminum foil loaded with microparticles were coated with gold metal under vacuum and afterward examined by SEM (EVOLS25, Zeiss, Germany). In the current study, the diatomite-processed diatomite (PD) underwent some stages and pre-treated for the hemostatic effects. These stages were as follows: washing with hydrogen peroxide (100 mL/1000 g), dried at 35°C for 2 hours, stirred for 24 hours in aqueous media and dried, separation of dusts and foreign materials after drying, calcination at 700°C, dried at 35°C for 6 hours after cooling, adjustment of pH at 5.5– 9.0, sterilization and preparation for ready-to-use. The prepared material in the powder form was used.

SEM Analyses The surface morphology of microparticles related to scaffold structures (PD, chitosan) was observed by a scanning electron microscope (SEM). The aluminum foil loaded with microparticles were coated with gold metal under vacuum and afterward examined using SEM (EVOLS25, Zeiss, Germany).

Histopathological Evaluation For this study, formalin-fixed and paraffin-wax embedded samples were obtained from the vessels of all rats. For routine histological examination, wound site tissues taken from rats and Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

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450

0

Group Control Chitosan PD

400 350

-1 -2

300

-3

250 -4

200

-5

150

Control Chitosan PD

-6

100 50

Group

-7

Bleeding time

Weight loss

Figure 1. The box-plot graphics of hemorrhage time (min) for the control, chitosan and PD groups.

Figure 2. The box-plot graphics of weight loss for the control, chitosan and PD groups before and after experiment.

solved in formaldehyde (10%) were used. Then, dehydrated in a gradient ethanol series and cleaned in xylene and embedded in paraffin. For each sample, 5μM paraffine sections were cut. After deparaffinization and rehydration, all sections were colored with Masson trichrome. The morphological evaluation of the samples was performed, and photographs were taken with a photomicroscope (Olympus BX-51, Tokyo, Japan).

with scaffold and bleeding after scaffolding within groups. Analyses were conducted using Turcosa Cloud (Turcosa Ltd Co, Turkey) statistical software. A p-value of less than 5% was considered statistically significant.

Statistical Analyses The normality of the data was assessed using the Shapiro Wilk normality test and Q-Q graphs. Data were expressed as numbers for categorical variables and mean±SD for continuous variables. Comparisons between groups were performed using One-Way ANOVA Analysis of Variance (post-hoc test: Tukey). The chi-square test was used to reveal to relation

RESULTS After modeling for rat hemorrhage, hemorrhage time boxplot graphics for the control, chitosan and PD groups are given in Figure 1. In Figure 2, hemorrhage loss for all groups was demonstrated. Accordingly, hemorrhage times were significantly decreased in the PD and chitosan groups versus the control group (Table 1). The highest weight loss after hemorrhage was detected in the control group, while the loss was significantly decreased in the PD and chitosan groups (Table 1).

Table 1. Distribution of variables by groups Continues variables

Groups Control (n=6)

Mean±SD

Weight difference

5.0±1.3a

Bleeding time Categorical variables

Chitosan (n=8) Mean±SD

p

Processed diatomite (n=8) Mean±SD

2.9±1.1b 2.7±1.0b 0.003

305.0±99.3a 101.3±39.1b 78.8±22.3b <0.001 n (%)

n (%)

n (%)

p

0 (0)a

6 (75)b

7 (87.5)b 0.002

6 (100)

2 (25)

1 (12.5)

Scaffold formation

Complete

Weak

Bleeding after scaffold

+

6 (100)a

4 (50)ab

1 (12.5)b 0.006

–

0 (0)

4 (50)

7 (87.5)

Data n (%), mean±SD or average. According to multiple comparison tests (Tukey), groups with different superscript letters were found to have statistically significant differences. Post power: Power of performed test with alpha (0.05) for bleeding time, weight difference, Scaffold formation and Bleeding after scaffold = 0.99, 0.89, 0.90 and 0.85, respectively. a: Statistically significantly different from other groups. b: Statistically significantly different from control group.

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Group Control Chitosan PD

7

6

5

5

4

4

Count

Count

6

3

3

2

2

1

1

0

0

1

Scaffold

Group Control Chitosan PD

7

0

0

After scaffold

1

Figure 3. The graphics of the scaffold formation (0: no formation 1: weak formation).

Figure 4. The distribution graphics of the hemorrhage formation after scaffold.

Scaffold formation after hemorrhage model for rats in all groups is given in Figure 3. There was no scaffold formation in the control group. The highest scaffold formation was in chitosan and PD groups. Hemorrhage formation after scaffold removal is shown in Figure 4.

tus was evaluated and in the control group, all rats had bleeding. In contrast, bleeding was detected in four (50%) rats in the chitosan group and only one (12.5%) rat in the PD group, respectively. In conclusion, no bleeding (n=7, 87.5%) sign despite the removal of scaffold was significant (p=0.006) (Table 1).

In Table 1, the weight difference, bleeding time, scaffold formation and hemorrhage after scaffold for rats were given before and after the experiment. The weight loss in the control group was the maximum.

The demonstration of PD in powder form used for rats, dissection of femoral site and formation of the femoral artery and vein hemorrhage, application of PD agent on hemorrhage site, removing of scaffold formation from wound site is shown in Figure 5.

When the control group versus the chitosan and PD groups were compared concerning the difference in weight, the difference was significant. The mean weight loss was 5.0±1.3 g in the control group, 2.9±1.1 g in the chitosan group and 2.7±1.0 g in the PD group, respectively (p=0.003) (Table 1).

For histological examination and determining the vessel structure, Masson trichrome coloring technique is used. The histological section of femoral veins of control, chitosan and PD groups are shown in Figures 6, 7 and 8, respectively.

Scaffold formation was compared between groups and evaluated as weak or complete scaffold formation. In the control group, for all rats, scaffold formation was weak. However, in the chitosan group, scaffold formation was complete for six (75%) rats and weak for two (25%) rats. In the PD group, the scaffold formation was complete for seven (87.5%) rats and weak for one (12.5%) rat. There was a significant difference between control versus chitosan and PD groups (p=0.002). After removing scaffold from the wound site, hemorrhage sta-

The complete section of the images demonstrates all sections of the veins in the femoral site. The general structure of femoral veins is standard in all groups. Only in the control group, where the hemorrhage was stopped by surgical sponge, hemorrhage sites other than veins were detected. These hemorrhage sites were not observed in PD and chitosan groups. Again in all groups, endothelium, media, and adventitia were not affected by the treatment on blood vein walls. The contraction of smooth muscles and the circular ap-

(a)

(b)

(c)

(d)

Figure 5. (a) Powder form of the PD agent. (b) Dissection of the femoral site and hemorrhage formation in femoral artery and vein. (c) Application of the PD agent on hemorrhage site. (d) Removing of the scaffold formation from wound site.

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(a)

(b)

(c)

(d)

(e)

(f)

Figure 6. The scaffold imaging by SEM analysis. The surface morphology of microparticles for scaffold structure (PD, chitosan) was analyzed using SEM. (a, b) Are the SEM images of scaffold structures formed by PD. (c, d) Are the SEM images of scaffold structures formed by chitosan. (c, d) Demonstrates the microscopic image of the cut of the rat femoral artery and vein for hemorrhage model and pressure application with a surgical sponge for three minutes until the hemorrhage stops. The freely leaking blood in the control group formed clot during sample collection (star: hemorrhage site, arrow: inner elastic lamina, Masson’s trichrome, original magnification x20).

pearance are given in Figure 6. In Figure 8, the intense fold of inner elastic lamina for hemorrhage control with PD is given.

DISCUSSION Foremost in emergency services, as well as in ambulances and in clinics, the control of hemorrhage is crucial. The inUlus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

sufficiency in homeostasis may induce many complications, including massive bleeding and death.[16] Several kinds of hemorrhage may come across: from a leakage type hemorrhage from the surgical incision area to hemorrhages with need of transfusion and even disturbing organ functions with haemorrhagic shock and ultimately cause the patient’s death. In 167

Altıntop et al. A novel hemostatic scaffold material and the importance of scaffold formation on ending hemorrhage

the field of medicine, many hemostatic agents are used.[1,16] In the current study, chitosan, the mostly used hemostatic agent in recent years, is used.[17–19] As being a natural product, chitosan is produced from the salts formed from the fossiles of oyster shells living in oceans. There are some difficulties in its use.[2] We searched the effects of new hemostatic agent-PD on scaffold formation and stopping hemorrhage and compared with chitosan. The most important factor in controlling hemorrhage is fibrin formation. The fibrin formed in the hemorrhagic area is called as scaffold. The hemorrhage is bestly controlled by the strength of scaffold structure. In the literature, there are studies on the strengthening of fibrin and bioabsorbable fibrin. Yasuda et al.,[11] with bioabsorbable fibrin matrix model, detected minimal absorption in cranial region and dura mater. We planned PD for extracellular use and cleaning from wound site after bleeding without any absorption. Thus, we examined the regional effects of PD. After bleeding modelling in rats, scaffold formation was given in Figure 3. Accordingly, there was no scaffold formation in the

control group. No scaffold formation was less in PD group than the chitosan group. In Tong et al.’s.[10] study on diabetic rats, they revealed that the sponge they produced by chitosan constituted an ideal scaffold on wound site. Similarly, although we detected successful scaffold formation with chitosan, the highest scaffold formation was observed with PD. The most important characteristic of scaffold formation is its contribution to a permanent process for bleeding ending. [11,12] In our bleeding model, we demonstrated the presence of bleeding after removing of the scaffold in Figure 4. In the current literature, the majority of the studies focused on the duration spent on ending bleeding because wound repair will be necessary after ending of bleeding. No bleeding should occur after removal of hemostatic agent from the wound site, so an ideal repairment starts after surgical procedures and treatments. In the current study, there was bleeding after surgical dressing removal in all rats in the control group and bleeding was continued until the bleeding stops. In chitosan and PD groups, there was non-significant bleeding.

(a)

(b)

Figure 7. (a, b) The inner fold of inner elastic lamina significant with its round shape in chitosan group is given (star: hemorrhage site, arrow: inner elastic lamina, Masson’s trichrome, original magnification x20).

(a)

(b)

Figure 8. (a, b) Hemorrhage stops in a few minutes by the applied agent which induced complete obstruction in the vein in PD group (star: hemorrhage site, arrow: inner elastic lamina, Masson’s trichrome, original magnification x20).

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It is difficult to detect bleeding time in rats. Thus, the bleeding time may only be calculated by intermediary controls for the ending of bleeding. Dikme et al.,[20] determined oxycellulose powder to be efficient in ending bleeding in rats. Similar to our study, Crofton et al.[21] used the powder form of chitosan directly on the bleeding site and found it successful. In our study, both chitosan and PD were successful in ending bleeding versus the control group. You et al.,[5] by using a powdered form of a medical glue including aldehyde dextran and ε-poly (L-lysine), detected bleeding time as 174.2 seconds. In the current study, we detected bleeding time for chitosan and PD groups as 101.3±39.1 and 78.8±22.3 seconds, respectively. It is important to stop bleeding in case of emergency but also toxic haemostatic agent should not be used and no cellular damage should be caused when stopping bleeding. In our bleeding model treated with PD, we histopathologically examined the femoral sites. We revealed that PD had no effect on femoral vessels, and the vessels preserved the natural form of the cellular structure (Fig. 4). In sites other than bleeding site, we demonstrated that endothelin, media and adventitial regions were not affected. Our SEM analyses revealed PD, with the porous structure and high absorbing capacity, as a hemostatic agent supporting the scaffold structure. Zhang et al.[22] used diatomite and mesalamine as carriers for gastrointestinal nanoprednisone and successfully tested it for an experimental model. Terracciano et al.[23] evaluated the effects of diatomite in cytotoxicity tests and stated to be an available material. According to our histological evaluation, PD did not induce damage to the natural structure at the wound site and was concordant with the data in the current literature (Fig. 4). Hemostatic agents, including fibrinogen (Fibrin Glue, Tissel, Berilast, Hemaseal, and Crosseal), bovine albumin and glutaraldehyde (BioGlue), had toxic characteristics compared to topical hemostatic agents. [24,25] Plant-based hemostatic agents (Arista and HemoStase) induce thrombocyte and serum protein concentration at the application site.[24,26] Due to protein denaturation, with these agents, wound healing delays and microemboli may occur.[24,26] PD, besides its hemostatic properties, may be improved as a hemostatic agent and be preferred for its harmless effects on the histopathologic structure. The hemostatic agents with compression and stopper effects exert their effects solely by their mechanic effect on the vessel after pressure. These agents do not possess bleeding ending characteristics.[27] When gelatine group drugs, belonging to anastomotic glue group, contact with the blood protein gelatine bloats and induce clotting by thrombin and mechanical effects.[27] In our study, we revealed by SEM analyses that PD and chitosan have roles by forming a scaffold structure contribute to mechanic fibrin. In the current literature, various agents are used for ending bleeding. Eryilmaz et al.,[28] in their study performed with zeolite-based QuikClot, determined a tendency to diminish Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

bleeding; however, they failed to stop bleeding completely. In the same study, the researchers emphasized the insufficiency of clinic tests. According to the first studies conducted with the bentonite-a type of zeolite, it had an effect on stopping bleeding. In their research using bentonite Acosta et al.,[29] besides decreasing bleeding and bleeding time, it may also affect ending bleeding. However, several studies pointed out the toxic effects of zeolite derivatives. Thus, differing from natural agents as being a non-zeolite derivative, PD, an algae fossil, was used for similar effects.[30] New studies are required on PD.

Conclusion PD had strong and significant scaffold effects. PD compound was detected as effective as chitosan for controlling bleeding. The agents used for ending bleeding should be natural and also should not induce cellular damage. We histopathologically demonstrated that PD did not impair the natural structure of cells and vessels in the femoral site. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: İ.A., M.T.; Design: İ.A., Z.S., A.H.Y.; Supervision: İ.A., M.T.; Fundings: İ.A.; Materials: İ.A., Z.S., Ç.K.; Data: İ.A., A.H.Y., A.Ö.; Analysis: İ.A., A.Ö., Ç.K.; Literature search: İ.A., M.T.; Writing: İ.A.; Critical revision: İ.A., A.Ö. Conflict of Interest: None declared. Financial Disclosure: Financial support has been received from the Ministry of Health Kayseri Training and Research Hospital.

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Altıntop et al. A novel hemostatic scaffold material and the importance of scaffold formation on ending hemorrhage 10. Tong C, Hao H, Xia L, Liu J, Ti D, Dong L, et al. Hypoxia pretreatment of bone marrow-derived mesenchymal stem cells seeded in a collagen-chitosan sponge scaffold promotes skin wound healing in diabetic rats with hindlimb ischemia. Wound Repair Regen 2016;24:45−56. 11. Yasuda H, Kuroda S, Shichinohe H, Kamei S, Kawamura R, Iwasaki Y. Effect of biodegradable fibrin scaffold on survival, migration, and differentiation of transplanted bone marrow stromal cells after cortical injury in rats. J Neurosurg 2010;112:336–44. 12. Li Q, Mu L, Zhang F, Sun Y, Chen Q, Xie C, et al. A novel fish collagen scaffold as dural substitute. Mater Sci Eng C Mater Biol Appl 2017;80:346−51. 13. Yamada Y, Boo JS, Ozawa R, Nagasaka T, Okazaki Y, Hata K, et al. Bone regeneration following injection of mesenchymal stem cells and fibrin glue with a biodegradable scaffold. J Craniomaxillofac Surg 2003;31:27−33. 14. Kalantyrskaia MA, Romanenko GF. Diatomite treatment of late ulcerous dermal x-ray lesions. [Article in Russian]. Sov Med 1968;31:112–5. 15. Le TDH, Bonani W, Speranza G, Sglavo V, Ceccato R, Maniglio D, et al. Processing and characterization of diatom nanoparticles and microparticles as potential source of silicon for bone tissue engineering. Mater Sci Eng C Mater Biol Appl 2016;59:471−9. 16. Recinos G, Inaba K, Dubose J, Demetriades D, Rhee P. Local and systemic hemostatics in trauma: a review. Ulus Travma Acil Cerrahi Derg 2008;14:175–81. 17. Ong SY, Wu J, Moochhala SM, Tan MH, Lu J. Development of a chitosan-based wound dressing with improved hemostatic and antimicrobial properties. Biomaterials 2008;29:4323–32. 18. Gsponer NS, Spesia MB, Durantini EN. Effects of divalent cations, EDTA and chitosan on the uptake and photoinactivation of Escherichia coli mediated by cationic and anionic porphyrins. Photodiagnosis Photodyn Ther 2015;12:67–75. 19. Kim IY, Seo SJ, Moon HS, Yoo MK, Park IY, Kim BC, et al. Chitosan and its derivatives for tissue engineering applications. Biotechnol Adv 2008;26:1−21. 20. Dikme O, Ersoy G, Yilmaz O, Dikme O, Gokmen N, Ilyas K. The ef-

fect of application of local oxidised cellulose powder on hemostasis time in a rat model with femoral artery bleeding. Acta Medica Mediterr 2015;31:179–82. 21. Crofton A, Chrisler J, Hudson S, Inceoglu S, Petersen F, Kirsch W. Effect of Plasma Sterilization on the Hemostatic Efficacy of a Chitosan Hemostatic Agent in a Rat Model. Adv Ther 2016;33:268–81. 22. Zhang H, Shahbazi MA, Mäkilä EM, da Silva TH, Reis RL, Salonen JJ, et al. Diatom silica microparticles for sustained release and permeation enhancement following oral delivery of prednisone and mesalamine. Biomaterials 2013;34:9210−9. 23. Terracciano M, Shahbazi MA, Correia A, Rea I, Lamberti A, De Stefano L, et al. Surface bioengineering of diatomite based nanovectors for efficient intracellular uptake and drug delivery. Nanoscale 2015;7:20063−74. 24. Chao HH, Torchiana DF. BioGlue: albumin/glutaraldehyde sealant in cardiac surgery. J Card Surg 2003;18:500–3. 25. Kim KD, Wright NM. Polyethylene glycol hydrogel spinal sealant (DuraSeal Spinal Sealant) as an adjunct to sutured dural repair in the spine: results of a prospective, multicenter, randomized controlled study. Spine (Phila Pa 1976) 2011;36:1906–12. 26. Hoffmann NE, Siddiqui SA, Agarwal S, McKellar SH, Kurtz HJ, Gettman MT, et al. Choice of hemostatic agent influences adhesion formation in a rat cecal adhesion model. J Surg Res 2009;155:77−81. 27. Lan G, Lu B, Wang T, Wang L, Chen J, Yu K, et al. Chitosan/gelatin composite sponge is an absorbable surgical hemostatic agent. Colloids Surf B Biointerfaces 2015;136:1026−34. 28. Eryilmaz M, Ozer T, Menteş O, Torer N, Durusu M, Günal A, et al. Is the zeolite hemostatic agent beneficial in reducing blood loss during arterial injury? Ulus Travma Acil Cerrahi Derg 2009;15:7−11. 29. Acosta JA, Yang JC, Winchell RJ, Simons RK, Fortlage DA, Hollingsworth-Fridlund P, et al. Lethal injuries and time to death in a level I trauma center. J Am Coll Surg 1998;186:528−33. 30. Wang Y, Cai J, Jiang Y, Jiang X, Zhang D. Preparation of biosilica structures from frustules of diatoms and their applications: current state and perspectives. Appl Microbiol Biotechnol 2013;97:453–60.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Yeni bir hemostatik scaffold materyali ve kanama durdurmada fibrin çatı oluşumunun önemi: Deneysel sıçan çalışması Dr. İsmail Altıntop,1 Dr. Mehmet Tatlı,1 Dr. Zeynep Soyer,4 Dr. Arzu Hanım Yay,5 Dr. Ahmet Öztürk,3 Dr. Çiğdem Karakükçü2 Sağlık Bilimleri Üniversitesi Kayseri Eğitim ve Araştırma Hastanesi, Acil Tıp Anabilim Dalı, Kayseri Sağlık Bilimleri Üniversitesi Kayseri Eğitim ve Araştırma Hastanesi, Biyokimya Anabilim Dalı, Kayseri Erciyes Ünivrsitesi Tıp Fakültesi, Bioistatistik Anabilim Dalı, Kayseri 4 Erciyes Ünivrsitesi Hakan Çetinsaya Deneysel Araştırma Merkezi, Kayseri 5 Erciyes Ünivrsitesi Tıp Fakültesi, Histoloji ve Embiryoloji Anabilim Dalı, Kayseri 1 2 3

AMAÇ: Kanamayı kontrol etmek için farklı farmakolojik ajanlar geliştirilmekle birlikte; geliştirilen ajanların yara yerinde pıhtı oluşumunu tetiklemesi ve devam ettirmesi için vasokonstrüksiyon, koagülasyon ve scaffold (çatı) etkisi oluşturması önemlidir. Amacımız, cilt yarıkları, vücut dışı yaralanmalar, travmatik kesikler, kendiliğinden ya da cerrahi girişimler sonrası oluşan minör ve majör açık kanamaların durdurulması için kullanılacak ajanların kanama durdurucu özelliği yanında scaffold özelliğinin gösterilmesi amaçlanmıştır. GEREÇ VE YÖNTEM: Çalışmamız deneysel olarak sıçanlar üstünde yapıldı. Sıçanlarda oluşturulmuş femoral kanama modelimize kanama durdurucuların etkileri incelendi. Araştırmamızda kanama zamanı, scaffold oluşumu, histopatojik etki, SEM analizleri yapıldı. BULGULAR: Deney modelinde ağırlık kaybı kontrol grubunda ortalama 5.0±1.3 gr, kitosan grubunda ortalama 2.9±1.1 gr, PD grubunda ortalama 2.7±1.0 olarak tespit edildi. Deney öncesi ve sonrası ağırlık farkı için kontrol grubu ile kitosan ve PD grubu karşılaştırıldığında değişim istatistiksel anlamlı bulundu. Scaffold oluşumu incelenirken gruplar arası karşılaştırma yapıldı ve istatistiksel olarak anlamlı idi. Scaffold oluşumu kitosan grubunda 6 (%75) tam, 2 (%25) zayıf olarak tespit edildi. PD grubunda ise 7 (%87.5) tam scaffold oluşumu, 1 (%12.5) zayıf scaffold oluşumu tespit edildi. Scaffold oluşumu kontrol grubu ile kitosan ve PD grubu ile karşılaştırıldığında sonuç anlamlı idi (p=0.002). TARTIŞMA: Çalışmamızda PD ile oluşturulan scaffold; uygun bir gözeneklilik ve fibrin çatıya destek sağladığı ve kanamanın yeniden oluşmasını önlediğini ortaya koymuştur. PD’nin scaffold etkisi güçlüdür ve istatistiksel olarak anlamlı bulunmuştur. PD bileşiği kitosan kadar kanama durdurmada etkili bulunmuştur. PD’nin hisopatolojik olarak femoral bölgede hücrelerin ve damarların doğal yapısına zarar vermediği gösterilmiştir. Anahtar sözcükler: Diatomit; fibrin çatı; kanama durdurucu ajan; kitosan. Ulus Travma Acil Cerrahi Derg 2020;26(2):163-170

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EXPERIMENTAL STUDY

The effects of nitroglycerin in the zone of stasis in a rat burn model Metin Gündüz, M.D.,1 Tamer Sekmenli, M.D.,1 Ceyhan Uğurluoğlu, M.D.,2 İlhan Çiftçi, M.D.1 1

Department of Pediatric Surgery, Selçuk University Faculty of Medicine, Konya-Turkey

2

Department of Pathology, Selçuk University Faculty of Medicine, Konya-Turkey

ABSTRACT BACKGROUND: Studies evaluating the recovery of the zone of stasis is an important issue in burn research. In this study, we aimed to evaluate and compare the efficiency of an anti-ischemic and vasodilatory agent, a topical agent containing 2% nitroglycerin with 1% silver sulfadiazine, and bacitracin-neomycin sulfate in the zone of stasis histomorphologically and immunohistochemically. METHODS: We conducted an experimental study using 30 Wistar-Albino rats, each weighing 250–300 grams. The rats were divided randomly into five groups (six rats in each group). In this study, the “comb model,” which was deemed to be the most appropriate experimental model to produce an injury with predictable zones and was first described by Regas and Erhlich, was used. The following were applied to the zone of stasis after creating a burn model in 0, 24, and 48 hours: topical 2% nitroglycerin, 1% silver sulfadiazine, bacitracin-neomycin sulfate, and Vaseline-lanolin (sham). After 72 hours, biopsies were performed from the zone of stasis and evaluated by histomorphological and immunohistochemical CD 34 (expressed in human endothelial and hematopoietic cells) and D 2–40 (expressed in the endothelium of lymphatic capillaries) methods. The results were evaluated using the chi-square test. RESULTS: Compared with the other groups, a statistically significant difference was found in edema, inflammation, and vascular proliferation in the nitroglycerin group. Significantly more intense staining for CD 34 was found in the nitroglycerin group compared with the other groups. Immunohistochemical staining for D 2-40 was also found statistically significant in the nitroglycerin group (p<0.05). CONCLUSION: A topical containing 2% nitroglycerin increases vascular proliferation in the zone of stasis affects the recovery and may be used as a new agent in burn injury treatment. Keywords: Burn injury; nitroglycerin; the zone of stasis.

INTRODUCTION Studies evaluating the recovery of the zone of stasis are an important issue in burn research. According to Jackson’s model, based on the severity of thermal injury destruction and blood flow alterations, three distinct zones of tissue injury are known.[1] The zone of coagulation is at the center of the wound without living tissue. Altough the zone of stasis is ischemic due to capillary vasoconstruction, it is vital. The outer periphery of the burn wound is the zone of hyperemia, with increased blood perfusion mediated by local inflammatory responses.[2] The tissue in this zone usually re-

covers completely unless complicated by infection or severe hypoperfusion. In the zone of stasis, blood flow is impaired on the first day of the burn, and the depth of burn necrosis might be decreased by preventing progressive capillary stasis in the early post-burn hours.[3,4] The most common topical agents being used in wound care for burned patients to delay wound colonization are 1% silver sulfadiazine and bacitracin neomycin pomade.[5] A topical agent containing 2% nitroglycerin induces a local vasodilatory response in dermal vessels. [6,7] In the present study, we aimed to evaluate and compare the efficiency of an anti-ischemic and vasodilatory agent, a topical agent containing 2% nitroglycerin with 1% silver sulfa-

Cite this article as: Gündüz M, Sekmenli T, Uğurluoğlu C, Çiftçi İ. The effects of nitroglycerin in the zone of stasis in a rat burn model. Ulus Travma Acil Cerrahi Derg 2020;26:171-177. Address for correspondence: Metin Gündüz, M.D. Selçuk Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, 42131 Konya, Turkey Tel: +90 332 - 241 21 81 E-mail: drmetingunduz@yahoo.com Ulus Travma Acil Cerrahi Derg 2020;26(2):171-177 DOI: 10.14744/tjtes.2019.00005 Submitted: 10.05.2018 Accepted: 04.02.2019 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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diazine, and bacitracin-neomycin sulfate in the zone of stasis histomorphologically and immunohistochemically. We anticipated the anti-ischemic and vasodilatory effects of 2% nitroglycerin could prevent the zone of stasis and could be a new agent in clinical use.

MATERIALS AND METHODS The study protocol was approved by the Selçuk University Medical Faculty Ethics Committee (2015/85-29/09/2015) and founded by the Selçuk University Research Projects Fund Committee (16401032-07/10/2015). Thirty Wistar-Albino rats, each weighing 250–300 grams, were used. They were caged in a controlled environment of 22 °C with 12 hours of light and dark cycles. Standard rat laboratory feed and water were provided. All animals in the present study received humane care in compliance with the Guide for the Care and Use of Laboratory Animals published by the Ethics Council. General anesthesia was induced with intraperitoneal ketamine 500 mg (Ketalar 500 mg Pfizer) at 50 mg/kg and 2% xylazine (Xylazinbo 2% Bioveta). The entire backs of the rats were shaved, and the procedure for creating a “comb burn” model, which was deemed to be the most appropriate experimental model to produce an injury with predictable zones and was first described by Regas and Erhlich, was used.[8] In this model, a probe, consisting of four rows (10 mm x 20 mm) and three interspaces (5 mm x 20 mm), was immersed in boiling water for five minutes for thermal equilibrium and was held for 20 seconds without applying pressure on the back of the rat 5 mm lateral to the midline (Fig. 1a). By this model, we also tried to protect the agent itself from disappearing, oozing away using touching around and licking. They were divided randomly into five groups with six rats in each group (control, Vaseline-lanolin (sham), bacitracin-neomycin sulfate, 2% nitroglycerin, and silver sulfadiazine 1%, respectively). Topical agents containing 2% nitroglycerin, 1% silver sulfadiazine, bacitracin-neomycin sulfate, and Vaseline-lanolin (sham) were applied until covering the surface of the burn area, including the zone of stasis, after creating a burn model

(a)

in 0, 24, and 48 hours we did not use overlying dressing. One rat died in Group 3 (bacitracin-neomycin sulfate) 48 hours later. After 72 hours, the rats were sacrificed under general anesthesia; then biopsies were performed from the zone of stasis (Fig. 1b) and evaluated by histomorphological (edema, congestion, inflammation, and vascular proliferation) and immunohistochemical CD 34 (expressed in human endothelial and hematopoietic cells) and D 2-40 (expressed in the endothelium of lymphatic capillaries) methods. Histomorphological and immunohistochemical analyses were performed in all cases on formalin-fixed, paraffin-embedded tissues. Serial sections (4µ) from the zone of stasis were cut and used for hematoxylin-eosin and immunohistochemistry. An immunohistochemistry technique following the protocol was used to characterize the CD 34 and D 2-40 tissue activity in the cells according to the manufacturer’s instructions. CD 34 (Anti-Human CD34 Monoclonal Antibody [Endothelial Cell], BioGenex, the Netherlands) staining is specifically used to evaluate the number of vessels and vascularization. D 2-40 (FLEX Monoclonal Mouse Anti-Human Podoplanin Clone D2-40, Dako, Denmark) is expressed in the endothelium of lymphatic capillaries. A Carl Zeiss AXIO imager A1 microscope was used, and the pathologist was blinded. Brown-colored staining was considered a positive in both for CD 34 and D 2-40 antibodies. All parameters were graded based on the scale of absent:0, weakly positive:1, moderate:2, and strongly positive:3, retrospectively as Kayapınar et al.,[9] Kukreja et al.,[10] and Salzman et al.[11] described. The results were evaluated using the chi-square test. We used the statistical software package SPSS version 19.0 for statistical analyses. A p-value of <0.05 was considered statistically significant.

RESULTS Histological parameters in hematoxylin-eosin stained tissues included edema, congestion, inflammation, and vascular proliferation. Comparing in all groups group (control, Vaselinelanolin (negative control-sham), bacitracin-neomycin sulfate, 2% nitroglycerin, and silver sulfadiazine %1) in the zone of

(b)

Figure 1. “Comb burn” model was created, the zone of stasis is seen. (a) The zone of stasis. (b) The zone of stasis biopsies taken from.

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(a)

(b)

(d)

(e)

(c)

Figure 2. Staining with hematoxylin-eosin, 10x10, vascular proliferation was seen higher in Group 4 (2% nitroglycerin). (a) Control, (b) sham, (c) bacitracin neomycin sulfate, (d) topical %2 nitroglycerin, (e) silver sulfadiazine.

stasis, vascular proliferation was determined to be significantly higher in Group 4 (2% nitroglycerin) (p<0.05) (Fig. 2). Inflammation was seen in all groups, but in Group 4 (2% ni-

troglycerin), it was strongly positive (p<0.05). Edema was also significantly higher in Group 4 (2% nitroglycerin) (Table 1). No difference was found in congestion.

Table 1. Histomorphologic evaluation and scoring system

Group 1 Group 2 Group 3 Group 4 Group 5 (n=6) (n=6) (n=5) (n=6) (n=6)

p

Edema Absent

4 3 2 0 0 0.002

Weakly positive 2 3 3 0 3 Moderate

0 0 0 1 3

Strongly positive 0 0 0 5 0 Congestion Absent

2 0 1 0 0 0.121

Weakly positive 4 5 2 2 5 Moderate

0 1 2 2 1

Strongly positive 0 0 0 2 0 Inflammation Absent

Weakly positive

Moderate

4 1 1 0 1 0.004 2

4

2

0

5

0 1 2 3 0

Strongly positive 0 0 0 3 0 Vascular proliferation Absent

5 3 0 0 1 0.001

Weakly positive 1 0 2 0 5 Moderate

0 3 2 1 0

Strongly positive 0 0 1 5 0 n: Number of biopsies taken from each rat. Absent, weakly positive, moderate, and strongly positive were graded as 0, 1, 2, and 3 retrospectively.

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(a)

(b)

(d)

(e)

(c)

Figure 3. Staining with CD34, 20x10, vascular proliferation was seen higher in Group 4 (2% nitroglycerin). (a) Control, (b) sham, (c) bacitracin neomycin sulfate, (d) topical %2 nitroglycerin, (e) silver sulfadiazine.

In immunohistochemical evaluation compared with other groups, staining with CD 34 was strongly positive in Group 4 (2% nitroglycerin) (p<0.05) (Fig. 3). Comparing with other groups, D 2-40 staining was also significantly higher in Group 4 (2% nitroglycerin) (p<0.05) (Fig. 4, Table 2).

DISCUSSION Recovery in the zone of stasis is possible due to preventing necrosis in burned tissue.[12] Inflammatory reaction, the proliferative process, and tissue remodeling are the basic parts of acute wound healing. The reconstitution of the dermis includes new blood vessel formation and angiogenesis that

(a)

(b)

(d)

(e)

involves a phenotypic alteration of endothelial cells.[13] Several studies were performed to evaluate the zone of stasis. In an experimental study, intraperitoneal and oral N-acetylcysteine (NAC) administration were used in treatment groups, and the possible saving the effect of NAC on the zone of stasis was shown.[14] Wang et al.[15] studied oxidative stress in the comb burn model. They applied a lotion that consists of two components EDTA disodium as the active, chelating agent and methyl sulfonyl methane as a permeation enhancer every eight hours for three days. Burn progression was protected by this lotion in their report. Different from the present study, they evaluated an antioxidant agent’s effect.

(c)

Figure 4. Staining with D2-40 10x10, lymphatic proliferation was seen higher in Group 4 (2% nitroglycerin). (a) Control, (b) sham, (c) bacitracin neomycin sulfate, (d) topical %2 nitroglycerin, (e) silver sulfadiazine.

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Table 2. Immunohistochemical evaluation and scoring system

Group 1 Group 2 Group 3 Group 4 Group 5 (n=6) (n=6) (n=5) (n=6) (n=6)

p

CD34 Absent

1 5 0 0 0 0.001

Weakly positive 5 0 2 0 6 Moderate

0 1 1 0 0

Strongly positive 0 0 2 6 0 D2-40 Absent

3 1 0 0 1 0.002

Weakly positive 3 3 1 0 4 Moderate

0 2 0 0 0

Strongly positive 0 0 4 6 1 n: Number of biopsies taken from each rat. Absent, weakly positive, moderate, and strongly positive were graded as 0, 1, 2, and 3 retrospectively.

The physiologic anticoagulant activated protein C was administered intravenously after two hours of burn induction in a rat model. Blood-flow measurements with laser Doppler flowmetry in the activated protein C–treated group were shown to be significantly higher on the third-day post-burn in their study.[12] Similar to the present study, activated protein C improved the perfusion of the zone of stasis but in a different mechanism. Türkaslan et al.[16] reported the effects of hyperbaric oxygen treatment in recovering the zone of stasis. Hyperbaric oxygen treatments were administered at 2.5 atmospheres for 90 minutes twice a day for one day on the first day in the first group and five days in the second group. According to their results, hyperbaric oxygen treatment stops the progression of the zone of stasis in necrosis in the first 24 hours. Our results also support neo-angiogenesis. The effects of a topical antiseptic agent, cerium nitrate, which also reduce the alarm cytokine levels, macromolecular leakage, and decreases leukocyte activation, were evaluated in the zone of stasis following the burn. Rats were kept in basins filled with 0.09% saline and cerium nitrate for the control and treatment groups, respectively. They reported the prevention of progressive tissue necrosis in the zone of stasis by cerium nitrate bathing. The viability of the zone of stasis was assessed with 99-m Tc-sestamibi scintigraphy.[17] Kayapınar et al.[9] injected melatonin intraperitoneally for seven days after creating a burn comb model in rats. Due to its antioxidant effect, melatonin showed favorable results in saving the zone of stasis in their study. A different mechanism was observed in our study to prevent the stasis zone. Firat et al.[18] applied β-glucan, which has immunomodulatory and antioxidant effects, to the zone of stasis and pointed to Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

its efficacy. They compared treatment with β-glucan ± topical pomade with no treatment and topical treatment alone (bacitracin-neomycin sulphate) in the comb burn model. Severe inflammation and edema were also seen. The vasodilator effect of 2% nitroglycerin may have increased edema and inflammation in our study. Treatment with recombinant tissue–type plasminogen activator in rats also demonstrated the benefits of saving the zone of stasis in burns.[19] Results were due to its fibrinolytic effects, which constituted a different way of protecting the stasis zone. Topical nitroglycerin is being used in the treatment of anal fissures and is recommended as an alternative treatment option to surgery.[20] Differently, to prevent tissue necrosis in the zone of stasis, we hypothesized that a topical agent containing 2% nitroglycerin should decrease it by affecting a vascular response and improve blood supply. Several studies reported the effects of nitroglycerin in the dermal vasculature. For evaluation of early post-burn ischemic necrosis of the skin, Tagkalakis et al.[21] investigated the effects of 0.4% nitroglycerin ointment in comparatively to no application and placebo in an experimental study. Experimental burn model, evaluation with laser Doppler at 15, 30, 45, 60, 120 and 180 minutes after preparation application, and percentage of nitroglycerin ointment were the differences. As in the present study, the use of 0,4% nitroglycerin ointment improved perfusion.[21] Gorman et al.[22] compared topical nitroglycerin and flurbiprofen in the rat comb model. Differently from the present study, they had four rats each in the 5% flurbiprofen group and 2% nitroglycerin group. Also, they excised specimens after 24 hours. The 2% nitroglycerin–treated rats demonstrated full 175

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patency of the interspatial dermal blood vessels. We showed significant vascular proliferation in the 2% nitroglycerin group. Additionally, three days of the treatment may provide greater clinical effects. Yregård et al.[23] investigated the effects of topical local anaesthetics on the inflammatory cascade of a burn wound in vivo. They covered the experimental burn area with lidocaine/ prilocaine cream and evaluation was performed after two hours. Improved circulation in the postburn area was shown due to the inhibitory effects of the local anesthetic cream on thromboxane release. Supporting our results, Kleydman et al.[7] mentioned the improvement of flow in the dermal vasculature after soft tissue augmentation by the use of a nitroglycerin paste. Davis et al.[24] compared topical anti-ischemic agents in the salvage of failing random-pattern skin flaps in rats. They used nifedipine, trolamine-salicylate, nitroglycerin, a trolamine-salicylate nitroglycerin combination, and a nifedipine trolaminesalicylate nitroglycerin combination as topical agents. They suggested that these anti-ischemic agents are effective in reducing the ischemic necrosis of failing, random-pattern skin flaps. Although the experimental model was different, the main effect and results of these agents were similar to our hypothesis and results. In an experimental study, botulinum toxin A and nitroglycerin increased flap viability on random skin flaps.[25] Topical nitroglycerin was also used in the management of tissue ischemia in mastectomy skin flaps, and as in our study, improvement in perfusion was shown but differently by angiography.[26] We aimed to limit the progression of necrosis and to salvage the zone of stasis. Prevention from infection is an important factor in burn recovery.[5] Additionally, as mentioned above, there are many agents for salvaging the zone of stasis in the burn as antioxidants, immunomodulators, anticoagulants, anti-inflammatories, fibrinolytics, and hyperbaric oxygen treatment. Inflammation, reepithelialization, fibroplasia, and angiogenesis are the processes of wound healing.[13] The topical containing 2% nitroglycerin in the present study can be applied easily. By a different route, vascular and lymphatic proliferation due to 2% nitroglycerin was shown in our study. Improving the blood supply in the stasis zone reduces necrosis. Different from other agents, such as melatonin, recombinant tissue-type plasminogen activator, topical 2% nitroglycerin can be applied easily. Also, further studies evaluating the effects of topical 2% nitroglycerin at later times as days 10 and 14 may enlarge and support our hypothesis. While generalizing the comb burn model to human burns, the effects of probe rows are similar to body surface that directly contacts with burn agent. Also, interspaces of the probe are similar to the surrounding area of the contacted body. The effects of many agents in different mechanisms like topically 176

applied metal chelators,[15] β-glucan[18] were used in the comb burn model. Those agents are not being used in humans. Although topical nitroglycerin has a similar limitation in burns and needs further studies, it can be used in anal fissure treatment in humans.[20] Another limitation is the side effects like headache, dizziness, faintness, and various allergic reactions, such as itching; swelling of the lips, throat, or tongue; and difficulty in breathing are the side effects of topical 2% nitroglycerin.[27] Different from the present study, results may differ in studies, including overlying dressing.

Conclusion This study demonstrated the increase of vascular proliferation due to topical 2% nitroglycerin in the zone of stasis in the burn, which could possibly affect recovery and should be studied in future clinical trials. Funding: This study was funded by the Selçuk University Research Projects Fund Committee (16401032-07/10/2015). Ethics Committee Approval: This study protocol was approved by the Selçuk University Medical Faculty Ethics Committee (2015/85-29/09/2015). Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: M.G., İ.Ç.; Design: M.G., T.S., C.U., İ.Ç.; Supervision: M.G.; Fundings: M.G., T.S., C.U., İ.Ç.; Materials: M.G., T.S., C.U.; Data: M.G., C.U.; Analysis: M.G., C.U., İ.Ç.; Literature search: M.G.; Writing: M.G.; Critical revision: M.G., İ.Ç. Conflict of Interest: None declared. Financial Disclosure: Selçuk University Research Projects Fund Committee (16401032-07/10/2015).

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Gündüz et al. The effects of nitroglycerin in the zone of stasis in a rat burn model sis in burns with melatonin: an experimental study in rats. Ulus Travma Acil Cerrahi Derg 2015;21:419–24. 10. Kukreja I, Kapoor P, Deshmukh R, Kulkarni V. VEGF and CD 34: A correlation between tumor angiogenesis and microvessel density-an immunohistochemical study. J Oral Maxillofac Pathol 2013;17:367–73. 11. Salzman R, Stárek I, Kučerová L, Skálová A, Hoza J. Neither expression of VEGF-C/D nor lymph vessel density supports lymphatic invasion as the mechanism responsible for local spread of recurrent salivary pleomorphic adenoma. Virchows Arch 2014;464:29–34. 12. Nisanci M, Eski M, Sahin I, Ilgan S, Isik S. Saving the zone of stasis in burns with activated protein C: an experimental study in rats. Burns 2010;36:397–402. 13. Li J, Chen J, Kirsner R. Pathophysiology of acute wound healing. Clin Dermatol 2007;25:9–18. 14. Deniz M, Borman H, Seyhan T, Haberal M. An effective antioxidant drug on prevention of the necrosis of zone of stasis: N-acetylcysteine. Burns 2013;39:320–5. 15. Wang CZ, Ayadi AE, Goswamy J, Finnerty CC, Mifflin R, Sousse L, et al. Topically applied metal chelator reduces thermal injury progression in a rat model of brass comb burn. Burns 2015;41:1775−87. 16. Türkaslan T, Yogun N, Cimşit M, Solakoglu S, Ozdemir C, Ozsoy Z. Is HBOT treatment effective in recovering zone of stasis? An experimental immunohistochemical study. Burns 2010;36:539–44. 17. Eski M, Ozer F, Firat C, Alhan D, Arslan N, Senturk T, et al. Cerium nitrate treatment prevents progressive tissue necrosis in the zone of stasis following burn. Burns 2012;38:283−9. 18. Firat C, Samdanci E, Erbatur S, Aytekin AH, Ak M, Turtay MG, et al. β-Glucan treatment prevents progressive burn ischaemia in the zone of stasis and improves burn healing: an experimental study in rats. Burns

2013;39:105–12. 19. Işik S, Sahin U, Ilgan S, Güler M, Günalp B, Selmanpakoğlu N. Saving the zone of stasis in burns with recombinant tissue-type plasminogen activator (r-tPA): an experimental study in rats. Burns 1998;24:217–23. 20. Ehrenpreis ED, Rubin DT, Ginsburg PM, Meyers JS. Treatment of anal fissures with topical nitroglycerin. Expert Opin Pharmacother 2001;2:41–5. 21. Tagkalakis P, Dionyssopoulos A, Karkavelas G, Demiri E. Topical use of Rectogesic® and Emla® to improve cutaneous blood perfusion following thermal injury. A comparative experimental study. Ann Burns Fire Disasters 2015;28:134–41. 22. Gorman PJ, Saggers G, Ehrlich P, Mackay DR, Graham WP 3rd. Effects of topical nitroglycerin and flurbiprofen in the rat comb burn model. Ann Plast Surg 1999;42:529−32. 23. Yregård L, Cassuto J, Tarnow P, Nilsson U. Influence of local anaesthetics on inflammatory activity postburn. Burns 2003;29:335–41. 24. Davis RE, Wachholz JH, Jassir D, Perlyn CA, Agrama MH. Comparison of topical anti-ischemic agents in the salvage of failing random-pattern skin flaps in rats. Arch Facial Plast Surg 1999;1:27–32. 25. Ghanbarzadeh K, Tabatabaie OR, Salehifar E, Amanlou M, Khorasani G. Effect of botulinum toxin A and nitroglycerin on random skin flap survival in rats. Plast Surg (Oakv) 2016;24:99–102. 26. Sanniec K, Teotia S, Amirlak B. Management of Tissue Ischemia in Mastectomy Skin Flaps: Algorithm Integrating SPY Angiography and Topical Nitroglycerin. Plast Reconstr Surg Glob Open 2016;4:e1075. 27. Salari M, Salari R, Dadgarmoghadam M, Khadem-Rezaiyan M, Hosseini M. Efficacy of egg yolk and nitroglycerin ointment as treatments for acute anal fissures: A randomized clinical trial study. Electron Physician 2016;8:3035–41.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Sıçanlarda deneysel yanık modelinde oluşan staz zonunda nitrogliserinin etkisi Dr. Metin Gündüz,1 Dr. Tamer Sekmenli,1 Dr. Ceyhan Uğurluoğlu,2 Dr. İlhan Çiftçi1 1 2

Selçuk Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Konya Selçuk Üniversitesi Tıp Fakültesi, Patoloji Anabilim Dalı, Konya

AMAÇ: Yanıkta direkt termal etkiyle doku ölümü dışında dermal vasküler oklüzyon ve akut tromboz görülür. Jackson tarafından termal yanığın başlangıcında ortaya çıkan koagülasyon, staz ve hiperemi zonlarında oluşan yanık modeli tariflenmiştir. Bu çalışmada antiiskemik ve vazodilatör etkinliği olan %2 nitrogliserin staz bölgesine uygulanarak rutin tedavide kullanılan gümüş sulfadiyazin %1 krem ve basitrasin-neomisin pomad ile karşılaştırılarak yanık tedavisinde etkinliği ve kullanılabilirliğinin histomorfolojik ve immünhistokimyasal olarak değerlendirilmesi amaçlandı. GEREÇ VE YÖNTEM: Çalışmamızda beş gruptan oluşan 30 adet sıçan kullanıldı. Grup 1; kontrol, 2; sham, 3; basitrasin-neomisin sülfat, 4; %2 nitrogliserin ve 5; gümüş sülfadiazin %1 olarak oluşturuldu. ‘Comb’ yöntemiyle yanık oluşturulup 0, 24 ve 48. saatlerde bu bölgelere lokal olarak vazelin-lanolin, basitrasin-neomisin sülfat, %2 nitrogliserin ve gümüş sülfadiazin %1 uygulanıp 72. saate patolojik değerlendirme için biyopsi alındı. Alınan materyaller uygun şekilde saklanıp histomorfolojik ve CD 34 ve D 2-40 immün boyaları ile boyanarak vasküler ve lenfatik yapılar immünohistokimyasal olarak değerlendirildi. BULGULAR: Histopatolojik incelemelerde %2 nitrogliserin uygulanan grupta diğer gruplarla karşılaştırıldığında ödem, enflamasyon ve vasküler proliferasyonda istatistiksel olarak anlamlı artış saptandı. TARTIŞMA: İskemik olan staz zonunda topikal %2 nitrogliserinin vasküler proliferasyonu artırdığı gözlenmiş olup yanık tedavisinde etkinliğinin olabileceği gösterilmiştir. Anahtar sözcükler: Nitrogliserin; staz zonu; yanık. Ulus Travma Acil Cerrahi Derg 2020;26(2):171-177

doi: 10.14744/tjtes.2019.00005

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ORIGIN A L A R T IC L E

A new technique in the evaluation of strangulated and incarcerated hernias: Near-infrared spectroscopy Murat Ziyan, M.D.,1 Asım Kalkan, M.D.,2 Özlem Bilir, M.D.,1 Deniz Özel, M.D.,3 Özlem Uzun, M.D.,4 Semih Korku, M.D.5

Gökhan Ersunan, M.D.,1

1

Department of Emergency Medicine, Recep Tayyip Erdoğan University Faculty of Medicine, Rize-Turkey

2

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

3

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

4

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

5

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

ABSTRACT BACKGROUND: The present study aims to investigate the usefulness of NIRS in identifying decreased blood flow in intestinal tissue inside the hernial sac in incarcerated hernias. METHODS: Forty patients with manually irreducible inguinal hernias and with ileus determined by clinical findings and imaging were included in this study. Patients’ intestinal oxygenatıons were measured by placing NIRS probes over the areas of inguinal hernia and over non-herniated areas immediately lateral to these. Differences in oxygenation between normal and herniated areas were evaluated. RESULTS: Forty patients, 14 women (35.0%) and 26 (65.0%) men, with a mean age of 65±14, were enrolled in this study. Intestinal oxygenation was lower in areas of irreducible hernia compared to normal regions (p<0.001). Incarceration and/or strangulation were detected when hernial sacs with low intestinal oxygenation were operated on. Low NIRS measurements were able to identify incarceration and/or strangulation in the intestine but were unable to distinguish between them. CONCLUSION: In conclusion, in the light of the findings of this study, although not capable of differentiating incarceration from strangulation, NIRS appears to be a good method for showing impaired intestinal oxygenation. NIRS can be used to support ultrasonography findings in irreducible hernias. Therefore, this technique could be used in the future to evaluate and monitor intestinal oxygenation in the Emergency Department. Keywords: Intestinal oxygenation; irreducible inguinal hernia; oximetry.

INTRODUCTION Hernia is defined as an internal or other organ extending through the muscle tissue anterior to it and protruding from the abdominal wall. The protrusion of the intestines through the inguinal canal is known as inguinal hernia. Incarceration is defined as the impossibility of returning the intestines protruding through the abdominal wall back inside the abdomen (irreducible hernia). Impaired blood flow in the incarcerated intestine is known as a strangulated hernia (Fig. 1). Necrosis

may also occur in the intestinal wall in association with impaired blow flow in the event of strangulation. Irreducible hernias of the intestinal wall represent an important proportion of cases presenting at the Emergency Department due to abdominal pain. Emergency surgery due to incarceration and obstruction may be required in 5–13% of the patients with an abdominal wall hernia. In addition, resection is required due to necrosis in 10–15% of the cases of the strangulated abdominal wall hernia. The fundamental problem in incarcerated hernias is whether ischemia will develop in the intesti-

Cite this article as: Ziyan M, Kalkan A, Bilir Ö, Ersunan G, Özel D, Uzun Ö, et al. A new technique in the evaluation of strangulated and incarcerated hernias: Near-infrared spectroscopy. Ulus Travma Acil Cerrahi Derg 2020;26:178-185. Address for correspondence: Asım Kalkan, M.D. Okmeydanı Egitim ve Araştırma Hastanesi, Acil Tip Kliniği, 34384 Şişli, İstanbul, Turkey Tel: +90 212 - 314 55 55 E-mail: drasimkalkan@hotmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):178-185 DOI: 10.14744/tjtes.2019.72627 Submitted: 14.11.2018 Accepted: 21.05.2019 Online: 02.03.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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Intestines

Intestines

Intestines Strangulated hernia (Impaired blood flow in the incarcerated intestine)

Hernial sac (intestines can easily be pushed in manually

Abdominal wall

Incarcerated hernia sac (it is impossibil of returning the intestines protruding though the abdominal wall

Necrosis in the intestinal wall

Abdominal wall

Figure 1. Anatomical descriptions of the normal hernial sac, incarcerated hernia and strangulated hernia.

nal tissue that cannot be returned back inside the abdomen. The basic treatment in both incarceration and strangulation is surgical abdominal wall repair involving returning the intestinal tissue within the hernial sac inside the abdomen. Since necrosis occurs in the intestines in strangulation, this region requires resection, which gives rise to increased morbidity and mortality in strangulated hernias.[1] Near-infrared spectroscopy (NIRS) has a wide range of scientific applications, from agriculture to medicine. While in medical terms, NIRS is more concerned with cerebral oxygenation, in recent years, it has begun to be used to assess oxygenation of all tissues. Although there have been many studies of brain tissue oxygenation, the use of NIRS in assessing oxygenation of the intra-abdominal organs and intestines is particularly noteworthy.[2–6] In an experimental study by Gay et al.,[7] which evaluated oxygenation of the intra-abdominal organs and intestines in piglets using NIRS, reduced blood flow was reported in the intestine and intra-abdominal organs in animals with induced hemorrhagic shock. No significant difference was determined between invasive methods and NIRS measurements. The authors concluded that NIRS probes attached to the anterior abdominal wall of the animals assessed the oxygenation of intra-abdominal organs and intestines as effectively as invasive methods. Various studies of large intestinal wall ischemia, or necrotizing enterocolitis, have reported that NIRS measurements from the anterior abdominal wall are useful in predicting the development of necrotizing enterocolitis.[3,8,9] These studies have essentially been based on determining a decrease in blood flow to the intestines. Bozzetti et al.[10] compared Doppler ultrasound and NIRS measurements concerning blood flow in the mesenteric artery, the artery supplying the intestines. Newborn infants, with immature intestines, are known to be predisposed to necrotizing enterocolitis. Studies emphasizing the importance of monitoring intestinal oxygenation have compared intestinal blood flow before and after oral nutrition using NIRS and have maintained that NIRS is useful for that purpose. In a previous experimental animal study by the current study authors, NIRS was used to evaluate intestinal oxygenation. Measurements of intestinal oxygenation were taken from the abdominal anterior wall at specific intervals in Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

animals following ligation of the mesenteric arteries providing blood supply to the intestines. Lower intestinal oxygenation was determined compared to pre-mesenteric artery ligation values and compared to healthy animals.[11] Although ultrasonography can be used to assess oxygenation in the hernia sac in incarcerated hernias, it has 74.5% specificity and 92% sensitivity. In addition, ultrasonographic findings may vary depending on the experience of the operator.[12–14] Therefore, there is a need for additional methods capable of supporting other techniques in the determination of oxygenation of intestinal tissue in incarcerated hernias and of corroborating hypoxia findings. In the light of the above research, the basic aim of this study was to investigate the usefulness of NIRS in identifying decreased blood flow in intestinal tissue inside the hernial sac in incarcerated hernias.

NIRS Recent years have witnessed significant use of photonic technologies to assist the medical and biological investigation of a range of different organisms (including cells, small animals, and humans). Spectroscopy and biological tissue imaging now provide a broad sphere of application for light-based technologies. The concept of light usually refers to the visible (400–700 nm, VIS) and near-infrared (700–2000 nm, NIR) areas of the spectrum. In common with numerous other materials, biological tissues are opaque to VIS and NIR light due to factors, including light absorption and dispersion. These phenomena derive from frequency changes exhibiting dielectric characteristics taking place at the microscopic level. Light absorption is partly caused by the presence of chromophores, including hemoglobin, water, fats, and collagen, in biological tissues. Light dispersion is affected by the shape and size of cells and intracellular structures (including nuclei, and mitochondria). Light dispersion in a specific tissue is thus determined by the effects of absorption and scattering. Light dispersion values range between 5 and 30 cm in the VIS and NIR spectrum range, but absorption values are very much lower, at 0.02–2 cm-1, meaning that biological tissues are regarded as light-dispersive. Hemoglobin exhibits a high absorption co179

Ziyan et al. A new technique in the evaluation of strangulated and incarcerated hernias: NIRS

efficient at short wavelengths (<600 nm), and water a high coefficient at longer wavelengths (>1100 nm), meaning that light can only penetrate tissue by a few millimeters. Light absorption in therapeutic and diagnostic ranges (650–850 nm) is usually very low (<0.2 cm-1), limiting the tissue-penetrating capacity of light. Optic mammography and muscle and brain oximetry capable of deep and non-invasive tissue examination are therefore used in medical procedures.[15] The significant attenuation of NIR light occurring in biological tissue results from hemoglobin, a chromophore, in small vessels (<1 mm in diameter) of the microcirculation, such as capillary, arteriolar and venous beds. Since vessels >1 mm in diameter absorb light completely, NIRS exhibits low sensitivity to these. The arterial compartments contain 30% of the blood in the human brain, and NIRS basically measures changes in oxygenation in venous blood.[16]

Oximeters INVOS-5100c (INVOS 5100c Covidien, Boulder, CO, USA) The terms diffuse optical spectroscopy (DOS) and diffuse optical imaging (DOI) refer to methodologies using VIS and NIR to examine diffusive environments in biological tissues in a non-invasive manner. In DOS measurement, light is typically transmitted to and collected from the sample using optical fibers (optodes), or otherwise, by placing light sources and detectors in direct contact with the tissue under examination. The simplest DOS measurement configuration is the transmittance state, in which the injection and collection fibers are installed on opposite surfaces. The reflectance-mode exploits that due to scattering, light is highly diffused in the sample volume, and DOS measurements can be made by placing a pair of optic fibers on the same surface of the tissue a few centimeters apart. For DOI, several injection and collection fibers permit topographic or tomographic procedures in a regularly spaced arrangement.[17] Three different DOS/DOI applications can be performed, independently of the measurement geometry: 1) Continuous-wave (CW) DOS/DOI uses a quadrature state light source (such as a light-emitting diode or continuous intensity laser) capable of modulation to a low frequency (several kHz) using the attenuator in phase-locked detection techniques and a detection device sensitive to light weakening changes (photodiode), 2) Frequency domain (FD) DOS/DOI is based on amplitudemodulated light sources (at 100 MHz or higher frequencies or up to ~1 GHz) and detection of light modulation and demodulation phase changes, 3) Time domain (TD) DOS/DOI uses a pulsed light source. It typically uses a laser providing a light pulse lasting a few 180

picoseconds and a sub-nanosystem scale with a temporal resolution detection device.[18] The INVOS-5100c CW procedure used in the current study used a single light source and near-field detectors. Spatiallyresolved NIR evaluated the scattering components of light attenuation and permitted an absolute evaluation of the total hemoglobin ratio expressed as the percentage of Hb02 (oxyhemoglobin) oxygen saturation.[4,19] As a general rule, photons are dispersed by passing through a ‘banana-shaped’ area, and the depth of their penetration is directly proportional to the distance of the source-detector. The INVOS 5100 device (Somanetics/Covidien, Mansfield, USA) measures the tissue oxygenation percentage known as the total oxygen index (TOI). It also permits the evaluation of fractional tissue oxygen extraction (FTOE), the balance between the oxygen to be used by the tissue and the delivery of that oxygen.[20,21] This value is expressed as a percentage representing saturation. In the current study, intestinal oxygenation inside the hernial sac was compared with measurements from the normal abdominal region in the same patient. Comparisons were also made of the hernial sac measurements and normal region measurements in all patients.

MATERIALS AND METHODS Study Design Following approval from the local Ethics Committee, this study was performed in the Emergency Department (ED) of the Recep Tayyip Erdogan University Training and Research Hospital between January 2013 and October 2014. This ED is in a tertiary healthcare institution serving a mean 150,000 patients a year on the basis of existing conditions and criteria in Turkey.

Patients Age, gender, additional disease and number of hours of pain in patients presenting at the ED were recorded at the time of presentation. The patient group enrolled in this study consisted of patients with a manually irreducible abdominal wall hernia. Inclusion criteria were age >18 years, location of the hernial sac in the abdominal wall, that the hernia was manually irreducible, and findings of ileus, strangulation or incarceration on radiographic imaging (direct abdominal radiography in the standing position or supported by ultrasonography). Patients aged <18 years, morbidly obese patients and patients for whom radiological images did not support strangulation or incarceration were excluded from this study. Patients with hyperbilirubinemia were also excluded from this study since Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

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surements were recorded, and the differences between them were subjected to statistical analysis.

Statistical Analysis Descriptive statistics were expressed as frequency, percentage, mean, standard deviation and median, maximum and minimum values. The Mann-Whitney U test and Independent Samples t-test were used for the analysis of differences between measurement values in the comparison of normal NIRS, hernial NIRS and delta values in the strangulated and incarcerated groups. The Paired t-test was used for the analysis of differences between dependent variables in the comparisons of normal and hernial NIRS values. Receiver Operating Characteristics (ROC) analysis was performed for the calculation of sensitivity, specificity and area under the curve (AUC) values of specific variables for the differentiation of patients with incarceration/strangulation. A value of p<0.5 was accepted as statistically significant. Analyses were performed on SPSS 18.00 (SPSS, Chicago, IL, USA) software.

Figure 2. Measurements performed by attaching the NIRS probes above the inguinal hernial sac and to the healthy abdominal region.

this might affect NIRS measurements. A total of 70 patients with abdominal hernia were identified as a result of physical examination and radiological tests. Of these patients, 20 were morbidly obese, two had hyperbilirubinemia and eight had no external abdominal wall hernia, and these were excluded from this study, leaving a total of 40 patients for evaluation.

NIRS Measurements

RESULTS

NIRS is capable of measuring FTOE. While capable of exhibiting individual differences, some studies have regarded decreases of 25% from baseline tissue oxygenation as a hypoxia marker.[22] One study of volunteers compared INVOS and EQUANOX oximetry measurements by inducing hypoxia, hyperoxia and reperfusion in the right and left legs and no difference was determined between the two measurements. Baseline INVOS measurements of 81%±9% were determined in the right and left legs, compared to 52%±11% in cases of hypoxia.[23] Thus, we decided to use this value. After the herniated abdominal areas had been cleaned, the NIRS probe was attached. Another probe was attached immediately to the lateral aspect of the herniated area, again including the intestinal segments. Patients were monitored with INVOS® 5100C device somatic probes (Fig. 2). After measurements had been recorded for approximately 5 min, they were then recorded as the minimum and maximum values. Herniated intestinal segment and non-herniated normal region mea-

A total of 40 patients were included in this study comprising 26 (65.0%) males and 14 (35.0%) females with a mean age of 65±14 years (range, 29–92 years). The decision to operate was made in cases where a hernia was determined, which was not reducible manually. Following surgery, strangulation was detected in 24 (60%) patients and incarceration in 16 (40%) (Table 1). A statistically significant difference was determined in NIRS measurements between tissue saturation in areas in which strangulation or incarceration was detected and normal areas. NIRS measurement values (rSO2) in hernial areas in which strangulation was detected postoperatively were 65.08±12.5 (min-max 39–85). rSO2 values in the normal areas with no hernial sac in the same patient group were 77.92±10.49 (min-max 56–95.) The difference was statistically significant

Table 1. Patient characteristics and demographic data and a comparison of tissue oxygenation values between incarcerated and strangulated hernial sacs and compared to those in normal areas

Characteristics

Age (Mean±SD)

65±14

Male

26 (65%)

Number (%)

Strangulated Incarcerated

n

Mean±SD

Median (Min-Max)

n

Mean±SD

Median (Min-Max)

p*

NIRS measurements in herniated areas

24

65.08±12.52

65 (39–85)

16

67.63±15.62

73 (35–86)

0.572

Measurements in normal areas

24

77.92±10.49

77(56–95)

16

81.81±9.58

83.5 (61–93)

0.241

P** *

<0.001 <0.001

Independent Samples t-test; **Paired t-test. NIRS: Near-infrared spectroscopy; SD: Standard deviation; Min: Minimum; Max: Maximum.

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to these findings, tissue saturation ≤66 indicates that strangulation or incarceration is present in the hernial sac (sensitivity=52.50%, specificity=87.50%) (Table 2).

1.0

Sensitivity

0.8

DISCUSSION

0.6 0.4 0.2 0.0

0.0

0.2

0.4 0.6 1 - Specificity

0.8

1.0

Diagonal segments are produced by ties

Figure 3. ROC analysis between regions with strangulation and incarceration.

(p<0.001). Tissue saturation in the hernia area of patients with irreducible incarcerated hernial sacs was 67.63±15.62 (min-max 35–86), compared to 81.81±9.58 (min-max 61–93) in normal areas in the same patient group. The difference between the incarcerated areas and normal areas was statistically significant (p<0.001) (Table 1). No statistically significant difference was determined between hernial sacs with strangulation and incarceration. In other words, NIRS can detect strangulation or incarceration, but could not detect impaired intestinal oxygenation and strangulation inside the hernial sac (p=0.572). No statistically significant difference was determined when all groups were compared concerning oxygenation of normal areas (p=0.241) (Table 1). No significant difference was determined in the ROC analysis performed for measurements between the hernial sacs with strangulation and incarceration. Incarceration and strangulation in the intestines inside the hernial sac could not be differentiated based on the study data (p<0.815). However, it provided clear information concerning intestinal ischemia when compared with the normal areas of the same patients. Oxygenation in the hernial sac decreased when the analysis was performed between normal areas and hernial sacs in the same patient group (Fig. 3). Either strangulation or incarceration in the hernial sac can be detected with NIRS. According Table 2. ROC analysis of the tissue oxygenation values between incarcerated and strangulated hernial sacs, and compared to those in normal areas

Delta Saturation

Area under the curve

0.522

Cut-off

0.772

>19 ≤66

p

0.815 0.0001

Sensitivity

31.25% 52.50%

Specificity

87.5% 87.5%

ROC: Receiver Operating Characteristics.

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Intestinal tissue oxygenation of irreducible hernias was lower than that in normal areas. On the basis of these findings, irreducible hernias indicated impaired blood flow in intestinal tissues trapped within the hernial sac. Although previous studies have evaluated the oxygenation of the intestines and intra-abdominal organs, to our knowledge, this is the first study to investigate intestinal oxygenation in incarcerated hernias.[24–28] The principal reason for the comparison of intestinal oxygenation inside the irreducible hernial sac with that in intestinal tissue in the normal, contralateral side was to obtain a basal value. It was anticipated that oxygenation in the hernial sac would be lower than that in normal regions since the intestines are trapped and blood flow is impaired, as shown in Figure 1. More importantly, even lower oxygenation was anticipated in conditions in which the blood flow is completely stopped, known as strangulation. Decreased intestinal oxygenation was determined in both strangulation and incarceration. NIRS was capable of identifying compromised intestinal oxygenation, but not to the extent of differentiating strangulation from incarceration. Several previous studies support these findings. Arterioles that supply the intestinal wall and venules smaller than 1 cm in diameter are suitable for NIRS measurement. The principal reason for our low measurements is the impairment of this arterial and venous oxygenation in the intestines. A previous study comparing jugular venous oxygen saturation, and hepatic venous oxygen saturation with NIRS measurements to confirm hypoxia occurring globally in the body (in the brain and other organs) described NIRS as a non-invasive and practicable technique. In that study, Li et al.[29] compared cerebral and abdominal tissue oxygen saturation values in newborns undergoing cardiopulmonary surgery with oxygenation markers, such as systemic oxygen delivery, oxygen extraction rate, mean arterial pressure, pulmonary blood flow, systemic blood flow, and superior vena cava saturation. A significant correlation was determined between NIRS measurements and these oxygenation markers and it was concluded that NIRS is a good method for monitoring abdominal oxygenation. Given that this study involved newborns is important concerning the measurements eliciting accurate results. Due to the distance between the INVOS 5100c probes, tissue oxygenation can be measured to a depth of approximately 3–4 cm. It can be considered that Li et al.’s measurements gave positive results since the abdominal skin in newborns is very thin. The advantage of the patients in the current study is that the intestinal tissue had passed the abdominal wall and approached the subcutaneous region. The high accuracy rate can be attributed to the low depth of intestinal tissues approaching the skin. Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

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One of the studies providing the most support for the idea that intestinal oxygenation in incarcerated hernias can be assessed using NIRS was that of Toraman et al. They set out to monitor abdominal saturations in patients on whom they performed coronary bypass surgery to determine whether or not abdominal saturation would decrease. The advantage of that study was that skin thickness in the abdominal region was measured using ultrasonography. NIRS probes were attached to points from which appropriate measurements could be made. USG measurements elicited a hepatic skin distance of 2.1±0.5 cm and a renal skin distance of 4.2±1.5 cm. Oxygenation was monitored with an INVOS 5100 device. It was stated that this was a practical method for monitoring the oxygenation of intra-abdominal organs, particularly in thinner patients.[30] Since no complication, such as hypoxia developed in any of the patients, no statistically significant difference could be determined between pre-, peri-, and postoperative values. However, it was reported that had hypoxia developed in patients, it could have been identified with NIRS. In the current study, no difference was determined between incarcerated and strangulated hernia measurements. This can be attributed to the entrapment of irreducible intestinal tissue and impaired blood flow. Since intestinal tissue blood flow in normal areas was not impaired, it is not surprising that oxygenation should be better than in incarcerated hernias.

between patients, is also a finding of good oxygenation evaluation.

Another study supporting these findings was performed by Varela et al.[28] Ischemia can be determined using NIRS in conditions in which abdominal pressure increases, known as abdominal compartment syndrome. Varela et al. stated that NIRS could reveal early changes in mesenteric and systemic perfusion. Abdominal circulation was evaluated in that study using mesenteric artery catheterization, an invasive technique, while simultaneously assessing tissue saturation using NIRS. No significant difference was determined in abdominal saturation measurements between invasive techniques and NIRS, and it was therefore proposed that NIRS can be employed for the purpose described. The authors also suggested that changes in mesenteric perfusion can affect systemic perfusion and that changes in systemic perfusion in the early stages can be detected using NIRS, thus supporting the hypothesis of the current study. Tissue saturation in the Valera et al.’s study was measured from the anterior abdominal wall. Since the current study measurements were performed directly from the hernial sac, this appears to be a good method of assessing intestinal blood circulation, or intestinal perfusion.

In conclusion, in the light of the findings of this study, although not capable of differentiating incarceration from strangulation, NIRS appears to be a good method for showing impaired intestinal oxygenation. NIRS can be used to support ultrasonography findings in irreducible hernias. Therefore, this technique could be used in the future to evaluate and monitor intestinal oxygenation in the ED D.

Another advantage of the current study is that intestinal oxygenation in non-herniated normal areas exhibited no statistical difference in any of the patients. Despite individual variations, these findings show that NIRS assessed the oxygenation of intestinal tissue with good blood flow very well. Low measurement values in all patients in incarcerated or strangulated hernias, and the absence of any difference Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Limitations The main limitation of this study was the low number of patients. Further, multi-center studies with larger patient populations may provide further confirmation of this theory. The second limitation of this study was that no NIRS measurements were performed from the hernial region after surgery in patients where intestinal resection was not performed. Intestinal saturation within the sac could have been re-assessed with new measurements performed post-surgically. Another limitation of the study was that the abdominal wall blood supply was not analyzed, although hypoxia developing in the hernial area in the abdominal wall might have affected the measurements. The assessment of vessels supplying the abdominal wall using Doppler ultrasound might have imparted greater value to this study. In particular, evaluation using Doppler ultrasound of the arteria iliaca externa and arteria thoracica interna that supply the abdominal wall might have made a particular contribution to this research. Further studies assessing variations between abdominal wall thicknesses may elicit more definitive information concerning measurement depth.

Conclusion

Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: A.K., M.Z., O.B., G.E.; Design: A.K., M.Z., O.B., G.E.; Supervision: O.U., S.K., A.K.; Fundings: A.K., G.E.; Materials: M.Z., A.K., O.B., G.E.; Data: M.Z., A.K., O.B., G.E.; Analysis: D.E.; Literature search: A.K., O.B., M.Z., G.E.; Writing: A.K., M.Z.; Critical revision: S.K., A.K., O.U., O.B., G.E. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

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1999;15:R41−93. 18. Leff DR, Orihuela-Espina F, Elwell CE, Athanasiou T, Delpy DT, Darzi AW, et al. Assessment of the cerebral cortex during motor task behaviours in adults: a systematic review of functional near infrared spectroscopy (fNIRS) studies. Neuroimage 2011;54:2922−36. 19. Meng L, Cannesson M, Alexander BS, Yu Z, Kain ZN, Cerussi AE, et al. Effect of phenylephrine and ephedrine bolus treatment on cerebral oxygenation in anaesthetized patients. Br J Anaesth 2011;107:209−17. 20. da Costa CS, Greisen G, Austin T. Is near-infrared spectroscopy clinically useful in the preterm infant?. Arch Dis Child Fetal Neonatal Ed 2015;100:F558–61. 21. Naulaers G, Meyns B, Miserez M, Leunens V, Van Huffel S, Casaer P, et al. Use of tissue oxygenation index and fractional tissue oxygen extraction as non-invasive parameters for cerebral oxygenation. A validation study in piglets. Neonatology 2007;92:120−6. 22. Edmonds HL Jr, Ganzel BL, Austin EH 3rd. Cerebral oximetry for cardiac and vascular surgery. Semin Cardiothorac Vasc Anesth 2004;8:147– 66. 23. Fellahi JL, Butin G, Fischer MO, Zamparini G, Gérard JL, Hanouz JL. Dynamic evaluation of near-infrared peripheral oximetry in healthy volunteers: a comparison between INVOS and EQUANOX. J Crit Care 2013;28:881.e1–881.e8816. 24. Westgarth-Taylor C, de Lijster L, van Bogerijen G, Millar AJ, Karpelowsky J. A prospective assessment of renal oxygenation in children undergoing laparoscopy using near-infrared spectroscopy. Surg Endosc 2013;27:3696–704. 25. Gillam-Krakauer M, Cochran CM, Slaughter JC, Polavarapu S, McElroy SJ, Hernanz-Schulman M, et al. Correlation of abdominal rSO2 with superior mesenteric artery velocities in preterm infants. J Perinatol 2013;33:609−12. 26. Nahum E, Skippen PW, Gagnon RE, Macnab AJ, Skarsgard ED. Correlation of near-infrared spectroscopy with perfusion parameters at the hepatic and systemic levels in an endotoxemic shock model. Med Sci Monit 2006;12:BR313–7. 27. Said MM, Niforatos N, Rais-Bahrami K. Validation of near infrared spectroscopy to measure abdominal somatic tissue oxygen saturation in neonates. J Neonatal Perinatal Med 2013;6:23–30. 28. Varela JE, Cohn SM, Giannotti GD, Dolich MO, Ramon H, Wiseberg JA, et al. Near-infrared spectroscopy reflects changes in mesenteric and systemic perfusion during abdominal compartment syndrome. Surgery 2001;129:363−70. 29. Li J, Van Arsdell GS, Zhang G, Cai S, Humpl T, Caldarone CA, et al. Assessment of the relationship between cerebral and splanchnic oxygen saturations measured by near-infrared spectroscopy and direct measurements of systemic haemodynamic variables and oxygen transport after the Norwood procedure. Heart 2006;92:1678−85. 30. Toraman F, Ustalar Özgen S, Arıtürk C, Sayın J, Erkek E, Güçlü P, et al. Is It Effıcient to Use NIRS to Calculate Hepatic and Renal Oxygen Saturation During Extracorporeal Circulation?. ACU Sağlık Bil Derg 2012;3:164−9.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Strangüle ve inkarsere hernilerin değerlendirilmesinde yeni bir teknik: Near infrared spectroscopy Dr. Murat Ziyan,1 Dr. Asım Kalkan,2 Dr. Özlem Bilir,1 Dr. Gökhan Ersunan,1 Dr. Deniz Özel,3 Dr. Özlem Uzun,4 Dr. Semih Korkut5 Recep Tayyip Erdoğan Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Rize Okmeydanı Egitim ve Araştırma Hastanesi, Acil Tip Kliniği, İstanbul Akdeniz Üniversitesi Tıp Fakültesi, Bioistatistik Anabilim Dalı, Antalya 4 Bağcılar Egitim ve Araştırma Hastanesi, Acil Tip Kliniği, İstanbul 5 Kartal Dr. Lütfi Kırdar Egitim ve Araştırma Hastanesi, Acil Tip Kliniği, İstanbul 1 2 3

AMAÇ: Bu çalışmamızın amacı, redükte edilemeyen inguinal hernilerde bağırsak oksijenizasyonunu değerlendirmek için yeni bir yöntem olan near infrared spektrofotometri (NIR) spektroskopi tekniğini kullanmaktır. Böylece erken dönemde bağırsak oksijenizasyonu hakkında bilgi edinmeyi ve NIRS’nin kullanılabilirliğini değerlendirmeyi amaçladık. GEREÇ VE YÖNTEM: Çalışmamıza inguinal hernileri olup elle redükte edilemeyen ve klinik bulgu ve görüntüleme yöntemleri ile ileus tespit edilen 40 hasta alındı. Hastaların inguninal herni olan bölgeleri ile tam lateralinde herni olmayan bölgelerine NIRS propları yapıştırılarak bağırsak oksijenizasyonları ölçüldü. Normal ve herni olan bölgeler arasındaki oksijenizasyon farkları değerlendirildi. BULGULAR: Yaş ortalaması 65±14 olan, 14’ü kadın (%35.0) ve 26’sı erkek (%65.0) toplam 40 hasta bu çalışmaya alındı. Hastaların redükte edilemeyen herni bölgesinde bağırsak oksijenizasyonları normal bölgelerine göre düşüktü (p<0.001). Bağırsak oksijenizasyonları düşük olan inguinal herni keseleri ameliyat edildiğinde inkarserasyon ve/veya strangülasyon tespit edildi. NIRS ölçümlerinin düşük ölçülmesi bağırsaktaki inkarserasyon ve/ veya strangülasyonu tespit edebiliyordu fakat ikisi birbirinden ayırt edilemiyordu. TARTIŞMA: Bu çalışmanın bulguları ışığında, strangülasyondan hapsedilmeyi ayırt edememesine rağmen, NIRS bozulmuş bağırsak oksijenasyonu için iyi bir yöntem olarak görünmektedir. NIRS, indirgenemez fıtıklarda ultrasonografi bulgularını desteklemek için kullanılabilir. Bu nedenle, gelecekte acil serviste bağırsak oksijenasyonunu değerlendirmek ve izlemek için bu teknik kullanılabilir. Anahtar sözcükler: İntestinal oksijenizasyon; oksimetri; redükte edilemeyen herni. Ulus Travma Acil Cerrahi Derg 2020;26(2):178-185

doi: 10.14744/tjtes.2019.72627

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ORIGIN A L A R T IC L E

Should percutaneous cholecystostomy be used in all cases difficult to manage? Erdem Barış Cartı, M.D.,1

Koray Kutlutürk, M.D.2

1

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

2

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

ABSTRACT BACKGROUND: Cholecystectomy is the well-accepted management method for acute cholecystitis in patients suitable for surgery. Percutaneous cholecystostomy is planned and used in patients at high surgical risk due to acute symptomatic cholecystitis and/or acute or chronic comorbidity. Percutaneous cholecystostomy can provide permanent treatment, or it may act as a bridge for elective cholecystectomy. METHODS: We presented the outcomes of 50 patients who initially underwent ultrasound-guided transhepatic percutaneous cholecystostomy and 4–6 weeks later, an interval cholecystectomy. All patients had either impaired gallbladder wall integrity on contrastenhanced abdominal computed tomography performed during admission or had grade II acute cholecystitis according to the Tokyo Guidelines 13 diagnostic criteria and severity grading of acute cholecystitis or exhibited clinical signs of acute cholecystitis on the fifth day of non-operative treatment. RESULTS: Our results suggest that although percutaneous cholecystostomy is a useful method for alleviation of the emergency clinical condition in acute cholecystitis, it makes the interval cholecystectomy more difficult to perform due to the dense fibrosis developing during the healing process, eventually complicating laparoscopic cholecystectomy. CONCLUSION: Cholecystostomy may cause fibrosis during the healing process, eventually complicating laparoscopic cholecystectomy. Thus, there is a need for better evaluation during the identification of indications for cholecystostomy. Keywords: Acute cholecystitis; laparoscopic cholecystectomy; open cholecystectomy; percutaneous cholecystostomy.

INTRODUCTION Acute cholecystitis is one of the common causes of acute abdominal pain. Acute calculous cholecystitis that occurs due to obstruction of the gallbladder neck or the cystic duct with gallstones is responsible for the pathophysiology of up to 90% of these cases.[1] Cholecystectomy is the well-accepted management method for acute cholecystitis in patients suitable for surgery. Laparoscopic cholecystectomy, a minimally invasive technique, is now the standard treatment option in the management of benign biliary disorders, including acute cholecystitis.[2] According to the Tokyo guidelines, which was first published in 2007 concerning the diagnostic criteria and severity

grading of acute cholecystitis and was updated in 2013, the acute cholecystitis is classified into three grades, mild (grade I), moderate (grade II), and severe (grade III). Grade I (mild acute cholecystitis) is defined as acute cholecystitis in a patient with no organ dysfunction and limited disease in the gallbladder, making cholecystectomy a low-risk procedure. Grade II (moderate acute cholecystitis) is associated with no organ dysfunction; however, there is an extensive disease in the gallbladder, resulting in increased difficulty in safely performing a cholecystectomy and an increased risk of biliary tract injury during the inflammation-related cholecystectomy surgery. Grade III (severe acute cholecystitis) is defined as acute cholecystitis with organ dysfunction.[3]

Cite this article as: Cartı EB, Kutlutürk K. Should percutaneous cholecystostomy be used in all cases difficult to manage?. Ulus Travma Acil Cerrahi Derg 2020;26:186-190. Address for correspondence: Erdem Barış Cartı, M.D. Adnan Menderes Üniversitesi Tıp Fakültesi, Genel Cerrahi Kliniği, Aydın, Turkey Tel: +90 850 - 340 12 56 E-mail: erdemcarti@yahoo.com Ulus Travma Acil Cerrahi Derg 2020;26(2):186-190 DOI: 10.14744/tjtes.2020.73557 Submitted: 01.10.2019 Accepted: 11.02.2020 Online: 21.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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Computed tomography is useful in diagnosing complicated acute cholecystitis (emphysematous, gangrenous, and perforated). In addition, it is particularly useful in the differential diagnosis of other intraabdominal disorders in patients in whom the use of abdominal ultrasound (US) is limited, such as the obese patients or patients with abdominal gaseous distension.[4] Percutaneous cholecystostomy (PC) is planned and used in patients at high surgical risk due to acute symptomatic cholecystitis and/or acute or chronic comorbidity. Draining the infected bile via a percutaneous cholecystostomy contributes to the resolution of inflammation, leading to an improvement in clinical status.[5] Our aim in this study was to present and compare with the literature the outcomes of ultrasound-guided transhepatic percutaneous cholecystostomy performed patients in our clinic.

MATERIALS AND METHODS A total of 512 patients with acute calculous cholecystitis were admitted to the General Surgery Clinic of Adnan Memderes University Training and Research Hospital between March 2016 and March 2018. Among these, 66 patients who were at high surgical risk due to acute symptomatic cholecystitis and/or acute or chronic comorbidity underwent ultrasoundguided transhepatic percutaneous cholecystostomy under local anesthesia with a pigtail catheter by an interventional radiologist. Fifteen patients underwent percutaneous cholecystostomy due to acute or chronic comorbidities and the presence of high postoperative mortality risk (Tokyo grade III) and were excluded from this study. One patient developed free perforation of the gallbladder during the procedure and was excluded from this study due to the need for an emergency operation after the procedure. All of the 50 patients included in this study had impaired gallbladder wall integrity (intraparenchymal fluid in the gallbladder bed or excess fluid around the gallbladder, together with ongoing gallbladder distension) on contrast-enhanced abdominal CT performed during admission or had grade II acute cholecystitis according to the TG13 diagnostic criteria and severity grading of acute cholecystitis exhibited clinical signs of acute cholecystitis on day five despite non-operative treatment (discontinuation of oral intake, intravenous hydration, and intravenous ceftriaxone treatment), and underwent ultrasound-guided transhepatic percutaneous cholecystostomy initially and 4-6 weeks later, an interval cholecystectomy in our clinic. We retrospectively investigated the outcomes of these patients.

Statistical Analysis The Statistical Package for the Social Sciences (SPSS 21.0 software, IL-Chicago- USA) was used for data analyses. DeUlus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

scriptive analysis was carried out for demographic and clinical features. The results were presented as percentages for continuous variables, and the number/percentage for categorical variables.

RESULTS The mean age of 50 patients included in this study was 52.5 years. The male/female ratio was 1.6. In all patients, the symptoms (right upper quadrant pain, fever, and fatigue) improved after percutaneous cholecystostomy. On the first few days after percutaneous cholecystostomy, some patients required daily recurrent saline irrigations through the cholecystostomy drainage catheter for removing the dense contents of the gallbladder. Oral food intake was started when post-procedural relief was observed, and solid foods were gradually administered. The mean hospital stay after percutaneous cholecystostomy was 1.8 days. Our patients were discharged following training for changing the dressing around the entry hole for cholecystostomy, the evacuation of the cholecystostomy tube, and with an oral antibiotic prescription, diet recommendation, together with an outpatient appointment. In the General Surgery Outpatient Clinic, all patients were examined by the surgeon who followed them during their hospitalizations, and they underwent cholecystectomy performed by the same surgeon 4–6 weeks later. The cholecystostomy catheters of the patients were withdrawn on the operating table just before the cholecystectomy operation. The operation was started with the laparoscopic approach in the first ten consecutive patients. However, the operation was converted to an open cholecystectomy procedure (anterograde or fundus-down approach) through a right subcostal incision in eight patients due to the encountered difficulties in dissection and the inability to clearly identify the anatomy. The rate of conversion from laparoscopic cholecystectomy to open cholecystectomy was calculated as 80%. Since the conversion rate was high in the first 10 patients, the interval cholecystectomy following percutaneous cholecystostomy was performed as a conventional open cholecystectomy through a right subcostal incision in the remaining 40 patients. The mean postoperative hospital stay was 2.8 days with null mortality. One patient encountered a bile duct injury of Strasberg A (cystic duct stump leak) type and was discharged from hospital after a coated stent was introduced by endoscopic retrograde cholangiopancreatography (ERCP). Wound infection was detected in four patients. None of our patients developed additional morbidity.

DISCUSSION The management of patients with acute cholecystitis in our clinic can be summarized as follows: Patients with acute cholecystitis whose present complaints during admission have not exceeded 24–48 hours undergo emergency laparoscopic cholecystectomy; patients with acute cholecystitis 187

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whose complaints present during admission have exceeded 24–48 hours are discharged after non-operative treatment (discontinuation of oral intake, intravenous hydration, and intravenous ceftriaxone treatment) and undergo elective laparoscopic cholecystectomy 4–6 weeks later. Patients with impaired gallbladder wall integrity (intraparenchymal fluid in the gallbladder bed or excess fluid around the gallbladder, together with ongoing gallbladder distension) on contrast-enhanced abdominal CT performed at the time of admission or who have a grade II acute cholecystitis according to the Tokyo 2013 diagnostic criteria and severity grading guidelines of acute cholecystitis who exhibit clinical signs of acute cholecystitis on day five despite non-operative treatment (discontinuation of oral intake, intravenous hydration, and intravenous ceftriaxone treatment), undergo ultrasound-guided transhepatic percutaneous cholecystostomy procedure initially and 4–6 weeks later, an interval cholecystectomy in our clinic. Our treatment protocol was shown in Figure 1.

ing emergency surgery, enabling earlier discharge from the hospital (Fig. 3). PC is a well-defined, effective method for providing immediate decompression of the inflamed gallbladder in patients whose general condition is not suitable for emergency cholecystectomy.[10–14] By this means, it helps early recovery by reversing the inflammatory process and shortens the duration of hospitalization. The response rate to percutaneous cholecystostomy varies between 56% and 100% in the literature.[12–17] Boland et al.[12] found that 17 (89%) of 19 patients with a positive sonographic Murphy sign responded to PC, whereas only 29 (46%) of 63 patients with a negative sonographic Murphy sign responded. The early complications of percutaneous cholecystostomy involve bleeding, vagal reactions, sepsis, biliary peritonitis, pneumothorax, intestinal perforation, secondary infection, and catheter dislodgement whereas its late complications are catheter dislodgement and recurrent cholecystitis.[18,19] Major and minor complication rates vary between 3–8% and 4–13%, respectively.

Cholecystectomy, when used as the first treatment approach for cholecystitis in high-risk patients, has been reported to have a morbidity rate of 62% and a mortality rate of 50%.[6–9] Even though our patients were classified as grade II according to the TG13 diagnostic criteria and severity grading of acute cholecystitis, all patients were either not able to respond to administered intravenous antibiotics or had impaired gallbladder wall integrity (Fig. 1) (intraparenchymal fluid in the gallbladder bed or excess fluid around the gallbladder, together with ongoing gallbladder distension) (Figs. 2). We suggest that our patients should be classified as having a higher severity within TG13 grade II by considering the preoperative conditions which were previously mentioned.

Although percutaneous cholecystostomy is a very effective method for resolving an acute clinical condition, it leads to

Percutaneous cholecystostomy was performed in this patient group, considering that cholecystostomy might reduce both the inflammation and the risk of bile duct injury by postponFigure 2. CT image of case with acute cholecystitis with perforation into the gallbladder bed but preserved gallbladder wall integrity.

Figure 1. CT image of case with acute cholecystitis with perforation into the gallbladder bed.

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Figure 3. CT image of the same case after percutaneous cholecystostomy.

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the development of fibrosis between the corpus and the fundus of the gallbladder and the liver in most of the patients.[20] Such development of fibrosis makes it more difficult to remove the gallbladder, and it was observed intraoperatively to develop in all patients (Fig. 4). Other studies have reported that cholecystectomy, when performed after cholecystostomy, is usually performed with laparoscopy.[6] In a study, 245 patients had undergone cholecystostomy, and then, 71 of them underwent cholecystectomy. In 63 of them, the operation was started using a laparoscopic approach. In 13 of them, laparoscopic cholecystectomy was converted to open cholecystectomy, and in the remaining 50 patients, the operation was completed with laparoscopic cholecystectomy. [21] Based on this information, we started the operation with the laparoscopic approach in our first ten patients. However, the laparoscopic cholecystectomy was converted to open cholecystectomy in eight of them due to various difficulties encountered in the dissection of the Calot’s triangle because of fibrosis. Based on our experience gained from the first ten patients, we performed open cholecystectomy in the following patients. We suggest that the reason for the higher conversion rate in our study compared to the rates of the studies mentioned above may be that our patients had additional findings, such as not responding to intravenous antibiotics or impaired gallbladder wall integrity, which increase the severity of cholecystitis even though they were classified as grade II according to the TG13 diagnostic criteria and severity grading of acute cholecystitis. Although the Tokyo Guideline, which had been developed for classifying the severity of cholecystitis patients and was updated in 2013, is a guide for determining the treatment modality in patients with cholecystitis, grade II acute cholecystitis defined in the guideline has a broad spectrum. It can

be suggested that grade II acute cholecystitis should be divided into subgroups to be more instructive regarding the modality of treatment. Even though cholecystostomy contributes to the improvement of the acute condition, we can also suggest that cholecystostomy should not be decided without thinking carefully especially in patients with grade I and II acute cholecystitis since it leads to fibrosis and that it should not be acted liberally in the preference of this type of intervention. Given that dense fibrosis develops during healing, especially in patients who do not respond well to intravenous antibiotics or have gallbladder perforation like our patients, we can say that percutaneous cholecystostomy will reduce the likelihood of performing laparoscopic cholecystectomy subsequently. There is a need for a study involving a large number of patients with grade I and II acute cholecystitis for comparison of those necessitating long-term hospitalization and administration of intravenous antibiotics and hydration with the cholecystectomy patients necessitating short-term hospitalization only and having the early recovery advantage concerning interval cholecystectomy, assessing the conversion rate from laparoscopic to open cholecystectomy and the morbidity (bile duct injury). We have planned such a study in the Hepatobiliary and Organ Transplantation Unit, Department of General Surgery, Adnan Memderes University.

Conclusion Although percutaneous cholecystostomy is a useful method for alleviation of the emergency clinical condition in acute cholecystitis, it makes the interval cholecystectomy more difficult to perform due to the dense fibrosis developing during the healing process. The previous study reports about the usual successful completion of a laparoscopic cholecystectomy following a cholecystostomy are in contradiction with our findings. The reason for this contradictory situation might be our patients having comorbidities, such as being unresponsive to intravenous antibiotics and gallbladder perforation, even though they were classified as grade II according to the TG13 diagnostic criteria and severity grading of acute cholecystitis. New studies are needed to explain whether cholecystostomy increases the rate of conversion from laparoscopic cholecystectomy to open cholecystectomy. Our results suggest that cholecystostomy may cause fibrosis during the healing process, eventually complicating laparoscopic cholecystectomy, and thus, there is a need for better evaluation during the identification of indications for cholecystostomy. Ethics Committee Approval: Retrospective study. Peer-review: Internally peer-reviewed.

Figure 4. Perioperative image of a patient who underwent interval cholecystectomy showing the fibrosis around the gallbladder developed following percutaneous cholecystostomy.

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Authorship Contributions: Concept: E.B.C.; Design: E.B.C.; Supervision: E.B.C.; Materials: E.B.C.; Data: E.B.C.; Analysis: E.B.C.; Literature search: E.B.C.; Writing: E.B.C.; Critical revision: K.K. 189

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Conflict of Interest: None declared.

gallbladder empyema. Diagn Imaging 1980;49:330–3.

Financial Disclosure: The autors declared that this study has received no financial support.

REFERENCES 1. Rassameehiran S, Tantrachoti P, Nugent K. Percutaneous gallbladder aspiration for acute cholecystitis. Proc (Bayl Univ Med Cent) 2016;29:381– 4. 2. Ambe PC, Kaptanis S, Papadakis M, Weber SA, Zirngibl H. Cholecystectomy vs. percutaneous cholecystostomy for the management of critically ill patients with acute cholecystitis: a protocol for a systematic review. Syst Rev 2015;4:77. 3. Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gomi H, Yoshida M, et al; Tokyo Guidelines Revision Committee. TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2013;20:1−7. 4. Gomes CA, Junior CS, Di Saverio S, Sartelli M, Kelly MD, Gomes CC, et al. Acute calculous cholecystitis: Review of current best practices. World J Gastrointest Surg 2017;9:118−26. 5. La Greca A, Di Grezia M, Magalini S, Di Giorgio A, Lodoli C, Di Flumeri G, et al. Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study. Eur Rev Med Pharmacol Sci 2017;21:4668−74. 6. Winbladh A, Gullstrand P, Svanvik J, Sandström P. Systematic review of cholecystostomy as a treatment option in acute cholecystitis. HPB (Oxford) 2009;11:183–93. 7. Houghton PW, Jenkinson LR, Donaldson LA. Cholecystectomy in the elderly: a prospective study. Br J Surg 1985;72:220–2. 8. Kirshtein B, Bayme M, Bolotin A, Mizrahi S, Lantsberg L. Laparoscopic cholecystectomy for acute cholecystitis in the elderly: is it safe?. Surg Laparosc Endosc Percutan Tech 2008;18:334–9. 9. Morse BC, Smith JB, Lawdahl RB, Roettger RH. Management of acute cholecystitis in critically ill patients: contemporary role for cholecystostomy and subsequent cholecystectomy. Am Surg 2010;76:708–12. 10. Radder RW. Ultrasonically guided percutaneous catheter drainage for

11. Akhan O, Akinci D, Ozmen MN. Percutaneous cholecystostomy. Eur J Radiol 2002;43:229–36. 12. Boland GW, Lee MJ, Leung J, Mueller PR. Percutaneous cholecystostomy in critically ill patients: early response and final outcome in 82 patients. AJR Am J Roentgenol 1994;163:339–42. 13. Vogelzang RL, Nemcek AA Jr. Percutaneous cholecystostomy: diagnostic and therapeutic efficacy. Radiology 1988;168:29–34. 14. Chopra S, Dodd GD 3rd, Mumbower AL, Chintapalli KN, Schwesinger WH, Sirinek KR, et al. Treatment of acute cholecystitis in non-critically ill patients at high surgical risk: comparison of clinical outcomes after gallbladder aspiration and after percutaneous cholecystostomy. AJR Am J Roentgenol 2001;176:1025−31. 15. Hatjidakis AA, Karampekios S, Prassopoulos P, Xynos E, Raissaki M, Vasilakis SI, et al. Maturation of the tract after percutaneous cholecystostomy with regard to the access route. Cardiovasc Intervent Radiol 1998;21:36−40. 16. Browning PD, McGahan JP, Gerscovich EO. Percutaneous cholecystostomy for suspected acute cholecystitis in the hospitalized patient. J Vasc Interv Radiol 1993;4:531–8. 17. Chang L, Moonka R, Stelzner M. Percutaneous cholecystostomy for acute cholecystitis in veteran patients. Am J Surg 2000;180:198–202. 18. vanSonnenberg E, D’Agostino HB, Goodacre BW, Sanchez RB, Casola G. Percutaneous gallbladder puncture and cholecystostomy: results, complications, and caveats for safety. Radiology 1992;183:167–70. 19. van Overhagen H, Meyers H, Tilanus HW, Jeekel J, Laméris JS. Percutaneous cholecystectomy for patients with acute cholecystitis and an increased surgical risk. Cardiovasc Intervent Radiol 1996;19:72–6. 20. Paran H, Zissin R, Rosenberg E, Griton I, Kots E, Gutman M. Prospective evaluation of patients with acute cholecystitis treated with percutaneous cholecystostomy and interval laparoscopic cholecystectomy. Int J Surg 2006;4:101–5. 21. Khasawneh MA, Shamp A, Heller S, Zielinski MD, Jenkins DH, Osborn JB, et al. Successful laparoscopic cholecystectomy after percutaneous cholecystostomy tube placement. J Trauma Acute Care Surg 2015;78:100−4.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Perkütan kolesistostomi yönetimi zor olan tüm olgularda yapılmalı mıdır? Dr. Erdem Barış Cartı,1 Dr. Koray Kutlutürk2 1 2

Adnan Menderes Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Aydın İnönü Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Malatya

AMAÇ: Kolesistektomi, cerrahiye uygun olan kolesistit hastalarında kabul görmüş bir tedavi yöntemidir. Perkütan kolesistostomi ise cerrahi açıdan yüksek riskli akut semptomlu kolesistit hastalarında geçici bir tedavi yöntemi olmakla beraber elektif kolesistektomi için hastaya zaman kazandırabilir. GEREÇ VE YÖNTEM: Bu çalışmada ultrason eşliğinde perkütan transhepatik kolesistostomi yapılmış ve dört–altı hafta sonra interval kolesistektomi uygulanmış olan 50 olgu sunuldu. Tüm hastalarda bilgisayarlı tomografide safra kesesi duvar bütünlüğünde bozulma veya Tokyo Guidelines 13 tanısal kriterlerine göre grade II akut kolesistit bulgusu saptanmış olup beş günlük tıbbi tedaviye yanıt alınamayan hastalara kolesistostomi işlemi yapılmasına karar verildi. BULGULAR: Kolesistostomi her ne kadar akut kolesistit tablosunun yatışmasında etkili bir yöntem olsa da kolesistostomili olgularda dens fibrozis gelişimi nedeni ile yapılacak olan interval kolesistektominin daha komplike bir hal aldığı ve olgunun laparoskopik bitirilmesini zorlaştırdığı görülmüştür. TARTIŞMA: Kolesistostomi iyileşme süreci içerisinde dens fibrozis gelişimine neden olarak laparoskopik kolesistektomiyi daha komplike hale getirmektedir. Dolayısıyla kolesistostomi yapılacak olgular bu bilgi de göz önünde bulundurularak daha dikkatle seçilmelidir. Anahtar sözcükler: Açık kolesistektomi; akut kolesisti; laparoskopik kolesistektomi; perkütan kolesistostomi. Ulus Travma Acil Cerrahi Derg 2020;26(2):186-190

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doi: 10.14744/tjtes.2020.73557

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ORIGIN A L A R T IC L E

Diagnostic value of GCP-2/CXCL-6 and hs-CRP in the diagnosis of acute appendicitis Çiğdem Yücel, M.D.,1 Esra Fırat Oğuz, M.D.,2 Sadettin Er, M.D.,3 İlhan Balamir, M.D.,4 Turan Turhan, M.D.,2 Mesut Tez, M.D.3 1

Department of Clinical Biochemistry, Gülhane Training and Research Hospital, Ankara-Turkey

2

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

3

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

4

Department of Clinical Biochemistry, Ankara Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: Acute appendicitis (AA) is one of the major causes of acute abdomen pain. Various laboratory markers have been studied for diagnosis of AA, but none of them have shown superiority to physical examination or imaging. GCP-2/CXCL6 is a chemokine expressed by macrophages and epithelial and mesenchymal cells during inflammation. The present study aims to investigate the diagnostic role of GCP-2/CXCL6 in AA patients. METHODS: In this cross-sectional study, the serum level of GCP-2/CXCL6 was measured in 56 AA patients and 32 healthy control subjects. Also, hs-CRP and white blood cell count (WBC) levels of the patient and control groups were evaluated. RESULTS: GCP-2/CXCL-6, hs-CRP and WBC levels of the AA group were significantly higher than the control group (p<0.05 for all comparisons). Among AA group, GCP-2/CXCL6 levels were higher in complex AA (gangrenous, abscess and perforation) ones when compared to non-complex AA (p<0.05). A strong positive correlation was found between GCP-2/CXCL6 levels and hs-CRP levels (r=0.756, p=0.003) and a moderate positive correlation between GCP-2/CXCL6 levels and WBC count (r=0.468, p=0.003). CONCLUSION: GCP-2/CXCL6 can be a useful marker in AA diagnosis and discrimination of complex cases, especially if combined with other laboratory markers and imaging techniques. Keywords: Acute appendicitis; chemokine; complication; diagnosis; prognosis.

INTRODUCTION Acute appendicitis (AA) is one of the major causes of urgent abdominal operations. Although the signs and symptoms of AA are well-known, sometimes, it is challenging to diagnose AA. Delayed diagnosis leads to complex AA (gangrenous, abscess and perforation).[1] To distinguish between non-specific abdominal pain and AA is of critical importance. Physical examination, clinical symptoms and radiological findings can be inefficient sometimes to determine the extent of the disease. Twenty percent of neg-

ative laparotomy rates in AA have empowered the need for laboratory tests in the diagnosis of the acute disease. Several biochemical parameters like white blood cell count (WBC), Creactive protein, procalcitonin, erythrocyte sedimentation rate (ESR) have been used as potential predictors of complicated appendicitis. Also, members of the interleukin family (IL-6, IL10, IL-4, IL-5 and IL-12), tumor necrosis factor (TNF) alpha, fibrinogen and alpha-1 antitrypsin have been studied for the diagnosis of AA. However, none of these parameters were found to be superior to clinical history, physical examination, and usual laboratory parameters in predicting appendiceal perforation, and therefore, are not used widely in clinical practice.[2–5]

Cite this article as: Yücel Ç, Fırat Oğuz E, Er S, Balamir İ, Turhan T, Tez M. Diagnostic value of GCP-2/CXCL-6 and hs-CRP in the diagnosis of acute appendicitis. Ulus Travma Acil Cerrahi Derg 2020;26:191-196. Address for correspondence: Esra Fırat Oğuz, M.D. Ankara Numune Eğitim ve Araştırma Hastanesi, Acil Biyokimya Laborautvarı, 06130 Altındağ, Ankara, Turkey Tel: +90 312 - 508 40 95 E-mail: dr_esrafirat@hotmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):191-196 DOI: 10.14744/tjtes.2019.26270 Submitted: 09.04.2019 Accepted: 20.06.2019 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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Chemokines are a large family of peptides characterized by four conserved cysteine residues in their NH2 terminus. [5] These molecules are responsible for leukocyte trafficking and activation in both health and disease. They are important for host defense, but they also have fundamental roles in the development and homeostasis of the immune system.[6–8] The CXC chemokines contain one amino acid between the two NH2 terminal cysteines. A subfamily of the CXC chemokines is further categorized by the presence of an ELR (glutamic acid- leucine-arginine) motif immediately before the CXC sequence. These ELR+CXC chemokines are potent neutrophil chemo-attractants. In humans, seven ELR+CXC chemokines have been identified. Human granulocyte chemotactic protein-2 (GCP-2)/CXCL6 is a 77 amino acid protein that belongs to this family.[9,10] In the case of leukocytes, GCP-2/CXCL6 binding to receptors causes cellular activation, chemotaxis and sometimes cytotoxic effector functions.[5] GCP-2/CXCL6 is expressed by macrophages and epithelial and mesenchymal cells during inflammation. Up to date, this chemokine has shown to be activated in lung pathologies, arthritis, colitis and ischemia-reperfusion injury.[11–14]

Patients having any other acute or chronical inflammatory disease and/or malignancy, diabetes mellitus, chronic renal/ hepatic failure and cirrhosis and patients younger than 18 years old were excluded from this study. The control group was composed of 32 healthy individuals with no signs of acute or chronical illness.

C-reactive protein (CRP) as an acute phase reactant increases in appendicitis, and its serum and probably salivary level may be helpful in early diagnosis. CRP is a commonly used tool in emergency medicine, especially in febrile and equivocal infections. CRP was classified as an “acute phase protein” in the 1930s, and since then, CRP is considered as a screening test for tissue inflammation, a biomarker of disease activity and a predictive tool in many acute and chronic infections.[15–17] CRP is also a helpful reference for decision making in patients with abdominal pain, with its specificity of 89% and a positive predictive value of 88%. CRP has found a place as a biochemical marker in AA diagnosis along with WBC count, and serial CRP measurements in AA among clinical examination is a tool of reference in predicting appendicitis and perforated appendicitis.[18,19] High-sensitivity CRP (hs-CRP) is more precise than standard CRP when measuring baseline (i.e. normal) concentrations and enables a measure of inflammation.[20]

Statistical Analysis

In this study, we aimed to determine whether especially serum GCP-2/CXCL6 can be used as a biochemical indicator of AA and its complications.

MATERIALS AND METHODS Fifty-six patients who were operated emergently for diagnosis of Ankara Numune Training and Research Hospital during the period between October 2016 and January 2017 were included in this prospective study. This study was performed in accordance with the “Declaration of Helsinki guidelines,” and informed consent was obtained from all the participants. This study was approved by the local ethical committee with the number 993/2016. 192

The demographic features of all participants were recorded. Ultrasonographic (US) and computerized tomography (CT) evaluation of patients was made by expert radiologists. The patients were characterized into two groups according to the histopathological results of the resected appendices: non-complexAA and complexAA. Ten mL of venous blood samples were collected from the participants. Blood samples collected for hs-CRP and GCP-2/CXCL6 analysis were centrifuged at 4000 rpm for 10 minutes. Separated sera were aliquoted into Eppendorf tubes and stored at -80 °C until the time of analysis. R&D Systems Quantikine ELISA Human GCP-2 Elisa kit was used for Human GCP-2/CXCL6 detection. High-sensitivity CRP was studied with the immunoturbidimetric method, while WBC analysis was carried out by VCS (volume, conductivity, and scatter) technique.

Data analysis was carried out using SPPS for Windows 15 programme. The normality tests were performed using the Kolmogorov-Smirnov test. Descriptive statistics of normally distributed continuous variables are illustrated as mean ± standard deviation (SD). Descriptive statistics of non-normally distributed continuous variables are illustrated as median (interquartile range) values. Among group differences of normally distributed variables were analyzed with Student’s t-test, while non-normally distributed variables were analyzed using Mann-Whitney U test. Kruskal Wallis test was used for comparison of more than two groups. Correlation analyses were performed using Pearson’s test. P<0.05 was accepted as statistically significant for all tests.

RESULTS Patient group consisted of 56 cases; 26 males (46.4%), 30 females (53.6%), while the control group consisted of 32 individuals, 17 females (52.4%) and15 males (47.6 %). Mean age of the patient and control groups were 30.8±0.95 and 32.7±1.1 years, respectively. When compared with the control group, GCP-2, hs-CRP and WBC levels of the patient group were significantly higher p<0.001 (Table 1). GCP-2/CXCL6 levels were compared between control, perforated and non-perforated groups. Statistically significant differences were found among groups hs-CRP levels were also significantly different among three groups. A statistically significant difference was found between WBC levels when perforated and non-perforated groups were compared with the control group. No significant difference was found between perforated and nonperforated groups concerning WBC count (Table 2). Also, Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Yücel et al. Diagnostic value of GCP-2/CXCL-6 and hs-CRP in the diagnosis of AA

Table 1. Clinicopathological characteristics of the acute appendicitis patients

600.00

Characteristics

500.00

Age (y)

30.8±0.95

White blood cell (µL)

14.9±0.73

GCP2 (ng/mL)

n % Mean±SD

Gender Male

26 46.4

Female

30 53.6

400.00 300.00 200.00 100.00

Ultrasonographic (n=56) Normal

8 14.2

Appendicitis without perforation

22

39.2

Appendicitis with perforation

26

46.4

0.00 Control

Perforated

Figure 1. Box-Whiskar Plot for GCP-2 levels in patient and control groups.

Computerized tomography Normal

Non-perforated

0 0

Appendicitis without perforation

10

47.6

Appendicitis with perforation

11

52.4

CXCL6 levels and hs-CRP levels (r=0.756, p=0.003) and also a moderately positive correlation between GCP-2/CXCL6 levels and WBC count (r=0.468, p=0.003).

Pathological diagnosis

Acute appendicitis

27

48.2

Gangrenous/perforated appendicitis

29

51.8

DISCUSSION

SD: Standard deviation.

GCP-2/CXCL6 levels of the perforated group were higher than the non-perforated group. GCP-2/CXCL6 levels of the patient and control groups are shown in a Box-Whiskarplot (Fig. 1). The pathological diagnosis was acute appendicitis in 27 (48.2%), and gangrenous/perforated appendicitis in 29 (51.8%) patients. The clinical, radiological and pathological characteristics of the patient group are summarized in Table 3. When levels of GCP-2/CXCL-6, hs-CRP and WBC were compared between perforated and non-perforated appendicitis cases, the findings showed that levels of GCP-2/CXCL-6 and hs-CRP was higher in the perforated group when compared to nonperforated group (p=0.003 and p=0.018, respectively). WBC levels of perforated and non-perforated patients did not show a statistically significant difference (p=0.062) (Table 4). The correlation between GCP-2/CXCL6 levels and hs-CRP and WBC levels and were statistically evaluated. It was found that there was a strong positive correlation between GCP-2/

Acute appendicitis is the most common indication for emergency surgery, affecting patients at any age group. Appendiceal perforation is especially the initial clinical presentation in a significant number of patients with AA in the elderly. Despite the presence of various imaging modalities, biochemical markers, and scoring systems, the negative appendectomy rate remains high.[21] Laboratory studies, along with the clinical presentation, can help in the diagnosis of AA. However, all clinical and laboratory variables are weak discriminators individually although they can achieve a high discriminatory power when combined. ComplexAA is associated with increased morbidity and mortality. Thus, it is important to identify patients with complex AA for surgical planning, for further treatments and for the decision of non-operative therapy, which can be an option in non-complex AA cases.[22,23] Many attempts have been made to determine ways of decreasing the negative laparotomy rate in clinically suspected AA. Unfortunately, there is no specific diagnostic test for the determination of AA. In medical practice, WBC count is commonly used for the diagnosis of AA. Although rises

Table 2. GCP-2/CXCL6, hs-CRP and WBC levels of patient and control groups Variable

Control Non-perforated Perforated p 194 (157.4–275.5)a,c

268 (257–351.1)a,b

hs-CRP (ng/L)

1.07 (0.60–2.16)

26.64 (19.26–50.78)

WBC (103/µL)

6.5 (5.10–7.40)a,c

12.8 (11.60–15.80)a

GCP-2/CXCL6 (ng/mL)

a,c

a,b

354 (312.1–393.7)b,c <0.05 65.08 (22.49–125.04)b,c <0.05 13.8 (7.40–19.30)c <0.05

GCP-2: Granulocyte chemotactic protein-2; CXCL6: Chemokin Ligand-6; hs-CRP: High-sensitivity C-reactive protein; WBC: White blood cell. a: Statistically significant difference between perforated and control group (p<0.05). b: Statistically significant difference between perforated and non-perforated group (p<0.05). c: Statistically significant difference between non-perforated and control group (p<0.05).

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Table 3. The sex distribution, mean ages, WBC, hs-CRP and GCP-2 levels of the acute appendicitis and control groups

Acute appendicitis Control (n=56) (n=32)

p

Age (mean±SD)

30.8±0.95

32.7±1.16

0.266

Gender (%) (Female/Male)

53.6/46.4

52.4/47.6

0.945

WBC (103/µL) (mean±SD)

14.9±0.73

6.5±0.24

0.000*

hs-CRP (ng/L) (mean±SD)

41 (2.1–188)^

GCP-2/CXCL6 (ng/mL) (mean±SD)

310±13.0

1.25 (0.19–4.18)^ 0.000* 220±13.7

0.000*

GCP-2: Granulocyte chemotactic protein-2; CXCL6: Chemokin Ligand-6; hs-CRP: High-sensitivity C-reactive protein; WBC: White blood cell; SD: Standard deviation. ^: Continuous variables that do not show normal distribution; *: Statistically significant.

Table 4. GCP-2/CXCL6, hs-CRP and WBC levels of the perforated and non-perforated patients Variable

Non-perforated Perforated p

GCP-2/CXCL6 (ng/mL)

268 (257–351.1)

354 (312.1–393.7)

0.003*

hs-CRP (ng/L)

26.64 (19.26–50.78)

65.08 (22.49–125.04)

0.018*

WBC (10 /µL)

12.8 (11.60–15.80)

13.8 (7.40–19.30)

0.622

3

GCP-2: Granulocyte chemotactic protein-2; CXCL6: Chemokin Ligand-6; hs-CRP: High-sensitivity C-reactive protein; WBC: White blood cell.

in WBC count is associated with the severity of AA, it is not absolute and not reliable in predicting the extent of the disease.[22,24] In our study, WBC levels of the AA group were significantly higher than the control group. This is consistent with the literature.

especially in the complicated appendicitis, although GCP-2/ CXCL-6 and hs-CRP levels were statistically significant, the significance value of GCP-2/CXCL-6 level was found to be higher. Here, the increase in GCP-2/CXCL-6 level has shown that it can be used as a potential marker, especially in the diagnosis of complicated AA.

Previous studies have shown that elevated CRP levels, along with leukocytosis, improve the diagnostic value in AA. In AA, especially in 12–24 hours, CRP seems to be useful, especially when serial levels show an increase.[18,25] Although CRP, especially hs-CRP, is a useful marker in the management of acute abdominal pain, it should be combined with CT results and clinical examinations. A meta-analysis exploring the diagnostic accuracy of CRP revealed a very wide range of sensitivity and specificity (47–74%, and 55–89%, respectively).[25] In our study, consistent with literature knowledge, hs-CRP levels in the patient group were significantly higher than that of the control group. The level of C-reactive protein alone does not influence the decision to confirm or exclude the diagnosis of AA safely or sufficiently. Thus, a stronger parameter of confidence in doubtful cases is needed.

The value of various biochemical/hematologic parameters other than WBC and CRP (Mean platelet volume, lymphocyte/leucocyte ratio, interleukin (IL)-6, IL-10, IL-4, IL-5, IL12, tumour necrosis factor alpha (TNF-a), endotoxin, erythrocyte sedimentation rate, procalcitonin, fibrinogen, alpha 2-macroglobulin, alpha 1- antitrypsin, D-lactate) have been studied for diagnosis of AA. However, none of them has found place in the routine clinical practice.[2] For the prevention of negative laparotomy rates and also delayed diagnosis of AA, new biochemical markers are still is a topic of interest. In our study, there was a significant difference between GCP2/CXCL6 levels of patient and control groups. This data can provide us with a positive opinion especially about the discriminatory power of this chemokine in the diagnosis of AA.

As stated in the literature, inflammatory markers may be useful when deciding operative management.[26] In the field of cardiology, hs-CRP has been a research topic in assessing heart failure.[27] Also, the use of hs-CRP to detect the severity of preeclampsia has been the subject of intensive research in particular.[28] The usefulness of inflammatory markers has also been investigated in the differentiation of complicated and uncomplicated acute diverticulitis recently.[29] In our study,

Recently, the treatment of appendicitis with antibiotics instead of surgery has been a topic of interest all over the world. In their study, Hansson et al.[30] proposed a model to identify patients with phlegmonous appendicitis, as these patients had an 80% probability of recovering with antibiotic therapy. Furthermore, Di Saverio et al.[31] provide further evidence that antibiotic treatment can be safe and effective in selected patients with suspected acute appendicitis.

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In summary, it seems unclear at which stage of disease progression antibiotic therapy is still feasible. Therefore, the suspected acute appendicitis is the one that requires markers to distinguish between cases with diagnosed or complicated appendicitis. In particular, a marker that can support the diagnosis of complicated acute appendicitis can help us. Here, GCP2/CXCL-6 and hs-CRP may be useful markers in this respect. When we compared AA and complex AA groups, we found that GCP-2/CXCL6 levels were higher in complicated than in non-complex AA cases. This chemokine is not routinely used in clinical settings, so automated kits are not found yet for quick analysis. This may limit the usage for now in emergency settings, but our study can be accepted as a pioneer study as, to our knowledge, this is the first study in the literature to show the correlation between GCP-2/CXCL6 levels and AA. Another shortcoming of our study may be the limited patient number.

Conclusion This study showed that GCP-2/CXCL6 could be a candidate biochemical marker in the diagnosis of AA. Also, it can be helpful in distinguishing complex AA from noncomplex AA. An additional study can be planned to discuss the difference in a larger study group. This can be accepted as a pioneer study in understanding the role of GCP-2/CXCL6 in AA. More detailed studies are needed to be carried out about protein expressions, immunohistochemistry and kinetics of GCP-2/CXCL6 production for further understanding of the nature of this chemokine and mechanisms of action in AA. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: Ç.Y., E.F.O., S.E., İ.B., T.T., M.T.; Design: Ç.Y., E.F.O., S.E., İ.B.; Supervision: Ç.Y., E.F.O., S.E., İ.B., T.T., M.T.; Fundings: Ç.Y., E.F.O., S.E., İ.B., T.T., M.T.; Materials: Ç.Y., E.F.O., S.E., İ.B., T.T., M.T.; Data: Ç.Y., E.F.O., S.E., İ.B., T.T., M.T.; Analysis: Ç.Y., E.F.O., S.E., İ.B.; Literature search: Ç.Y., E.F.O., S.E., İ.B.; Writing: Ç.Y., E.F.O., S.E., İ.B., T.T., M.T.; Critical revision: Ç.Y., E.F.O., S.E., İ.B., T.T., M.T. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

REFERENCES 1. Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management [published correction appears in Lancet 2017;390:1736]. Lancet 2015;386:1278–87. 2. Sack U, Biereder B, Elouahidi T, Bauer K, Keller T, Tröbs RB. Diagnostic value of blood inflammatory markers for detection of acute appendicitis in children. BMC Surg 2006;6:15. 3. Kim TH, Cho BS, Jung JH, Lee MS, Jang JH, Kim CN. Predictive

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Factors to Distinguish Between Patients With Noncomplicated Appendicitis and Those With Complicated Appendicitis. Ann Coloproctol 2015;31:192–7. 4. Baggiolini M. Chemokines in pathology and medicine. J Intern Med 2001;250:91–104. 5. Baggiolini M. Chemokines and leukocyte traffic. Nature 1998;392:565−8. 6. Luster AD. Chemokines--chemotactic cytokines that mediate inflammation. N Engl J Med 1998;338:436–45. 7. Zlotnik A, Yoshie O. Chemokines: a new classification system and their role in immunity. Immunity 2000;12:121–7. 8. Sadik CD, Kim ND, Luster AD. Neutrophils cascading their way to inflammation. Trends Immunol 2011;32:452–60. 9. Proost P, De Wolf-Peeters C, Conings R, Opdenakker G, Billiau A, Van Damme J. Identification of a novel granulocyte chemotactic protein (GCP-2) from human tumor cells. In vitro and in vivo comparison with natural forms of GRO, IP-10, and IL-8. J Immunol 1993;150:1000–10. 10. Linge HM, Collin M, Nordenfelt P, Mörgelin M, Malmsten M, Egesten A. The human CXC chemokine granulocyte chemotactic protein 2 (GCP-2)/CXCL6 possesses membrane-disrupting properties and is antibacterial. Antimicrob Agents Chemother 2008;52:2599–607. 11. Chandrasekar B, Smith JB, Freeman GL. Ischemia-reperfusion of rat myocardium activates nuclear factor-KappaB and induces neutrophil infiltration via lipopolysaccharide-induced CXC chemokine. Circulation 2001;103:2296–302. 12. Kwon JH, Keates AC, Anton PM, Botero M, Goldsmith JD, Kelly CP. Topical antisense oligonucleotide therapy against LIX, an enterocyte-expressed CXC chemokine, reduces murine colitis. Am J Physiol Gastrointest Liver Physiol 2005;289:G1075–83. 13. Smith E, McGettrick HM, Stone MA, Shaw JS, Middleton J, Nash GB, et al. Duffy antigen receptor for chemokines and CXCL5 are essential for the recruitment of neutrophils in a multicellular model of rheumatoid arthritis synovium. Arthritis Rheum 2008;58:1968−73. 14. Shafi SM, Afsheen M, Reshi FA. Total leucocyte count, C-reactive protein and neutrophil count: diagnostic aid in acute appendicitis. Saudi J Gastroenterol 2009;15:117–20. 15. Clyne B, Olshaker JS. The C-reactive protein. J Emerg Med 1999;17:1019–25. 16. Ho KM, Lipman J. An update on C-reactive protein for intensivists. Anaesth Intensive Care 2009;37:234–41. 17. Radović VV. Predictive value of inflammation and myocardial necrosis markers in acute coronary syndrome. [Article in Serbian]. Med Pregl 2010;63:662–7. 18. Chi CH, Shiesh SC, Chen KW, Wu MH, Lin XZ. C-reactive protein for the evaluation of acute abdominal pain. Am J Emerg Med 1996;14:254–6. 19. Wu HP, Lin CY, Chang CF, Chang YJ, Huang CY. Predictive value of C-reactive protein at different cutoff levels in acute appendicitis. Am J Emerg Med 2005;23:449–53. 20. Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB, Gibbons R, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129:S49−73. 21. Sammalkorpi HE, Mentula P, Savolainen H, Leppäniemi A. The Introduction of Adult Appendicitis Score Reduced Negative Appendectomy Rate. Scand J Surg 2017;106:196–201. 22. Kılıç MÖ, Güldoğan CE, Balamir İ, Tez M. Ischemia-modified albumin as a predictor of the severity of acute appendicitis. Am J Emerg Med 2017;35:92–5.

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Yücel et al. Diagnostic value of GCP-2/CXCL-6 and hs-CRP in the diagnosis of AA 23. Albayrak Y, Albayrak A, Albayrak F, Yildirim R, Aylu B, Uyanik A, et al. Mean platelet volume: a new predictor in confirming acute appendicitis diagnosis. Clin Appl Thromb Hemost 2011;17:362−6. 24. Nyuwi KT, Singh CG, Khumukcham S, Rangaswamy R, Ezung YS, Chittvolu SR, et al. The Role of Serum Fibrinogen Level in the Diagnosis of Acute Appendicitis. J Clin Diagn Res 2017;11:PC13−5. 25. Feng YY, Lai YC, Su YJ, Chang WH. Acute perforated appendicitis with leukopenic presentation. Am J Emerg Med 2008;26:735.e3–4. 26. Beecher SM, Hogan J, O’’Leary DP, McLaughlin R. An Appraisal of Inflammatory Markers in Distinguishing Acute Uncomplicated and Complicated Appendicitis. Dig Surg 2016;33:177–81. 27. Pearson MJ, Mungovan SF, Smart NA. Effect of aerobic and resistance training on inflammatory markers in heart failure patients: systematic review and meta-analysis. Heart Fail Rev 2018;23:209–23. 28. Jannesari R, Kazemi E. Level of High Sensitive C-reactive Protein and

Procalcitonin in Pregnant Women with Mild and Severe Preeclampsia. Adv Biomed Res 2017;6:140. 29. Hogan J, Sehgal R, Murphy D, O’Leary P, Coffey JC. Do Inflammatory Indices Play a Role in Distinguishing between Uncomplicated and Complicated Diverticulitis?. Dig Surg 2017;34:7–11. 30. Hansson J, Khorram-Manesh A, Alwindawe A, Lundholm K. A model to select patients who may benefit from antibiotic therapy as the first line treatment of acute appendicitis at high probability. J Gastrointest Surg 2014;18:961–7. 31. Di Saverio S, Sibilio A, Giorgini E, Biscardi A, Villani S, Coccolini F, et al. The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis. Ann Surg 2014;260:109−17.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut apandisit tanısında GCP-2/CXCL-6 ve hs-CRP’nin tanısal değeri Dr. Çiğdem Yücel,1 Dr. Esra Fırat Oğuz,2 Dr. Sadettin Er,3 Dr. İlhan Balamir,4 Dr. Turan Turhan,2 Dr. Mesut Tez3 Gülhane Eğitim ve Araştırma Hastanesi, Tıbbi Biyokimya Kliniği, Ankara Ankara Numune Eğitim ve Araştırma Hastanesi, Tıbbi Biyokimya Kliniği, Ankara Ankara Numune Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Ankara 4 Ankara Atatürk Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi, Klinik Biyokimya Kliniği, Ankara 1 2 3

AMAÇ: Akut apandisit (AA), akut karın ağrısının en önemli nedenlerinden biridir. AA tanısı için çeşitli laboratuvar belirteçleri çalışılmıştır, ancak hiçbiri fizik muayene veya görüntülemeye üstünlük göstermemiştir. GCP-2/CXCL6, enflamasyon sırasında makrofajlar ve epitelyal ve mezenkimal hücreler tarafından eksprese edilen bir kemokindir. Bu çalışmanın amacı AA hastalarında GCP-2/CXCL6’nın tanısal rolünü araştırmaktır. GEREÇ VE YÖNTEM: Bu kesitsel çalışmada, serum GCP-2/CXCL6 düzeyi 56 AA hastası ve 32 sağlıklı kontrolde ölçülmüştür. Ayrıca, hasta ve kontrol gruplarının hs-CRP ve lökosit (WBC) düzeyleri değerlendirilmiştir. BULGULAR: Akut apandisit grubunun GCP-2/CXCL-6, hs-CRP ve WBC düzeyleri kontrol grubundan anlamlı derecede yüksekti (tüm karşılaştırmalar için p<0.05). AA grubu arasında ise, GCP-2/CXCL6 seviyeleri kompleks AA’da (gangrenöz, apse ve perforasyon), kompleks olmayan AA’lara göre daha yüksekti (p<0.05). GCP-2/CXCL6 seviyeleri ile hsCRP seviyeleri arasında güçlü bir pozitif korelasyon bulunmuştur (r=0.756, p=0.003) ve GCP-2/CXCL6 seviyeleri ile WBC sayısı arasında orta derecede pozitif korelasyon bulunmuştur (r=0.468, p=0.003). TARTIŞMA: GCP-2/CXCL6, AA teşhisinde ve karmaşık olguların ayırt edilmesinde, özellikle diğer laboratuvar belirteçleri ve görüntüleme teknikleriyle birleştirildiğinde yararlı bir belirteç olabilir. Anahtar sözcükler: Akut apandisit; kemokin; komplikasyon; prognoz; tanı. Ulus Travma Acil Cerrahi Derg 2020;26(2):191-196

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doi: 10.14744/tjtes.2019.26270

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ORIGIN A L A R T IC L E

An updated analysis of the surgical and urological complications of 789 living-related donor kidney transplantations: Experience of a single center Tayfun Oktar, M.D., Taner Koçak, M.D., Tzevat Tefik, M.D., Öner Şanlı, M.D., H. Orhan Ziylan, M.D., İsmet Nane, M.D.

Selçuk Erdem, M.D.,

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

ABSTRACT BACKGROUND: This study aims to review retrospectively the surgical and urological complications encountered in 789 cases of living-related donor kidney transplantations (LRDKTs). METHODS: In this study, the clinical records of 789 LRDKTs, which were performed between 1983 and 2017, were reviewed retrospectively concerning surgical and urological complications. RESULTS: Overall, urological and surgical complications were encountered in 87 (11.02%) of the cases. Of the 789 patients, urological complications were detected in 44 of them (5.6%), including 8 urinary fistula (with 1 distal ureteral necrosis), 10 ureteric stenosis, 1 renal calculus, 9 symptomatic vesicoureteral reflux and 16 lymphoceles requiring intervention. As surgical complications (n=43), vascular complications were encountered in 8 cases; there were 5 cases with renal artery stenosis and 3 with renal vein thrombus. Wound infection was detected in 14 patients. Eighteen patients underwent surgical explorations due to perinephric hematoma during the early postoperative period. Renal allograft rupture due to accelerated rejection was developed in 2 cases. A lower segmental arterial injury occurred in 1 patient during the operation. CONCLUSION: In our series, urological and surgical complications were detected in 11.02% of the recipients. Although complications still encountered, early identification of these complications with proper management strategies significantly decreases the risk of graft loss. Keywords: Living donor kidney transplantation; surgical complication; urological complication.

INTRODUCTION Living-related donor kidney transplantation (LRDKT) is a significant source of graft, especially in countries that have problems in cadaveric donor source. The surgical and urological complications after kidney transplantation still remain a challenging problem despite refinements and almost standardization of surgical techniques. These complications may lead to devastating consequences, such as graft loss or even death. Thus, early diagnosis and proper management are crucial when dealing with these complications.

The urological complications have been reported to be 2.8% to 12.5% in large series.[1–6] In our previous study, which was published in 2004, urological complications were detected in 8% of the 362 consecutive living-related donor kidney transplantations and surgical complications were encountered in 7.7% of them.[1] In this present study, we reviewed the urological and surgical complications in 789 consecutive livingrelated kidney transplantations.

MATERIALS AND METHODS The clinical records of 789 LRDKTs, which were performed

Cite this article as: Oktar T, Koçak T, Tefik T, Erdem S, Şanlı Ö, Ziylan HO, et al. An updated analysis of the surgical and urological complications of 789 living-related donor kidney transplantations: Experience of a single center. Ulus Travma Acil Cerrahi Derg 2020;26:197-202. Address for correspondence: Tayfun Oktar, M.D. İstanbul Üniversitesi İstanbul Tıp Fakültesi, Üroloji Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 14 20 00 E-mail: tayfunoktar@hotmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):197-202 DOI: 10.14744/tjtes.2019.78805 Submitted: 13.04.2019 Accepted: 07.05.2019 Online: 25.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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Oktar et al. An updated analysis of the surgical and urological complications of 789 LRDKTs

between 1983 and 2017, were reviewed retrospectively concerning surgical and urological complications. Of the 789 recipients, 528 were male and 261 were female. The mean age of the recipients was 30.7 (Range: 4–67) years. Living donor nephrectomy was performed by the open approach in 694 and by laparoscopy in the last 95 cases. A flank incision with either 11th or 12th rib resecting or intercostal approach was used in open donor nephrectomy. The kidney was then placed in an ice-cold solution and flushed with heparinized Ringer’s solution. In the laparoscopic approach, the patients were placed on a lateral position with flexion of the operative table. A 15-mmHg pneumoperitoneum was created and four ports were placed. Extraction was performed via an ipsilateral modified Gibson incision through a specimen bag. In the surgical technique for adult recipients, as also previously described, the kidney was engrafted extraperitoneally in the contralateral iliac fossa via Gibson incision. The renal vein was anastomosed end-to-side to the external iliac vein with continuous 6/0 monofilament, polypropylene sutures, and the renal artery was anastomosed end-to-end to the internal iliac artery with interrupted sutures or in certain cases end-toside to the external iliac artery, using 6/0 monofilament, nonabsorbable polypropylene sutures. In the presence of multiple renal arteries, reconstruction with side-to-side ‘Gun-barrel’ anastomosis was performed on the bench. Before all types of vascular anastomosis, vessel lumens were flushed with heparinized saline. Low molecular weight heparins were started on a weight-based dosage postoperatively. The The Extravesical anterolateral ureteroneocystostomy technique (Lich-Gregoir method) was used for vesicoureteric anastomosis. Before 1997, double-J ureteral catheters were only used in some selected complicated cases; however, after this period, ureteral stents were routinely placed to secure anastomosis and to decrease urological complications. The second generation prophylactic antibiotics were started before the operation and continued until postoperative cultures were known. Indwelling Foley catheters were removed after five to seven days postoperatively in uncomplicated patients. Informed consents were given to all subjects before the procedures and the protocols conformed to the ethical guidelines of the 1975 Helsinki Declaration. The study protocol was approved by the institutional review board (IRB: 293862).

RESULTS Overall, 87 (11.02%) urological and surgical complications were detected in 789 consecutive living-related kidney transplantations. Urological complications occurred in 44 (5.6%) transplants, including 10 ureteral stricture, 9 symptomatic vesicoureteral reflux (VUR), 8 urinary fistulas, 1 renal calculi, and 16 lymphoceles requiring intervention. As surgical complications (n=43), vascular complications were encountered 198

in 8 cases; there were 5 cases with renal artery stenosis and 3 with renal vein thrombus. Eighteen recipients were surgically explored due to perinephric hematoma during the early postoperative period. Renal allograft rupture due to accelerated rejection was observed in 2 patients. A lower segmental arterial injury occurred in 1 patient during donor nephrectomy. Wound infection was detected in 14 patients. Stricture at the ureterovesical anastomosis was observed in 10 patients. Initially, the double-J ureteral stent was placed to six cases and percutaneous nephrostomy placement was performed to four patients, in whom double-J stent insertion was unsuccessful. Five of the six ureteric stenoses having ureteric stents were managed by balloon-dilatation of the ureter, without requiring further interventions. One patient was under close follow-up with periodical stent renewal. Of four ureteric stenoses that were initially managed by percutaneous nephrostomy, 3 of them underwent open reconstruction with pyeloureterostomy (1) and ureteroneocystostomy (2) and balloon dilatation with ureteral stent placement was performed to the remaining patient. Urine leakage at the ureterovesical anastomosis was detected in 8 patients. All of them diagnosed in the early postoperative period, including 1 case whose leakage developed after surgical exploration for early postoperative hematoma. Open reconstruction was performed to all cases, including the renewal of the anastomosis in 6 cases and pyeloureterostomy to native ureter in 2 patients due to distal ureteric necrosis. Symptomatic VUR to the transplanted kidney was detected in 9 patients. These patients had recurrent and symptomatic urinary tract infections and were diagnosed during screening VCUG. Endoscopic suburethral injection was performed to 4 patients and 2 cases were treated with surgical reconstruction. The remaining 3 patients with low-grade VUR are under close follow-up, without requiring any surgical intervention. Postoperative stone formation in the transplanted kidney was observed in 1 patient, and successfully managed by percutaneous nephrolithotomy due to failure to ESWL. In another case, a lower pole stone in the donor kidney was removed by flexible ureteroscopy on the bench side after donor nephrectomy and transplanted to the recipient without any complication. Lymphoceles requiring interventions were observed in 16 cases. Percutaneous drainage was performed in 10 cases. In the remaining 6 lymphoceles, intraperitoneal drainage with fenestration was required, including 4 with open surgery and 2 with a laparoscopic approach. Renal vein thrombosis developed in 3 recipients. Allograft nephrectomy was performed in 2 cases. In 1 patient, early exploration and thrombectomy, with subsequent explanation were performed and the kidney was successfully placed to the contralateral side, with an uneventful postoperative period. Renal arterial stenosis was observed in 5 cases. Percutaneous angioplasty was performed Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Oktar et al. An updated analysis of the surgical and urological complications of 789 LRDKTs

Table 1. Comparison of the urological complications between 1983–2002 and 2002–2017 Urological complications

1983–2002 2002–2017 Overall (n=362) (n=427) (n=789)

Ureteric obstruction

2

8

10

Urinary leakage

5

3

8

VUR (Vesico-ureteral reflux)

8

1

9

Calculi

1 0 1

Lymphocele

13 3 16

Overall

29 (8.01%)

15 (3.5%)

44 (5.6%)

Table 2. Comparison of the surgical complications between 1983–2002 and 2002–2017 Surgical complications Renal artery stenosis

1983–2002 2002–2017 Overall (n=362) (n=427) (n=789) 5

0

Renal vein thrombosis

0

3

3

Perinephric hematoma

14

4

18

Renal allograft rupture

2

0

2

Wound infection

6

8

14

Lower segmental arterial injury Overall

1

0

1

28 (7.7%)

15 (3.5%)

43 (5.44%)

to 3 patients and in the remaining 2 recipients, stenosis was diagnosed to be less than 50% of the artery with no renal functional impairment, and no intervention was required. In one patient, the lower segmental artery was unintentionally injured during donor nephrectomy, reconstructed intraoperatively and anastomosis was performed. However, on a postoperative day 14, lower pole resection was required due to poor circulation. The postoperative period was uneventful. The comparison of urological and surgical complications between two periods of time (1983–2002 vs 2002–2017) is given in Table 1 and Table 2, respectively.

DISCUSSION Kidney transplantation is the ideal management of the patients with end-stage renal disease. However, in some countries, there may be problems to find cadaveric donor candidates due to social and religious factors and in these situations, living-related kidney donors become a viable option for kidney transplantation. However, urological and surgical complications are still a major source of morbidity and may lead to graft and even patient loss. In our series, overall, urological and surgical complications were detected in 11.02% of the cases. Urological complications have been reported to be between 2.8% and 12.5% in some large series.[1–6] Bessede et al.[6] have Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

5

detected urological complications in 11.2% of 3129 kidney transplants, which were mainly recovered from cadaveric donors (92.5%). The different rates of complications in the literature could be partially explained by the inclusion of all types of complications, such as stricture, obstruction, reflux, lymphoceles and stones, in these series. In our series, urological complications were observed in 5.6% of the recipients. Urological complications are mainly due to technical factors. Preservation of periureteric fatty tissue to maintain ureteral blood supply is a crucial factor to decrease ureteral ischemia related complications. Also, to shorten the ureter to a minimum length necessary to achieve a tension-free anastomosis without kinking and with a lesser risk of ischemic injury is an important surgical principle for the reduction of these complications.[6,7] The type of ureteral reimplantation is another significant factor affecting complication rates. In our series, extravesical ureteroneocystostomy (Lich-Gregoir) was performed in all cases. This technique has several advantages, including decreased bladder bleeding, the use of a shorter segment of the ureter and decreased operative time.[8] Ureteral stricture and urinary leakage are the most commonly reported urological complications. In our series, ureteral stricture was observed in 10 (1.26%) cases. Ureteral strictures are mainly due to ureteral ischemia resulting in fibrosis, immunological factors, infections, extrinsic compression by hematoma or lymphocele, and acute or chronic rejec199

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tion episodes.[9–11] Ureteral stenting after balloon dilatation or surgical reconstruction is the treatment options for the management of these strictures. Although reimplantation of the ureter is the treatment of choice for the ureterovesical complications, the use of native ureter, when available, as pyeloureterostomy or ureteroureterostomy, is a valuable management alternative, with good long-term results reported in the literature.[12,13] In our series, although balloon dilatation and ureteral stenting were successful in five cases, open reconstruction with pyeloureterostomy (2) and ureteroneocystostomy (1) was required in three patients, without any further complications. The urinary leakage was reported to be 1.2% to 13% in the literature.[4–6,14] The early postoperative leakage is generally due to anastomosis dehiscence, and ureteral ischemia with necrosis is the most common cause of the late presented cases. In our series, urinary leakage was observed in 8 (1.01%) patients, all requiring open reconstruction. The use of ureteral stents in renal transplantation remains a controversial topic and has been debated extensively in the literature. The rationale for the routine use of the stents is to decrease the complications related to the ureterovesical anastomosis, as used in other reconstructive urological operations. In a meta-analysis, including five randomized studies and 44 case series, it was reported that stented extravesical ureteroneocystostomy had a significantly lower urologic complication rate than those with non-stented anastomosis which was 1.5% in stented versus 9% in non-stented subjects in controlled trials group.[15] In a more recent meta-analysis, Wilson et al.[16] reported that the incidence of major urological complications was significantly reduced by prophylactic stenting. In our series, since 1997, we have routinely used ureteral stents in renal recipients. The incidence of post-transplant VUR has been reported to be between 1% to 86% in the literature.[17–20] This wide range of VUR detection can be explained by the differences in the indications and timing of imaging and surgical techniques used for implantation. The clinical consequences of post-transplant VUR and its impact on graft function is also a matter of debate. In a study with 1008 adult renal transplant recipients of whom a 1-week post-transplant voiding cystourethrogram was available, VUR was detected 106 (10.5%) graft recipients.[20] Oneand 5-year graft survival in patients with VUR was 85.8% and 82.1% compared to 87.3% and 83.0% in patients without VUR and no significant difference was observed between the two groups. However, in case of recurrent, symptomatic infections, interventions for correction of post-transplant reflux are indicated, which includes endoscopic injection treatment and open surgical reconstruction. In our series, endoscopic suburethral injection or surgical reconstruction was performed to 6 patients. The remaining 3 patients with low-grade VUR are under close follow-up, without requiring further treatment. Lymphoceles requiring interventions were observed in 16 cases. Careful ligation of lymphatic vessels originating from 200

the recipient’s peri-iliac network and the hilum of the donor kidney significantly reduces the formation of lymphoceles. Percutaneous drainage was performed in 10 cases. In the remaining 6 lymphoceles, intraperitoneal drainage was required, including 4 with open surgery and 2 with the laparoscopic approach. The post-transplant incidence of urolithiasis is reported to be between 0.2 and 1.8% in the literature.[9,21,22] The stone can be formed de novo or can be donor-related. Although it is a rare event, urinary obstruction, sepsis and loss allograft function are the potentially serious complications requiring proper diagnosis and management. In our series, the post-transplant stone was observed in one patient, and successfully managed by percutaneous nephrolithotomy due to failure to ESWL. In another case, a lower pole stone in a donor kidney was successfully managed by flexible ureteroscopy on the bench side and the stone-free graft was transplanted to the recipient, which might be a useful approach to donor kidneys with stones, especially in case of shortage of grafts. Renal artery stenosis after transplantation has been reported to be 1% to 23% in the literature, although the true incidence may vary depending on the routine screening and the method of diagnosis of the stenosis.[23,24] Graft dysfunction and hypertension are the most common indications for intervention. Treatment options include medical management, percutaneous transluminal angioplasty, stent placement and surgical reconstruction. Percutaneous transluminal angioplasty is the most commonly used treatment modality. In our series, post-transplant renal artery stenosis was detected in 5 cases, and percutaneous angioplasty was required in 3 of them. In the remaining two patients, stenosis was diagnosed to be less than 50% of the artery with no renal functional impairment and no intervention was required. Renal vein thrombosis is a serious vascular complication, usually occurring in the early postoperative period and is one of the main causes of early graft dysfunction and loss. The reported incidence ranges from 0.1% to 4.2%.[25–27] The etiologic factors are technical issues, including anastomotic stenosis and kinking of the vein, compression of renal vein by hematomas or lymphoceles, atherosclerotic vessels in recipients and immunosuppression. Renal vein thrombosis developed in three of our patients. Allograft nephrectomy was performed to two of them. In one patient, early exploration and thrombectomy, with subsequent explanation were performed and the kidney was successfully placed to the contralateral side, with an uneventful postoperative period. The use of kidneys from living donors with renal artery aneurysms (RAA) is an option for selected cases having problems in finding donor kidney source. In our series, a donor kidney from a 64 years old male with a 1.5 cm saccular RAA at the branch of the left renal artery was reconstructed on the bench, using an arterial wall patch and transplanted successfully, without any postoperative complication. Overall, in our series of 789 LRDKTs, the urological and surgical complications tend to decrease with time. The use of routine ureteral stents for Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

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ureterovesical anastomosis and to limit the dissection of external iliac veins for the reduction of lymphoceles is important technical factors for the prevention of these complications. For vascular complications, proper management strategies, including early intervention, can prevent graft loss in selected cases. In case of graft shortage, surgical reconstruction and bench interventions may expand the donor selection, as in our donor case with renal arterial patch and the other donor kidney with lower pole stone. In conclusion, modifications and standardization of surgical techniques of kidney transplantation, as well as early identification of complications, significantly decrease the risk of graft loss. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: T.O., T.K.; Design: T.O., T.K.; Supervision: T.O., T.K., H.O.Z, İ.N.; Materials: T.O., T.K., T.T., S.E., Ö.Ş., H.O.Z., İ.N.; Data: T.O., T.K., T.T., S.E., Ö.Ş., H.O.Z., İ.N.; Analysis: T.O., T.K.; Literature search: T.O., T.K., T.T., S.E.; Writing: T.O., T.K.; Critical revision: T.O., T.K., Ö.Ş., H.O.Z., İ.N. Conflict of Interest: None declared.

9. Krajewski W, Dembowski J, Kołodziej A, Małkiewicz B, Tupikowski K, Matuszewski M, et al. Urological complications after renal transplantation - a single centre experience. Cent European J Urol 2016;69:306−11. 10. Shoskes DA, Hanbury D, Cranston D, Morris PJ. Urological complications in 1,000 consecutive renal transplant recipients. J Urol 1995;153:18–21. 11. Palazzetti A, Oderda M, Dalmasso E, Falcone M, Bosio A, Sedigh O, et al. Urological consequences following renal transplantation: a review of the literature. Urologia 2015;82:211−8. 12. Salomon L, Saporta F, Amsellem D, Hozneck A, Colombel M, Patard JJ, et al. Results of pyeloureterostomy after ureterovesical anastomosis complications in renal transplantation. Urology 1999;53:908−12. 13. Schult M, Küster J, Kliem V, Brunkhorst R, Nashan B, Oldhafer KJ, et al. Native pyeloureterostomy after kidney transplantation: experience in 48 cases. Transpl Int 2000;13:340−3. 14. Dörsam J, Knopp MV, Carl S, Oesingmann N, Schad L, Brkovic D, et al. Ureteral complications after kidney transplantation--evaluation with functional magnetic resonance urography. Transplant Proc 1997;29:132−5. 15. Mangus RS, Haag BW. Stented versus nonstented extravesical ureteroneocystostomy in renal transplantation: a metaanalysis. Am J Transplant 2004;4:1889–96. 16. Wilson CH, Rix DA, Manas DM. Routine intraoperative ureteric stenting for kidney transplant recipients. Cochrane Database Syst Rev 2013;:CD004925.

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

17. Kayler L, Kang D, Molmenti E, Howard R. Kidney transplant ureteroneocystostomy techniques and complications: review of the literature. Transplant Proc 2010;42:1413–20.

REFERENCES

18. Coosemans W, Rega F, Roels L, Peeters J, Donck J, Vanwalleghem J, et al. Impact of early vesico ureteral reflux on the transplanted kidney. Transplant Proc 1999;31:362−4.

1. Koçak T, Nane I, Ander H, Ziylan O, Oktar T, Ozsoy C. Urological and surgical complications in 362 consecutive living related donor kidney transplantations. Urol Int 2004;72:252–6. 2. Ohl DA, Konnak JW, Campbell DA, Dafoe DC, Merion RM, Turcotte JG. Extravesical ureteroneocystostomy in renal transplantation. J Urol 1988;139:499–502. 3. Mundy AR, Podesta ML, Bewick M, Rudge CJ, Ellis FG. The urological complications of 1000 renal transplants. Br J Urol 1981;53:397–402. 4. Streeter EH, Little DM, Cranston DW, Morris PJ. The urological complications of renal transplantation: a series of 1535 patients. BJU Int 2002;90:627–34. 5. Mäkisalo H, Eklund B, Salmela K, Isoniemi H, Kyllönen L, Höckerstedt K, et al. Urological complications after 2084 consecutive kidney transplantations. Transplant Proc 1997;29:152−3. 6. Bessede T, Hammoudi Y, Bedretdinova D, Parier B, Francois H, Durrbach A, et al. Preoperative Risk Factors Associated With Urinary Complications After Kidney Transplantation. Transplant Proc 2017;49:2018−24. 7. Raman A, Lam S, Vasilaras A, Joseph D, Wong J, Sved P, et al. Influence of ureteric anastomosis technique on urological complications after kidney transplantation. Transplant Proc 2013;45:1622−4. 8. Butterworth PC, Horsburgh T, Veitch PS, Bell PR, Nicholson ML. Ureterovesical anastomosis in renal transplants: fewer complications with the extravesical technique. Transplant Proc 1997;29:151.

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19. Mastrosimone S, Pignata G, Maresca MC, Calconi G, Rabassini A, Butini R, et al. Clinical significance of vesicoureteral reflux after kidney transplantation. Clin Nephrol 1993;40:38−45. 20. Molenaar NM, Minnee RC, Bemelman FJ, Idu MM. Vesicoureteral Reflux in Kidney Transplantation. Prog Transplant 2017;27:196–9. 21. Mamarelis G, Vernadakis S, Moris D, Altanis N, Perdikouli M, Stravodimos K, et al. Lithiasis of the renal allograft, a rare urological complication following renal transplantation: a single-center experience of 2,045 renal transplantations. Transplant Proc 2014;46:3203−5. 22. Saxena S, Sadideen H, Goldsmith D. Treating stones in transplanted kidneys. Minerva Med 2013;104:31–40. 23. Chen LX, De Mattos A, Bang H, Vu CT, Gandhi M, Alnimri M, et al. Angioplasty vs stent in the treatment of transplant renal artery stenosis. Clin Transplant 2018;32:e13217. 24. Bruno S, Remuzzi G, Ruggenenti P. Transplant renal artery stenosis. J Am Soc Nephrol 2004;15:134–41. 25. El Zorkany K, Bridson JM, Sharma A, Halawa A. Transplant Renal Vein Thrombosis. Exp Clin Transplant 2017;15:123–9. 26. Bakir N, Sluiter WJ, Ploeg RJ, van Son WJ, Tegzess AM. Primary renal graft thrombosis. Nephrol Dial Transplant 1996;11:140–7. 27. Fathi T, Samhan M, Gawish A, Donia F, Al-Mousawi M. Renal allograft venous thrombosis is salvageable. Transplant Proc 2007;39:1120–1.

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Oktar et al. An updated analysis of the surgical and urological complications of 789 LRDKTs

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Canlı donörden böbrek transplantasyonunda cerrahi ve ürolojik komplikasyonların 789 olguda güncellenmiş analizi: Tek bir merkez tecrübesi Dr. Tayfun Oktar, Dr. Taner Koçak, Dr. Tzevat Tefik, Dr. Selçuk Erdem, Dr. Öner Şanlı, Dr. H. Orhan Ziylan, Dr. İsmet Nane İstanbul Üniversitesi İstanbul Tıp Fakültesi, Üroloji Anabilim Dalı, İstanbul

AMAÇ: Bu çalışmanın amacı, 789 canlı donörden böbrek transplantasyon (CDBT) olgusunda cerrahi ve ürolojik komplikasyonların geriye dönük olarak değerlendirilmesidir. GEREÇ VE YÖNTEM: Anabilim dalımızda 1983 ve 2017 yılları arasında yapılan 789 CDBT olgusunun klinik bilgileri cerrahi ve ürolojik komplikasyonlar bakımından geriye dönük olarak değerlendirildi. BULGULAR: Ürolojik ve cerrahi komplikasyonlar 87 (%11.02) olguda tespit edildi. Olguların 44’ünde (%5.6) görülen ürolojik komplikasyonlar sekiz olguda üriner fistül (1’i distal üreter nekrozu ile birlikte), 10 olguda üreter stenozu, 1 olguda renal kalkül, 9 olguda semptomatik vezikoüreteral reflü ve 16 hastada girişim gerektiren lenfosel idi. Cerrahi komplikasyonlar ise (n=43), 5’i renal arter stenozu ve 3’ü renal ven trombozu olmak üzere toplam 8 olguda vasküler komplikasyon, 14 yara yeri enfeksiyonu, 18 erken ameliyat sonrası cerrahi eksplorasyon gerektiren perinefrik hematom, 2 akselere rejeksiyon nedeniyle renal allograft rüptürü ve bir ameliyat sırasında alt segmental arter hasarı idi. TARTIŞMA: Çalışmamızda ürolojik ve cerrahi komplikasyonlar alıcıların %11.2’sinde saptanmıştır. Bu komplikasyonların erken tanınması ve uygun stratejilerle yönetilmesi greft kaybı riskini anlamlı ölçüde azaltmaktadır. Anahtar sözcükler: Canlı donörden böbrek transplantasyonu; cerrahi komplikasyon; ürolojik komplikasyon. Ulus Travma Acil Cerrahi Derg 2020;26(2):197-202

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doi: 10.14744/tjtes.2019.78805

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ORIGIN A L A R T IC L E

Endoscopic and surgical management of iatrogenic biliary tract injuries Turan Acar, M.D.,1 Özlem Gür, M.D.,1

Nihan Acar, M.D.,2 Feyyaz Güngör, M.D.,1 Emrah Alper, M.D.,3 Hakan Çamyar, M.D.,4 Mehmet Hacıyanlı, M.D.,1 Osman Nuri Dilek, M.D.1

1

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

2

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

3

Department of Gastroenterology, Koç University Faculty of Medicine, İstanbul-Turkey

4

Department of Gastroenterology, İzmir Atatürk Training and Research Hospital, İzmir-Turkey

ABSTRACT BACKGROUND: Iatrogenic biliary tract injury (BTI) is a rare complication but has high risks of morbidity and mortality when it is not early noticed. Although the treatment varies depending on the size of injury and the time until the injury is noticed, endoscopic and percutaneous interventions are usually sufficient. However, it should be remembered that these interventions may cause major complications in the following years, such as biliary stricture, recurrent episodes of cholangitis and even cirrhosis. In this paper, we aimed to present our approach to BTI following cholecystectomy and our treatment management in the light of the literature. METHODS: The medical records of 105 patients who were treated for BTI between January 2015 and July 2019 were evaluated retrospectively. The majority of the patients consisted of the patients who underwent cholecystectomy at an external medical center and were referred to our clinic due to biliary leakage (BL). Patients were grouped according to Strasberg classification determined by the place of leakage. RESULTS: Among 105 patients included in this study, 55 were male, and 50 were female. Mean age was 55.2 ±16.26 years (range, 21– 93 years). According to Strasberg classification, type A, B, C, D and E injuries were detected in 57, 1, 3, 29 and 15 patients, respectively. Eighty-five patients were successfully treated with endoscopic and percutaneous interventions, while 20 patients underwent surgery. CONCLUSION: In all patients with suspected BTI, a detailed screening and appropriate treatment provide a significant decline in morbidity and mortality. Therefore, early diagnosis is very important for both early and late outcomes. Keywords: Biliary tract injuries; endoscopy; iatrogenic; surgery.

INTRODUCTION Cholecystectomy has become standard procedure in the treatment of symptomatic gallstones. Biliary leakage (BL) following cholecystectomy is a rare complication but has high risks of morbidity and mortality when it is not early noticed. [1] The rate of this complication is higher in laparoscopic cholecystectomy (LC) than open cholecystectomy (OC). Cystic duct stump and Luschka (subvesical bile duct) are the most common places of the leakage. Leakage that occurs due

to iatrogenic injuries is mostly seen in the proximal parts of the hepatic duct.[2] Anatomic variation and inexperienced surgeon were presented to be the most common causes of the injuries.[2] In the late postoperative period, it can cause some late complications, such as biliary stricture or recurrent cholangitis, which may bring serious legal problems for us as physicians.[3] Currently, treatment of the bile duct injuries recorded significant improvement with the development of laparoscopic and endoscopic procedures.[4] Most cases can be treated with

Cite this article as: Acar T, Acar N, Güngör F, Alper E, Gür Ö, Çamyar H, et al. Endoscopic and surgical management of iatrogenic biliary tract injuries. Ulus Travma Acil Cerrahi Derg 2020;26:203-211. Address for correspondence: Turan Acar, M.D. İzmir Katip Çelebi Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İzmir, Turkey Tel: +90 232 - 329 35 35 E-mail: drturanacar1982@gmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):203-211 DOI: 10.14744/tjtes.2019.62746 Submitted: 15.08.2019 Accepted: 18.12.2019 Online: 21.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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Acar et al. Endoscopic and surgical management of iatrogenic biliary tract injuries

endoscopic sphincterotomy and/or stenting without any need for surgical intervention.[4] In this study, our aim was to seek answers to the following five questions: 1.Whatare the factors that increase the risk of injury? 2. What is the most common type of injury, according to Strasberg classification? 3. Which type of injury has a higher success rate for the endoscopic/percutaneous interventions? 4. Which procedure is our primary preference for surgical treatment? 5. What are the probable complications that may be encountered during the short and long term follow-up of these cases, and how should they be managed?

MATERIALS AND METHODS The medical records of the patients who underwent cholecystectomy between January 2015 and December 2019 in our clinic or were referred to our clinic from other hospitals due to BL were evaluated retrospectively. Average 6500 cholecystectomy procedures were performed in five years. One hundred five patients, who had been diagnosed with BL and had been treated successfully, were included in the study group. The majority of the patients consisted of the patients who underwent cholecystectomy at an external medical center and were referred to our clinic due to BL. Biliary leakage was diagnosed with the postoperative clinical signs, drainage follow-up and/or imaging methods. Clinicopathologic features of the patients, performed surgical procedures, place and amount of the leakage, the success of the endoscopic interventions and the need for additional percutaneous drainage and/or secondary operation were analyzed. Types of the injury were classified according to Strasberg classification[5] (Fig. 1, Table 1). The patients who were treated in the same session owing to detecting biliary tract injury during the operation (n=9), could not be followed up after treatment (n=6) and had spontaneous closure of the fistula without any endoscopic or surgical procedure within five days (n=12) were excluded from this study.

ERCP (Endoscopic Retrograde Cholangiopancreatography) Following the oropharyngeal lidocaine anesthesia and intravenous premedication (Diazepam or meperidine and midazolam), ERCP was performed using Olympus TJF 10, 20, Pentax FD- 34X duodenoscopies or Olympus TJF-240 videoduodenoscopy (Fig. 2). Sphincterotomy was performed, and catheter or plastic stent (various sizes) was placed when it was essential according to imaging results.

Roux- Y Hepaticojejunostomy (HJ) The jejunum was cut from 25 cm proximal of the ligament of treitz and prepared. The distal end was brought to the 204

E1 (>2 cm)

A

B

C

D

E2 (<2 cm)

E4

E3

E5

Figure 1. Strasberg-Bismuth classification of injuries to the biliary tract.

Table 1. Strasberg classification for biliary tract injuries Type A

Bile leak from cystic duct or liver bed without further

injury Type B

Partial occlusion of the biliary tree, most frequently

of an aberrant right hepatic duct (RHD)

Type C

Bile leak from duct (aberrant RHD) that is not

communicating with the common bile duct (CBD)

Type D

Lateral injury of the biliary system, without loss of

continuity Type E1

Common hepatic duct division ≼2 cm from bifurcation

Type E2

Common hepatic duct division <2 cm from bifurcation

Type E3

Common duct division at the bifurcation

Type E4

Separate left and right hepatic duct strictures

Type E5

Combined injury to main duct at the bifurcation and

right segmental bile duct

hilus of the liver by passing through the mesocolonretrocolically. Roux limb was anastomosed end-to-side to the hepatic duct with interrupted 4.0 PDS sutures (Fig. 3). Afterwards, a double-layer side-to-side enteroenterostomy was applied between 40–60 cm distal of Roux limb and the proximal end of the jejunum, which was divided at the beginning. We perUlus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Acar et al. Endoscopic and surgical management of iatrogenic biliary tract injuries

Table 2. Demographic and clinical characteristics of the patients (n=105) Age (range)

Mean

55.2±16.26 (21–93)

Male

60.2±14.26 (37–90)

Female

50.8±17.24 (21–93)

Gender, n (%)

Female

50 (47.6)

Male

55 (52.4)

Operation type, n (%)

Laparoscopic cholecystectomy (LC)

Laparoscopic switched to open surgery

13 (12.25)

79 (75)

Open surgery

13 (12.25)

Symptom, n (%)

Figure 2. Bile tract injury detection with ERCP (Type E leakage).

Distention, fever

24 (23.1)

Biloma

17 (16.3) 35 (32.7)

Bile leak

Peritonitis

8 (7.7)

Obstructive jaundice

7 (6.7)

Cholangitis

14 (13.5)

Strasberg classification according to the type of injury, n (%)

Type A

57 (54.1)

Type B

1 (1)

Type C

3 (2.9)

Type D

29 (27.6)

Type E1

3 (2.9)

Type E2

5 (4.8)

Type E3

4 (3.8)

Type E4

2 (1.9)

Type E5

1 (1)

Risk factors, n (%) Figure 3. Hepaticojejunostomy.

formed portoenterostomy in some patients with complete bile duct trauma. We added these patients to the HJ patient group.

RESULTS Demographics and clinical characteristics of the patients are given in Table 2. Among 105 patients, 52.4% were male. Mean age was 55.2±16.26 years (range, 21–93 years). Seventy-nine patients (75%) diagnosed with BL had undergone LC, 13 patients (12.5%) had undergone laparoscopic switched to OC, and 13 (12.5%) patients had undergone OC. The most common symptom was bile flow from the drain and/or wound (32.7%) and other common symptoms were abdominal distention, biloma, peritonitis, obstructive jaundice and cholangitis. Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Cholecystitis

24 (23.1)

Obesity

6 (5.7)

History of previous surgery

9 (8.7)

Pancreatitis

6 (5.7)

Bleeding disorders

4 (3.8)

Other

8 (7.7)

Biliary obstruction (e.g., stone and

27 (26)

stenosis)

Unspecified

48 (45.3)

Leak flow, n (%)

High flow (>300 ml/day)

27 (25.7)

Low flow

78 (74.3)

Ultrasonography (USG) and computed tomography (CT) were performed for the diagnosis initially. Magnetic Resonance Cholangiopancreatography (MRCP) was performed to 45 205

Acar et al. Endoscopic and surgical management of iatrogenic biliary tract injuries

(43.3%) patients who were not certain for BL and/or for identifying the place of injury (Fig. 4). All patients underwent ERCP both for diagnosis and treatment. After all tests and examinations, patients were classified using Strasberg Classification. According to this classification, type A injury was detected in 57 (54.1%) patients, type B injury was detected in one (1%) patient, type C injury was detected in three (2.9%) patients, type D injury was detected in 29 (27.6%) patients and type E injury was detected in 15 (14.4%) patients (Fig. 5a, b). Leakage with a daily amount of below 300 milliliters was defined as low, and above 300 milliliters was defined as highoutput. According to this, 74% of the patients had low-output leakage. 57 (54.7%) patients had risk factors, such as the previous episodes of acute cholecystitis, obesity, history of previous surgery, pancreatitis episode, diabetes mellitus and bleeding disorders. It was observed that previous biliary tract disorders significantly increase the risk of leakage.

The findings showed that 81% of all patients were successfully treated with endoscopy. Leakage was spontaneously closed after ERCP without any additional intervention in nine patients, all with the low-output leakage. The period for the spontaneous closure after ERCP was average seven (3–14) days. Spontaneous closure was achieved in 14 patients who underwent sphincterotomy during ERCP and in 56 patients who underwent plastic stent placement additionally to sphincterotomy. Percutaneous drainage catheter was placed to cholecystectomy site in addition to sphincterotomy and stent in six patients. Twenty (19%) patients underwent surgery in which ERCP had been failed. Primary repair, T-tube drainage and reconstruction were applied to 5, 2 and 12 of these patients, respectively. Additional right hepatectomy was performed in one patient because of the necrotic areas in the right lobe of the liver due to the complete right portal vein and hepatic artery injuries. Peroperativecholangiography was performed not to miss the multiple leakages and in cases that place of leakage could not be detected. One patient was found to have multiple metal clips at the level of intrahepatic bile tracts, proximal to the leakage site (Fig. 6). Performed interventions are presented in Tables 3, 4, and postoperative complications are presented in Table 5. Pancreatitis occurred in three (2.9%) patients and perforation occurred in one (1%) patient after the endoscopic intervention. One patient with high-risk factors, such as comorbidity and advanced age, was exitus after surgical reconstruction during the postoperative follow-up. Duration of the hospital stay after the treatment was found to be average 7.7 (4–21) days in the patient group who recovered spontaneously during the follow-up and/or after ERCP and 18.4 (10–27) days in the patient group who underwent surgery. Mean follow-up duration was 33 (1–57) months. Fistula developed in six patients in the early period but closed spontaneously without any additional intervention. Cholangitis

Figure 4. Bile tract injury detection with MRCP (Type E leakage).

(a)

(b)

Figure 5. (a, b) Type E bile duct injury (Intraoperative view).

206

Figure 6. Intraoperative cholangiography (Type E leakage).

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Acar et al. Endoscopic and surgical management of iatrogenic biliary tract injuries

Table 3. The management of bile tract injury with endoscopy (n=85) Type

Patient (n)

ERCP+follow

ERCP+SF

ERCP+SF+stent

ERCP+ PD

A

56

6

10

37

3

C

3

1

D

26

2

4

19

1

Total, n (%)

85

9 (10.6)

14 (16.5)

56 (65.8)

6 (7.1)

2

ERCP: Endoscopic Retrograde Cholangio-Pancreatography; SF: Sphincterotomy; PD: Percutaneous drainage.

Table 4. The management of bile tract injury with surgery (n=20) Type

Patient (n)

ERCP+primary repair

ERCP+T-tube drainage

A

1

B

1

ERCP+Roux-Y HJ* HP

1 1

D

3

2

1

E

15

2

1

11

E1

3

1

2

E2

5

1

4

E3

4

1

3

E4

2

2

E5

Total, n (%)

1 20

5 (25)

2 (10)

12 (60)

1

1 1 (5)

ERCP: Endoscopic Retrograde Cholangio-Pancreatography; HJ: Hepaticojejunostomy, HP: Hepatectomy.

Table 5. Treatment modalities and complications of the patients (n=105) Treatment modality Endoscopic intervention

Complications, n(%) Pancreatitis Perforation Cholangitis Fistula 3 (2.9)

1 (1)

4 (3.8)

Primary repair

1 (1)

T-tube drainage

1 (1)

2 (1.9) 1 (1)

Hepaticojejunostomy

2 (1.9)

Hepatectomy

1 (1)

occurred in four patients with stent placement, one patient with primary repair, and one patient with T-tube drainage. Tests revealed biliary duct stenosis in these patients. Upon this, ERCP and Percutaneous Transhepatic Cholangiography (PTC) were performed and self-expanded metal stent (FCSEMS) was placed after balloon dilation. We have still been following-up these six patients, and none of them have had any additional complaints or the episode of cholangitis.

DISCUSSION Cholecystectomy is one of the most common operations performed by surgeons. Although the complaints recover in a Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

short time after the operation in many patients, undesirable complications may cause high morbidity and mortality. Symposiums about safe cholecystectomy techniques are held in many medical centers to minimize and manage these complications properly. However, there is still no significant decline in complication rates. Biliary duct injury from these complications after cholecystectomy is the most feared major complication with high morbidity (9.3%–43%) and early mortality (0%–1.7%). [6,7] Biliary tract injury after cholecystectomy was evaluated in many previous studies.[6,7] The importance of endoscopic 207

Acar et al. Endoscopic and surgical management of iatrogenic biliary tract injuries

treatment was emphasized in many of them, and morbidity and mortality rates were reported to be increased, especially in late diagnosis and the cases which had to undergo surgery. However, there is no clear treatment algorithm based on the type of biliary tract injury, which leads to a more invasive surgical intervention to an injury that can be treated with less complex endoscopic procedures in some cases. Therefore, it would be more appropriate to determine the type of injury in the preoperative period and to apply step-wise interventions. In this article, we aimed to present the efficacy of endoscopic and surgical treatments in acute BL after cholecystectomy, the management of the treatment in the light of literature and our long-term results. In addition, we sought to classify the patients according to the type of injury and to establish a treatment algorithm. Our data support prior studies in the literature with the results showing that type A was the most common type of injury and 81% of these were treated successfully with endoscopic interventions. Surgery was required, especially in Type E injuries and the most preferred surgical procedure was HJ. The risk of BL is higher in males, and its incidence increases significantly with the presence of previous episodes of acutecholecystitis.[8] Histopathological alterations develop in the gallbladder, and its surrounding tissues due to acute cholecystitis contribute to the risk of iatrogenic injuries.[8] Among other major risk factors are anatomic variations, obesity, shortcysticduct, cystic duct running parallel to the common bile duct (CBD) and history of previous surgery.[8,9] Also, leakage may occur due to technical problems that arise from the insufficiency of the clip used in the closure of the cystic duct. In our study, the number of male patients (52.4%) was higher than females, and 54.7% of all patients had many risk factors, such as previous or ongoing acute cholecystitis leading them (23.1%). Other risk factors included obesity, history of previous surgery, pancreatitis, bleeding disorders and use of the inappropriate clips. Additional to the risk factors, bile tract stones, or benign stenosis were detected in 27 patients. These pathologies are assumed to lead the cystic duct leakages by causing an increase in the pressure of the bile tract. Postoperative diagnosis varies depending on the presence of a drain and type of the injury. In the present study, the mean time between cholecystectomy and the detection of bile leak was 5.3 days (range, 1 to 21) with non-specific symptoms, such as nausea, distention, fever, vomiting, bloating, widespread abdominal pain, general discomfort, and anorexia. [10] Early diagnosis of the leakage has a significant effect on morbidity and mortality rates.[10,11] If detected late, larger amounts of bile will be collected in the abdomen, which leads to a more severe clinical picture of biliary peritonitis. In our study, the mean time between cholecystectomy and the detection of bile leak was 6.1 days (range, 1 to 24), and 208

most of the patients were diagnosed with bile flow from the drain. Also, some patients had developed symptoms, such as abdominal distension, fever, biloma collection in the cholecystectomy area, jaundice and cholangitis. In general, imaging USG and CT should be performed firstly. Thus, preliminary information about intra-abdominal fluid collection and characteristics of this fluid if there is any can be obtained. Also, it may detect probable CBD dilatation and associated vascular injury.[12] Afterwards, ERCP, which allows determining the exact diagnosis and localization, is required. [13] Being an invasive procedure that may develop complications, such as perforation, pancreatitis creates a disadvantage for ERCP.[13] [12]

The output of the leakage can also be detected with MRCP. Thus, recently, the use of MRCP for this purpose has become more common.[14] However, since MRCP is inadequate to show collapsed bile tracts, MRCP should be performed in case of the biliary tract is dilated due to an obstruction rather than the biliary tract perforation where there is BL into the peritoneal cavity. Another disadvantage of MRCP is that you cannot perform any therapeutic interventions in contradistinction to ERCP. Perioperative cholangiography confirms the location of the leakage that was diagnosed in the preoperative period, and additionally, to detect any second leakage, if there is, it increases the success rate.[15] Therefore, intraoperative cholangiography is very important to evaluate the biliary tree. We had firstly performed USG and CT when BL was suspected. Magnetic Resonance Cholangiopancreatography was performed in 43.3% of the patients who could not be certainly diagnosed with bile tract injury and/or when the injury could not be localized. We obtained the definitive diagnosis with these imaging methods, but we could not identify the localization and/or type of the injury in most of the patients. Thus, all of the patients underwent ERCP. Patients were classified for output of the leakage and type of the injury according to ERCP results. Three patients had a pancreatitis episode, and one patient had perforation after the endoscopic intervention. None of these complications were mortal. We performed perioperative cholangiography for all patients. Additional to the preoperative localization of the leak, we detected leak also in the intrahepatic duct in one patient and in subvesical bile duct (Luschka) in one patient. Treatment varies depending on the type of injury. Cystic duct and Luschka are the most common places of the leakage.[16] The duct of Luschka mostly drains into the right and common hepatic ducts, and less frequently drains into the subsegmental ducts, sectoral ducts, and left hepatic duct.[16] Due to this anatomy, injury to the right and main duct is more frequent than left. Sphincterotomy and plastic stent placement with ERCP are usually sufficient in patients who have Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Acar et al. Endoscopic and surgical management of iatrogenic biliary tract injuries

an intact tract and do not have signs of peritonitis.[17] Therefore, laparotomy should not be performed unless the injury is properly classified.[17] According to the European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline, partial divisions of ducts can be successfully treated endoscopically in more than 90% of the cases.[18] Also, Jabłonska et al. reported that endoscopic interventions had a 93% success rate, especially in type A and D injuries.[19] This rate is 100% in sole cystic duct leakages.[19] The type, optimal diameter and length of the stent to be placed may vary according to the type of injury.[20] Sometimes, when the diameter of the plastic stent is small, and the stent cannot be kept in the bile duct longer than 4-8 weeks, usage of self-expanding metal stents (SEMS) or multiple plastic stents may be required [21]. In previous studies, success and complication rates of both stents were the same.[20–22] Surgical reconstruction is required when endoscopic intervention failed; bile duct was cut completely or tied and in patients who have severe symptoms. Purpose of this was to provide a proper bile flow to the feeding route.[19] The success of surgery depends on many factors, such as the timing of repair, level of injury, presence of infection, associated vascular injury and poor operative technique.[23] Many publications suggest that late-detected BL and patients with diffuse peritonitis should wait three months for definitive surgery after primary control surgery to relieve the inflammation for best results.[1,23,24] Roux-Y HJ is usually preferred as surgical procedure.[25,26] However, depending on the type of injury, more complicated procedures like Kasai can also be performed.[27] Results are more promising if there is a not complete cut in CBD and evidence of diffuse peritonitis. Lubikowski et al. reported that 92% of patients with Roux-Y HJ remained in good condition with normal liver function tests after a median follow-up of 59 months (6–102 months).[28] T-tube and end-to-end anastomosis are the other surgical options which have conflicting results about their success.[19,29] However, there are studies reporting that the leakage area would be widened, tension would occur in the anastomosis line and stenosis may develop in up to 80% during the long-term follow-up.[30] In some rare cases, hepatectomy may be required due to concomitant vascular injuries; proximal BDI and liver/bile duct necrosis and/or failed surgical reconstruction.[31] In our study, ERCP was successful in 98.2% patients with type A injury, 100% patients with type C, and 89.7% patients with type D, a total number of 85 (81%) patients. Primary repair, Ttube drainage, Roux-Y HJ and hepatectomy were performed in patients with Type B and DBLin which ERCP had failed. Although ERCP is expected to be adequate for type B injury, one patient with type B injury from our series had to undergo surgery since the patient had a past surgical history of antrecUlus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

tomy. Hepaticojejunostomy was preferred as the surgical modality instead of primary repair or T-tube drainage since this patient was young and did not receive sphincterotomy. Complications after the surgical procedures, such as pancreatitis, fistula in the early period and stenosis, cirrhosis and acute-chronic hepatic insufficiency in later times, may occur during the follow-up.[28–30] Previous studies introduced several risk factors for the late anastomotic stricture, which were multiple attempts for repair, presence of peritonitis, postoperative biliary fistula, anastomosis on a non-dilated duct, preoperative and postoperative percutaneous biliary drainage, associated vascular injury and level of injury according to biliary bifurcation.[32] Most of the fistulas can be followed without any additional intervention, and stenosis can be treated with dilatation with ERCP or PTC. Surgery is required when the fistula turns to have uncontrolled output, and the stenosis cannot be identified with endoscopic procedures.[29,33] In our patient group, fistula occurred in six of our patients, but they spontaneously closed without the need for any additional intervention. Six patients had recurrent cholangitis episodes due to stenosis of the bile duct. Balloon dilatation with ERCP was performed and self-expanding metal stent (FC-SEMS) was placed. These six patients who are already in our follow-up have not had any additional complaints or cholangitis episodes yet. In addition to its distinct aspects, there are also few limitations of this study, including its retrospective and single-centerdesign. Also, data on long term follow-up of the patients after surgery are limited.

Conclusion Currently, bile duct injuries are managed with a multimodal approach, including radiology, endoscopy and surgery. The best solution in cases with biliary duct injuries, especially in low volume hospitals, is to refer these cases to the experienced centers with hepatobiliary units or experienced surgical teams. According to our own experience, BL due to cystic duct, Luschka, or right intrahepatic branch (due to anatomical variation) injury is more common. It is very crucial to realize and to treat these injuries in the early period before developing peritonitis. The majority of BL (especially Type A and Type D injuries) can be treated with sphincterotomy and stents by ERCP. In case of a complete cut in the CBD (Type E), the only treatment method is surgery, and HJ is usually performed because of its better long-term results. It should be kept in mind that patients who underwent surgery due to major injuries may develop some complica209

Acar et al. Endoscopic and surgical management of iatrogenic biliary tract injuries

tions, such as cirrhosis, hepatic insufficiency, and especially cholangitis episodes and jaundice due to the stricture. The majority of the strictures can be treated with minimally invasive methods, such as dilatation or placing self-expanding metal stents with PTK, while liver transplantation may be required for other major complications.

Acknowledgments The authors thank all the general surgery staff for their cooperation Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: T.A., N.A.; Design: T.A., N.A.; Supervision: E.A., Ö.G., M.H., O.N.D.; Fundings: F.G., H.Ç.; Materials: T.A., N.A., E.A., H.Ç., O.N.D.; Data: T.A., N.A., F.G., O.N.D.; Analysis: E.A., Ö.G., M.H., O.N.D.; Literature search: T.A., N.A.; Writing: T.A., N.A.; Critical revision: E.A., H.Ç., M.H., O.N.D. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

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laparoscopic cholecystectomy. J Gastrointest Surg 2012;16:815–20. 32. Turcu F, Dragomirescu C, Pletea S, Bănescu B. The problem of iatrogenic common bile duct injury, or the picture of an iceberg peak. [Article in Romanian]. Chirurgia (Bucur) 2011;106:187–94. 33. Varabei A, Arlouski Y, Vizhinis E, Shuleika A, Lagodich N, Derkacheva N. The use of double balloon enteroscopy for diagnosis and treatment of strictures of hepaticojejunal anastomoses after primary correction of bile duct injuries. Wideochir Inne Tech Maloinwazyjne 2014;9:219–25.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

İyatrojenik safra yolu yaralanmalarının endoskopik ve cerrahi yönetimi Dr. Turan Acar,1 Dr. Nihan Acar,2 Dr. Feyyaz Güngör,1 Dr. Emrah Alper,3 Dr. Özlem Gür,1 Dr. Hakan Çamyar,4 Dr. Mehmet Hacıyanlı,1 Dr. Osman Nuri Dilek1 İzmir Katip Çelebi Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İzmir İzmir Atatürk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İzmir Koç Üniversitesi Tıp Fakültesi, Gastroenteroloji Anabilim Dalı, İstanbul 4 İzmir Atatürk Eğitim ve Araştırma Hastanesi, Gastroenteroloji Kliniği, İzmir 1 2 3

AMAÇ: İyatrojenik safra yolu yaralanmalarını, nadir görülen bir komplikasyon olup erken tanınmadığında yüksek morbidite ve mortaliteye neden olur. Tedavisi, yaralanma boyutu ve yaralanmanın fark edilmesine dek geçen süreye göre değişmekle birlikte, çoğunlukla endoskopik ve perkütan girişimler yeterli olmaktadır. Fakat bu tedaviler sonrasında ilerleyen yıllarda biliyer striktür, tekrarlayan kolanjit atakları ve hatta siroz gibi majör komplikasyonlara neden olabileceği unutulmamalıdır. Bu yazımızda postkolesistektomi biliyer kaçaklara yaklaşımımızı ve literatür eşliğinde tedavi yönetimini sunmayı amaçladık. GEREÇ VE YÖNTEM: Ocak 2015–Temmuz 2019 tarihleri arasında biliyer kaçak nedeniyle tedavi ettiğimiz 105 hastanın dosyası geriye dönük olarak değerlendirildi. Hastaların çoğunluğunu, dış merkezde kolesistektomi geçirip, biliyer kaçak saptanması üzerine kliniğimize sevk edilenler oluşturmakta idi. Hastalar kaçak yeri ve miktarına göre belirlenen Strasberg sınıflandırmasına göre gruplandırıldı. BULGULAR: Çalışmaya alınan 105 hastanın 55’i erkek, 50’si kadın olup ortalama yaş 55.2±16.26 yıl (21–93 yıl) idi. Strasberg sınıflamasına göre; 57 hastada tip A, 1 hastada tip B, 3 hastada tip C, 29 hastada tip D ve 15 hastada tip E yaralanma mevcut idi. Seksen beş hasta endoskopik ve girişimsel radyolojik yöntemlerle başarı ile tedavi edilirken, 20 hastaya cerrahi girişim yapıldı. TARTIŞMA: Biliyer kaçaktan şüphelenilen her hastada, ayrıntılı tarama ve uygun tedavi morbidite ve mortalitede önemli bir düşüş sağlar. Bu sebeple, erken tanı hem erken hem de geç dönem sonuçlar açısından çok önemlidir. Anahtar sözcükler: Cerrahi; endoskopi; iyatrojenik; safra yolu yaralanmaları. Ulus Travma Acil Cerrahi Derg 2020;26(2):203-211

doi: 10.14744/tjtes.2019.62746

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ORIGIN A L A R T IC L E

Correlation between optic nerve sheath diameter and Rotterdam computer tomography scoring in pediatric brain injury Yasemin Kayadibi, M.D.,1 Nazan Ülgen Tekerek, M.D.,2 Osman Yeşilbaş, M.D.,2 Serhat Tekerek, M.D.,1 Emel Üre, M.D.,3 Turgut Kayadibi, M.D.,4 Deniz Esin Tekcan Şanlı, M.D.5 1

Department of Radiology, Van Training and Research Hospital, Van-Turkey

2

Department of Pediatric Intensive Care Unit, Van Training and Research Hospital, Van-Turkey

3

Department of Radiology, Hakkari State Hospital, Hakkari-Turkey

4

Department of Plastic Surgery, Van Training and Research Hospital, Van-Turkey

5

Department of Radiology, Kahramanmaraş Necip Fazıl City Hospital, Kahramanmaraş, Turkey

ABSTRACT BACKGROUND: Pediatric head trauma is the most common presentation to emergency departments. Increased intracranial pressure (ICP) may lead to secondary brain damage in head trauma and early diagnosis of increased ICP is very important. Measurement of optic nerve sheath diameter (ONSD) is a method that can be used for determining increased ICP. In this study, we aimed to evaluate the relationship between optic nerve sheath diameter (ONSD) and Rotterdam computer tomography scores (RCTS) in pediatric patients for severe head trauma. METHODS: During January 2017–April 2018, medical records and imaging findings of children aged 0–18 years who underwent computed tomography (CT) imaging for head trauma (n=401) and non-traumatic (convulsions, respiratory disorders, headache) (n=255) complaints, totally 656 patient were evaluated retrospectively. Patients’ age, sex, presentation and trauma type (high energy-low energy) were identified. Non-traumatic patients with normal cranial CT findings were considered as the control group. CT findings of traumatic brain injury were scored according to Rotterdam criteria. Patients were divided into groups according to their age as follows: 0–3 years, 3–6 years, 6–12 years and 12–18 years. RESULTS: In our study, tomographic reference measurements of the ONSD in pediatric cases were presented according to age. There was a statistically significant difference between ONSD of severe traumatic patients and the control group. Correlation between RCTS and ONSD was determined and age-specific cut-off values of ONSD for severe traumatic scores (score 4–5–6) were presented. CONCLUSION: In our study, reference ONSDs of the pediatric population for CT imaging was indicated. Our study also showed that ONSD measurement is a parameter that can be used in addition to the RCTS to determine the prognosis of the patient in severe head trauma, by reflecting increased intracranial pressure. Keywords: Brain edema; intracranial pressure; optic nerve sheath diameter; pediatric head trauma; Rotterdam computer tomography score.

INTRODUCTION Head trauma is the most frequent pediatric presentation to emergency departments and the most important cause of

pediatric morbidity and mortality. Falling from high and traffic accidents are the most common causes of head trauma. [1,2] Especially in moderate and severe head trauma patients, the role of initial cranial computed tomography (CT) is very

Cite this article as: Kayadibi Y, Ülgen Tekerek N, Yeşilbaş O, Tekerek S, Üre E, Kayadibi T, et al. Correlation between optic nerve sheath diameter (ONSD) and Rotterdam computer tomography scoring in pediatric brain injury. Ulus Travma Acil Cerrahi Derg 2020;26:212-221. Address for correspondence: Yasemin Kayadibi, M.D. Van Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, Van, Turkey Tel: +90 432 - 444 99 65 E-mail: ysmnkayadibi@gmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):212-221 DOI: 10.14744/tjtes.2019.94994 Submitted: 12.09.2018 Accepted: 30.04.2019 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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important in diagnosis by its high sensitivity for intracranial bleeding and fractures.[1] Marshall and Rotterdam CT scoring systems, which have numerical values from one to six are the most commonly used two scoring systems to assess the relationship between prognosis and findings of traumatic brain at the first scan.[3] Since the Marshall scoring system does not evaluate epidural and subdural lesions separately and does not include subarachnoid hemorrhage in scoring, the RCTS system is more preferred today.[4] Both of these systems have been created for adult patients and there is a limited number of studies evaluating the prognostic outcome for pediatric patients.[5] There are differences between adult and pediatric brain damage after the injury due to such factors like thickness of the cranium, the ratio of cerebrospinal fluid (CSF)/brain parenchyma, myelination of the brain tissue and mechanism of the trauma.[3,6] While skull fracture, epidural hematoma and axonal damage are frequently encountered in the pediatric patient group, subdural hematomas and midline shifts are more common in the adult group.[3,7] High intracranial pressure (ICP) (above from 20 mmHg) is one of the most important factors affecting mortality and morbidity after traumatic brain injury and causes secondary damage to the ischemic brain. Early diagnosis and treatment of increased ICP is very important to reduce brain damage after trauma.[8,9] Intraventricular catheter placement is the gold standard method for measuring intracranial pressure.[10] However, it cannot be applicable for every patient in every center due to reasons, such as lack of skilled technical team and equipment, inadequate ventricular width, risk of bleeding. [8–10] Because of these reasons, most emergency departments use CT to investigate increased brain pressure with findings of brain edema.[3,11] On the other hand, optic nerve has direct contact with dura mater and subarachnoid space. In the literature, many studies, both with pediatric and adult patients, have shown that optic nerve sheath diameter (ONSD) has a correlation with ICP and mortality.[8,10,12–17] Although ONSD can be measured with ultrasonography (US), magnetic resonance imaging (MRI) and CT, in the literature, the US examination is more preferred because it does not contain ionizing radiation, reflects instantaneous values and can easily be applied at the bedside in intensive care units. However, there are some disadvantages of the US usage, like person dependence and need of technical expertise to obtain optimal images. Still, there is at least one initial referral CT of serious head trauma patients for determining the severity of the trauma and the necessity for emergency surgery. ONSD can be easily measured using CT and this method could give more objective values. High resolution of MRI facilitates ONSD measurement. However, are disadvantages like the high cost, need of sedation, low sensitivity for bleeding and fractures in the traumatic brain injury. CT and MRI studies were limited in pediatric population. In this study, we aimed to investigate the age-related correlation between the ONSD measurements and the Rotterdam CT scores of initial CT imaging. Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

MATERIALS AND METHODS This study was started in a single-center after the approval from our hospital ethics committee. Pediatric patients who underwent a cranial CT scan for traumatic and non-traumatic reasons (upper respiratory tract infection, headache, convulsions, fever) from January 2017 through April 2018 in the emergency department were included in this study The nontraumatic patient group was determined as a control group. Patients’ demographic characteristics (age, sex), trauma patterns (low-energy or high-energy) were retrospectively screened from the medical records of the hospital.

Selection of the Patients and the Control Group Criteria of the Patient Group for Acceptance to the Study Patients who admitted to the emergency department for traumatic brain injury and underwent CT imaging within the first 24 hours after the trauma under the age of 18 were included in this study. Patients were excluded if they had facial trauma or artifacts that could affect the optic channel.

Criteria of the Control Group for Acceptance to the Study Patients who admitted to the emergency department for non-traumatic reasons (upper respiratory tract infection, headache, convulsions, fever) under the age of 18 were included in this study. Patients were excluded if they had any circumscribing lesion that could affect the intracranial pressure, such as hydrocephalus, tumor, arachnoid cyst or artifacts that affect the optic channel.

Examination of the Head CTs Taken initial admission CT images for all included cases were imported into picture archiving and communication system (PACS). Pediatric head CTs were independently reviewed by two different radiologists (YK and ST) to prevent bias. Radiologists were unaware of the patients’ age, trauma shape, and Glasgow Coma Score. All the CT scans were obtained by the 16-slice CT scanner (Alexion 16, Toshiba Medical Systems, Tochigi, Japan), a 3 mm single slice section. Scans of the cranium were displayed using a standard Toshiba mediastinum algorithm at a window level, of 10 and window width of 300 HU. All measurements were made using the same window, contrast and brightness. ONSD was measured as suggested in the literature, posterior to the orbital cortex at a distance of 3 mm from the optic disc.[14,18] Firstly, measurements were taken from both optical sheaths, and then an average value was obtained for each patient by one of the radiologists. Patients who could not be measured from both eyes were excluded from this study. One of the radiologists evaluated, head CT images, for fracture, hemorrhage (subdural-epidural-subarachnoid-intraventricular), basal cistern compression, herniation, the shift in midline structures and calculated RCTS according to prespecified parameters.[19] 213

Kayadibi et al. Correlation between ONSD and RCTS in pediatric brain injury

Statistical Analysis

RESULTS

Data were statistically analyzed with SPSS 22.0 software (IBM, Armonk, NY). Continuous variables were presented as mean±SD or median (with interquartile range), and categorical variables were expressed as numbers and percentages, where appropriate. The comparison between the two groups for data with normal distribution was performed using Student’s t-test, and the comparison between groups for data that did not show a normal distribution was performed using the Mann-Whitney U test. Categorical variables were compared using χ2 test. For multigroup comparison, One-way ANOVA (for data showing normal distribution) or Kruskal Wallis (for data which did not show normal distribution) was used. Receiver operating characteristic (ROC) curves were utilized to evaluate the accuracy of optic nerve diameter to diagnose increased ICP. The area under ROC curve (AUC) and cut-off values were compared using MedCalc for Windows, version 9.2 (MedCalc Software, Ostend, Belgium). All probabilities were two-tailed and p<0.05 was regarded as significant.

General and Demographic Data Between January 2017 and April 2018, a total of 800 patients admitted to the emergency department and underwent CT imaging. When retrospective CT images were analyzed, 656 of these patients met the inclusion criteria. The summary of the demographic data is shown in Table 1. The number of patients considered to have traumatic brain injury (TBI) was 401 and the number of non -traumatic patient group was 255. The mean age of TBI patients was 84 months (1–216 months), while the mean age of the control group was 144 months (1–216). One hundred thirty-nine of TBI patients were female, 262 were male, and in the control group, 126 of them were female and 129 were male. Approximately one-quarter of the patients with TBI (n=101) suffered from low-energy trauma (falling, blunt trauma, beating); three quarters (n=300) suffered from high-energy trauma (traffic accidents, and falling from high). The reasons

Table 1. The summary of the demographic data and average of the ONSDs Age, months (min-max)

TBI group (n=401) Mild trauma (score 1–2–3) (n=343)

Severe trauma (score 4–5–6) (n=57)

100 (1–216)

106 (1–216)

Control group (n=255)

144 (1–216)

Gender, n

Girl

Boy

221

16

126

122

41

129

Trauma patterns, n High-speed

62

38

–

Low-speed

281

19

–

Cephal hematoma, n Present

51

50

–

Absent

292

7

–

Fracture, n

Thin, non-displaced

Multiple, displaced

Absent

78

20

–

22

10

–

243

27

–

Bleeding, n Present

132

30

–

Absent

211

27

–

ONSD, mean mm (min-max)

0–3 years

3.6 (2.45–5.1)

3.82 (2.6–5.6)

3.25 (2.15–4.6)

3–6 years

4 (3.05–5.45)

4.34 (3.5–5.55)

3.60 (2.75–4.45)

6–12 years

4.04 (3.78–6.35)

4.48 (3.5–5.8)

3.80 (3.15–4.65)

12–18 years

4.17 (3.15–6)

4.84 (4.2–7.4)

3.85 (3.20–4.95)

ONSD: Optic nerve sheath diameter.

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for admission to the emergency department in the non-traumatic control group were febrile convulsions (34), headache (140), afebrile convulsions (20), vomiting (16), syncope (6) and upper respiratory tract infection (39).

ONSD Measurements Patients and control groups were classified according to range of age 0–3 years, 3–6 years, 6–12 years and 12–18 years. The mean ONSD values in patients with TBI and the control group were summarized in Table 1. According to age groups, ONSD showed a rapid increase in the first three years of age and drew a plateau after six years. There was no significant difference between gender both for the control group and the patient group (p>0.005). We did not find any significant difference between ONSD diameters taken separately for both eyes (p>0.005).

Rotterdam CT Scores Of the 401 patients in the TBI group, 14 of them were scored 1; 296 of them scored 2; 32 of them were scored 3; 19 of them were scored 4; 26 of them were scored 5; 13 of them were scored 6. A total of 342 headache traumas with a score of 1–2–3 were identified as mild head trauma, and 58 of them

(a)

(b)

with score 4–5–6 were identified as severe head trauma (Fig. 1, 2).

Relationship Between Severe Brain Injury and ONSD There was a significant correlation between ONSD and severe (RCTS 4–5 and 6) traumatic brain injury patients for each age range with p-value equal to 0.0001. Cut-off values of TBI patients according to ROC curves plotted for mild and severe head trauma according to each age group were 4.40 mm (66.7% sensitivity, 95.4% specificity) in the 0–3 age range, 4.45 mm (100% sensitivity, 87.7% specificity), in the 3–6 age range 4.25 mm (100% sensitivity, 81.2% specificity) in the 6–12 age range, 4.45 mm (100% sensitivity, 91% specificity) in the 12–18 age range, respectively (Table 2, Fig. 3).

DISCUSSION CT is the most preferred imaging modality in cases of severe head trauma. It is fast and easily accessible in most of the centers. Besides, it helps to determine the severity of the trauma and necessity for surgical intervention.[3,4] RCTS system is mainly developed upon adult patients, and data on this system in children are less well documented.[1,3,5] When com-

(c)

Figure 1. A 15 year old male patient after a traffic accident, RBTS 5; Intraparenchymal subdural-subraracnoid haemorrhage areas in left frontobasal and bilateral cephal hematoma, slight shift in midline structures, effacement in basal cisterns (a), fragmented fractures in parieto-occipital bone (b) increase of ONSD (5.8 mm) (c).

(a)

(b)

(c)

(d)

Figure 2. A 6 year old male patient after falling from high, RBTS 6; Subarachnoid and ventricular hemorrhage (a, b), effacement in basal cisterns (a) and dilatation of ventricules (b) blurring on white-gray matter separation (a, b) in both cerebral hemispheres, cervical dislocation (c), in-crease of ONSD (5.8 mm) (d).

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Table 2. Cut-off values of ONSDs concerning brain edema in patients with high scores

AUC

Cut-off value (mm)

Sensitivity

Specificity

p

0–3 years

0.81

4.40

66.7

95.4

0.0001

3–6 years

0.95

4.45

100

87.7

0.0001

6–12 years

0.96

4.25

100

81.2

0.0001

12–18 years

0.95

4.45

100

91

0.0001

AUC: Area under curve; ONSD: Optic nerve sheath diameter.

pared to adults, pediatric patients have lower survival rates in higher scores and higher survival rates in lower scores, but it can still be used in risk calculation in severe pediatric head trauma.[5] Raised ICP is associated with secondary brain damage and poor prognosis after traumatic injury.[8] Especially in pediatric population, clinical symptoms of raised ICP are less reliable, and clinicians should be more vigilant in this regard. Symptoms and imaging findings may differ according to age. 0–3 years

100

80

80

60

60

40

20

0

0

20

40 60 100-Specificity

80

0

100

6–12 years

0

20

80

80

60

60

40

20

40 60 100-Specificity

80

100

80

100

12–18 years

100

Sensitivity

Sensitivity

40

20

100

0

3–6 years

100

Sensitivity

Sensitivity

Previous studies have shown that CT findings are sometimes inadequate in determining brain edema, which can be fatal if not been treated early.[11] According to Hirsch et al.’s[11] study, the extra-axial distance is larger in pediatric head and unlike the adult brain, the ICP increases after filling of this compensatory distance in pediatric brains. Findings, such as narrowing of CSF distances, a decrease of brain parenchyma density, midline shifts that we can evaluate by radiologically, are reflections of very high ICP values. Unfortunately, these traditional CT findings are inadequate for identification of [7]

40

20

0

20

40 60 100-Specificity

80

100

0

0

20

40 60 100-Specificity

Figure 3. ROC analysis for the relationship between high RCTS (4–5–6) and ONSD for all age groups.

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Table 3. Characteristics of the ONSD studies in pediatric population Study, year Used modality

Measurement

Helmke K et al., USG 3 mm posterior to papilla 1996[8]

Study group

Mean age

Results

Cut-off value

13 healthy children 24 children with in-creased ICP

4.8 years (range two months to 18 years)

For control group: ONSD (avg) 3 mm For patient group: ONSD (avg) 5.3 mm

<4 years 4 mm >4 years 5 mm

Ballantyne et al., USG 3 mm posterior 102 children <15 years with non- 1999[26] to papilla neurological disease

0–2 month NA ONSD (avg.) 2.7 mm 2–3 month ONSD (avg.) 2.95 mm 3–12 month ONSD (avg.) 3.21 mm 1–2 year ONSD (avg.) 2.99 mm 2–3 year ONSD (avg.) 3.03 mm 3–4 year ONSD (avg.) 3.15 mm 4–5 year ONSD (avg.) 3.23 mm 5–10 year ONSD (avg.) 2.98 mm 10–15 year ONSD (avg.) 3.26 mm

Malayeri et al., USG 3 mm posterior 78 healthy children 2004[28] to papilla 78 children with increased ICP

For patient group: <4 yr ONSD (avg) 5.55 mm >4 yr ONSD (avg) 5.68 mm For control group: <4 yr ONSD (avg) 3 mm >4 yr ONSD (avg) 3.60 mm

NA

For control group: ONSD (avg) 3.4 mm For patient group: ONSD (avg) 5.6 mm

4.5 mm

Korber et al., USG 3 mm posterior 2005[27] to papilla

For patient group: 6.9 years (range two weeks to 17 years For control group: 6.8 years (range five weeks to 16.5 years

466 healthy 7.5 years children (range from 17 children four days to with increased 24 years) ICP

Beare et al., USG 3 mm posterior 30 healthy children 2008[12] to papilla 21 children with neurological disease

For patient For patient group: group: ONSD (avg) 5.4 mm 5.7 years For control group: For control ONSD (avg) 3.6 mm group: 2.7 years

4.5 mm (sensitivity of 100% and specificity of 86%)

Le et al., USG 3 mm posterior 64 children <14 years NA to papilla with increased 2009[29] ICP

<1 year 4.0 mm >1 year 4.5 mm (sensitivity of 83%, specificity of 38%)

Steinborn et al., USG and 3 mm posterior 65 children 11.3 years MR to papilla with various 2011[30] disease

NA

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For USG group: ONSD (avg) 5.86 mm For MR group: ONSD (avg) 5.86 mm

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Table 3. Characteristics of the ONSD studies in pediatric population (continuation) Study, year Used modality

Measurement

Study group

Mean age

Shofty et al., MRI 10 mm anterior 86 healthy <18 years children (range from 2012[13] to the optic foramina 29 children four months with idiopatic to 17 years) intracranial hypertension Agrawal et al., USG 3 mm posterior 11 ICP- 2012[31] to papilla monitored children

Results

Cut-off value

For control group: 0–3 yr ONSD (avg.) 3.1 mm 3–6 yr ONSD (avg.) 3.41 mm 6–12 yr ONSD (avg.) 3.55 mm 12–18 yr ONSD (avg.) 3.56 mm For patient group: 0–3 yr ONSD (avg.) 4.35 mm 3–6 yr ONSD (avg.) 4.37 mm 6–12 yr ONSD (avg.) 4.25 mm 12–18 yr ONSD (avg.) 4.69 mm

NA

9.2 years For patient group: NA (range from <1 years ONSD (avg) 4.0 mm two years >1 years ONSD (avg) 4.5 mm to 15 years)

Young et al., CT 3 mm posterior 36 TBI 8.2 years For patient group: patients Right ONSD (avg) 5.6+2.5 mm 2016[18] to papilla Left ONSD (avg) 5.9+3.2 mm

6.1 mm (sensitivity 77%, specificity 91%) 4.9 mm (100% sensitivity, 26% specificity)

Steinborn et al., USG and 3 mm posterior For USG MR to papilla 99 healthy 2015[32] children For MR 59 healthy children

NA

For USG: 12 years (range from 5.6 years to 18.6 years) For MR: 12,3 years (range from 5.1 years to 17.4 years)

For USG group: ONSD (avg) 5.75 mm For MR group: ONSD (avg) 5.69 mm

Padayachy et al., USG 3 mm posterior 174 ICP- 36 months For ICP <20 mmHg: 2015[15] to papilla monitored ONSD (avg) 4.8 mm patients For ICP ≥20 mmHg: >1 years ONSD (avg) 5.92 mm

<1 years 5.16 mm (sensitivity of 80%, specificity of 76.1%) >1 years 5.75 mm (sensitivity of 85.9%, specificity of 70.4%) 1–4 years 5.92 mm >4 years 5.70 mm

Irazuzta et al., USG 3 mm posterior 2015[33] to papilla

4.5 mm (sensitivity of 100%, specificity of 100%)

218

13 children with idiopatic intracranial hypertension

14 years For patient group: (range from ONSD (avg) 5 mm 12 years to 18 years)

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Table 3. Characteristics of the ONSD studies in pediatric population (continuation) Study, year Used modality

Measurement

Study group

Mean age

Results

Cut-off value

Padayachy et al., USG 3 mm posterior 174 ICP- Mean age ONSD (avg) 5.56 mm monitored 36 months 2016[16] to papilla patients <14 years

5.5 mm (sensitivity of 93.2% and specificity of 74%)

Marchese et al., USG 3 mm posterior 76 children with 2017[34] to papilla ketoasidozis

4.5 mm sensitivity and specificity were 90% and 55%

brain edema, especially in pediatric patients. Therefore, some additional parameters should be considered to reflect brain edema in addition to RCTS. The optic nerve is an extension of the central nervous system and is covered with dura mater. Thus, CSF fills the distance between the dura mater and optic nerve; any change of pressure in the intracranial area will directly reflect the ONSD. Correlation between ONSD and ICP has been shown many times in both adult and pediatric studies.[12,14–16,20,21] Many pathologies, such as diabetic ketoacidosis, anesthetic drug usage, hydrocephalus, could increase the ONSD by increasing the ICP.[22,23] Correlations between RCTS and ONSD have been shown in a previous study for adult traumatic brain injury, and measures above 5.8 mm for ONSD have been determined for severe TBI for adults.[24] However, to our knowledge, there is no study yet for the pediatric head injury that comparing RCTS and ONSD. A summary of the studies with the pediatric population on ONSD is presented in Table 3.[12,13,15,16,18,25–32]

Median age For suspected: was 11.7 years ONSD (avg) 5.6 mm (range, For non-suspected: 1.0 years to ONSD (avg) of 4.5 mm 17.9 years)

studies were conducted with children under sedation in intensive care units and used an ICP catheter inserted into the ventricle as a reference with mean ONSD values between 4 mm and 5.9 mm. Even some of these children were already undergone a surgical operation before.[13,15,25,27–29,31] We think these factors may have caused their cut-off values to be high. In our study, we compared severe traumatic brain injury (score 4–5–6) for reference and according to the other studies, our study has the largest patient population. Cut-off values in studies of Le et al.,[29] Körber et al.,[27] Beare et al., [12] Irazuzta et al.[33] and Marchese et al.,[34] are quiet similar with ours. Young et al.[18] who had a small patient population compared to us, found no correlation between Marshall CT scores and ONSD in their study with pediatric brain injury patients. We found a positive correlation between ONSD and high RCTSs for pediatric patients like Sekhon et al. whose study showed a correlation between ONSD and RCTSs in the adult patient group.[35]

Values determined by USG in normal child populations were mentioned previously by Ballantyne et al.,[26] in 1999 and results were quite similar to our result that between 3,6 mm and 4 mm. Shofty et al.[13] used MRI for measurement in their study and their results for normal brains were a bit lower and for patient group, their results a bit higher than our results. However, their patients’ group consisted of 29 patients with idiopathic intracranial hypertension (IIH). The perioptic subarachnoid space distention is one of the diagnostic features of IIH. This may be the reason for the difference in patient groups. We noticed that ONSD shows a rapid increase with age and draws a plate by the age of six. This finding is compatible with the study of Shofty et al.[13] and Ballantyne et al.[26]

We believe that this study provides useful information and can help in the understanding of the prognostic role of ONSD in traumatic brain injury. We emphasize that, in evaluating the initial CT images, ONSD should be assessed, as well as the other parameters of the RCTS. Even ONSD measurement may be more objective and useful evidence of brain injury than other conventional CT findings. CT cannot be used for instantaneous ICP measurement because of radiation exposure and mobility difficulties of intensive care patients. However, almost every patient with a severe traumatic head injury has at least one initial head CT image and evaluating ONSD upon CT image is more objective and simple compared to other methods. CT can be very useful in the investigation of brain edema and arrangement of treatment in cases where catheter placement is contraindicated.

Although the cut-off values that reflecting the brain edema in some studies indicated in Table 3 showed higher values than our study. In the literature, previous studies have reported that sedation could increase ICP values.[15,16] Most of these

There are some limitations to our study. Inter and intraobserver variability was not evaluated in our study. Pathologies that may affect optic nerve size, such as optic atrophy and thyroid ophthalmopathy, were ignored if CT findings were

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not apparent. The optic nerve is not a perfectly cylindrical structure and the images were evaluated only in the axial plane, which may cause the differences in the measurements. Because of the necessity of the multidisciplinary approach, we did not consider shaken baby syndrome.

Conclusion CT examination is the easiest and fastest radiological imaging method that can be used in head trauma patients in most centers. In our study, the relationship between ONSD and severe traumatic brain injury in CT was demonstrated, reference values of ONSD according to age groups in severe head trauma and age-related cut-off values for brain edema in severe head trauma have been determined. In addition to the diagnostic assessment of the first CT scan, ONSD measurement may be useful in early diagnosis and treatment of brain edema.

RJ. Ultrasonographic measured optic nerve sheath diameter as an accurate and quick monitor for changes in intracranial pressure. J Neurosurg 2015;123:743–7. 9. Narayan V, Mohammed N, Savardekar AR, Patra DP, Notarianni C, Nanda A. Noninvasive Intracranial Pressure Monitoring for Severe Traumatic Brain Injury in Children: A Concise Update on Current Methods. World Neurosurg 2018;114:293–300. 10. Aduayi OS, Asaleye CM, Adetiloye VA, Komolafe EO, Aduayi VA. Optic nerve sonography: A noninvasive means of detecting raised intracranial pressure in a resource-limited setting. J Neurosci Rural Pract 2015;6:563–7. 11. Hirsch W, Beck R, Behrmann C, Schobess A, Spielmann RP. Reliability of cranial CT versus intracerebral pressure measurement for the evaluation of generalised cerebral oedema in children. Pediatr Radiol 2000;30:439–43. 12. Beare NA, Kampondeni S, Glover SJ, Molyneux E, Taylor TE, Harding SP, et al. Detection of raised intracranial pressure by ultrasound measurement of optic nerve sheath diameter in African children. Trop Med Int Health 2008;13:1400−4.

Peer-review: Internally peer-reviewed.

13. Shofty B, Ben-Sira L, Constantini S, Freedman S, Kesler A. Optic nerve sheath diameter on MR imaging: establishment of norms and comparison of pediatric patients with idiopathic intracranial hypertension with healthy controls. AJNR Am J Neuroradiol 2012;33:366–9.

Authorship Contributions: Concept: Y.K.; Design: N.Ü.T.; Supervision: Y.K., T.K.; Materials: D.E.T.Ş., E.Ü., O.Y.; Data: S.T.; Analysis: N.Ü.T.; Literature search: O.Y.; Writing: Y.K.; Critical revision: Y.K., N.Ü.T.

14. Legrand A, Jeanjean P, Delanghe F, Peltier J, Lecat B, Dupont H. Estimation of optic nerve sheath diameter on an initial brain computed tomography scan can contribute prognostic information in traumatic brain injury patients. Crit Care 2013;17:R61.

Ethics Committee Approval: Approved by the local ethics committee.

Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

REFERENCES 1. Alexiou GA, Sfakianos G, Prodromou N. Pediatric head trauma. J Emerg Trauma Shock 2011;4:403–8. 2. Adelson PD, Pineda J, Bell MJ, Abend NS, Berger RP, Giza CC, et al; Pediatric TBI Demographics and Clinical Assessment Working Group. Common data elements for pediatric traumatic brain injury: recommendations from the working group on demographics and clinical assessment. J Neurotrauma 2012;29:639−53.

15. Padayachy LC, Padayachy V, Galal U, Gray R, Fieggen AG. The relationship between transorbital ultrasound measurement of the optic nerve sheath diameter (ONSD) and invasively measured ICP in children : Part I: repeatability, observer variability and general analysis. Childs Nerv Syst 2016;32:1769–78. 16. Padayachy V. Transorbital measurement of the optic nerve sheath diameter (ONSD) as a screening tool for raised intracranial pressure (ICP) in an acute care setting in children. University of Cape Town, March 3rd, 2016. 17. Vaiman M, Sigal T, Kimiagar I, Bekerman I. Intracranial Pressure Assessment in Traumatic Head Injury with Hemorrhage Via Optic Nerve Sheath Diameter. J Neurotrauma 2016;33:2147–53.

3. Tasker RC. CT characteristics, risk stratification, and prediction models in traumatic brain injury. Pediatr Crit Care Med 2014;15:569–70.

18. Young AM, Guilfoyle MR, Donnelly J, Scoffings D, Fernandes H, Garnett M, et al. Correlating optic nerve sheath diameter with opening intracranial pressure in pediatric traumatic brain injury. Pediatr Res 2017;81:443−7.

4. Waqas M, Bakhshi SK, Shamim MS, Anwar S. Radiological prognostication in patients with head trauma requiring decompressive craniectomy: Analysis of optic nerve sheath diameter and Rotterdam CT Scoring System. J Neuroradiol 2016;43:25–30.

19. Hukkelhoven CW, Steyerberg EW, Habbema JD, Farace E, Marmarou A, Murray GD, et al. Predicting outcome after traumatic brain injury: development and validation of a prognostic score based on admission characteristics. J Neurotrauma 2005;22:1025−39.

5. Liesemer K, Riva-Cambrin J, Bennett KS, Bratton SL, Tran H, Metzger RR, et al. Use of Rotterdam CT scores for mortality risk stratification in children with traumatic brain injury. Pediatr Crit Care Med 2014;15:554−62.

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

6. Sarkar K, Keachie K, Nguyen U, Muizelaar JP, Zwienenberg-Lee M, Shahlaie K. Computed tomography characteristics in pediatric versus adult traumatic brain injury. J Neurosurg Pediatr 2014;13:307–14.

21. Yesilaras M, Kilic TY, Yesilaras S, Atilla OD, Öncel D, Çamlar M. The diagnostic and prognostic value of the optic nerve sheath diameter on CT for diagnosis spontaneous subarachnoid hemorrhage. Am J Emerg Med 2017;35:1408–13.

7. Singh N, Singhal A. Challenges in minor TBI and indications for head CT in pediatric TBI—an update. Child’s Nervous System : Chns : Official Journal of the International Society for Pediatric Neurosurgery 2017;33:1677−81. 8. Maissan IM, Dirven PJ, Haitsma IK, Hoeks SE, Gommers D, Stolker

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22. Choi SH, Min KT, Park EK, Kim MS, Jung JH, Kim H. Ultrasonography of the optic nerve sheath to assess intracranial pressure changes after ventriculo-peritoneal shunt surgery in children with hydrocephalus: a prospective observational study. Anaesthesia 2015;70:1268–73.

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Kayadibi et al. Correlation between ONSD and RCTS in pediatric brain injury 23. Min JY, Lee JR, Oh JT, Kim MS, Jun EK, An J. Ultrasonographic assessment of optic nerve sheath diameter during pediatric laparoscopy. Ultrasound Med Biol 2015;41:1241–6. 24. Das SK, Shetty SP, Sen KK. A Novel Triage Tool: Optic Nerve Sheath Diameter in Traumatic Brain Injury and its Correlation to Rotterdam Computed Tomography (CT) Scoring. Pol J Radiol 2017;82:240–3. 25. Helmke K, Hansen HC. Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension. I. Experimental study. Pediatr Radiol 1996;26:701–5. 26. Ballantyne J, Hollman AS, Hamilton R, Bradnam MS, Carachi R, Young DG, et al. Transorbital optic nerve sheath ultrasonography in normal children. Clin Radiol 1999;54:740−2. 27. Körber F, Scharf M, Moritz J, Dralle D, Alzen G. Sonography of the optical nerve-experience in 483 children. [Article in German]. Rofo 2005;177:229–35. 28. Malayeri AA, Bavarian S, Mehdizadeh M. Sonographic evaluation of optic nerve diameter in children with raised intracranial pressure. J Ultrasound Med 2005;24:143–7. 29. Le A, Hoehn ME, Smith ME, Spentzas T, Schlappy D, Pershad J. Bedside sonographic measurement of optic nerve sheath diameter as a predictor of increased intracranial pressure in children. Ann Emerg Med 2009;53:785–91.

30. Steinborn M, Fiegler J, Ruedisser K, Hapfelmeier A, Denne C, Macdonald E, et al. Measurement of the Optic Nerve Sheath Diameter in Children: Comparison Between Transbulbar Sonography and Magnetic Resonance Imaging. Ultraschall Med 2012;33:569−73. 31. Agrawal S, Brierley J. Optic nerve sheath measurement and raised intracranial pressure in paediatric traumatic brain injury. Eur J Trauma Emerg Surg 2012;38:75–7. 32. Steinborn M, Friedmann M, Hahn H, Hapfelmeier A, Macdonald E, Warncke K, et al. Normal values for transbulbar sonography and magnetic resonance imaging of the optic nerve sheath diameter (ONSD) in children and adolescents. Ultraschall Med 2015;36:54−8. 33. Irazuzta JE, Brown ME, Akhtar J. Bedside Optic Nerve Sheath Diameter Assessment in the Identification of Increased Intracranial Pressure in Suspected Idiopathic Intracranial Hypertension. Pediatr Neurol 2016;54:35–8. 34. Marchese RF, Mistry RD, Binenbaum G, Liu GT, Scarfone RJ, Woodford AL, et al. Identification of Optic Nerve Swelling Using Point-of-Care Ocular Ultrasound in Children. Pediatr Emerg Care 2018;34:531−6. 35. Sekhon MS, McBeth P, Zou J, Qiao L, Kolmodin L, Henderson WR, et al. Association between optic nerve sheath diameter and mortality in patients with severe traumatic brain injury. Neurocrit Care 2014;21:245−52.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Pediatrik beyin hasarında optik sinir kılıf çapı ile Rotterdam bilgisayarlı tomografi skorlama arasındaki korelasyon Dr. Yasemin Kayadibi,1 Dr. Nazan Ülgen Tekerek,2 Dr. Osman Yeşilbaş,2 Dr. Serhat Tekerek,1 Dr. Emel Üre,3 Dr. Turgut Kayadibi,4 Dr. Deniz Esin Tekcan Şanlı5 Van Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, Van Van Eğitim ve Araştırma Hastanesi, Çocuk Yoğun Bakım Kliniği, Van Hakkari Devlet Hastanesi, Radyoloji Kliniği, Hakkari 4 Van Eğitim ve Araştırma Hastanesi, Plastik Cerrahi Kliniği, Van 5 Kahramanmaraş Necip Fazıl Şehir Hastanesi, Radyoloji Kliniği, Kahramanmaraş 1 2 3

AMAÇ: Kafa travması pediatrik hastalarda acil servise en sık başvuru sebebidir. Kafa travmasında kafa içi basıncın (KİB) artması ikincil beyin hasarına neden olmakla birlikte, hastanın tedavisinde önemlidir. Optik sinir kılıf çapının (OSKÇ) ölçümü artmış KİB’nin belirlenmesinde kullanılabilir bir yöntemdir. Biz bu çalışmada ciddi kafa travmalı pediatrik olgularda OSKÇ ile prognoz açısından önemli Rotterdam bilgisayarlı tomografi skorlama (RBTS) sistemi arasındaki ilişkiyi araştırmayı hedefledik. GEREÇ VE YÖNTEM: Ocak 2017–Nisan 2018 tarihleri arasında 0–18 yaş aralığında hastanemiz acil servisine kafa travması (n=401) ve kafa travması dışı (konvülziyon, solunum sıkıntısı, baş ağrısı) (n=255) şikayetlerle başvuran, bilgisayatlı tomografi (BT) çekilen toplam 656 hastaların görüntüleri ve tıbbi kayıtları geriye dönük olarak değerlendirildi. Hastaların yaşı, cinsiyeti, geliş şikayeti, travmanın şekli (yüksek enerjili-düşük enerjili) kaydedildi. Kafa travması ile başvuran hastalar, hasta grubu; travma dışı sebeplerle başvuran ve çekilen beyin BT’si normal olarak yorumlanan hastalar kontrol grubu olarak belirlendi. BT bulgularına göre travmatik beyin hasarları Rotterdam kriterlerince skorlandı. Hastalar 0–3 yaş, 3–6 yaş, 6–12 yaş ve 12–18 yaş olarak yaşlarına göre sınıflandırıldı. BULGULAR: Çalışmamızda pediatrik olgular için OSKÇ’nin yaş aralıklarına göre tomografik referans değerleri belirlendi. Ciddi kafa travmalı hastaların OSKÇ ile kontrol grubu arasında anlamlı farklılık mevcuttu (p<0.05). RBTS ve OSKÇ arasında korelasyon izlenmiş olup ciddi kafa travmasında (scor 4–5–6) kullanılabilecek, yaş aralıklarına göre kestirim değerleri belirlendi. TARTIŞMA: Çalışmamız pediatrik ciddi kafa travmasınında prognozu belirlemede RBTS sistemine ek olarak artmış KİB’nin gösterilmesinde OSKÇ değerlerinin de kullanılabileceğini göstermiştir. Ayrıca çalışmamızda pediatrik hastalar için OSKÇ’nin tomografik referans değerleri belirlenmiştir. Anahtar sözcükler: Beyin ödemi; kafaiçi basınç; optik sinir kılıf çapı; pediatrik kafa travması; Rotterdam bilgisayarlı tomografi skoru. Ulus Travma Acil Cerrahi Derg 2020;26(2):212-221

doi: 10.14744/tjtes.2019.94994

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ORIGIN A L A R T IC L E

Electrical burns and complications: Data of a tertiary burn center intensive care unit Abdulkadir Başaran, M.D., Kayhan Gürbüz, M.D., Özer Özlü, M.D., Mete Demir, M.D., Orhan Eroğlu, M.D., Koray Daş, M.D. Department of General Surgery, Adana City Training and Research Hospital, Burn Center, Adana-Turkey

ABSTRACT BACKGROUND: To review the records of electrical burn patients hospitalized in our burn intensive care unit (ICU) and to report the complications together with our treatment results. METHODS: Demographic data, burn mechanism, presentation, percentage of burn total body surface area (TBSA), abbreviated burn severity index (ABSI) scores, complications and treatment approaches of electrical burn patients admitted to our burn ICU between September 2017 and August 2018 were evaluated retrospectively in this study. RESULTS: Electrical burn injury patients consisted of 17.9% of the patients who were hospitalized in burn ICU (n=139). All patients were male, and the median age was 27.0 years. Twenty-three patients (92%) were burned with high voltage electricity. The median percentage of burn TBSA score was 20.0. Eight patients had an accompanying head, a vertebra or extremity injuries. Sixteen patients (64%) were injured at work. Sixteen patients (64%) recovered with complications. ICU stay and total hospital stay were significantly higher in the group that healed with complications (p=0.005 and p=0.001, respectively). However, no significant differences were detected in burn TBSA and ABSI scores. TBSA and ABSI scores were correlated with ICU and total hospital stay. CONCLUSION: The proportion of our electrical burn patients is higher than reported in the literature. Burn TBSA and ABSI scores seem unrelated to prognosis. As the majority of patients are burned with high-voltage electricity at work, these injuries can be reduced by following occupational safety principles. Because of the high rate of complications in electrical burns, an experienced health team in well-equipped centers should treat patients in accordance with updated guidelines. Keywords: Burn; complications; electrical injury.

INTRODUCTION Electrical burns and burn-related mortality are increasing due to the use of electricity in all areas of life and technology. Electricity-related injuries are known for their destructive complications and prolonged socioeconomic effects resulting in high morbidity and mortality in all age groups.[1] Electrical injuries represent 4% of the patients admitted to burn centers and are more common in males.[2–7] Electricity may cause external burns with flash injury, while internal burns can be seen by electricity warming the bone and burning the muscle nearby. Electrical injuries are classified as injuries due

to low voltage (<1000V) and high voltage (>1000V). Thirtyseven percent of electrical injuries arises from low voltage and 63% by high voltage.[8] Low-voltage injuries are usually more common in domestic settings and children, while adult injuries usually occur at workplaces.[9–12] One-third of electrical injuries and most of the high-voltage injuries are related to work. More than 50% of the work-related injuries arise from the contact with the power line and are in the 4th rank among the causes of death due to work accidents.[13,14] Electric burns have three potential injury types as follows: electric damage due to flow, injury from electric arc passing from the electric source to an object and flame damage due to igni-

Cite this article as: Başaran A, Gürbüz K, Özlü Ö, Demir M, Eroğlu O, Daş K. Electrical burns and complications: Data of a tertiary burn center intensive care unit. Ulus Travma Acil Cerrahi Derg 2020;26:222-226. Address for correspondence: Abdulkadir Başaran, M.D. Adana Şehir Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Yanık Merkezi, Adana, Turkey Tel: +90 322 - 455 90 00 E-mail: adkbasar@yahoo.com Ulus Travma Acil Cerrahi Derg 2020;26(2):222-226 DOI: 10.14744/tjtes.2019.65780 Submitted: 17.12.2018 Accepted: 08.05.2019 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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tion of clothing or surrounding area. In high-voltage injuries, it is not necessary to contact with the electrical current directly. The wrist and ankle are the most affected parts, whereas the severity of injury decreases proximally. Macroscopic and microscopic vascular injuries may occur immediately and are often irreversible.[15–18] Electrical exposure may also cause cardiac arrhythmias and serious injuries to other organ systems.[2,19]

After completing the treatments in the burn ICU, the patients were transferred to the burn ward and their treatment was continued there. The wounds of all patients were photographed before and after the interventions. Debridement procedures, escharotomy, fasciotomy, amputations and reconstructive procedures were all recorded. These patients were followed up later in the rehabilitation phase.

Tissue resistance against electricity decreases with bone, fat, tendon, skin, muscle, vein, and nerve order. Bone warms up to high temperatures and burns surrounding structures like muscles, which leads to muscular edema and compartment syndrome in high-voltage electrical injuries. The entry and exit wounds should be carefully assessed to determine which extremities should be closely monitored for compartment syndrome.[2,20]

Statistical Analysis

Because of the different characteristics of electrical burns, in this study, we aimed to analyze retrospectively the data of electrical burn patients admitted to the burn intensive care unit (ICU) and compare our data with the current literature.

MATERIALS AND METHODS This study was conducted at the Burn Center of Adana City Training and Research Hospital between September 2017 and August 2018. The local Clinical Research Ethical Committee of the Adana City Training and Research Hospital approved the study (Decision no: 279). The patients admitted to our emergency department or referred from another hospital with an electrical burn diagnosis were evaluated in this study. After the first intervention and evaluation, the patients who were hospitalized to our burn ICU were included in this study. Initial interventions were made at the emergency unit of the hospital where the patients were first admitted. X-rays, MR/ CT imaging, abdominal USG, Doppler USG examinations, electrocardiography and cardiac enzyme levels to determine arrhythmias and other cardiac injuries, as well as routine laboratory tests, were conducted. Patients were admitted to the burn ICU after consultations such as cardiology, orthopedics, neurosurgery, general surgery, thoracic surgery, and anesthesiology were done, if needed. Patients’ burn TBSA and Abbreviated Burn Severity Index (ABSI) scores were recorded. The ABSI is a five-variable scale to help assess burn severity and predict the probability of survival. The variables are sex, age, presence of inhalation injury, presence of a full-thickness burn, and percentage of total body surface area burned. Higher ABSI scores correspond to a lower probability of survival.[21] The burn wounds were closed with appropriate dressings after performing escharotomy, fasciotomy, debridement and grafting depending on the condition of the burned area in the surgery room of our burn center. Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Statistical Package for Social Sciences 20.0 for Windows was used for the analysis of the data. The normal distribution of the variables was checked with normality tests. Since the data were not distributed normally, the Mann-Whitney U test was used for the analysis of continuous variables. Correlations between the variables were assessed using the Spearman rank correlation test. The results were expressed as median (interquartile range, Q1-Q3), n and percent (%). The values of p<0.05 were considered as statistically significant.

RESULTS A total of 444 patients were admitted to our burn center between September 2017 and August 2018. Among these patients, 39 (8.8%) were electrical burns. Of the 139 patients hospitalized at our Burn Center ICU, 25 (17.9%) were electrical burns. All patients were male, and the median age was 27.0 (18). In 23 patients (92%), the injury arose from high voltage and in two patients (8%) by low voltage. The electrical injury occurred outdoors in 22 patients (88%), and in three patients (12%) indoors. Ten patients (40%) had a history of falling during the injury. The percentage of burn TBSA in our patients was 20.0 (6.5–44.5) and the ABSI score was 5.0 (5.0–7.5). The length of burn ICU stay was 10.0 (4.5–20.0) days, and the length of hospital stay was 38.0 (12.5–58.0) days And 64% of our patients were workers (five electricians, five painters, six construction worker), 24% were children (n=6) and 12% (n=3) were of other occupational groups. The demographic and clinical data of our patients are given in Table 1. In 21 of the patients (84%), the entry was the upper extremity or scalp. Four patients (16%) had a flash injury. In 17 of the 21 patients who had an entry site, the electrical exit was from inferior limbs, and no electrical exit was detected in four patients. Fifteen patients (60%) had no additional injuries. Head trauma was present in six patients (24%), vertebra injury in one patient (4%), and fracture in the lower extremity in one patient (4%) and inhalation burn in two patients (8%). Nine patients (36%) were hospitalized from our hospital’s emergency department, while the others were referrals from secondary (n=12) and tertiary (n=4) care hospitals. Fasciotomy (n=3, 12%), escharotomy (n=9, 36%), debridement (n=13, 52%) and grafting (n=11, 44%) were the first intervention procedures. Patients were followed by these interventions depending on the wound. Vacuum-assisted closure was applied when needed. Amputation was performed in patients 223

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when complete demarcation observed (n=5, 14 finger amputations, one transtibial amputation). Following amputations, defects were closed primarily or by grafting where necessary. During hospitalization, consultations from the Departments of Orthopedics, Plastic and Reconstructive Surgery and Neurosurgery were requested according to the injured body part and severity of the injury. Also, physical therapy and rehabilitation methods were applied to the patients. Table 1. Demographic and clinical data of our patients

Median (Q1-Q3)

Age (years)

27.0 (17.5–35.5)

Gender (M/W)* 25/0 Profession (Worker/Other)* 16/9 Cause of injury (High/Low voltage)* 23/2 Injury place (Outdoor/Indoor)* 22/3 Burn TBSA (%)

20.0 (6.5–44.5)

ABSI score

5.0 (5.0–7.5)

ICU stay (day)

10.0 (4.5–20.0)

Total hospital stay (day)

38.0 (12.5–58.0)

The data are given as number (n). TBSA: Total body surface area; ABSI: Abbreviated burn severity index; ICU: Intensive care unit.

*

Table 2. Correlation between burn TBSA, ABSI score, intensive care stay and total hospital stay ABSI score

0.918

0.690

0.000 0.000

Burn TBSA

0.775

0.558 0.009 0.628

0.000 0.002 Intensive care stay

Supraventricular tachycardia was observed in only one patient, which was treated by a single dose of the beta-blocking agent. No other cardiac event was detected. When we analyzed the correlations between TBSA, ABSI score, ICU stay and total hospital stay, moderate-good correlations were detected between these variables (r>0.50) (Table 2), which means the higher the scores, the longer the ICU and total hospital stay. We further analyzed our data according to the subgroups “healing without complication” and “healing with complication.” No significant differences were detected concerning age, TBSA and ABSI scores (p=0.10, p=0.06 and p=0.07, respectively) between these groups. However, the duration of ICU stay and total hospital stay were significantly higher in the group healing with complications (p=0.005 and p=0.001, respectively) (Table 3).

DISCUSSION

Burn TBSA ICU stay Total hospital stay

Nine of our patients (36%) recovered without complications. Sixteen (64%) of the patients developed one or more complications: One patient developed an incomplete tetraplegia due to fall during electrical injury, nine patients developed contracture of joints, nine patients had sepsis, three patients had median nerve damage due to injury at wrist and five patients developed necrosis requiring amputation of total 14 fingers. One of these patients later underwent transtibial amputation. One patient with accompanying inhalation burn (TBSA=64%) died on day 14.

0.762

0.000 TBSA: Total body surface area; ABSI: Abbreviated burn severity index; ICU: Intensive care unit. [In the rows, r values (correlation coefficient) are in the first and p values are in the second order].

Electrical burns are quite different from thermal and chemical burns. The severity of the electrical injury depends on many factors, such as the voltage, duration of contact, tissue resistance, skin moisture, and the presence of flash components and the ignition of clothing. Most of these injuries among adults are due to high voltage electric lines.[13,15] Electrical injuries account for up to 4% of the patients hospitalized in burn centers.[2] Albayrak et al.[22] stated, in their retrospective study, that 5.3% of the patients who were hospitalized in the burn center for eight years were electrical burns. Brandão et al.[23] reported this rate as 5.84% in the patients they followed for 10 years.

Table 3. Comparison of groups healing without or with complication Age (years)

Without complication (n=9) Median (Q1-Q3)

With complication (n=16) Median (Q1-Q3)

p

19.0 (16.5–31.0)

28.5 (21.0–40.25)

0.10

Burn total body surface area (%)

7.0 (4.5–29.0)

28.5 (12.0–52.5)

0.06

Abbreviated Burn Severity Index score (n)

5.0 (3.5–5.5)

6.0 (5.0–8.75)

0.07

Intensive care unit stay (day)

5.0 (3.5–7.5)

15.5 (8.5–30.5)

0.005

14.0 (8.0–20.0)

51.5 (38.0–70.5)

0.001

Total hospital stay (day)

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In the current study, the rate of electrical burns among the patients who were hospitalized in our burn center was 8.8%. This rate is considered to be higher than that reported in the literature since we serve as a tertiary burn center and 64% of our patients were referred from secondary and tertiary care hospitals. For the same reason, the high voltage electrical injury rate was higher in our patients (92%). Aghakhani et al.[24] examined the effects of current pathways on the mortality and morbidity in electrical burns and determined seven different groups according to the entry and exit points of the current. The authors concluded that the most common entry-exit sites were right upper-left lower extremities and the morbidities, such as mortality and amputation were not different between these pathways. Similarly, in our patients, the most frequent entry-exit pathway was the upper-lower extremity. In the literature, different data have been reported regarding the complications seen in electrical burns and the proportions of these complications.[22,23,25–27] Li et al.[27] analyzed the data of 82 patients who underwent amputation among the patients they followed for 12 years and reported that 51.2% of them were due to electrical burns. Zikaj et al.[25] reported a 40.7% amputation and 12.1% cardiorespiratory distress rate in 31 patients they followed between 2015 and 2017. The amputation rate was 20% in our patient group during the one-year study period. Only one of the patients who was monitored during ICU hospitalization had a short-term ventricular tachycardia and no serious cardiac event was observed in our study. Although it is not statistically significant, Brandão et al.[23] found the amputation rate (16.7%) higher in the high voltage electrical burn group in their study. Since 92% of our patients were high-voltage electrical burns, no such sub-analysis was performed. Kurt et al.[26] reported the infection rate as 32.9% in 94 patients they followed for four years. Similarly, the infection rate was 36% in our study. Cancio et al.[3] stated that there is no index available for electrical injury, analogous to burn size for the thermal injury that allows one to quantify the severity of the injury. Li et al.[28] analyzed the wound treatment data in 595 patients with electrical burns between 2013 and 2015. They found that high-voltage electrical current injuries and the number of operations performed per patient were major risk factors for hospital stay and amputations. The duration of ICU and total hospital stay was found to be significantly longer in the group that healed with complications (including amputations) in our study. However, as the TBSA and ABSI scores were not significantly higher in the group healing with complications, we can comment that these scores are not useful for predicting prognosis in electrical burn injuries, as also stated by Cancio et al.[3] Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

The relatively small number of patients and the limited follow-up data together with shortness of our follow-up time can be listed among the limitations of our study. In conclusion, electrical burns differ from other burns concerning mechanism, presentation, morbidity, complications and treatment strategies. The surgical management of electrical burns is characterized by early debridement. Appropriate skin grafts or myocutaneous pedicle flaps are used for repairing tissue defects. Amputations should be avoided until the demarcation line is settled completely. Although the percentage of electrical burns is lower among all burn patients, the rate of admission to ICU is higher. In addition, the TBSA and ABSI scores used in predicting the prognosis in burn patients are not directly related to the prognosis in electrical burns. The majority of our patients were adult males injured by a high voltage at work. Therefore, compliance with occupational safety principles and regular monitoring of electrical networks may reduce injuries. These patients should be addressed in well-equipped centers in accordance with experienced team members and updated guidelines. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: A.B., K.G., Ö.Ö., K.D.; Design: A.B., K.G., Ö.Ö., M.D.; Supervision: Ö.Ö., M.D., O.E., K.D.; Materials: A.B., K.G., Ö.Ö.; Data: A.B., K.G., Ö.Ö., M.D., O.E.; Analysis: A.B., K.D.; Literature search: A.B., K.G.; Writing: A.B., K.G., K.D.; Critical revision: K.G., Ö.Ö., K.D. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

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20. Piccolo NS, Piccolo MS, Piccolo PD, Piccolo-Daher R, Piccolo ND, Piccolo MT. Escharotomies, fasciotomies and carpal tunnel release in burn patients--review of the literature and presentation of an algorithm for surgical decision making. Handchir Mikrochir Plast Chir 2007;39:161–7. 21. Dahal P, Ghimire S, Maharjan NK, Rai SM. Prediction of outcome of acute burn injury by Baux’s and abbreviated burn severity index score. JCMS Nepal 2015;11:24−7. 22. Albayrak Y, Temiz A, Albayrak A, Peksöz R, Albayrak F, Tanrıkulu Y. A retrospective analysis of 2713 hospitalized burn patients in a burns center in Turkey. Ulus Travma Acil Cerrahi Derg 2018;24:25–30. 23. Brandão C, Vaz M, Brito IM, Ferreira B, Meireles R, Ramos S, et al. Electrical burns: a retrospective analysis over a 10-year period. Ann Burns Fire Disasters 2017;30:268−71. 24. Aghakhani K, Heidari M, Tabatabaee SM, Abdolkarimi L. Effect of current pathway on mortality and morbidity in electrical burn patients. Burns 2015;41:172–6. 25. Zikaj G, Xhepa G, Belba G, Kola N, Isaraj S. Electrical Burns and Their Treatment in a Tertiary Hospital in Albania. Open Access Maced J Med Sci 2018;6:835–8. 26. Kurt A, Yıldırım K, Yağmur Ç, Kelahmetoğlu O, Aslan O, Gümüş M, et al. Electrical burns: Highlights from a 5-year retrospective analysis. Ulus Travma Acil Cerrahi Derg 2016;22:278−82. 27. Li Q, Wang LF, Chen Q, Wang SJ, Li F, Ba T. Amputations in the burn unit: A retrospective analysis of 82 patients across 12 years. Burns 2017;43:1449–54. 28. Li H, Tan J, Zhou J, Yuan Z, Zhang J, Peng Y, et al. Wound management and outcome of 595 electrical burns in a major burn center. J Surg Res 2017;214:182−9.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Elektrik yanıkları ve komplikasyonları: Üçüncü basamak yanık merkezi yoğun bakım ünitesi verileri Dr. Abdulkadir Başaran, Dr. Kayhan Gürbüz, Dr. Özer Özlü, Dr. Mete Demir, Dr. Orhan Eroğlu, Dr. Koray Daş Adana Şehir Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Yanık Merkezi, Adana

AMAÇ: Yanık merkezi yoğun bakım ünitemizde tedavi edilen elektrik yanıklı hastaların verilerini gözden geçirerek tedavi sonuçlarımız ile birlikte komplikasyonları tartışmak amaçlanmıştır. GEREÇ VE YÖNTEM: Eylül 2017–Ağustos 2018 tarihleri arasında yanık merkezi yoğun bakım ünitesinde yatan elektrik yanıklı hastaların demografik verileri, yanık mekanizması, prezentasyonu, ortalama yanık total vücut alanı yüzdesi (TBSA), kısaltılmış yanık şiddeti indeksi (ABSI) skorları, komplikasyonlar ve tedavi yaklaşımları geriye dönük olarak incelendi. BULGULAR: Yanık merkezi yoğun bakım ünitemize yatırılan hastaların (n=139) %17.9’u elektrik yanığı hastası idi. Hastaların tümü erkekti ve ortanca yaşları 27.0 yıl idi. Hastaların 23’ü yüksek voltaj (%92), ikisi düşük voltaj (%8) elektrik ile yanmıştı. Ortanca yanık TBSA skoru 20.0 idi. Sekiz hastada eşlik eden baş, vertebra veya ekstremite yaralanmaları mevcuttu. Hastaların 16’sı (%64) işte yaralanmıştı. On altı hasta (%64) komplikasyonla iyileşti. Komplikasyonla iyileşen grupta yoğun bakım ve toplam hastane kalış süreleri istatistiksel olarak anlamlı derecede yüksekti (sırasıyla, p=0.005 ve p=0.001), ancak TBSA ve ABSI skorlarında anlamlı farklılık görülmedi. TBSA ve ABSI skorları yoğun bakım ve toplam hastane yatış süreleri ile korele bulundu. TARTIŞMA: Elektrik yanıklı hastalarımızın yüzdesi literatürde belirtilenden yüksektir. Yanık TBSA ve ABSI skorlarının prognozla ilişkili olmadığı görülmüştür. Elektrik yanıklı hastaların çoğunluğu iş kazasında yüksek voltajla yaralandığından, iş güvenliği ilkelerine uyulması bu yaralanmaları azaltabilir. Elektrik yanıklarında komplikasyon oranı yüksek olduğundan hastaların deneyimli sağlık ekibi eşliğinde, tam donanımlı merkezlerde, güncel rehberlere göre tedavisi yapılmalıdır. Anahtar sözcükler: Elektrik yaralanması; komplikasyonlar; yanık. Ulus Travma Acil Cerrahi Derg 2020;26(2):222-226

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ORIGIN A L A R T IC L E

Non-operative management of civilian abdominal gunshot wounds Adnan Özpek, M.D.,

Tolga Canbak, M.D.

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

ABSTRACT BACKGROUND: In this study, we aimed to evaluate the results of selective non-operative management in patients with civilian abdominal gunshot wounds. METHODS: Patients hospitalized and monitored in our clinic due to civilian abdominal gunshot wounds between January 2009 and January 2018 were retrospectively examined. Patients were studied concerning age, gender, mechanism of injury, anatomic injury site, Penetrating Abdominal Trauma Index (PATI), Injury Severity Score (ISS), Revised Trauma Score (RTS), treatment method, time to operation, days of hospitalization and mortality. RESULTS: Of the patients, 84 (89.4%) were male, and 10 (10.6%) were female with a mean age of 32.7 (range 4–60). The mean ISS, RTS and PATI values of all patients were 17.05, 7.27 and 9.21, respectively. Immediate laparotomy and/or thoracotomy were performed in 21 (22.3%) of the patients due to hemodynamic instability and in 27 (28.7%) of the patients because of peritonitis findings. The remaining 46 (48.9%) patients were managed non-operatively. Among these patients, early laparotomy was performed in five (5.3%) and late laparotomy in eight (8.5%) patients who developed peritonitis symptoms. The other 33 (35.1%) patients were treated non-operatively. Of these patients, 61.1% of the patients with flank injuries, 50% of the patients with right thoracoabdominal injuries, 44.4% of the patients with posterior abdominal injuries, 42.1% of the patients with pelvic injuries and 27.8% of the patients with left thoracoabdominal injuries were successfully treated non-operatively. Non-therapeutic or negative laparotomy was performed on six (6.4%) patients. Mortality was 10.6% (n=10) in all patients. CONCLUSION: Some patients with a civilian abdominal gunshot wound in certain anatomical localization who are hemodynamically stable and have no peritonitis symptoms can be non-operatively managed just as in patients with abdominal stab wounds. Success rates of selective non-operative management are high, especially in gunshot wounds of flank, posterior abdominal, thoracoabdominal and pelvic regions. Keywords: Abdominal trauma; civilian; gunshot wound; selective non-operative management.

INTRODUCTION While mandatory explorative laparotomy has been performed in penetrating abdominal traumas in the first half of the 20th century, selective non-operative management (SNOM) became a current issue and was introduced especially in abdominal stab wounds (ASW) after a study published by Shaftan in 1960. Later, in 1974, Nance et al. reported that SNOM is a safe and effective method in abdominal gunshot wounds (AGSW).[1]

In the following years, SNOM has been recognized in ASW by surgeons worldwide and is still commonly applied today. However, surgeons’ hesitation in practice still continues about SNOM for AGSW in our country and in many countries of the world. In several surveys conducted among surgeons in our country and other countries around the world, at least half of surgeons did not find SNOM as a safe and effective method in AGSW.[2–4]

Cite this article as: Özpek A, Canbak T. Non-operative management of civilian abdominal gunshot wounds. Ulus Travma Acil Cerrahi Derg 2020;26:227-234. Address for correspondence: Adnan Özpek, M.D. Sağlık Bilimleri Üniversitesi, Ümraniye Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey Tel: +90 216 - 632 18 18 E-mail: adnanozpek@mynet.com Ulus Travma Acil Cerrahi Derg 2020;26(2):227-234 DOI: 10.14744/tjtes.2020.86132 Submitted: 01.07.2019 Accepted: 06.01.2020 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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In this study, we aimed to investigate the safety and effectiveness of SNOM in patients with AGSW who were treated in our clinic.

MATERIALS AND METHODS This clinical study was approved by the Health Sciences University, Umraniye Training and Research Hospital Clinical Research Ethics Committee (Reference Number: 2019/23526665). Written informed consent was obtained from all patients. Patients hospitalized and monitored in our clinic due to civilian AGSW between January 2009 and January 2018 were retrospectively examined from the prospective database. Patients were studied regarding age, gender, mechanism of injury, anatomic injury site, Penetrating Abdominal Trauma Index (PATI), Injury Severity Score (ISS), Revised Trauma Score (RTS), treatment method, time to operation, days of hospitalization and mortality. Resuscitation was performed in the emergency room in accordance with the Advanced Trauma Life Support (ATLS) guidelines. Patients who were hemodynamically unstable or with peritonitis symptoms were immediately taken to operation wheras patients who were hemodynamically stable and without peritonitis symptoms underwent double or triple contrast CT. Patients with no evidence of hollow viscus injury on CT were hospitalized and monitored in our clinic. These patients were followed-up with intermittent physical examination and laboratory testing as much as possible by the same team. Among these, patients who developed peritonitis symptoms or with unsustainable hemodynamic stability were operated. In addition, rectosigmoidoscopy or colonoscopy was performed in patients when necessary depending on anatomic localization and/or clinical findings. Appropriate surgical procedures were performed in patients with rectum or colon wounds detected by endoscopy. The remaining patients were non-operatively treated.

Statistical Analysis The Statistical Package for the Social Sciences statistical software package (version 21.0 SPSS Inc, Chicago, Illinois) was used. Variables were expressed as mean ± standard deviation (SD) or median (range), depending on their distribution. Categorical variables were expressed as frequencies and percentages. Chi-square test was used for comparison of continuous parametric variables. The differences were considered statistically significant if the p-value was less than 0.05.

Anatomic Localization Posterior abdomen: Bilaterally, superiorly posterior subcostal margins, laterally posterior axilla lines, inferiorly hip folds. Flank: Bilaterally, superiorly arcus costarum margins, ante228

riorly anterior axilla lines, posteriorly posterior axilla lines, inferiorly upper margins of the iliac spine. Pelvic region: Superiorly a horizontally line crossing spina iliaca anterior superiors, inferiorly perine region.

Operation Time Immediate laparotomy: Laparotomy performed within two hours of the patient’s admission to the emergency room. Early laparotomy: Laparotomy performed between 2–8 hours of admission. Late laparotomy: Laparotomy performed eight hours after admission.

RESULTS Among a total of patients with GSW hospitalized and treated in our clinic during the study period, 94 patients with civilian AGSW were included in this study. Among these patients, there was not any patient injured with military guns. Of the patients, 84 (89.4%) were male, 10 (10.6%) female and the mean age was 32.7±10.3 (range 4–60). Eighty-two (87.2%) patients were injured with bullet and 12 (12.8%) with buckshot. Immediate laparotomy and/or thoracotomy were performed in 21 (22.3%) patients due to hemodynamic instability and in 27 (28.7%) patients because of peritonitis findings. The other 46 (48.9%) patients underwent double or triple contrast CT examination, hospitalized and monitored in our clinic and managed with SNOM. Among these patients, early laparotomy was performed in five (5.3%) patients and late laparotomy in eight (8.5%) patients who developed peritonitis symptoms. The other 33 (35.1%) patients were non-operatively treated. Statistically, the rate of successful SNOM was significantly higher in patients with buckshot injuries than patients with bullet injuries (p=0.028) (Table 1). Of the patients who underwent immediate operation due to hemodynamic instability; 13 underwent laparotomy, six patients underwent thoracotomy and two patients underwent laparotomy plus thoracotomy. All other operated patients underwent laparotomy. Tube thoracostomy was inserted in 13 (13.8%) patients. Non-therapeutic or negative laparotomy was performed on six (6.4%) patients. Of these patients, two patients were operated immediately due to hemodynamic instability, two patients were operated immediately because of peritonitis symptoms, one patient underwent early laparotomy and one patient underwent late laparotomy with peritonitis symptoms (Table 1). The mean ISS, RTS and PATI values of all patients were calculated as 17.05±1.29, 7.27±0.15 and 9.21±1.19, respectively. In Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Özpek et al. Non-operative management of civilian abdominal gunshot wounds

Table 1. Distribution of patients according to the mechanism of injury and treatment

Bullet Buckshot Total (n=82) (n=12) (n=94)

p*

Immediate laparatomy (Hemodynamic instability)

20

1

21

0.0134**

Immediate laparatomy (Peritonitis)

26

1

27

Early laparotomy

5

–

5

0.3793

Late laparatomy

5

3

8

0.0284**

Negative laparatomy

5

1

6

0.5699

Successful SNOM

26

7

33

0.0206**

Chi-square test; **Statistically significant (p<0.05).

*

Table 2. Mean ISS, PATI and RTS values of operated and SNOM patients

Operated SNOM

p*

ISS 21.90±1.63 8.09±0.84 <0.0001** PATI

13.72±1.56

0.88±0.34

<0.0001**

RTS 6.29±0.20 7.84±0.0 0.0119** ISS: Injury Severity Score; PATI: Penetrating Abdominal Trauma Index; RTS: Revised Trauma Score; SNOM: Selective non-operative management. *Chi-square test; **Statistically significant (p<0.05).

operated patients, these values were 21.90±1.63, 6.30±0.20, 13.72±1.55, respectively. In patients who was treated with SNOM, values were 8.09±0.84, 7.84±0.0, 0.88±0.34, respectively. There was a statistically significant difference between the operated and non-operated patients in all scores (p<0.0001, p<0.0001, p=0.0119, respectively) (Table 2). A total of 112 differrent anatomical site injuries were determined in this study. Twenty-eight of these injuries were anterior

(a)

abdominal, nine posterior abdominal, 20 right thoracoabdominal, 18 left thoracoabdominal, 18 flank and 19 were pelvic. Of these patients, 61.1% of the patients with flank injuries, 50% of the patients with right thoracoabdominal injuries, 44.4% of the patients with posterior abdominal injuries, 42.1% of the patients with pelvic injuries and 27.8% of the patients with left thoracoabdominal injuries were successfully treated with SNOM, whereas SNOM could be successfully performed only in one (3.4%) of the patients with anterior abdominal region wound (Figs. 1a, b and 2a-d). Although there was no statistically significant difference in other anatomical site injuries, the rate of successful SNOM in flank injuries was statistically significant higher than the others (p=0.031) (Table 3). Liver, spleen, heart, intraabdominal or iliac large vessel injuries and massive haemothorax were the most common causes in patients who were operated immediately with haemodynamic instability. In patients who were operated with signs of peritonitis, small intestine, colon and stomach injuries were the main causes. There were three Grade II liver injury, one Grade III spleen injury and one Grade I kidney injury in CT images of patients treated with SNOM (Table 4).

(b)

Figure 1. (a) Patient with a bullet injury localized in left flank successfully treated with SNOM. (b) Patient with right thoracoabdominal bullet injury successfully treated with SNOM.

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Özpek et al. Non-operative management of civilian abdominal gunshot wounds

(a)

(b)

(c)

(d)

Figure 2. (a) CT image of a patient with right thoracoabdominal buckshot injury successfully treated with SNOM. (b) CT image of a patient with pelvic buckshot injury successfully treated with SNOM. (c) CT image of a patient with left thoracoabdominal GSW and grade III spleen injury successfully treated with SNOM. (d) CT image of a patient with pelvic bullet injury and iliac fracture successfully treated with SNOM.

The mean duration of hospitalization was found as 9.96±6.55 (range 4–22) days in patients operated, 3.41±2.67 (range 1–11) days in patients with successful SNOM, 7.40±2.70 (range 4–11) days in patients underwent early laparotomy, 11.14±7.31 (range 5–27) days in patients underwent late laparotomy and 7.16±4.70 (range 4–19) days in patients underwent non-therapeutic or negative laparotomy. Average number of hospitalization days was statistically significant lower

in patients who were successfully treated with SNOM than operated patients (p=0.031) (Table 5). A total of 10 patients (10.6%) resulted in mortality. Of these, nine patients were operated immediately due to hemodynamic instability, and one patient underwent SNOM and had external iliac and femoral vessel injury that accompanying pelvic region wound.

Table 3. Distribution of patients according to anatomical injury sites and treatment modalities Injury sites

Immediate L. (H.instability)

Immediate L. Early L. Late L. Negative L. (Peritonitis)

Successful SNOM (%)

p*

Anterior abdominal (n=28)

7

13

4

3

1

1 (3.4%)

0.070

Posterior abdominal (n=9)

2

3

–

–

–

4 (44.4%)

0.711

Right thoracoabdominal (n=20)

8

2

–

–

–

10 (50%)

0.216

Left thoracoabdominal (n=18)

7

4

–

2

1

5 (27.8%)

0.789

Flank (n=18)

2

4

–

1

2

11 (61.1%)

0.031** 0.608

Pelvic (n=19)

1

4

1

5

3

8 (42.1%)

Total (n=112)

27

30

5

11

7

39 (34.8%)

H: Hemodynamic; L: Laparatomy; *Chi-square test; **Statistically significant (p<0.05).

230

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Özpek et al. Non-operative management of civilian abdominal gunshot wounds

Table 4. Organ injuries in all patients underwent surgery and treated with SNOM Injured organ

Immediate L/T. (H. instability)

Immediate L. (Peritonitis)

Stomach

3

Duodenum Small intestine

Early Laparotomy

Late Laparotomy

SNOM

Total

6

–

1

– 10

3

–

1

–

– 4

6

13

3

3

–

Colon

5

8

1

2

– 16

Rectum

1

1

–

1

– 3

Liver

6

3

2

–

3 14

Gallbladder

1

–

–

–

– 1

Pancreas

2

1

–

–

– 3

Spleen

2

3

–

–

1 6

Portal vein

1

–

–

–

–

1

V. cava inferior

7

2

1

–

–

10

Aorta

1

–

–

–

– 1

Iliac vessels

4

–

–

–

1

5

Massive haemotx.

4

–

–

–

–

4

Diaphragma

3

3

–

–

– 6

Heart

3

–

–

–

– 3

Lung

3

–

–

–

6 9

Kidney

2

1

–

–

1 4

Bladder

2

2

–

–

– 4

Urethra

–

1

–

–

1 2

25

L: Laparatomy; T: Thoracotomy; H: Haemodynamic instability; SNOM: Selective non-operative management.

Table 5. Average number of hospitalization days Duration of hospital stay (mean±SD) Range (day)

Operated patients

SNOM patients

Early L.

Late L.

Negative L.

p*

9.96±6.55

3.41±2.67

7.40±2.70

11.14±7.31

7.16±4.70

0.031**

4–32

1–11

4–11

5–27

4–19

SNOM: Selective non-operative management; L: Laparatomy; SD: Standard deviation. *Chi-square test; **Statistically significant (p<0.05).

Intraabdominal or iliac major vascular injuries, high-grade liver injuries, heart injuries and massive hemothorax were the leading causes of mortality (Table 6). The mean ISS, RTS and PATI values of died patients were 37.50±4.38, 3.30±0.63 and 24.10±6.26, respectively. In surviving patients, values were 14.62±1.08, 6.93±0.03,7.44±0.96, respectively. There was a statistically significant difference for all scores between patients who died and survivors (p<0.0001, p<0.0001, p<0.0001, respectively) (Table 7).

DISCUSSION There are different reasons why SNOM is not widely accepted among surgeons in ASGW. In a study published by Velmahos et al. that gathered the reasons of this hesitate unUlus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

der three titles: First, belief of that the incidence of intraabdominal injury is higher than 90% in AGSWs; second, thought of that explorative laparotomy does not harm the patient and third, belief of that clinical examination is not safe in followup of these patients whereas, the same study conducted with 1,856 patients showed that these dogmas were not true and 38% of patients were successfully treated non-operatively.[5] Similarly, in our present study, we found the rate of succesful SNOM to be 34.8%. The goal of SNOM in penetrating abdominal traumas is to reduce unnecessary laparotomies and associated complications and to shorten the duration of hospitalization.[2,5] Studies have shown that unnecessary laparotomy leads to various complications up to 41% and extend the duration of hos231

Özpek et al. Non-operative management of civilian abdominal gunshot wounds

tent physical examinations and laboratory findings for at least 24–48 hours.

Table 6. Organ injuries of the died patients Injured organ

Number of the patients

V.cava inferior

6

Iliac vessels

3

Studies reported between 16% and 50% successful non-operative treatment rates for all anatomical abdominal regions. [10–15] In the current study, we achieved similar results (35.1%).

Liver 3 Heart 2 Massive haemothorax

2

Diaphragma 2 Aorta 1 Stomach 2 Duodenum 2 Pancreas 2 Small intestine

3

Colon 2 Rectum 1 Kidney 2 Urethra 1

Table 7. Mean ISS, PATI and RTS values of survivor and died patients

Survivors Non-survivors

p

*

ISS

14.62±1.08

37.50±4.38

<0.0001**

PATI

7.44±0.96

24.10±6.26

<0.0001**

RTS

6.93±0.03

3.30±0.63

<0.0001**

ISS: Injury Severity Score; PATI: Penetrating Abdominal Trauma Index; RTS: Revised Trauma Score; *Chi-square test; **Statistically significant (p<0.05).

pitalization in patients with abdominal penetrating traumas. [6–8] In the present study, we found that the duration of hospitalization was shorter in patients who underwent SNOM compared to patients who underwent negative laparotomy (3.41±2.67 vs. 7.16±4.70 days). SNOM-related studies in patients with AGSW stated that the patient should be hemodynamically stable, should have no peritonitis symptoms, and should be evaluable for clinical examination (no accompanying head trauma and spinal injury, no intoxication due to alcohol or substances, and no need for sedation or intubation). Patients who meet these conditions can be managed with SNOM if there is no evidence of luminal organ injury on contrast-enhanced Computed Tomography (CT).[5,9] These patients should be monitored for at least 12– 24 hours and should be evaluated with intermittent physical examinations and laboratory tests by as much as possible the same surgical team.[9,10] In our study, all of the patients who underwent SNOM were conscious, and there was no evidence of hollow viscus injury on their computed tomography. We also monitored and observed our patients with intermit232

Successful results reaching high rates have been achieved, especially in flank, pelvis, hip and posterior abdominal GSWs that are likely to tangentially cross the peritoneum. Also, in the right and left thoracoabdominal GSWs, hollow viscus injuries occur less frequently even if they are penetrating the peritoneum. In their study, Velmahos et al.[5] reported successful SNOM results by 30% anterior AGSW and 65% posterior AGSW. In that study, since the authors included the right, left thoracoabdominal and pelvic regions into the anterior abdominal region, the rate of successful SNOM of the anterior abdominal GSWs is quite high. However, in our study, we found that the rate of successful SNOM in the injuries of the anterior abdominal region was very low (3.4%). Our results in posterior abdominal injury were more similar in the same study (44.4%). In another study by Velmahos et al., successful SNOM rates were reported by 40.5% in pelvic GSW.[16] The results of our study were similar (42.1%). DuBose et al.[10] reported that 12 of 13 patients with liver, spleen and kidney injuries due to ASGW treated non-operatively. In their study, Starling et al.[17,18] performed SNOM in 109 patients with Grade I-V liver injury due to the right thoracoabdominal GSW and laparotomy was needed only in four patients. In the same study, the failure rate of SNOM was 7.1% in 28 patients with Grade I-III kidney injuries. In our study, five of the patients treated with SNOM had solid organ injury on abdominal CT. Three of these had Grade II liver injuries, one had Grade III spleen and one had Grade I kidney injury. There are also systematic review studies on this issue. In a collective review study, Singh and Hardcastle[19] reviewed 37 studies between 1960 and 2003 and reported their results. In this study, 30.3% of the 21.300 patients with gunshot wounds were treated nonoperatively with a success rate of 85.2%. In a similar review study, Lamb and Garner[20] found that successful SNOM was performed in 32.2% of the 18,602 patients in 22 studies between 1990 and 2012. In that study, mortality was reported as 0.7% in patients who underwent SNOM and 1.1% in the non-therapeutic laparotomy group. In these studies, SNOM insufficiency was reported as approximately 15%. Reasons for this were reported as the development of peritonitis signs in 90% of the patients and unsustainable haemodynamic stability in 10%.[19,20] In the present study, the rate of SNOM was 48.9%, and the success rate was 71.7%. SNOM deficiency was due to the development of peritonitis findings in all of our patients. Mortality developed in one patient on whom we managed SNOM. However, this patient had a trans-pelvic injury and died from an external iliac artery injury, not an intra-abdominal organ injury. Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Özpek et al. Non-operative management of civilian abdominal gunshot wounds

In another study by Zafar et al.[21] reported that 22.2% of the 12,707 patients with AGSW were managed with SNOM between 2002 and 2008. In that study, late laparotomy increased the risk of mortality by approximately 4,5 folds. Conversely, there are publications reporting that late laparotomy does not increase morbidity and mortality in penetrating abdominal traumas.[22,23] In the present study, none of our patients who underwent late laparotomy resulted in mortality. In general, the results of our study are similar to the abovementioned studies. In our study, we performed SNOM successfully in 35.1% of selected patients with civilian AGSW and reduced the rate of unnecessary laparotomy to 6.4%.

Limitations The limitations of this study included the relatively small number of patients and were not performed prospectively because of the urgency of the patients.

Conclusion Rates of unnecessary laparotomies, associated morbidities and hospital stays can be reduced by performing SNOM in selected patients with civilian AGSW. Success rates of SNOM are high, especially in pelvic, thoracoabdominal, flank and posterior abdominal GSWs. However, prospective randomized studies and evidence are needed to reach a definite conclusion on this subject. It should be considered that SNOM can provide successful results in patients with civilian AGSW. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: A.Ö.; Design: A.Ö., T.C.; Supervision: A.Ö., T.C.; Materials: A.Ö., T.C.; Data: A.Ö.; Analysis: A.Ö., T.C.; Literature search: A.Ö.; Writing: A.Ö., T.C.; Critical revision: A.Ö. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

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5. Velmahos GC, Demetriades D, Toutouzas KG, Sarkisyan G, Chan LS, Ishak R, et al. Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care? Ann Surg 2001;234:395−402; discussion 402−3. 6. Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: a prospective study of morbidity. J Trauma 1995;38:350–6. 7. Weigelt JA, Kingman RG. Complications of negative laparotomy for trauma. Am J Surg 1988;156:544–7. 8. Demetriades D, Vandenbossche P, Ritz M, Goodmann D, Kowalszik J. Non-therapeutic operations for penetrating trauma: early morbidity and mortality. Br J Surg 1993;80:860–1. 9. Butt MU, Zacharias N, Velmahos GC. Penetrating abdominal injuries: management controversies. Scand J Trauma Resusc Emerg Med 2009;17:19. 10. DuBose J, Inaba K, Teixeira PG, Pepe A, Dunham MB, McKenney M. Selective non-operative management of solid organ injury following abdominal gunshot wounds. Injury 2007;38:1084–90. 11. Moore EE, Moore JB, Van Duzer-Moore S, Thompson JS. Mandatory laparotomy for gunshot wounds penetrating the abdomen. Am J Surg 1980;140:847–51. 12. Laing GL, Skinner DL, Bruce JL, Bekker W, Oosthuizen GV, Clarke DL. A multi faceted quality improvement programme results in improved outcomes for the selective non-operative management of penetrating abdominal trauma in a developing world trauma centre. Injury 2014;45:327–32. 13. Demetriades D, Charalambides D, Lakhoo M, Pantanowitz D. Gunshot wound of the abdomen: role of selective conservative management. Br J Surg 1991;78:220–2. 14. Okuş A, Sevinç B, Ay S, Arslan K, Karahan Ö, Eryılmaz MA. Conservative management of abdominal injuries. Ulus Cerrahi Derg 2013;29:153–7. 15. Lichte P, Oberbeck R, Binnebösel M, Wildenauer R, Pape HC, Kobbe P. A civilian perspective on ballistic trauma and gunshot injuries. Scand J Trauma Resusc Emerg Med 2010;18:35. 16. Velmahos GC, Demetriades D, Cornwell EE 3rd. Transpelvic gunshot wounds: routine laparotomy or selective management?. World J Surg 1998;22:1034–8. 17. Starling SV, de Azevedo CI, Santana AV, Rodrigues Bde L, Drumond DA. Isolated liver gunshot injuries: nonoperative management is feasible?. Rev Col Bras Cir 2015;42:238–43. 18. Starling SV, Rodrigues Bde L, Martins MP, da Silva MS, Drumond DA. Non operative management of gunshot wounds on the right thoracoabdomen. Rev Col Bras Cir 2012;39:286–94. 19. Singh N, Hardcastle TC. Selective non operative management of gunshot wounds to the abdomen: a collective review. Int Emerg Nurs 2015;23:22–31. 20. Lamb CM, Garner JP. Selective non-operative management of civilian gunshot wounds to the abdomen: a systematic review of the evidence. Injury 2014;45:659–66. 21. Zafar SN, Rushing A, Haut ER, Kisat MT, Villegas CV, Chi A, et al. Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database. Br J Surg 2012;99:155−64. 22. Peev MP, Chang Y, King DR, Yeh DD, Kaafarani H, Fagenholz PJ, et al. Delayed laparotomy after selective non-operative management of penetrating abdominal injuries. World J Surg 2015;39:380−6. 23. Hope WW, Smith ST, Medieros B, Hughes KM, Kotwall CA, Clancy TV. Non-operative management in penetrating abdominal trauma: is it feasible at a Level II trauma center?. J Emerg Med 2012;43:190–5.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Sivil nedenli abdominal ateşli silah yaralanmalarında non-operatif tedavi Dr. Adnan Özpek, Dr. Tolga Canbak Sağlık Bilimleri Üniversitesi, Ümraniye Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

AMAÇ: Bu çalışmada sivil nedenli abdominal ateşli silah yaralanmalı (ASY) hastalarda selektif non-operatif tedavi (SNOT) sonuçlarını değerlendirmeyi amaçladık. GEREÇ VE YÖNTEM: Kliniğimizde Ocak 2009 ile Ocak 2018 tarihleri arasında sivil nedenli abdominal ASY nedeniyle yatırarak takip ve tedavi ettiğimiz hastalar ileriye yönelik veri tabanında geriye dönük olarak incelendi. Hastalar yaş, cinsiyet, yaralanma şekli, anatomik yaralanma bölgesi, Yaralanma Şiddet Skoru (ISS), Revize Edilmiş Travma Skoru (RTS), Penetran Abdominal Travma İndeksi (PATI), uygulanan tedavi yöntemi, ameliyata alınma süresi, hastanede yatış gün sayısı ve mortalite yönünden irdelendi. BULGULAR: Hastaların 84’ü (%89.4) erkek, 10’u (%10.6) kadın, ortalama yaş 32.7 (4–60 yaş) idi. Seksen iki hasta (%87.2) tabanca mermisi, 12 (%12.8) hasta tüfek saçması ile yaralanmıştı. Tüm hastaların ortalama ISS, RTS ve PATI değerleri sırasıyla 17.05, 7.27 ve 9.21 bulundu. Hastaların 21’ine (%22.3) hemodinamik instabilite, 27’sine (%28.7) ise peritonit bulguları nedeniyle hemen acil laparatomi ve/veya torakotomi uygulandı. Diğer 46 (%48.9) hasta kliniğe yatırılarak takip edildi. Bu hastalardan peritonit bulguları gelişen 5’ine (%5.3) erken laparatomi, 8’ine (%8.5) geç laparatomi uygulandı. Geriye kalan 33 (%35.1) hasta non-operatif olarak tedavi edildi. Flank yaralanmalarının %61.1’i, sağ torakoabdominal yaralanmaların %50’si, posteriyor abdominal yaralanmaların %44.4’ü, pelvik yaralanmaların %42.1’i ve sol torakoabdominal yaralanmaların %27.8’i başarılı şekilde SNOT uygulaması ile taburcu edildi. Sadece 6 (%6.4) hastaya gereksiz laparatomi uygulandı, toplam 10 (%10.6) hastada mortalite gelişti. TARTIŞMA: Hemodinamisi stabil olan ve peritonit bulgusu mevcut olmayan, belirli anatomik lokalizasyondaki sivil nedenli abdominal ASY’li hastaların bir kısmı, delici-kesici alet yaralanmalı hastalar gibi non-operatif tedavi edilebilir. Böylece gereksiz laparatomi ve buna bağlı komplikasyonlar azaltılabilir. Özellikle flank, posterior abdominal, torakoabdominal ve pelvik bölgenin ASY’de non-operatif takip ve tedavinin başarı oranlarının yüksek olduğu hatırda tutulmalıdır. Anahtar sözcükler: Abdominal travma; ateşli silah yaralanması; seçici non-operatif takip; sivil yaralanma. Ulus Travma Acil Cerrahi Derg 2020;26(2):227-234

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doi: 10.14744/tjtes.2020.86132

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ORIGIN A L A R T IC L E

Fournier’s gangrene: Five years’ experience from a single center in Turkey Engin Hatipoğlu, M.D., Süleyman Demiryas, M.D., Kaya Sarıbeyoğlu, M.D., Salih Pekmezci, M.D.

Osman Şimşek, M.D.,

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

ABSTRACT BACKGROUND: Is the present study aims to analyze demographic, clinical and surgical data of all patients with FG (Fournier’s gangrene) admitted to a tertiary healthcare hospital in the largest city of Turkey. METHODS: This study included 35 patients with Fournier’s gangrene, who were followed by the General Surgery, Plastic Surgery, and Urology Departments of Istanbul University Cerrahpaşa Faculty of Medicine from January 2010 to January 2015. Demographic and clinical data, including gender, age, length of stay at the hospital, the underlying cause(s), number of debridement, predisposing factors, and surgical reconstructive data over 10 years were assessed and analyzed retrospectively. RESULTS: The mean age of the 35 patients was 58.14±12.71 years. Diabetes mellitus was present in 20 of the 35 (57.1%) patients. Twelve of the patients (34.2%) were hospitalized in the intensive care unit (ICU). Length of stay in the ICU was found to be significantly influenced by age, hematocrit level, FGSI and UFGSI (p=0.013, p=0.030 p=0.025 and p=0.002, respectively). CONCLUSION: Fournier’s gangrene is a fulminant infection with a high mortality rate. Physical examination and anamnesis are quite important for the diagnosis of FG. DM is the most common comorbidity. Age, hematocrit level, FGSI and UFGSI scores affect the patients’ length of stay in the ICU. Keywords: Fournier’s gangrene; prognosis; surgical debridement; treatment.

INTRODUCTION Fournier’s gangrene (FG) is the necrotizing fasciitis of the perineum, which progresses rapidly and has a high rate of mortality. FG frequently stems from an infection of the anorectal region (30–50%), uro-genitalia (20–40%), or genital region (20%). Most patients are males in their 60s or 70s. Fournier’s gangrene may occur due to trauma in the affected area and concomitant infection. Predisposing factors are a long list, including diabetes mellitus, alcoholism, atherosclerosis, peripheral arterial disease, Raynaud’s phenomenon, malnutrition, immunosuppression (e.g., chemotherapy, steroids, and malignancy), HIV infection, leukemia and liver diseases.[1,2] Necrosis of the tissues in the affected area, pain, and tenderness are the most common symptoms. Although a definite

diagnosis of FG can only be made after surgical examination, laboratory parameters and radiological results are helpful in risk assessment and in cases with uncertainty.[3] Unsuccessful debridement endangers the patient’s life; it may also lead to significant defects that may cause reconstructive difficulties.[4] It is important to know the clinical features and prognostic factors of the disease, especially when considering its incidence, prevalence, mortality and high treatment and rehabilitation costs to be able to manage the disease correctly. There is limited evidence about how the clinical and therapeutic features of FG are differentiated concerning the presence of DM, which is the most important predisposing factor. Also, evidence regarding how clinical progress of FG has changed concerning recurrence or intermittence of in-

Cite this article as: Hatipoğlu E, Demiryas S, Şimşek O, Sarıbeyoğlu K, Pekmezci S. Fournier’s gangrene: Five years’ experience from a single center in Turkey. Ulus Travma Acil Cerrahi Derg 2020;26:235-241. Address for correspondence: Engin Hatipoğlu, M.D. İstanbul Üniversitesi-Cerrahpaşa Cerrahpaşa Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 414 30 00 E-mail: enginhatipoglu@yahoo.com Ulus Travma Acil Cerrahi Derg 2020;26(2):235-241 DOI: 10.14744/tjtes.2020.66805 Submitted: 15.11.2019 Accepted: 12.02.2020 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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tensive care unit. We constructed this study on three different research questions as follows: (1) Were the treatment characteristics of patients with and without DM different? (2) Were the clinical and treatment characteristics of patients with or without ICU admittance different? (3) Were clinical and treatment characteristics of patients with and without recurrence changed? In this study, we aimed to analyze the clinical and surgical data of all FG patients admitted to a tertiary health care institute in Turkey.

MATERIALS AND METHODS Study Group This study included patients with Fournier’s Gangrene, who were followed by the General Surgery, Plastic Surgery, and Urology Departments of Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine from January 2010 to January 2015. The importance of this study was explained verbally to the participants, and written informed consent was obtained from all individuals before sampling.

Ethical Issues This study was approved by the ethics review committee of the Istanbul University-Cerrahpaşa in accordance with the World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects (Date: 05.12.2017, Approval Number: 83045809604.01.02).

Study Instrument Fournier Gangrene Index Score (FGSI) and Uludağ Fournier Gangrene’s Severity Index (UFGSI) were calculated for all patients. The FGSI is a 9-variable scoring system that is used to assess the severity of FG. Patients who have a total score above 9 points have been shown to have a 75% mortality rate.[5] The following parameters are assessed to calculate FGSI: heart rate, respiration rate, body temperature, serum levels of sodium, potassium, creatinine, hematocrit, bicarbonate, and leukocyte count. The UFGSI adds age and disease extent into the FGSI and is also used to predict mortality.[6] The following characteristics of patients were recorded: Age, gender, time until presentation to the hospital, presenting symptoms, physical examination findings, comorbidities, treatment modalities and length of hospitalization. Additionally, we also assessed the intensive care unit (ICU) medical files of patients who were treated in the ICU.

Non-normally distributed variables were analyzed with the Mann-Whitney U test. Categorical variables were evaluated Table 1. Patients’ characteristics Age

58.14±12.71

Gender

Male

31 (88.57%)

Female

4 (11.43%)

Weight (kg)

84.06±17.49

Height (cm)

173.54±9.77

Body mass index (kg/m ) 26.54±3.93 2

Time from symptom onset to the application (days)

4 (2–14)

Other surgery history

12 (34.29%)

Smokers

17 (48.57%)

Other chronic diseases

24 (68.57%)

Perianal surgery history

16 (45.71%)

Body temperature (°C)

37.07±0.77

Heart rate

91.10±13.26

Respiratory rate

20 (16–28)

Blood glucose (mg/dL)

132 (50–570)

Serum sodium (mmol/L)

136.27±6.67

Serum potassium (mmol/L)

4.10 (2.82–7.70)

Serum creatinine (mg/100/ml)

0.90 (0.55–5.39)

Hematocrit (%)

34.93±6.19

White blood cell (x1000/mm3) 15.95±7.38 C-reactive protein (mg/L) Serum bicarbonate (mmol/L) Length of stay in hospital (day)

205.5 (27.1–565) 21.54±2.80 20 (3–73)

Stoma

12 (34.29%)

Need for additional debridement

24 (68.57%)

Vacuum-assisted closure Hyperbaric oxygen treatment Need for reconstructive surgery

2 (5.71%) 2 (5.71%) 28 (80.00%)

Need for urologic surgery

9 (25.71%)

Stay in the intensive care unit

12 (34.29%)

Recovery

Primary

20 (57.14%)

Secondary

4 (11.43%)

Tertiary

7 (20.00%)

Flap

4 (11.43%)

Recurrence

12 (34.29%) 4 (11.43%)

Exitus

Fournier Gangrene Index Score

2 (0–14)

Statistical Analysis

Uludağ Fournier Gangrene’s Severity Index

4 (1–16)

All analyses were performed on SPSS v21. For the normality check, the Shapiro-Wilk test was used. Normally distributed variables were analyzed with the independent samples t-test.

Data given as mean ± standard deviation or median (minimum - maximum) for continuous variables regarding normality and frequency (percentage) for categorical variable.

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by employing Chi-square tests or Fisher’s exact test when required. Data were given as mean ± standard deviation or median (minimum-maximum) for continuous variables concerning the normality of distribution, and frequency (percentage) for categorical variables. Statistically, p<0.05 values were accepted to show significant results.

RESULTS

drainage in the last week and fournier gangrene developed as a result of insufficient drainage (case 12, 18, 20, 25). Other patients had previously undergone surgery due to any anorectal pathology (e.g., hemorrhoids, vaginal posterior wall rupture, orchiectomy). The median time interval between symptom onset and admission to the hospital was four (2–14) days. The most common symptoms were pain (n=21, 60%) and swelling (n=20, 57.1%).

A total of 35 patients were included in this study. Among them, four (11.43%) patients were female and 31 (88.57%) were male. The mean age of the patients was 58.14±12.71 years. The mean body mass index (BMI) was 26.54±3.93 (Table 1). Sixteen patients (45.7%) had a history of perianal surgery. Four patients had undergone perianal abscess

Diabetes mellitus was present in 20 out of 35 (57.1%) patients. Patients’ characteristics concerning the presence of Diabetes Mellitus are shown in Table 2. As seen, no significant difference was observed concerning neither presenting features (except serum glucose level) nor treatment options and outcome.

Table 2. Patients’ characteristics concerning diabetes mellitus

Diabetes mellitus

Absent (n=15)

Present (n=20)

p

Age

54.07±12.09

61.2±12.58

0.101

Gender

Male

Female

Time from symptom onset to the application (days) Other surgery history

14 (93.33%)

17 (85.00%)

1 (6.67%)

3 (15.00%)

0.619

5 (3–14)

3 (2–14)

0.373

6 (40.00%)

6 (30.00%)

0.797

Body temperature (°C)

37.26±0.83

36.94±0.72

0.255

Heart rate

90.92±14.11

91.22±13.04

0.952

20 (19–24)

20 (16–28)

0.183

117 (50–360)

181 (85–570)

0.009

Respiratory rate Blood glucose (mg/dL) Serum sodium (mmol/L)

136.75±9.44

135.94±4.25

0.752

Serum potassium (mmol/L)

4.1 (2.9–7.7)

4.15 (2.82–5.90)

0.859

1.08 (0.57–2.66)

0.90 (0.55–5.39)

0.767

35.77±6.06

34.36±6.37

0.535

Serum creatinine (mg/100/ml) Hematocrit (%) White blood cell (x1000/mm3) C-reactive protein (mg/L)

14.17±5.50 17.16±8.36 0.268 211 (27.1–409)

180 (53–565)

0.705

Serum bicarbonate (mmol/L)

20.80±2.94

22.06±2.65

0.239

Length of stay in hospital (day)

19 (3–42)

22 (5–73)

0.316

Need for additional debridement

8 (53.33%)

16 (80.00%)

0.144

Vacuum-assisted closure

1 (6.67%)

1 (5.00%)

1.000

0 (0.00%)

2 (10.00%)

0.496

Need for reconstructive surgery

Hyperbaric oxygen treatment

14 (93.33%)

14 (70.00%)

0.199

Need for urologic surgery

4 (26.67%)

5 (25.00%)

1.000

Stay in the intensive care unit

4 (26.67%)

8 (40.00%)

0.644

Recurrence

7 (46.67%)

5 (25.00%)

0.329

Exitus

3 (20.00%)

1 (5.00%)

0.292

Fournier Gangrene Index Score

2 (0–14)

2 (0–9)

0.791

Uludağ Fournier Gangrene’s Severity Index

4 (1–16)

4 (1–15)

1.000

Data given as mean±standard deviation or median (minimum–maximum) for continuous variables regarding normality and frequency (percentage) for categorical variable.

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Twelve of the patients (34.2%) were hospitalized in the ICU. The age of the patients hospitalized in the intensive care unit (ICU) was found to be higher than the patients who did not require ICU admittance (65.33±11.63 years vs. 54.39±11.79 years, respectively; p=0.013). Median FGSI score was 2 (0– 14), while the median UFGSI score was 4 (1–16). Median FGSI and UFGSI scores were found to be higher in patients accepted to the ICU compared to those who were not (4 vs. 2, p=0.025; and 6 vs. 3, p=0.002, respectively). Patients’ characteristics concerning the presence of intensive care unit intermittence are indicated in Table 3. Additional debridement(s) were required and performed in 24 (68.5%) patients. Reconstructive surgery was performed in 28 (80%) patients. Nine (25.7%) patients underwent urological surgery. Twelve (34.2%) patients had diverting stoma. Vacuum-assisted closure (VAC) was added to the procedure in the debridement of two patients (5.7%). Two patients (5.7%) underwent hyperbaric oxygen therapy (HBO). Primary recovery was achieved in 20 patients (57.1%) and flaps were utilized in four patients (11.4%). Recurrence developed in 12 (34.2%) patients. Perianal abscess drainage was repeated

in nine patients. The patients were sent home by dressing in the outpatient clinic. There was complete recovery in the first month of follow-up. Recurrent perianal abscess drainage was performed in one patient at different times. Partial recovery was achieved in this patient (case 12). Two patients underwent partial thickness skin grafts. The patients were followed up in the hospital after the procedure. Full recovery was achieved in these patients (cases 30 and 31). Respiratory rate and hematocrit levels were statistically different in patients with and without recurrence (20/min vs. 22/ min, p=0.023 and 39.1±3.1% vs. 33±6.3%, p=0.001, respectively) (Table 4). Among the 35 patients included in this study, four (11.4%) patients died.

DISCUSSION Fournier’s gangrene is characterized by a rapidly progressive, potentially fatal necrotizing infection of the external genitalia and perineum. This necrosis contributes to the growth of anaerobic bacteria that arises from vascular obliteration, causing edema, micro-thromboses and hypoxia. Early diagnosis is crucial for successful treatment and a favorable prognosis.[7]

Table 3. Patients’ characteristics concerning recurrence

Recurrence

Absent (n=23)

Present (n=12)

p

Age

59.87±12.37

54.83±13.21

0.272

Gender

Male

Female

21 (91.30%)

10 (83.33%)

2 (8.70%)

2 (16.67%)

0.594

Weight (kg)

79.89±21.42

88.75±11.30

0.299

Height (cm)

172.17±14.08

174.71±4.72

0.687

Body mass index (kg/m2) Time from symptom onset to the application (days)

24.43±4.30 28.35±2.69 0.070 4 (2–14)

4 (3–14)

0.979

Other surgery history

6 (26.09%)

6 (50.00%)

0.261

Perianal surgery history

10 (43.48%)

6 (50.00%)

0.992

Length of stay in the hospital (day)

19 (3–73)

21 (11–42)

0.611

Stoma

9 (39.13%)

3 (25.00%)

0.476

Need for additional debridement

15 (65.22%)

9 (75.00%)

0.709

1 (4.35%)

1 (8.33%)

1.000

Vacuum-assisted closure Hyperbaric oxygen treatment

1 (4.35%)

1 (8.33%)

1.000

18 (78.26%)

10 (83.33%)

1.000

Need for urologic surgery

5 (21.74%)

4 (33.33%)

0.685

Stay in the intensive care unit

10 (43.48%)

2 (16.67%)

0.149

Need for reconstructive surgery

Exitus

4 (17.39%)

0 (0.00%)

0.275

Fournier Gangrene Index Score

2.5 (0–14)

1.5 (0–6)

0.235

Uludağ Fournier Gangrene’s Severity Index

4.5 (1–16)

3.5 (1–9)

0.140

Data given as mean±standard deviation or median (minimum–maximum) for continuous variables regarding normality and frequency (percentage) for categorical variables.

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Table 4. Patients’ characteristics concerning intensive care unit admittance

Need for intensive care unit

Absent (n=23)

Present (n=12)

p

Age

54.39±11.79

65.33±11.63

0.013

Gender

Male

Female

21 (91.30%)

10 (83.33%)

0.594

2 (8.70%)

2 (16.67%)

Weight (kg)

88.08±15.77

71±18.46

0.088

Height (cm)

176.56±4.90

166.75±15.13

0.288

Body mass index (kg/m2)

27.06±3.75 25.37±4.67 0.498

Time from symptom onset to the application (days)

4 (3–7)

5.5 (2–14)

0.414

8 (34.78%)

4 (33.33%)

1.000

Smokers

11 (47.83%)

6 (50.00%)

1.000

Diabetes mellitus

12 (52.17%)

8 (66.67%)

0.644

Other chronic diseases

15 (65.22%)

9 (75.00%)

0.709

Perianal surgery history

11 (47.83%)

5 (41.67%)

1.000

Other surgery history

Length of stay in hospital (day)

19 (3–73)

27 (5–55)

0.384

Stoma

7 (30.43%)

5 (41.67%)

0.709

Need for additional debridement

17 (73.91%)

7 (58.33%)

0.451

1 (4.35%)

1 (8.33%)

1.000

Vacuum-assisted closure Hyperbaric oxygen treatment

2 (8.70%)

0 (0.00%)

0.536

17 (73.91%)

11 (91.67%)

0.380

Need for urologic surgery

6 (26.09%)

3 (25.00%)

1.000

Recurrence

10 (43.48%)

2 (16.67%)

0.149

Need for reconstructive surgery

2 (8.70%)

2 (16.67%)

0.594

Fournier Gangrene Index Score

Exitus

2 (0–9)

4 (2–14)

0.025

Uludağ Fournier Gangrene’s Severity Index

3 (1–10)

6 (4–16)

0.002

Data given as mean±standard deviation or median (minimum–maximum) for continuous variables regarding normality and frequency (percentage) for categorical variables.

Radiological techniques (e.g., ultrasonography, computed tomography, and magnetic resonance imaging) aid physicians in the assessment of the condition, while physical examination and anamnesis are crucial for the diagnosis of FG.[8–11] The most common symptoms of FG include scrotal pain, swelling and erythema. Systemic symptoms, such as fever, rigor and tachycardia, are often present. Rarely, subcutaneous gas with crepitation may be present. The definite diagnosis of FG is still accepted to be reliant on surgical examination.[3,12] Fournier’s gangrene was diagnosed by performing a physical examination and anamnesis in our study. The most common symptoms were pain (60%) and swelling (57.1%). Edema, necrosis and fluctuations were also frequently noted on physical examinations (Table 5). Fournier’s gangrene is known to be a rapid onset disease, but studies have shown that application to the hospital is delayed by an average of one week after initial symptoms have presented.[13] In our study, the median time from symptom Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Table 5. Frequency of the symptoms

n %

Pain

21 60.00

Swelling

20 57.14

Bad wound smell

1

Bleeding

1 2.86

2.86

Flix

7 20.00

Open wound

4

Rubor

13 37.14

Necrosis

2 5.71

11.43

Temperature increase

1

Fecaluria

1 2.86

2.86

Fever

2 5.71

Weakness

1 2.86

Abscess

2 5.71

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onset to hospital application was four (2–14) days. Immediate diagnosis and treatment of FG are known to affect prognosis. [4] Thus, these intervals have a significant impact on diagnosis and the success of treatment. Infections, diabetes mellitus, alcoholism, atherosclerosis, peripheral arterial disease, Raynaud’s phenomenon, malnutrition, immunosuppression (e.g., chemotherapy, steroids, and malignancy), HIV infection, leukemia and liver diseases are the most important predisposing factors for FG.[1] The underlying common ground of all these factors is the disruption of host immunity, which creates a favorable environment for infectious agents. In patients with DM, hyperglycemia has been shown to have destructive effects on host immunity via its effects on cellular adherence, chemotaxis and phagocyte activity. Diabetes has been frequently indicated as a predisposing factor in cases of Fournier’s gangrene (32% to 66% of the cases).[14,15] Glycemic control has been shown to be directly related to the extent of the disease and patient prognosis.[15] Therefore, diabetic patients may require more aggressive wound care and extensive debridement due to the likelihood of worse prognosis.[1] In our study, 57.1% of the patients had DM. There was no statistically significant difference between the laboratory, clinical and surgical results of patients with and without DM. In our study, twelve of the patients (34.2%) required ICU hospitalization. Significant relationships were found between length of ICU stay and parameters, such as age, hematocrit level, and FGSI and UFGSI scores. There are only a few studies that have assessed patients with FG in terms of factors related to their length of stay (LoS) in the ICU. In previous studies, mean LoS in ICU durations were reported as 36, 26 and 27.4 days. However, we found that several factors were affecting LoS in the ICU and we believe these results provide valuable data that require further comparative studies. Methods, such as VAC and HBO, can be utilized in patients with FG in an attempt to increase the speed of wound recovery. There are studies reporting that VAC treatment decreases debridement requirements and also eliminates the need for ostomy in select cases.[16,17] However, the possibility of brain and lung complications with HBO and high costs limit their use. HBO therapy, which has a physiological rationale, has not yet been shown to be effective for routine use in clinical trials. We utilized these treatment modalities in only four patients (two patients had HBO, two patients had VAC. However, others have suggested that VAC is a clinically effective treatment modality for the management of large wounds.[16–19] The only reliable way to evaluate this treatment in comparison with conventional dressings is to conduct prospective randomized studies. However, these are virtually impossible to conduct due to the rarity of FG and its high mortality rate, which may cause ethical limitations considering the nature of randomization. In our study, recurrence occurred in 12 patients. Except for one of these patients, full recovery was achieved. Partial re240

covery was achieved in one patient. In many studies, it has been stated that the important factor affecting the clinical outcome is timing and adequate surgical debridement.[1,2] In this context, we think that debridement and abscess drainage was insufficient in cases where recurrence developed in our study. Limitations of the present study include its retrospective, single-center design and the limited number of patients. However, FG is rather rare, and long-term follow up studies such as ours are few.

Conclusion Fournier’s gangrene is a fulminant infection with a high mortality rate. Early suspicion and diagnosis, followed by prompt surgical and systemic treatment are the only measures that have been shown to reduce mortality. Accurate physical examination and anamnesis are crucial for diagnosis. Age, hematocrit level, FGSI and UFGSI scores were found to significantly influence LoS in ICU. Thus, we believe further studies are required to validate these interesting results. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: E.H.; Design: E.H., S.D., O.Ş.; Supervision: S.P., K.S., E.H.; Materials: O.Ş., S.D., E.H.; Data: O.Ş., S.D. , E.H.; Analysis: K.S., E.H.; Literature search: E.H.; Writing: E.H.; Critical revision: S.P., K.S., E.H. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Fournier gangreni: Türkiye’deki tek bir merkezden beş yıllık deneyimlerimiz Dr. Engin Hatipoğlu, Dr. Süleyman Demiryas, Dr. Osman Şimşek, Dr. Kaya Sarıbeyoğlu, Dr. Salih Pekmezci İstanbul Üniversitesi-Cerrahpaşa Cerrahpaşa Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul

AMAÇ: Bu çalışmanın amacı, İstanbul’daki üçüncü basamak bir hastaneye başvuran Fournier gangreni hastalarının demografik, klinik ve cerrahi verilerini analiz etmektir. GEREÇ VE YÖNTEM: Çalışmaya Ocak 2010–Ocak 2015 tarihleri arasında İstanbul Üniversitesi-Cerrahpaşa Cerrahpaşa Tıp Fakültesi Genel Cerrahi, Plastik Cerrahi ve Üroloji Anabilim Dalları tarafından takip edilen Fournier gangrenli 35 hasta dahil edildi. Cinsiyet, yaş, yatış süresi, altta yatan neden(ler), debridman sayısı, predispozan faktörler ve 10 yıllık bir süre içinde cerrahi ile ilgili veriler geriye dönük olarak değerlendirildi ve analiz edildi. BULGULAR: Otuz beş hastanın yaş ortalaması 58.14±12.71 idi. Otuz beş hastanın 20’sinde (%57.1) diabetes mellitus (DM) mevcuttu. Hastaların 12’si (%34.2) yoğun bakım ünitesinde (YBÜ) yatırıldı. YBÜ’de kalma süresinin yaş, hematokrit seviyesi, FGSI ve UFGSI’den anlamlı derecede etkilendiği bulundu (sırasıyla, p=0.013, p=0.030 p=0.025 ve p=0.002). TARTIŞMA: Fournier gangreni, mortalite oranı yüksek fulminan bir enfeksiyondur. FG tanısı için fizik muayene ve öykü oldukça önemlidir. En sık görülen komorbidite DM’dir. Yaş, hematokrit seviyesi, FGSI ve UFGSI skorları hastaların YBÜ’de kalış sürelerini etkilediği bulunmuştur. Anahtar sözcükler: Cerrahi debridman; Fournier gangren; prognoz; tedavi. Ulus Travma Acil Cerrahi Derg 2020;26(2):235-241

doi: 10.14744/tjtes.2020.66805

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The importance of the injury severity scores and revised trauma scores for moderate traumas: A state hospital experience Feray Yıldırım Aydın, M.D.,1

Dilek Dülger, M.D.2

1

Department of General Surgery, 29 Mayıs State Hospital, Ankara-Turkey

2

Department of Microbiology, Karabük University Faculty of Medicine, Karabük-Turkey

ABSTRACT BACKGROUND: The degree of damage presents a pressing issue in determining trauma severity. Various trauma-scoring systems, such as the injury severity and revised trauma scores, are used worldwide. In this study, we aimed to evaluate the functionalities of these two trauma scoring systems, which are presently used frequently and have scientifically evolved at the state hospital level. METHODS: Following approval from the ethics committee to conduct clinical studies with retrospective archive screening, data between January 1, 2012, and December 31, 2017, were retrospectively analysed for determining the factors affecting mortality in all patients diagnosed with traumatic injury in 29 Mayıs State Hospital. Incomplete or unclear data were excluded from this study. Mean and standard deviation were used for continuous variables; percentage and frequency values were used for binary variables. For evaluating continuous variables, Student’s t-test or Mann–Whitney U-test was used in independent groups based on their distribution status. Dichotomous variables were evaluated using the chi-square test. The results and significant in univariate analyses were evaluated again by the linear and binary logistic regression model. RESULTS: Mean age of all patients was 37.53±14.47 years [male (35.68±13.9) versus female (40.61±15.1) (p=0.116)]. Mean injury trauma score for the general population was 3.18±8.46. No dissimilarity was noted regarding gender for the injury severity score (ISS) [(3.93±10.49 versus 1.91±2.34) (p=0.727)]. Regarding age, for revised trauma score (RTS), no statistical significance was noted [(7.60±0.91 versus 7.81±0.16) (p=0.207)]. Regarding the injury mechanism, we detected a difference between the two trauma scores; both ISS and RTS also had statistical significance. The results were found for ISS [penetrant (6.56±6.47) versus blunt (2.45±8.68) (p=0.002)] and for RTS [penetrant (7.41±0.54) versus blunt (7.74±0.79) (p=0.001)]. After the final statistics with logistic linear regression, the respiratory rate was statistically significant for penetrant injury [AOR 0.22 (0.001, 0.47) (p≤0.05)]. In the detailed subanalysis for RTS score components, respiratory rate was also significant in moderate traumas [AOR 0.22 (0.001, 0.47) (p=0.004)]. CONCLUSION: Both ISS and RTS are nonsignificant in all moderate injury types. On the other hand, respiratory rate is an important marker, especially in penetrant moderate injuries. Keywords: Injury severity score; moderate severe trauma; public hospital; revised trauma score.

INTRODUCTION The trauma scoring system is a vital triage process for comparing different trauma injuries and care models for quality. [1] Approximately 60 years previously, a series of scales that evaluated the severity of the injury was established, and AIS

was one of these. Since that day, the AIS scoring system has undergone changes and developed.[2] AIS-90 is a scoring system that includes the assessment of nine body regions (head, face, neck, thorax, abdomen, spine, upper extremities, lower extremities and external). Each injury site is given a score between 1 and 6, with a score of 1 corresponding to the slight-

Cite this article as: Yıldırım Aydın F, Dülger D. The importance of the injury severity scores and revised trauma scores for moderate traumas: A state hospital experience. Ulus Travma Acil Cerrahi Derg 2020;26:242-246. Address for correspondence: Feray Yıldırım Aydın, M.D. 29 Mayıs Devlet Hastanesi, Genel Cerrahi Kliniği, 06105 Ankara, Turkey Tel: +90 312 - 593 29 29 E-mail: ferayaydin2008@hotmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):242-246 DOI: 10.14744/tjtes.2020.06623 Submitted: 12.09.2019 Accepted: 11.02.2020 Online: 25.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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est injury, and 6 indicating the most severe injury, which is equivalent to mortality. In patients with multiple injuries, the highest AIS score is known as the maximum AIS (MAIS). However, it has been shown that although MAIS can be used for defining overall severity, MAIS does not achieve a significant association with mortality in damage assessments.[3,4] Owing to all these disadvantages, an AIS-based injury severity score (ISS) was developed by Baker et al.,[5] where in the head or neck, face, chest and abdomen or pelvic contents were classified as extremities or pelvic girdle and outer surface. The ISS was then calculated as the sum of the squares of the highest AIS scores for the three most severely injured body regions. An important condition is present in this damage calculation system. If the damage in a single body area corresponds to the value of 6, the injury corresponds to the value of 75 in the ISS scoring system. In addition, another important issue is that if the severity of an injury cannot be determined, anAIS of 9 is assigned, and 99 points are awarded.[2] Because the ISS is an anatomically based score system, some doubts remain regarding the suitability of its use in trauma assessments.[6] In the calculation of the revised trauma score (RTS), which is a physiological score, the formula RTS=0.9368 GCS + 0.7326 SBP + 0.2908 RR is applied, where GCS is the Glasgow coma scale, SBP is the systolic blood pressure and RR is the respiratory rate.[6] Although the physiological origin trauma score systems had more predictors of in-hospital mortality, such as RTS than with anatomic-based with anatomic scoring systems, such as ISS in this perspective, this may have changed in moderate injuries. At this point, we aimed to clarify this vague question, especially concerning the type of injury.

MATERIALS AND METHODS Following approval from the ethics committee for conducting clinical studies using retrospective archive screening, data between January 1, 2012, and December 31, 2017 were retrospectively analysed for determining the factors that affect mortality in all patients diagnosed with traumatic injury in 29 Mayıs State Hospital. Incomplete or unclear data were ex-

cluded from this study. Mean and standard deviation were used for the continuous variables, and percentage and frequency values were used for the binary variables. In the evaluation of the continuous variables, the Student’s t-test or Mann-Whitney U test was used in the independent groups on the basis of their distribution status. Dichotomous variables were evaluated using the chi-square test. The final results were obtained using the logistic regression model. Data were analyzed using SPSS™ for Windows22 (SPSS, Chicago, IL).

RESULTS For this study, between January 1, 2012, and December 31, 2017, a total of 680 patients were screened and a total of 91 patients concerning trauma injury clarification, who were admitted to the emergency department, were included in this investigation. Of these, 57 patients (60.0%) were male, and 35 (35.8%) were female. The mean age of all the patients was 37.53±14.7 years. The mean ages of males and females were 35.68±13.9 years and 40.62±15.1 years (p=0.12), respectively. When we look at the injury characteristics, both penetrant and blunt injuries were found in 13 males (81.3%) versus three females (11.8%) and 44 males (58.7%) versus 31 females (41.3%), respectively. Regarding trauma mechanism distribution, assault 27 (65.9%) versus 14 (34.1%), work accident 11 (61.1%) versus seven (38.9%), and traffic accident 19 (59.4%) versus 13 (40.6%) were found, respectively. The demographic characteristics of the patients are shown in Table 1.

DISCUSSION ISS is an important tool for the prediction of mortality if its value is >16, which may result in mortality, and the treatment of these patients was suggested at trauma care centres.[7,8] Although the RTS is a physiological scoring system, RTS includes the GCS. Thus, if there is any head injury, this scoring system can be used for better assessment. However, if there is no significant head trauma, RTS prediction can be decreased for the prediction of survival.[9,10] In the late 1990s, Bickell[11,12]

Table 1. Demographic and trauma characteristics of the patients with moderate injury Variables Age (year)

Male [(n=57) (62.6%)]

Female [(n=34) (37.4%)]

p≤0.05

Total mean±SD

35.68±13.9

40.62±15.1

0.12

37.53±14.7

0.09

Injury characteristics, n (%)

Penetrant (n=16)

13 (81.3)

3 (11.8)

Blunt (n=75)

44 (58.7)

31 (41.3)

Trauma mechanism, n (%)

Assault (n=41)

27 (65.9)

14 (34.1)

Work accident (n=18)

11 (61.1)

7 (38.9)

Traffic accident (n=32)

19 (59.4)

13 (40.6)

Total

57

0.84

34 91

SD: Standard deviation.

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noted that modest volume therapy with rapid fluid replacement, which is accepting hypotension within acceptable limits, was beneficial for patients with penetrating trauma. Also, the view that it is increasingly useful for cases of blunt trauma and haemorrhagic shock trauma concerning limited volume fluid replacement is gaining popularity.[13–17] In a recent study conducted in the US, Haut et al.[18] showed that intensive volume treatment was associated with worsened outcomes. The authors concluded that pre-hospital volume therapy is no longer useful. The advocates of large-volume replacement, however, justify its use by focusing on the importance of increasing mean arterial blood pressure and maintaining adequate organ perfusion.[19] However, its disadvantage is that it is more difficult to confirm the permissible hypotension in patients with concurrent severe traumatic brain injury. It should be well-established and, as stated in recent literature, normotension should be targeted for maintaining adequate cerebral perfusion pressure, and excessive volume replacement should be avoided.[20] At this point, we can see that parallel to the results, when normal cerebral perfusion is present, GCS is not very effective in evaluating trauma scoring if there is no severe head trauma, which may cause GCS to lose its effectiveness in predictability, especially in moderate- and lowgrade traumas. Singh et al.,[21] in their study, reported that the post-traumatic mortality risk ratio of those with lower than 90 mmHg SBP increased by 2.6 times. In another study Table 2. Results of Spearman’s correlation

Correlations

ISS

RTS

Spearman’s rho

ISS

Correlation coefficient Sig. (2-tailed)

N

Correlation coefficient

RTS

Sig. (2-tailed)

N

1.000

−0.427*

–

0.000

91

91

−0.427* 1.000 0.000 91

– 91

*Correlation is significant at the 0.01 level (2-tailed). ISS: Injury severity score; RTS: Revised trauma score.

conducted in 2019, Albuz stated that the risk of mortality was 4.6 in patients with 90 mmHg below SBP and serious penetrating injuries.[22] As mentioned previously, if the systolic pressure is not less than 90 mmHg, especially in trauma patients, the damage prediction value decreases. Because the SBP was above 90 mmHg in most of our cases, at this point, we can see that it is parallel to the results, when normal cerebral perfusion is present, GCS is not very effective in trauma scoring, which may cause GCS to lose its effectiveness, especially in moderate- and low-grade trauma. In addition, the predictive value of SBP in moderate-degree traumas was not significant as well, similar to GCS for both blunt and penetrant traumas. Regarding SBP and GCS as the subcomponents of RTS, we believe that the decreased predictive ability of the effectiveness of RTS depends on the inability of these two variables in the moderate traumas. Simply, we can say that for these two trauma scores, the higher the ISS, the higher the mortality risk, and the higher the RTS score, the lower the mortality risk. We, too, detected a negative correlation [(−0.423) (p≤0.05)] between the ISS and RTS scores, and this was significant (Table 2). Among our cases, one patient with severe blunt trauma resulted in mortality. The RTS score was also detected to be significantly higher in blunt than in penetrant traumas in univariate analysis, indicating the RTS could be better for blunt trauma victims regarding life chance. However, its statistical significance was lost after multiple linear regression. Even if SBP less than 90 mmHg was important for trauma mortality, in our study, systolic pressure was not predictive for mortality. We believe that this result depends on both patients with higher SBP and higher GCS values, on the basis of our trauma cases. However, because an anatomical scoring system, such as the ISS, is based on anatomy evaluation, we found that the score in penetrating injuries was significantly higher than the RTS value. However, ISS lost its significance with multiple linear regression similar to RTS (Table 3). Circulatory failure may affect respiratory physiology by altering both ventilation control and pulmonary perfusion. An increase in the left ventricular filling pressure (and therefore the pulmonary capillary pressure)—among others—affects pulmonary compliance and alveolocapillary membrane conductivity. These changes increase the respiratory rate.[23] In

Table 3. The results of the univariate and multivariate analyses with multiple logistic regression

Blunt (+)

Penetrant (–)

p≤0.05

ISS 2.45±8.68 6.56±6.47 0.002*

AOR [Exp(B)] (95% CI)

p≤0.05

0.26 (−018, 0.42)

0.432

RTS 7.74±0.79 7.4±0.54

0.001

0.24 (−0.267, 0.509)

0.537

SBP

119±17.14

106.4±16.12

0.002

−0.29 (−0.0012, −0.001)

0.03

RR

16.5±3.54

18.1±3.06

0.095

0.22 (0.001, 0.47)

0.04*

GCS

13.58±1.31

13±1.21

0.023

−015 (−0.163, 0154)

0.96

*

ISS: Injury severity score; RTS: Revised trauma score; SBP: Systolic blood pressure; RR: Respiratory rate; GCS: Glasgow coma scale; CI: Confidence interval. The Mann-Whitney U test results for ISS, RTS, and sub-compounds of RTS trauma scores (SBP, respiratory rates, and GCS), concerning injury characteristics. The results of blunt and penetrant injuries in terms of age with Student’s t-test for independent groups. *Significant final statistical results.

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addition, in a recent study, Barthel et al.[23] stated that the predictive feature of respiratory rate in mortality remains important even in this period when prognostic alternatives increase. Furthermore, Frank has proven pulmonary oedema to be a poor prognostic marker in acute MI.[24] In our study, too, the respiratory rate was significantly higher in penetrant traumas in linear regression results [AOR 0.22 (0.001, 0.47) (p≤0.05)].

Conclusion In summary, the main points include the following: haemothorax, pneumothorax, sail chest, superficial breathing owing to pain, and even back injuries (especially for pneumothorax) should not be overlooked. We believe that both RTS, which is a physiological scoring system, and ISS, which is based on the anatomic scoring systems, cannot predict with higher accuracy for moderate traumatic injuries, especially that traumatic flail chest is a rare consequence of blunt trauma. It usually occurs in the setting of a high-velocity motor vehicle accident, which usually leads to high morbidity and mortality. Any trauma should not be isolated. For example, whenever there is any penetrant chest trauma, we should keep in mind that the flail chest may occur owing to possible blunt trauma. Therefore, only respiratory rates are significant, especially for moderately penetrant injuries. In our next study, we have planned our time table for evaluating the effectivity of both respiratory rates and oxygen saturation in moderate injuries by multicentre prospective studies with the status of the state hospital. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: F.Y.A.; Design: F.Y.A.; Supervision: D.D.; Materials: F.Y.A.; Data: F.Y.A.; Analysis: F.Y.A.; Literature search: D.D.; Writing: D.D.; Critical revision: F.Y.A. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

REFERENCES 1. Roy N, Gerdin M, Schneider E, Kizhakke Veetil DK, Khajanchi M, Kumar V, et al. Validation of international trauma scoring systems in urban trauma centres in India. Injury 2016;47:2459−64. 2. Stevenson M, Segui-Gomez M, Lescohier I, Di Scala C, McDonaldSmith G. An overview of the injury severity score and the new injury severity score. Inj Prev 2001;7:10–3. 3. Association for the Advancement of Automotive Medicine. The abbreviated injury scale. Ilinois, U.S.A: AAAM;1990. 4. Wisner DH. History and current status of trauma scoring systems. Arch Surg 1992;127:111–7.

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5. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187–96. 6. Soni KD, Mahindrakar S, Gupta A, Kumar S, Sagar S, Jhakal A. Comparison of ISS, NISS, and RTS score as predictor of mortality in pediatric fall. Burns Trauma 2017;5:25. 7. Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW Jr, et al. The Major Trauma Outcome Study: establishing national norms for trauma care. J Trauma 1990;30:1356−65. 8. MacKenzie EJ, Shapiro S, Eastham JN Jr. Rating AIS severity using emergency department sheets vs. inpatient charts. J Trauma 1985;25:984–8. 9. Chawda MN, Hildebrand F, Pape HC, Giannoudis PV. Predicting outcome after multiple trauma: which scoring system?. Injury 2004;35:347– 58. 10. Ghag G, Jagdale A. Correlation of PTS, RTS or ISS with length of hospital stay in paediatric trauma patients. JCDR 2018;12:PC05−7. 11. Bickell WH, Stern S. Fluid replacement for hypotensive injury victims: how, when and what risks?. Current Opinion in Anaesthesiology 1998;11:177−80. 12. Bickell WH, Barrett SM, Romine-Jenkins M, Hull SS Jr, Kinasewitz GT. Resuscitation of canine hemorrhagic hypotension with large-volume isotonic crystalloid: impact on lung water, venous admixture, and systemic arterial oxygen saturation. Am J Emerg Med 1994;12:36–42. 13. Branas CC, Sing RF, Davidson SJ. Urban trauma transport of assaulted patients using nonmedical personnel. Acad Emerg Med 1995;2:486–93. 14. Dalton AM. Prehospital intravenous fluid replacement in trauma: an outmoded concept?. J R Soc Med 1995;88:213P–6P. 15. Kaweski SM, Sise MJ, Virgilio RW. The effect of prehospital fluids on survival in trauma patients. J Trauma 1990;30:1215–9. 16. Dula DJ, Wood GC, Rejmer AR, Starr M, Leicht M. Use of prehospital fluids in hypotensive blunt trauma patients. Prehosp Emerg Care 2002;6:417–20. 17. Talving P, Pålstedt J, Riddez L. Prehospital management and fluid resuscitation in hypotensive trauma patients admitted to Karolinska University Hospital in Stockholm. Prehosp Disaster Med 2005;20:228–34. 18. Haut ER, Haider AH, Cotton BA, Stevens KA, Cornwell EE 3rd, Efron DT. Reply to letter: “Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis”. Ann Surg 2014;259:e17–8. 19. Soudry E, Stein M. Prehospital management of uncontrolled bleeding in trauma patients: nearing the light at the end of the tunnel. Isr Med Assoc J 2004;6:485–9. 20. Tan PG, Cincotta M, Clavisi O, Bragge P, Wasiak J, Pattuwage L, et al. Review article: Prehospital fluid management in traumatic brain injury. Emerg Med Australas 2011;23:665−76. 21. Singh A, Ali S, Agarwal A, Srivastava RN. Correlation of shock index and modified shock index with the outcome of adult trauma patients: a prospective study of 9860 patients. N Am J Med Sci 2014;6:450–52. 22. Albuz Ö. Mapping and prediction of organ procurement in cases resulting in mortality due to traumatic injuries: A matched cohort analysis. Ulus Travma Acil Cerrahi Derg 2019;25:361–8. 23. Barthel P, Wensel R, Bauer A, Müller A, Wolf P, Ulm K, et al. Respiratory rate predicts outcome after acute myocardial infarction: a prospective cohort study. Eur Heart J 2013;34:1644−50. 24. Killip T 3rd, Kimball JT. Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients. Am J Cardiol 1967;20:457–64.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Yaralanma ciddiyeti skorları ve revize edilmiş travma skorlarının orta dereceli travmalar için önemi: Bir devlet hastanesi tecrübesi Dr. Feray Yıldırım Aydın,1 Dr. Dilek Dülger2 1 2

29 Mayıs Devlet Hastanesi, Genel Cerrahi Kliniği, Ankara Karabük Üniversitesi Tıp Fakültesi, Mikrobiyoloji Anabilim Dalı, Karabük

AMAÇ: Hasarın derecesi, travmanın ciddiyetinin belirlenmesinde halen güncel ve önemli bir konudur. Bu amaçla dünyada çeşitli travma skorlama sistemleri kullanılmaktadır. Yaralanma şiddeti skoru ve revize travma skorları bunlardan biridir. Bu yazıda, şu anda sıklıkla kullanılan ve bilim tarafından büyük ölçüde olgunlaşan bu iki travma puanlama sisteminin işlevlerini devlet hastanesi düzeyinde değerlendirmeyi amaçladık. GEREÇ VE YÖNTEM: Geriye dönük arşiv taraması ile klinik çalışmalar yürütmek üzere etik kurul onayını takiben; 1 Ocak 2012 ve 31 Aralık 2017 tarihleri arasındaki veriler, 29 Mayıs Devlet Hastanesi’nde travmatik yaralanma tanısı alan tüm hastalarda mortaliteyi etkileyen faktörleri belirlemek amacıyla geriye dönük olarak incelendi. Eksik veya net olmayan veriler çalışmaya alınmadı. Sürekli değişkenler için basit ve standart sapma, ikili değişkenler için yüzde ve frekans değerleri kullanıldı. Sürekli değişkenlerin değerlendirilmesinde, bağımsız gruplarda dağılım durumuna göre Student t-testi veya Mann-Whitney U-testi kullanıldı. İkili değişkenler ki-kare testi ile değerlendirildi. Tek değişkenli analizlerde anlamlı olduğu tespit edilen değişkenler lineer ve ikili lojistik regresyon (LR) modeli ile tekrar değerlendirildi. BULGULAR: Tüm hastaların yaş ortalaması 37.53±14.47 yıldı [erkek (35.68±13.9) – kadın (40.61±15.1) – (p=0.116)]. Genel popülasyon için ortalama yaralanma travma skoru 3.18±8.46 idi. Yaralanma şiddeti skoru (ISS) cinsiyeti ile ilgili farklılık görülmemiştir [(3.93±10.49 ve 1.91±2.34) (p=0.727)]. Yaş ile ilgili olarak, gözden geçirilmiş travma skoru (RTS) için istatistiksel anlamlılık kaydedilmedi [(7.60±0.91’e karşılık 7.81±0.16) (p=0.207)]. Yaralanma mekanizması ile ilgili olarak, iki travma skoru arasında bir fark saptandı; hem ISS hem de RTS’nin istatistiksel önemi vardı. Sonuçlar ISS [penetrant (6.56±6.47) ile künt (2.45±8.68) (p=0.002)] ve RTS [penetrant (7.41±0.54) ile künt (7.74±0.79) (p=0.001)] için bulundu. Lojistik lineer regresyon ile son istatistiklerden sonra, penetran yaralanma için solunum hızı istatistiksel olarak anlamlı idi [AOR 0.22 (0.001, 0.47) (p<0.05)]. RTS skoru bileşenleri için ayrıntılı subanalizde orta dereceli travmalarda solunum hızı da anlamlıydı [AOR 0.22 (0.001, 0.47) (p=0.004)]. TARTIŞMA: Her iki ISS ve RTS de orta dereceli yaralanma tiplerinin hepsinde önemsizdir. Diğer yandan solunum hızı özellikle penetran ve orta dereceli yaralanmalarda önemli bir belirteçtir. Anahtar sözcükler: Devlet hastanesi; orta şiddetli travma; revize travma skoru; yaralanma şiddeti skoru. Ulus Travma Acil Cerrahi Derg 2020;26(2):242-246

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ORIGIN A L A R T IC L E

Ingested foreign bodies in children: Do they really pass spontaneously from the gastrointestinal tract? A single-centre experience with 1000 cases Hasan Özkan Gezer, M.D., Semire Serin Ezer, M.D., Emine İnce, M.D., Akgün Hiçsönmez, M.D.

Abdulkerim Temiz, M.D.,

Department of Pediatric Surgery, Başkent University Faculty of Medicine, Adana-Turkey

ABSTRACT BACKGROUND: Foreign body (FB) ingestion is frequently encountered in all departments that treat children. FB may bring about significant anxiety for parents and physicians. The present study aims to determine the appropriate approach for FB ingestion in children. METHODS: The records of 1000 children with a history of FB ingestion between the years 2005 and 2017 were reviewed retrospectively in this study. RESULTS: Of 1000 children, 53.8% were male. The most common types of FBs were coins (35%). X-ray was negative in 49% of the patients, and 86% of these patients received no intervention. Of the 504 (51%) X-ray-positive patients, the oesophagus (68%) was the most common location. Life-threatening complications were tracheo-oesophageal fistula (1), Meckel’s diverticulum perforation (1), and perforation due to rigid endoscopy (1). CONCLUSION: We demonstrated that coins, which are the most commonly ingested FBs, have various types and sizes according to their countries of origin, and this affects spontaneous passage. We found that only 48% (quite low compared to the literature) of the coins passed spontaneously. In asymptomatic patients with a gastric button battery, we suggest a “watchful waiting” approach. The patients should be observed and managed at home. In our study, we found that 85% of the button batteries that reached the stomach passed spontaneously. Keywords: Battery; coin; foreign body; ingestion.

INTRODUCTION Foreign body (FB) ingestion is a common problem among children, with a peak incidence (up to 75% of the cases) between six months and three years of age.[1–3] The age range of the children and the types of ingested objects are known to vary considerably. Children most frequently swallow coins, toy parts, jewelry or batteries. These patients may have no symptoms, or they may present with severe complications, such as erosions, ulcers or perforations that require emergent medical attention.[3] The majority of ingested FBs (80–90%) passes spontaneously and causes no further harm, symptoms, or a

need for any further intervention. Thus, it is critical to decide whether the patient requires intervention or not.[4–6] Rapid diagnosis and proper management are integral to minimizing any negative outcomes. The indication and timing of interventions are dependent on the type and anatomic location of the FB, as well as the clinical status of the patient.[1] The present study aims to report our experience by presenting patients with suspected foreign body ingestion and reviewing various management options according to the type and location of the foreign body, as determined by a very simple direct X-ray.

Cite this article as: Gezer HÖ, Serin Ezer S, Temiz A, İnce E, Hiçsönmez A. Ingested foreign bodies in children: Do they really pass spontaneously from the gastrointestinal tract? A single-centre experience with 1000 cases. Ulus Travma Acil Cerrahi Derg 2020;26:247-254. Address for correspondence: Hasan Özkan Gezer, M.D. Başkent Üniversitesi Seyhan Adana Hastanesi, Çocuk Cerrahisi Anabilim Dalı, Seyhan, 01120 Adana, Turkey Tel: +90 322 - 458 68 68 E-mail: hozkangezer@yahoo.com.tr Ulus Travma Acil Cerrahi Derg 2020;26(2):247-254 DOI: 10.14744/tjtes.2019.40350 Submitted: 26.06.2019 Accepted: 18.10.2019 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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247

Gezer et al. Ingested foreign bodies in children: Do they really pass spontaneously from the gastrointestinal tract? Suspected foreign body ingestion Radiograph No object

Foreign body in the esophagus Coin

*Symptomatic *Located proximal esophagus Symptomatic Asymptomatic Fallow to decide to Do not intervention anything

Food bolus

Battery

Pointed

Battery

Coin

Hospitalization for 12 hrs; checking symptoms

Asymptomatic

Can wait 6-12 hrs after ingestion

Symptomatic

Passage into the stomach

Remove/ emergent? No

Discharge

Remove

Asymptomatic Discharge 48 hrs obsrvation at home

Remove/ emergent? Remove/ emergent?

Yes

Object distal to 2nd part of the duodenum

Foreign body in the stomach

Symptomatic

Asymptomatic

*Manage patient at home *Check stools *Radiograph if no passage observed 1 week later

Coin/ Blunt

Pointed/ sharp

Observe stools

Radiography every 3 days

Laparotomy if symptomatic or no progress for one week

If not pass the pylorus Remove/ emergent?

Remove

Remove

Figure 1. Management protocol of the suspected foreign body ingestion.

MATERIALS AND METHODS From November 2005 to June 2017, we retrospectively reviewed the medical records of 1000 children under 18 years old admitted to the hospital with reports of swallowing an FB. We assessed the patients’ demographic characteristics (including sex and age), the shape, size and location of the object(s), symptoms, complications, and endoscopic findings when available. All patients were managed according to a strict protocol, as shown in Figure 1. In all patients, within the first hour of admission, X-rays of the neck, chest and abdomen were obtained to determine the location of the FB, regardless of the ingestion time and clinical symptoms. If the patient was symptomatic and/or the FB was considered unsafe, they were hospitalized for intervention using a Foley catheter, McGill forceps, or flexible endoscopy by an experienced pediatric surgeon. The Foley catheter was used to “sweep out” coins lodged in the upper oesophagus while the patient was maintained in the Trendelenburg or lateral decubitus position at the emergency clinic, without any sedation or fluoroscopic guidance, by experienced pediatric surgeons. Only three attempts were made to remove the FB; if unsuccessful, no further attempts were made. Additional devices used to remove the FB included a retrieval net basket, snares, rat-toothed and biopsy forceps, and a Roth Net (US Endoscopy Inc., Mentor, OH, USA). After FB removal with endoscopy, a follow-up endoscopy was performed. Aiming to liquefy the oesophageal contents, patients with a food bolus impaction were asked to drink 100 mL of a carbonated beverage (e.g., Coca-Cola or soda water) every 6 h, in small sips, and always in a sitting position.[1] 248

Statistical analysis was performed using the Statistical Package Program for the Social Sciences 23.0 (SPSS Inc.). Categorical measurements were presented as number and percentage, and continuous measurements were summarised as mean and standard deviation (median and minimum-maximum where needed). This study was conducted in accordance with the Declaration of Helsinki and was approved by the institutional review board of the University Faculty of Medicine.

RESULTS During the study period, 1000 children (538 boys and 462 girls) under the suspicion of swallowing foreign bodies were included in this study. The mean age of all patients with suspected FB ingestion was 3.88 years (range, 1 month to 17.5 years), and the mean age of the patients with proven FB ingestion was three years (range, 1 month to 17.2 years). The time until admission to hospital was under 4 h in 69% of the patients and longer than one week in 5% (range, 12 min to 180 days; median, 1 h). Ninety (0.9%) patients had come from another city (distance range, 99–1170 km). Thirteen patients who were asymptomatic with no FB detected by X-ray had been referred to us from other cities, with a median distance of 384 km (range, 100–1200 km) from our city. These patients were discharged at the same night with no planned intervention, treatment or further clinical follow-up. Patients were divided into five groups according to their ages and FB ingested (Table 1). Many kinds of FBs (over 100) were ingested, such as a ball (glass), stone, bead, pen cap, glass fragment, button, buckle, nail, PEG catheter head, piece of meat, tooth and spoon (Fig. 2). The most common types of FBs, identified radiographically or endoscopically were coins (35%), BBs (19.5%) and pins (12%); blue beads attached to an open or closed safety pin, cultural pins, good luck charm pins and turban pins. Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Gezer et al. Ingested foreign bodies in children: Do they really pass spontaneously from the gastrointestinal tract?

Table 1. Ingested FBs according to age and sex

Age group

Coin

0–1 1–4 5–9 10–14 ≥15 Totally

Female Male Female Male Female Male Female Male Female Male 2 3 39 62 35 29 1 4 – 1 176

Battery 3 3 35 33 7 17 – – – – 98 Safetypin 10 11 3 7 1 – – – – – 32 Turban pin 4 3 2 2 3 2 9 4 1 30 Others 11 2 30 59 28 15 8 5 6 4 168 Others: 0–1: charm, meat, fishbone, plastic object, pouch, buckle, earring, nail, spoon, seashell, magnet; 1–4: Padlock, bracelet, bead, glass fracture, walnut, laundry latch bow, flower leaf, nail, piece of iron, whistle, button, piece of meat, thread, fishbone, plastic object, earring, mascot, drill bit, bullet, magnet, corn, badge, metal object, jewelry, stone, wire, buckle, screw, bow, ring, staples; 5–9: Blush, ball (glass), stone, bead, pen cap, glass fracture, button, buckle, nail, PEG catheter head, piece of meat, tooth, pepper gas capsule, fishbone, pendant, ring , plum kernel, metal button, magnet, plastic object, badge, clock, lighter stone, stone, chicken piece, wire buckle, screw, staple, foreign material; 10–14: paper clips (open), meat piece, pen tip, bulb, magnet, PEG catheter cap, buckle; 15–16: wire buckle, meat piece, fishbone, spoon.

The most common symptoms were vomiting, dysphagia, sore throat and abdominal pain observed in 12%, 8%, 3.6% and 4.8% of the patients, respectively. An X-ray examination was performed on all 1000 children admitted. Direct radiography was sufficient for diagnosis in 947 patients. Barium gastrointestinal radiography was used in patients either to demonstrate obstruction related to the FB (n=16) or distinguish the location stomach or colon (n=20). In 496 (49%) of the patients, the FBs were not evident in direct radiography. Of these, 379 (76%) patients were asymptomatic and no other interventions or clinical follow-up were planned. However, 73 of the remaining 120 patients underwent endoscopy due to a suspected FB ingestion and the presence of symptoms upon admission or during the follow-up period, and/ or due to findings on the physical examination. The FB was removed in six patients (0.05%), with removal of a button (n=2), bezoar (n=1), piece of food (n=2) and piece of a bag (n=1). In 504 (51%) patients, the FBs were observed via direct radiography.

(a)

(b)

(c)

Figure 2. 10-year-old girl ingested spoon (a) x-ray scan (b) endoscopic view (c) removed by laparotomy because endoscopy failed.

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Coins Of 176 children, FBs were in the oesophagus (n=56), stomach (n=78), small intestine (n=21) and colon (n=21). Treatment of the patients with coin ingestion is detailed in Figure 3. In one patient, admitted after six months, laparotomy and gastrostomy were needed because endoscopic removal was unsuccessful. Finally, in this study, only 48% of the ingested coins were able to pass spontaneously. Mild mucosal erosion (n=2) and oesophageal perforation (n=1) were seen. A 1.5-year-old boy was referred from another hospital due to perforation. We had learned from his history that a rigid endoscopy was performed within 4 h to retrieve the coin, which was in the distal oesophagus. However, the oesophagus was perforated during the procedure, and the coin could not be retrieved. After hospitalizing the patient in our facility, emergent endoscopy with removal of the FB was performed, and the patient was treated medically without operation during the 6-week postoperative period.

Button Batteries Seventy-six per cent of these patients were under four years of age. In 9% of the patients (9 of 98), the BB was in the oesophagus, and an emergent (within 2 h) endoscopy was performed. Variable grade corrosive esophageal burn complication was observed in all patients except two, whose admission time was shorter (≤2 h) (Fig 4). Treatment of the patients with battery ingestion is detailed in Figure 5. Serious BB-related complications were detected in 10% of the patients, which included tracheo-oesophageal fistula (TEF; n=1), Meckel’s diverticulum perforation (n=1) and corrosive burn (at the battery location, i.e. oesophagus, stomach) (n=8). A 1.7-year-old girl presented with TEF 25 days after ingestion. She had been admitted to many hospitals, but FB ingestion had not been considered, delaying the diagnosis. After removing the foreign body, she was treated medically for six months. The other serious complication, a Meckel’s diver249

Gezer et al. Ingested foreign bodies in children: Do they really pass spontaneously from the gastrointestinal tract?

Coins (n=176)

Oesophagus (32%) (n=56)

Asymptomatic (55%) (n=31) *median age 4 y Fail to pass spontaneously after 6–12

Stomach (44%) (n=78)

Symptomatic (45%) (n=25) *median age 3.2 y

Located proximal oesophagus

Removed (n=29)

Asymptomatic (88%) (n=69) *median age 3.4 y

59% (n=41) had passed spontaneously Removed emergent (n=25)

Distal to the 2nd part of the duodenum (23%) (n=42) Symptomatic (12%) (n=9) *median age 2.8 y

41% (n=28) Remove Due to delayed admission time (more than one month)

*median age 3.9 y Remove

Foley catheter (48%) (n=26) Endoscopy (52%) (n=28)

Endoscopy (n=36) Laparotomy/gastrostomy (n=1)

96% of the coins, located oesophagus, were removed

47% of the coins, located stomach, were removed

All of them passed spontaneously

48% of all ingested coins could be able to pass spontaneously Figure 3. Treatment of the coin ingested patients.

(a)

(b)

Foods Seventeen kinds of food, including fish/chicken bones (n=13), fruit seeds (n=11) and meat (n=11), had become lodged in the oesophagus of 15% of the patients in our study. We prefer the endoscopic “push technique” with air insufflations for all.

Figure 4. Endoscopic view of the corrosive esophageal burn (a) grade 3b: Extensive necrosis (b) grade 2b: Deep focal or peripheral ulceration.

ticulum perforation, occurred in a 1-year-old boy whose admission X-ray showed the FB located beyond the duodenum. He was discharged and recalled 48 h later but was admitted to hospital with abdominal pain after 36 h. He was treated with laparotomy and discharged seven days later. Finally, 76% (75/98) of the ingested batteries were spontaneously and uneventfully eliminated from the gastrointestinal tract.

Safety pins with blue beads and turban pins Sixty children ingested one of these, and 65% were under one year old. An intervention was performed in 28/60 (47%); this included endoscopy (n=26), McGill forceps (n=1) and laparotomy (n=1). Finally, 53% (32/60) of all swallowed pins were uneventfully passed through the gastrointestinal tract. 250

Of the 504 patients with ingested FBs, 223 (44%) underwent an intervention, such as the Foley catheter (n=27), McGill forceps (n=27), endoscopy (n=162) or laparotomy (n=7). Interventions in 24% of the patients were performed without any anaesthesia in the emergency room, and there were no complications. In one patient who had ingested a BB, laparotomy was performed due to a Meckel’s diverticulum perforation resulting from tissue necrosis. In four patients, the FB was in the stomach, and laparotomy was conducted to remove the FB following the failure of endoscopic attempts at removal. The characteristics of the other patients are presented in Table 2.

DISCUSSION FB ingestion is still a common health problem in the paediatric population. Most ingestions result in only a minor discomfort. [7] It has been reported that 80% or more of FBs could pass without the need for any intervention in the pre-endoscopic series in the literature.[6] However, according to our criteria, we found percentages that were quite low compared to those in the literature (56% for all ingested FBs, 48% for coins and 77% for button batteries). Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Gezer et al. Ingested foreign bodies in children: Do they really pass spontaneously from the gastrointestinal tract?

Batteries (n=98)

Oesophagus (9%) (n=9)

Stomach (57%) (n=56)

Asymptomatic (84%) (n=47) *median age 2.8 y

92% had passed spontaneously

*median age 2.3 y

Distal to 2nd part of the duodenum (35%) (n=33)

Symptomatic (16%) (n=9) *median age 1.4 y

Removed (8%) (n=4) After 24–48 hrs due to not passing the stomach

Removed emergent

Remove

* median age 2.9 y 97% had passed spontaneously One operated due to meckel diverticulum perforation

Endoscopy (n=12) Laparotomy/gastrostomy (n=1) 23% of the batteries, located stomach, were removed

77% of all ingested batteries could be able to pass spontaneously Figure 5. Treatment of the Button Battery ingested patients.

In the management of the FBs, radiographic identification and localisation should be the initial steps.[8] The plain radiograph still appears to be the best method. Additionally, the plain radiograph helps to distinguish the BB from the coin by demonstrating the double halo sign on anteroposterior views and the “step off” sign on lateral views.[9] It is also able to identify complications, such as free air and lung aspiration.[8] However, if the patient is unable to provide a satisfactory history, and X-ray studies are negative, then, other diagnostic modalities, such as computed tomography (CT) scanning, contrast examination, handle metal detector (HMD) and diagnostic endoscopy, may be used. Although it has been reported that CT scans without contrast are able to identify FBs in 80% to 100% of cases,[5] there are no paediatric studies.[6] A contrast examination should not be performed routinely in the patient with suspected proximal oesophageal obstruction, because of

the risk of bronchoaspiration, which may cause severe chemical pneumonitis. Contrast examination should never be used if perforation is suspected.[6] We have not utilised HMD yet, but it has gained popularity in recent years. It has been used for the diagnosis and follow-up of metallic coin FBs only, and it has clear limitations reported: it is not suitable for coins with a depth >7 cm from the skin or a low amount of metal. [10,11] Therefore, it can be used only when the parents know that a coin or a coin-like metallic FB was ingested.[12] In the present study, of the 1000 children admitted, an X-ray examination was performed for all patients and was sufficient for diagnosis in 947 patients. Sixty percent of symptomatic patients with a negative X-ray underwent endoscopy for diagnosis, instead of the preferred CT imaging, and 0.05% required FB removal. Thus, in parallel with the literature, we suggest that an endoscopic evaluation should be performed

Table 2. Patients underwent laparotomy Age group/sex FB Admission time after ingestion(hour) 10–14/ F

Two pins

Localization

Symptom

Laparotomy indication

725

Small intestine

–

Not relocated

1–4/F

Battery

50

Small intestine

Abdominal pain

Meckel diverticulum perforation

1–4/F

Coin

174

Stomach

–

Endoscopic removal failed

1–4/M

Battery

52

Stomach

–

Endoscopic removal failed

Coin

168

Stomach

–

Endoscopic removal failed

10–14/F

Bezoar

179

Stomach

Abdominal pain

Endoscopic removal failed

15–18/F

Desert spoon

7

Stomach

–

Endoscopic removal failed

10–14/F

F: Female; M: Male; FB: Foreign body.

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Gezer et al. Ingested foreign bodies in children: Do they really pass spontaneously from the gastrointestinal tract?

in patients with typical clinical presentations or with a strong suspicion of FB ingestion, even if the radiographic findings are normal.[8] The incidence of FB ingestion and the types of FBs, vary according to the geographic region, culture and patient’s age. In the paediatric population, coins are the most common ingested FBs (89%).[1] In this study, the most common types of FBs were coins (35%), batteries (19.5%) and pins (12%). In the oesophagus, the most common area of lodgment is at the cricopharyngeus muscle; many authors have generally confirmed that most of these need emergent removal.[1,7] However, there is no consensus concerning objects that have reached the stomach. The decision to remove them depends on many factors, including the patient’s age and clinical condition, the size, shape and type of the foreign body, and the technical skill of the endoscopist.[1]

Coins It is suggested that asymptomatic patients with oesophageal coins can be followed because the coin has a 30% to 60% chance of reaching the stomach spontaneously.[6,13,14] Additionally, waiting for 2–4 weeks was suggested in asymptomatic patients with gastric coins, despite there is no specific study in the paediatric patients.[9] However, for the reasons that we listed below, we consider that this period should be one week for the coin in the stomach: 1- During the followup period, parents are instructed to monitor the stools for passage of the coin and serial x-rays are needed until clearance can be documented. The undesirable effects of observation are increased family anxiety and exposure of children to radiation.[9] 2- Although it is not considered as important as its location and the patient’s age in the literature, the size of the coins is ≥2.5 cm in diameter in our country (“1 TL”, diameter 2.615 cm, thickness 1.95 mm).[13] Our study supports a contrary opinion based on the spontaneous coin passage rates, which were lower for both the oesophagus (4%) and the stomach (53%) locations. We attributed this to the age of the patients, most of whom were under four years old and to the size of coins in our country. Besides, in some studies reported in parallel to our study, the findings showed that coins >23.5 mm, such as the American and Canadian quarters (24 mm), especially affect children under five years of age.[10] 3- Our high experience in endoscopy. We consider that it is a trouble-free procedure by an experienced specialist and takes about 15 minutes under sedation anaesthesia. 4- We observed in 29% of the asymptomatic patients with gastric coins that the coins did not pass spontaneously after one month (literature’ maximum time limit). Finally, we prefer endoscopic removing of the coin one week later after ingestion. In our study, coin-related complications were seen in three patients as follows: mild mucosal erosion (n=2) and oesophageal perforation (n=1). The perforation was due to a rigid endoscopy performed at another hospital. 252

Batteries One in every 1000 BB ingestion causes serious injury.[7] “External circuit effect due to hydrolysis of tissue fluids” is the most recently identified and popular injury mechanism for BB ingestion.[7,15] Animal models have documented that necrosis within the oesophageal lamina propria may begin as soon as 15 minutes from the time of ingestion, with extension to the outer muscular layer within 30 minutes.[9] Delayed diagnosis is associated with serious complications, such as TEF, oesophageal perforation and oesophageal stricture. As a result, in the cases of delayed treatment, TEF or oesophageal perforation should be ruled out before beginning oral feeding.[16,17] For the presence of a BB in the stomach, the choice between a “watchful waiting” approach or an urgent endoscopic retrieval can pose a dilemma.[18] After the BB passes the pylorus, the risk of splitting decreases.[1] Some authors have suggested that patients younger than six years should be managed at home, with an X-ray to confirm passage in four days,[15] but others have suggested that a BB of diameter ≥2 cm should be removed in younger (under four years) children.[6] Our strategy includes hospitalization of all patients for the first 12 hours for observation. If the patient is asymptomatic and the BB is in the stomach, he or she is managed at home, with a follow-up X-ray in two days to confirm passage. If the BB has failed to pass into the intestine during that time, the child undergoes endoscopic removal. If it has passed the pylorus, the patient is managed at home again until elimination, with an X-ray to confirm passage in 2–4 days. The spontaneous passage should occur in 77% of gastric BBs and in 76% of all ingested BBs. Complications, such as a tracheo-oesophageal fistula in a patient examined 25 days after ingestion, were correlated with delayed admission. One patient with a BB located beyond the duodenum suffered a perforation of the Meckel’s diverticulum, whereas in 97%, the BB passed spontaneously and uneventfully. Finally, in our study, we found that if the BB had passed through the oesophagus and reached the stomach, 76/89 (85%) passed spontaneously and uneventfully through the gastrointestinal tract. Table 3. Timing of the endoscopic removal of the foreign bodies Emergent (immediate)

• Esophageal obstruction

• Battery in the esophagus

• Sharp-pointed objects in the esophagus

Urgent (within 24 hours)

• Esophageal objects that are not sharp and pointed

• Esophageal food impaction without complete obstruction

• Objects ≥6 cm at or above the duodenum

• Magnets within endoscopic reach

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Gezer et al. Ingested foreign bodies in children: Do they really pass spontaneously from the gastrointestinal tract?

Pins Due to unique regional and cultural differences, pins were the third most commonly swallowed FB. In our country, it is widely believed that a blue bead, typically attached to a baby’s clothing with a safety pin, protects small children from evil. Babies may swallow the blue beads with or without the safety pin. Additionally, turban pin ingestion was seen at every age due to either the patients or their parents covering their heads.[19] In our study, an endoscopy was performed in 71% (23/32) of the patients who ingested an open safety pin. This intervention was also performed for turban pins, although at a lower rate of 20%, as the patients were older, and the FBs passed spontaneously. Finally, 53% (32/60) of the pins that had reached the stomach was able to spontaneously pass through the gastrointestinal tract. There have been several methods described in the literature for removing an FB from the oesophagus, including McGill forceps, rigid and flexible oesophagoscopy, Foley catheters, oesophageal bougienage and open surgery.[20] Endoscopy is predominantly used as a surgical technique, and a Foley catheter is mostly preferred as a non-surgical technique, in which a deflated catheter is passed beyond the FB, inflated and removed under fluoroscopy.[1] However, we know that Foley catheter effectiveness is greatly operator-dependent, and this has led to concerns about perforation, aspiration and acute airway obstruction if performed incorrectly. In our study, there were no complications concerning Foley catheter use. Additionally, when we have the slightest suspicion that a FB can be a BB, we do not use the Foley catheter. Endoscopic removal is suggested for gastric FBs if they are sharp, long (≥4–5 cm for infants and young children, ≥6–10 cm for older children), or wide (≥2 cm in diameter for infants and young children, ≥2.5 cm in diameter for older children). Additionally, if the patient has a larger BB (≥2 cm), a BB which has remained in the stomach for over 48 hours, multiple magnets, or gastric retention of any objects for more than 3–4 weeks, endoscopic removal is also recommended.[3] The timing of the intervention was divided into three groups: emergent, urgent, and non-urgent.[8] Patients with proximal oesophageal obstruction and patients who have ingested BBs or long and sharp-pointed objects need emergent (immediate) intervention,[5] as presented in Table 3. The main limitations of our study are the differences in the incidence and types of FBs based on the geographic region, culture and age of the patients, in addition to the retrospective nature of this study.

Conclusion

At presentation, the physician can use a simple X-ray to determine the type and location of the ingested FB, and whether the patient requires immediate endoscopic intervention or can simply be observed on an outpatient basis. In our study, we clearly demonstrated two principles as follows. First, coins—the most commonly ingested FBs—have various Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

types and sizes according to their countries of origin, and we believe that the type and size of the coin and the patient’s age are more important for the spontaneous passage from the gastrointestinal tract. In our study, only 48% of all ingested coins passed spontaneously. Second, for a BB located in the stomach, we suggest a “watchful waiting” approach rather than an endoscopic retrieval. These patients should be observed and managed at home, with an X-ray to confirm passage two days after ingestion. In our study, we found that when BBs had passed through the oesophagus and reached the stomach, 85% passed spontaneously and uneventfully through the gastrointestinal tract. Ethics Committee Approval: The study protocol was approved by the Başkent University Faculty of Medicine Ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: H.Ö.G.; Design: H.Ö.G.; Supervision: S.S.E.; Fundings: E.İ.; Materials: H.Ö.G.; Data: E.İ.; Analysis: A.T.; Literature search: H.Ö.G.; Writing: H.Ö.G.; Critical revision: A.H. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

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Gezer et al. Ingested foreign bodies in children: Do they really pass spontaneously from the gastrointestinal tract? bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr 2015;60:562−74. 10. Nation J, Jiang W. The utility of a handheld metal detector in detection and localization of pediatric metallic foreign body ingestion. Int J Pediatr Otorhinolaryngol 2017;92:1–6. 11. Aljasser A, Elmaraghy CA, Jatana KR. Utilization of a handheld metal detector protocol to reduce radiation exposure in pediatric patients with esophageal coins. Int J Pediatr Otorhinolaryngol 2018;112:104–8. 12. Hamzah HB, James V, Manickam S, Ganapathy S. Handheld Metal Detector for Metallic Foreign Body Ingestion in Pediatric Emergency. Indian J Pediatr 2018;85:618–24. 13. Waltzman ML, Baskin M, Wypij D, Mooney D, Jones D, Fleisher G. A randomized clinical trial of the management of esophageal coins in children. Pediatrics 2005;116:614–19. 14. Caravati EM, Bennett DL, McElwee NE. Pediatric coin ingestion. A prospective study on the utility of routine roentgenograms. Am J Dis Child 1989;143:549–51.

15. Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics 2010;125:1168– 77. 16. Yalçin S, Karnak I, Ciftci AO, Senocak ME, Tanyel FC, Büyükpamukçu N. Foreign body ingestion in children: an analysis of pediatric surgical practice. Pediatr Surg Int 2007;23:755–61. 17. Kimball SJ, Park AH, Rollins MD 2nd, Grimmer JF, Muntz H. A review of esophageal disc battery ingestions and a protocol for management. Arch Otolaryngol Head Neck Surg 2010;136:866–71. 18. Lin CH, Chen AC, Tsai JD, Wei SH, Hsueh KC, Lin WC. Endoscopic removal of foreign bodies in children. Kaohsiung J Med Sci 2007;23:447–52. 19. Aydoğdu S, Arikan C, Cakir M, Baran M, Yüksekkaya HA, Saz UE, et al. Foreign body ingestion in Turkish children. Turk J Pediatr 2009;51:127−32. 20. Jayachandra S, Eslick GD. A systematic review of paediatric foreign body ingestion: presentation, complications, and management. Int J Pediatr Otorhinolaryngol 2013;77:311–7.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Çocuklarda yutulan yabancı cisimler: Gerçekten gastrointestinal sistemden kendiliğinden geçiyorlar mı? 1000 olgu ile tek merkezli deneyim Dr. Hasan Özkan Gezer, Dr. Semire Serin Ezer, Dr. Abdulkerim Temiz, Dr. Emine İnce, Dr. Akgün Hiçsönmez Başkent Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Adana

AMAÇ: Yabancı cisim (YC) yutulması, çocukları tedavi eden tüm kliniklerde sıkça karşılaşılan bir durumdur. Ebeveynler ve doktorlar için önemli kaygılara neden olmaktadır. Amacımız YC yutan çocuklarda en uygun yaklaşımı belirlemekti. GEREÇ VE YÖNTEM: 2005–2017 yılları arasında YC yutulması ile başvuran 1000 çocuğun kayıtları geriye dönük olarak incelendi. BULGULAR: Bin çocuğun %53.8’i erkekti. En sık görülen YC tipi madeni paraydı (%35). Hastaların %49’unda direkt grafide YC görülmedi ve bu hastaların %86’sına herhangi bir müdahale yapılmadı. Beş yüz dört (%51) X-ray pozitif olan hastada, özofagus (%68) en yaygın yerleşim yeriydi. Hayatı tehdit eden komplikasyonlar trakeoözofageal fistül (1), Meckel divertikül perforasyonu (1) ve rijit endoskopiye bağlı perforasyon (1) idi. TARTIŞMA: En fazla yutulan YC’lerden olan madeni paranın şekil ve büyüklüklerinin ülkelere göre değiştiğini ortaya koyduk ve bunun da kendiliğinden geçiş sonuçlarımızı etkilediğini gördük. Madeni paranın kendiliğinden gastrointestinal sistemi terk etme oranını literatüre göre oldukça düşük, %48 olarak bulduk. Düğme (saat) pili yutup midesine geçmiş, semptomsuz hastalarda ise, “acil endoskopik çıkarım” değil, “dikkatli/yakın takip” yaklaşımı öneriyoruz. Hastalar evde izlenmeli ve yönetilmelidir. Çalışmamızda, pilin mideye ulaşması durumunda, %85’inin gastrointestinal sistemden kendiliğinden ve sorunsuzca geçtiğini belirledik. Anahtar sözcükler: Madeni para; pil; yabancı cisim; yutma. Ulus Travma Acil Cerrahi Derg 2020;26(2):247-254

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Reversal of Hartmann’s procedure is still a high-morbid surgery? Ozan Akıncı, M.D.,1 Müge Yurdacan, M.D.,2 Başar Can Turgut, M.D.,2 Server Sezgin Uludağ, M.D.,2 Osman Şimşek, M.D.2 1

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

2

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

ABSTRACT BACKGROUND: This study evaluated the outcome of the reversal of Hartmann’s procedure based on preoperative and intraoperative risk factors. METHODS: We retrospectively reviewed 78 cases, whom we applied the Hartmann’s procedure either electively or under emergency conditions in our clinic between the years 2010 and 2016. RESULTS: Of the cases reviewed in this study, 45 patients were males, and 33 patients were females. Of all cases included in this study, 32 cases were operated due to malignancies, 15 cases were operated due to a perforated diverticulum, and 11 cases were operated due to sigmoid volvulus. Reversal of Hartmann’s was performed in 32 cases. The morbidity and mortality rates for the reversal of Hartmann’s procedure were 37.5% and 0.0%, respectively. CONCLUSION: The reversal of Hartmann’s procedure appears to be a safe operation with acceptable morbidity rates. If the correct patient selection, correct operation timing and meticulous surgical preparation are performed, the risk of morbidity and mortality of the reversal of Hartmann’s procedure can be minimized. Keywords: Hartmann’s procedure; morbidity; mortality; the reversal of Hartmann.

INTRODUCTION The Hartmann’s procedure was first described in 1923 by French surgeon Henry Hartmann as an alternative technique to abdominoperineal resections in left colon cancers and in high-risk cases.[1] Being developed to reduce the mortality associated with anastomotic leakages, this technique can be applied in a wide variety of indications today, including perforated diverticulitis, ischemic colitis, colonic obstructions, traumatic perforations, volvulus, inflammatory colitis, and anastomotic leakages.[2] The use of new and broad-spectrum antibiotics over time and the preoperative colon cleansing have resulted in the completion of operations with primary anastomosis.[3] Although the use of single-stage procedures for surgical cases with complications, such as diverticulitis and malignancy is

more prevalent today, the Hartmann’s procedure is still important because of the technical difficulties of single-stage methods, severe peritonitis, and hemodynamic instability. Reversal of Hartmann’s procedure requires a major abdominal surgical approach with a morbidity risk of 16–54%.[4–7] In addition, 28%–81% of the cases continue to live with a permanent stoma due to the failure of the second-stage operation or due to not being allowed to undergo a second stage operation at all.[4,8–10] In this study, we aimed to investigate the following parameters, including the operative indications, intraoperative and postoperative complications, the duration of the operations, the risks of morbidity and mortality due to 1st and 2nd-stage

Cite this article as: Akıncı O, Yurdacan M, Turgut BC, Uludağ SS, Şimşek O. Reversal of Hartmann’s procedure is still a high-morbid surgery?. Ulus Travma Acil Cerrahi Derg 2020;26:255-259. Address for correspondence: Ozan Akıncı, M.D. Hakkari Devlet Hastanesi, Genel Cerrahi Kliniği, Hakkari, Turkey Tel: +90 438 - 211 60 57 E-mail: ozanakinci1987@hotmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):255-259 DOI: 10.14744/tjtes.2019.71725 Submitted: 05.04.2019 Accepted: 21.05.2019 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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operations, as well as evaluating the outcomes of our surgical practices in the individuals who underwent the Hartmann’s procedure between the years 2010–2016 in our clinic.

MATERIALS AND METHODS Seventy-eight patients who underwent Hartmann’s procedure in our clinic between January 2010 and January 2016 were studied retrospectively. Patient information was obtained using the hospital discharge reports, surgery reports and pathology reports. We did not apply for an ethics committee because the study was retrospective. Resection of the sigmoid colon or rectum, closure of the distal segment, and end colostomy of the proximal segment were referred as the “Hartmann’s procedure” and “first-stage operation”; whereas the “reversal of Hartmann’s procedure” and “second-stage operation” terms were used to refer to the closure of an ostomy. The cases were evaluated concerning age, gender, comorbidities, operative indications, intraoperative and postoperative complications, the interval between the Hartmann and the reversal of Hartmann’s procedures, duration of the hospital stay, postoperative morbidity and mortality rates (mortality due to any reason within the first 30 days after surgery), and the anastomosis techniques of the reversal of Hartmann’s procedure.

Table 1. Demographic characteristics of the patients (n=78) Demographic characteristics

n

%

Male

45

58

Female

33

42

<30

3

3.8

31–40

0

0

41–50

9

11.5

51–60

20 25.6

61–70

20 25.6

71–80

18

23

>80

8

10.2

1

9

11.5

2

42 53.8

3

27 34.6

Sex

Age (years)

American Society of Anesthesiologists

Table 2. The primary indications requiring the Hartmann procedure (n=78) Indications

n %

RESULTS

Rectosigmoid cancer

32

41

Diverticulum perforation

15

19.2

Hartmann’s procedure was performed due to various indications in a total of 78 patients during six years. Of all cases, 33 cases were females and 45 were males. The mean age was 63 (25–86) and 50 (64%) cases were over 60 years old. Comorbid diseases were present in 56 of the patients. The three most common comorbidities were hypertension (38%), diabetes mellitus (23%), and ischemic heart disease (17%). According to the American Society of Anesthesiologists (ASA) classification, the majority of cases were in the ASA 2 or ASA 3 category (Table 1).

Sigmoid volvulus

11

14.1

Anastomotic leakage

5

6.4

Iatrogenic trauma

5

6.4

Ischemic colitis

3

3.8

Colovesical fistula

3

3.8

Stricture

2 2.5

Gunshot wound

1

1.2

Rectovaginal fistula

1

1.2

Hartmann’s procedure was most common (n=32, 41%) in the patients with tumors of the rectosigmoid region. Of these, 21 (27%) were operated due to tumor-associated obstruction and 11 (14%) were operated due to a tumor-induced perforation. Other indications requiring the Hartmann’s procedure are shown in Table 2. The mean duration of the first stage operation was 155 minutes and the mean duration of the second stage operation was 185 minutes. The average duration of hospital stay after the first stage operation was 17 days and it was 12 days after the second stage operation. Intraoperative complications developed in nine (11.5%) cases during the first stage operation (Table 3). In 32 cases (41%), 256

various surgical and medical postoperative complications were observed (Table 3). The most common of these complications was intraabdominal abscess formation or collections (n=17). Other postoperative complications associated with the first stage operation are shown in Table 3. There was more than one complication in some of the cases. Mortality occurred in 11 patients (14%) associated with the first-stage operation. The interval between the first-stage operation and the reversal of Hartmann was 185 days on the average. Of the 67 (86%) patients who survived the Hartmann’s procedure, 32 (41%) patients underwent a restorative colorectal anastomosis. The reversal of Hartmann’s procedure could not be performed in 35 cases. Of these cases, the second-stage operation could Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Akıncı et al. Reversal of Hartmann’s procedure is still a high-morbid surgery?

Table 3. Intraoperative and postoperative complications associated with the first stage operation Complication type

n

%

Intraoperative (n=9)

Intestinal injury

4

5.1

Splenic injury

3

3.8

Colonic injury

1

1.2

1

1.2

Hemorrhage

Postoperative (n=32)

Intraabdominal abscess

17

21.7

Pulmonary infection

5

6.5

Wound infection

4

5.1

Ileus

4

5.1

Urinary tract infection

4

5.1

Pulmonary embolism

2

2.5

Organ evisceration

1

1.2

Stomal necrosis

1

1.2

not be performed because 16 patients had comorbidities and they were at higher categories of ASA, eight patients withdrew their consents to undergo the second stage of operation, seven patients developed a recurrence of malignancy, and four patients were lost to follow-up surgery. The 30-day postoperative morbidity was 37.5% and the incidence of 30day mortality was 0.0%. In the second-stage operation, stapled or manual anastomoses were created in 26 and six patients, respectively. After the second stage operation, postoperative complications were observed in a total of 12 cases, including wound infections in five cases, strictures of the anastomoses in three cases, anastomosis leakages in two cases, and intraabdominal abscesses in two cases. Three patients with anastomotic strictures were successfully treated with colonoscopic balloon dilatation. In five cases developing anastomotic strictures and anastomotic leakages, it was observed that those anastomoses were created using a stapler.

DISCUSSION Although primary anastomotic resection procedures have become popular to treat the pathological lesions of the left colon in recent years, many surgeons prefer multi-stage procedures in cases with diffuse peritonitis, sepsis, and severe obstructions. Resolution of sepsis and developing a surgical strategy for damage control in the first operation is more important for survival compared to the maintenance of intestinal integrity. The restoration of gastrointestinal integrity depends on many factors, including the willingness of the patient, local factors, patient’s condition, estimated duration of survival, and the experience of the surgeon. Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

When the indications of the Hartmann’s procedure are examined, non-neoplastic etiologies are common in western societies. However, neoplastic etiologies predominate in Asian communities.[4] In the literature, it has been reported that the rates of the reversal of Hartmann’s procedure range from four to 85%, consisting mainly of benign pathologies. [6,11–15] We should note that 86% of our cases survived after undergoing the Hartmann’s procedure, but only 47% of them were able to undergo a restorative colorectal anastomosis. As mentioned above, the reasons for this include the unsuitability of the patient condition to undergo a second stage operation, the recurrence of malignancies, and the withdrawal of consent by the patients to undergo the operation. In our study, the patients who underwent the reversal of Hartmann’s procedure had been operated because of a perforation of a diverticulum in 40% of the cases (n=13) and due to malignancies in 37.5% of the cases (n=12). Of the 32 patients operated with indications associated with malignancies, only 12 cases were able to undergo the second-stage operation. Because the patients with malignant lesions present with a limited duration for survival, only a minority of them survive long enough after Hartmann’s procedure to be able to undergo an intervention for stoma closure. It should also be remembered that the emotional disturbances developing in patients with cancer after the first operations may represent another factor contributing to their refusal of the secondstage surgery. There is no consensus on the timing of the reversal of Hartmann’s procedure in the literature. Pearce et al.[16] reported that the most important factor in determining the morbidity and mortality occurring after the reversal of Hartmann’s procedure was the accurate timing. They added that it would be appropriate to perform the colostomy closure procedure at the end of the 6th month. In the study performed by Tan et al.,[4] the mean duration of the interval between the two stages of operation was found to be 23 weeks. However, it was reported that the timing of the operation was not associated with morbidity or mortality. On the other hand, 17. Geoghegan and Rosenberg[17] stated that the rate of complications was lower if the reversal procedure was performed within the first month. In our study, the mean period between the two surgical procedures was 185 days on average and this is an acceptable period of time compared to the literature. In our study, the average duration of the second stage operations was 185 minutes, which is compatible with the reports in the literature.[4,18] We suggest that the main factor affecting the duration of the second stage operation is the development of adhesions due to the first surgical intervention or due to the radiotherapy given to the malignant cases. The presence of intense adhesions and fibrotic tissues observed in the cases developing complications, especially after the firststage operation, makes the dissection more challenging and leads to the extension of the duration of the operation. 257

Akıncı et al. Reversal of Hartmann’s procedure is still a high-morbid surgery?

When we examined the morbidity and mortality rates associated with the reversal of Hartmann’s procedure in the literature, we identified that these rates occur in quite a wide range. In a study by Roque-Castellano et al.,[6] which included 162 patients, morbidity, and mortality rates were reported to be 54% and 0.0%, respectively. On the other hand, Zarnescu et al.,[7] reported morbidity and mortality rates to be 16%–3%, respectively and Tan et al.[4] reported 20.4%–0.0%, respectively. In our study, morbidity and mortality rates for the reversal of Hartmann’s procedure were 37.5% and 0.0%, respectively. These rates are found to be at acceptable levels compared with those reported in the literature. The main factors associated with the high morbidity and mortality rates of the first stage operation were the majority of the patients being older, the presence of accompanying comorbidities (88.5% of cases were ASA 2–3), the presence of malignant diseases leading to additional nutritional disorders, and patients being in septic shock at the time of admission. Even if the second stage is successful, we must remember that there are risks. We believe that the right patient selection, selection of the appropriate operation time according to the patient, evaluation of the distal segment with preoperative contrast radiography, preoperative preparation of the patient and optimal application of surgical dissection are the main reasons for the mortality rate is 0% in our patients who underwent the reversal of Hartmann. In recent years, parallel to the increasing experience of surgeons in laparoscopy, the laparoscopic reversal of Hartmann’s procedure has gained its popularity. Many studies have reported that the laparoscopic approach is superior to the open technique concerning the following parameters, including the duration of hospital stay, the presence of intraoperative bleeding, postoperative pain, the return of bowel functions, and the rates of morbidity and mortality.[19–22] Despite the high morbidity and mortality risks associated with the Hartmann’s procedure, its significance persists as a damage control surgical technique in the emergencies of the left colon for surgeons and patients. The reversal of Hartmann’s procedure appears to be a safe operation with acceptable morbidity rates. If the correct patient selection, correct operation timing and meticulous surgical preparation are performed, the risk of morbidity and mortality of the reversal of Hartmann’s procedure can be minimized.

Financial Disclosure: The autors declared that this study has received no financial support.

REFERENCES 1. Hartmann H. Note sur un procede nouveau d’extirpation des cancers de la parti edu colon.[Article in French] Bull Maem Soc Chir Paris 1923;49:1474−77. 2. Desai DC, Brennan EJ Jr, Reilly JF, Smink RD Jr. The utility of the Hartmann procedure. Am J Surg 1998;175:152–4. 3. Stone HH, Fabian TC. Management of perforating colon trauma: randomization between primary closure and exteriorization. Ann Surg 1979;190:430–6. 4. Tan WS, Lim JF, Tang CL, Eu KW. Reversal of Hartmann’s procedure: experience in an Asian population. Singapore Med J 2012;53:46−51. 5. Schmelzer TM, Mostafa G, Norton HJ, Newcomb WL, Hope WW, Lincourt AE, et al. Reversal of Hartmann’s procedure: a high-risk operation? Surgery 2007;142:598-606; discussion 606−7. 6. Roque-Castellano C, Marchena-Gomez J, Hemmersbach-Miller M, Acosta-Merida A, Rodriguez-Mendez A, Fariña-Castro R, et al. Analysis of the factors related to the decision of restoring intestinal continuity after Hartmann’s procedure. Int J Colorectal Dis 2007;22:1091−6. 7. Zarnescu Vasiliu EC, Zarnescu NO, Costea R, Rahau L, Neagu S. Morbidity after reversal of Hartmann operation: retrospective analysis of 56 patients. J Med Life 2015;8:488–91. 8. Haas PA, Haas GP. A critical evaluation of the Hartmann’s procedure. Am Surg 1988;54:380–5. 9. Bakker FC, Hoitsma HF, Den Otter G. The Hartmann procedure. Br J Surg 1982;69:580–2. 10. Hallam S, Mothe BS, Tirumulaju R. Hartmann’s procedure, reversal and rate of stoma-free survival. Ann R Coll Surg Engl 2018;100:301–7. 11. Oomen JL, Cuesta MA, Engel AF. Reversal of Hartmann’s procedure after surgery for complications of diverticular disease of the sigmoid colon is safe and possible in most patients. Dig Surg 2005;22:419–25. 12. Biondo S, Jaurrieta E, Martí Ragué J, Ramos E, Deiros M, Moreno P, et al. Role of resection and primary anastomosis of the left colon in the presence of peritonitis. Br J Surg 2000;87:1580−4. 13. Khan AL, Ah-See AK, Crofts TJ, Heys SD, Eremin O. Reversal of Hartmann’s colostomy. J R Coll Surg Edinb 1994;39:239–42. 14. Banerjee S, Leather AJ, Rennie JA, Samano N, Gonzalez JG, Papagrigoriadis S. Feasibility and morbidity of reversal of Hartmann’s. Colorectal Dis 2005;7:454–9. 15. Leong QM, Koh DC, Ho CK. Emergency Hartmann’s procedure: morbidity, mortality and reversal rates among Asians. Tech Coloproctol 2008;12:21–5. 16. Pearce NW, Scott SD, Karran SJ. Timing and method of reversal of Hartmann’s procedure. Br J Surg 1992;79:839–81. 17. Geoghegan JG, Rosenberg IL. Experience with early anastomosis after the Hartmann procedure. Ann R Coll Surg Engl 1991;73:80–2.

Peer-review: Internally peer-reviewed.

18. Boland E, Hsu A, Brand MI, Saclarides TJ. Hartmann’s colostomy reversal: outcome of patients undergoing surgery with the intention of eliminating fecal diversion. Am Surg 2007;73:664–8.

Authorship Contributions: Concept: O.A., O.Ş.; Design: O.A., M.Y.; Supervision: O.A., Materials: B.C.T., M.Y.; Data: O.A., B.C.T., S.S.U.; Analysis: O.A., O.Ş.; Literature search: O.A.; Writing: O.A.; Critical revision: O.Ş.

20. Mazeh H, Greenstein AJ, Swedish K, Nguyen SQ, Lipskar A, Weber KJ, et al. Laparoscopic and open reversal of Hartmann’s procedure--a comparative retrospective analysis. Surg Endosc 2009;23:496−502.

Ethics Committee Approval: Retrospective study.

Conflict of Interest: None declared. 258

19. Costantino GN, Mukalian GG. Laparoscopic reversal of Hartmann’s procedure. J Laparoendoscopic Surg 1994;4:429−33.

21. Toro A, Ardiri A, Mannino M, Politi A, Di Stefano A, Aftab Z, et

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Akıncı et al. Reversal of Hartmann’s procedure is still a high-morbid surgery? al. Laparoscopic Reversal of Hartmann’s Procedure: State of the Art 20 Years after the First Reported Case. Gastroenterol Res Pract 2014;2014:530140.

22. Walklett CL, Yeomans NP. A retrospective case note review of laparoscopic versus open reversal of Hartmann’s procedure. Ann R Coll Surg Engl 2014;96:539–42.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Hartmann kapatılması prosedürü hâlâ yüksek morbiditeli bir cerrahi midir? Dr. Ozan Akıncı,1 Dr. Müge Yurdacan,2 Dr. Başar Can Turgut,2 Dr. Server Sezgin Uludağ,2 Dr. Osman Şimşek2 1 2

Hakkari Devlet Hastanesi, Genel Cerrahi Kliniği, Hakkari İstanbul Üniversitesi-Cerrahpaşa, Cerrahpaşa Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul

AMAÇ: Bu çalışma Hartmann prosedürü kapatılmasının ameliyat öncesi ve ameliyat sırasında risk faktörlerine dayanarak sonuçlarını değerlendirmektedir. GEREÇ VE YÖNTEM: Kliniğimizde Ocak 2010–Ocak 2016 yılları arasında Hartmann prosedürü uygulanan 78 olgu geriye dönük olarak incelendi. BULGULAR: Olguların 45’i erkek, 33’ü kadındı. Olguların 32’si malignite, 15’i divertikül perforasyonu, 11’i sigmoid volvulus nedeniyle ameliyat edilmiştir. Otuz iki olguda Hartmann kapatılması yapılabilmiştir. Hartmann kapatılması için morbidite ve mortalite oranları sırasıyla %37.5–%0.0 idi. TARTIŞMA: Hartmann prosedürü kapatılması kabul edilebilir morbidite oranları ile güvenilir bir cerrahi olarak görünmektedir. Doğru hasta seçimi, doğru operasyon zamanlaması ve titiz bir cerrahi hazırlık yapıldığı takdirde Hartmann prosedürü kapatılmasının morbidite ve mortalite riski minimalize edilebilir. Anahtar sözcükler: Hartmann kapatılması; Hartmann prosedürü, morbidite; mortalite. Ulus Travma Acil Cerrahi Derg 2020;26(2):255-259

doi: 10.14744/tjtes.2019.71725

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Results of acromioclavicular joint reconstruction using a novel minimally invasive technique Gazi Huri, M.D.,1 Erdi Özdemir, M.D.,1 Nezih Ziroğlu, M.D.,2 John Costouros, M.D.,3 Edward McFarland, M.D.4 1

Departmant of Orthopaedics and Traumatology, Hacettepe University Faculty of Medicine, Ankara-Turkey

2

Departmant of Orthopaedics and Traumatology, Bakirköy Dr. Sadi Konuk Training and Research Hospital, İstanbul-Turkey

3

Departmant of Orthopaedics and Traumatology, Stanford University, CA-USA

4

Departmant of Orthopaedics and Traumatology, Shoulder Division Johns Hopkins University, MD-USA

ABSTRACT BACKGROUND: AC joint injury is a common disorder with a reported incidence of three to four cases per 100.000. A multitude of surgical techniques has been described for the treatment of the AC joint injuries with no clear consensus regarding the optimal treatment. We hypothesized that we would obtain favorable clinical outcomes using a novel minimally-invasive polymer cerclage wire system compared to other reported techniques in the literature. METHODS: All adult patients treated with subacute AC separations in our department between the dates of 2014–2017 were retrospectively reviewed clinically and radiographically. Clinical outcomes scores that were obtained preoperatively and postoperatively included ASES score, constant score and the UCLA shoulder rating scale. RESULTS: Five patients with Type 5 AC separations were included in this study who underwent surgical treatment by the same orthopedic surgeon (G.H.) using the same minimally-invasive technique. The mean follow-up period was 22.4 months (range 18 to 29). Mean preoperative coracoclavicular (CC) distance was 19.7 mm (range 16.4 to 24.5 mm) on the surgical side and 9.48 mm on the contralateral side. Mean early postoperative CC distance was 7.1 mm (range 4.5 to 11.2 mm). At the latest follow-up, the mean CC distance was 13.8 mm (range 7.3 to 21.2 mm). Mean preoperative Constant score was 48, the UCLA shoulder rating score was 14.8, and the ASES shoulder score was 49.26. Mean follow up Constant score was 91.6, UCLA shoulder rating score was 33.8 and ASES shoulder score was 93.75. No neurovascular complication was observed after procedure. There were no cases of clinical or radiographic failure or loss of fixation. No AC joint arthritis was observed at the latest follow-up. CONCLUSION: We present a novel minimally-invasive polymer cerclage wire technique which provides comparable results as other reported arthroscopic and open techniques for Type 5 AC joint separations. Keywords: AC joint; acromioclavicular; dislocation; injury; shoulder.

INTRODUCTION Acromioclavicular (AC) joint injury is a common disorder and seen in approximately three to four cases per 100.000.[1] AC joint injury comprises 12% of injuries about the shoulder girdle[2] and the incidence is rising due to increased participation in high-impact sports injuries and a reported increase in motorcycle accidents.[1,3]

The most common classification system continues to be that described by Rockwood and is based on the degree of displacement of the distal clavicle relative to the acromion. Rockwood described six types of AC separations: Type 1 injury is a mild sprain of AC ligament; Type 2 is a rupture of the AC ligament and sprained CC ligaments; Type 3 is a superior dislocation of the distal clavicle with ruptured AC and CC ligaments and joint capsule; Type 4 injury is a posterior dis-

Cite this article as: Huri G, Özdemir E, Ziroğlu N, Costouros J, McFarland E. Results of acromioclavicular joint reconstruction using a novel minimally invasive technique. Ulus Travma Acil Cerrahi Derg 2020;26:260-264. Address for correspondence: Gazi Huri, M.D. Hacettepe Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Ankara, Turkey Tel: +90 312 - 305 10 80 E-mail: gazihuri@yahoo.com Ulus Travma Acil Cerrahi Derg 2020;26(2):260-264 DOI: 10.14744/tjtes.2019.36897 Submitted: 21.05.2019 Accepted: 14.06.2019 Online: 21.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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location of the distal clavicle; Type 5 injury is a Type 3 injury with 300% superior dislocation of the distal clavicle; Type 6 injury is an inferior dislocation the distal clavicle.[4] Treatment of AC joint injuries is considered according the degree of injury. Non-operative treatment has traditionally been recommended for Rockwood Type 1–2 injuries, however, the accepted treatment of choice for Rockwood 3–6 continues to be controversial.[5]

using standardized plain radiographs in the AP and axillary lateral projections in the sitting position and without traction. The dominant side was affected in three out of five patients. Radiologic evaluation was performed preoperative and serial postoperative X-rays (Fig. 1a, b). CC distance was measured on X-rays and defined as the vertical distance between the superior surface of coracoid and the inferior surface of the clavicle. Functional outcome scores were analyzed with ASES shoulder score, constant shoulder score and UCLA shoulder rating scale on their follow-up visits.

Several numbers of techniques have been described for the surgical treatment of AC joint injuries but no clinical superiority of one technique over another has surfaced.[6] With this study we describe a minimally invasive coracoclavicular (CC) ligament reconstruction technique for the treatment of Type 5 AC joint separations using Ortholox© (Ankara, Turkey), an Ultra-high molecular polyethylene weight polietilen-based cerclage system, which is commonly used for spine surgery during the deportation process. We hypothesized that we will obtain favorable clinical outcomes compared to other reported techniques in the literature.

Surgical Technique Following the induction of general anesthesia, the patient was placed in the modified beach chair position, taking care to pad all bony prominences and appropriately position the neck and contralateral extremity. The shoulders were examined under anesthesia and showed no evidence of glenohumeral joint instability with well-preserved passive range of motion in all planes, but with obvious asymmetry and deformity at the AC joint (Fig. 2a). Intraoperative fluoroscopy was used to confirm the type of AC joint separation.

MATERIALS AND METHODS

The surgical procedure was performed with a special instrumentation set designed for his particular surgical technique (Fig. 2b). Two small incisions were made over the clavicle and coracoid process in a parallel fashion (Fig. 2c). The superior incision was made and carried sharply down to the underlying deltotrapezial fascia, which was opened in line with the clavicle. The inferior incision was performed meticulously to expose the coracoid.

This retrospective case series was designed to show the results of AC joint reconstruction using a OrtholoxGH® Cerclage Band System technique. This study was approved by the local ethics committee (number: GO 18/589). Eleven Type 5 AC joint injuries underwent surgical treatment our clinic between 2014–2017. Patients who underwent with other surgical techniques for Grade 5 AC joint separations were excluded from this study. Five patients were included this study who were operated on by the same orthopedic surgeon (G.H.) using the same technique. All patients were male. Mean age was 40 (range 26 to 67). Three of the patients injured their shoulder during a traffic accident, one patient during a water sport activity, and one after a fall onto his shoulder (Table 1). All injuries were subacute cases. All patients were recorded as Rockwood Type 5 AC joint injuries

(a)

Following blunt dissection of the soft tissues, the distal clavicle and coracoid process were clearly visualized. Through the inferior incision a flexible suture manipulator (Fig. 2b) was used to pass the polymer cerclage cable around the base of the coracoid. Once passed, a subcutaneous tunnel was created between the superior and inferior incisions. The free ends of the cerclage cable were carried to superior incision

(b)

Figure 1. (a) Preoperative X-ray, Rockwood type 5 AC injury. (b) Postoperative X-ray, demonstrating reduced AC joint.

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(a)

(b)

(c)

Figure 1. (a) Clinical deformity of the patient. (b) Polimer cerclage wire system. (c) 2 mini incisions of the minimally invasive technique.

through the tunnel. Next, the cable, already looped under the coracoid, was looped around the clavicle and tensioned using a tension device. After the AC joint reduction was confirmed with fluoroscopic guidance, the cable was locked with a set screw.

DISCUSSION In the present study, we describe a novel, minimally-invasive technique for the reconstruction of the coracoclavicular ligaments in grade 5 AC joint injuries using a polymer cerclage. Although several surgical techniques have been described for

RESULTS Mean follow-up period was 22.4 months (range 18 to 29). Mean preoperative CC distances were 19.7 mm (range 16.4 to 24.5 mm) on the operated side and 9.48 mm on the contralateral side (Table 2). Mean early postoperative CC distance was 7.1 mm (range 4.5 to 11.2 mm). Mean latest followup CC distance was 13.8 mm (range 7.3 to 21.2 mm). Mean preoperative Constant score was 48, UCLA shoulder rating score was 14.8 and ASES shoulder score was 49.26. Mean follow up Constant score was 91.6, UCLA shoulder rating score was 33.8 and ASES shoulder score was 93.75 (Table 3). No neurovascular complications or implant failures occurred in any of the patients. No AC joint arthritis was observed.

Table 2. Radiographic evaluation

Coracoclavicular distance

Preoperative

Effected side

19.7 mm (16.4–24.5)

Contralateral side

9.48 mm (6.4–14.9)

Early postoperative

7.1 mm (4.5–11.2)

Follow-up visit

13.8 mm (7.3–21.2)

Table 3. Patient reported functional outcome measures Outcome measure

Table 1. Patient demographics

Results

Constant score

Patient demographics Sex

Preoperative

Latest follow-up visit

48 (43–52) 91.6 (90–94)

Male

5

Female

0

Preoperative

14.8 (8–18)

40 (26–67)

Latest follow-up visit

33.8 (33–35)

Mean age Injury side

UCLA shoulder rating scale

ASES score

Dominant hand

3

Preoperative

Non-dominant hand

2

Latest follow-up visit

262

49.26 (36.6–54.9) 93.75 (91.6–95)

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the treatment Type 5 AC joint injuries, none of the defined techniques have shown clinical superiority.[3] Historically, surgical management strategies have varied widely from open reduction, direct repair of the AC capsule, and rigid internal fixation to minimally invasive techniques and arthroscopic procedures for reconstruction of the AC joint.[3] Most reported complications and residual pain are related to implant failure or progression of arthritis of the AC joint.[3] In this paper, we aimed to examine the results of our minimally invasive technique parallel to developing treatment strategies. Acute AC separation treatment strategies can be classified as rigid and non-rigid fixations. In terms of rigid fixation, screws, K-wires and hook plates can be used. These rigid fixation devices aim to maintain the AC joint in a reduced position while biological healing can occur.[7] The primary problems observed in screw and K-wire fixation are migration, osteolysis, loss of reduction and implant breakage. They also require an additional surgery for implant removal.[5] Another rigid fixation device is the hook plate which provides stronger stability. However, the hook plate which is inserted under acromion causes subacromial impingement and rotator cuff lesions. Also, it may cause shoulder pain in some cases.[8] Because of these inherent disadvantages, non-rigid fixation instruments are preferred for the AC joint separations today. These non-rigid treatment options include the endobutton sutures and CC ligament reconstructions. Endobutton technique carries the advantage of less soft tissue disruption during implantation and providing motion between scapula and clavicle. It has some disadvantages like button breakage, migration and clavicle fracture.[9,10] CC ligament reconstruction also requires a graft for additional strength of fixation. This method carries the additional burden of donor site morbidity with similar functional outcomes.[11] Our fixation method with polymer cerclage cable is a non-rigid fixation and does not require additional augmentation with graft. Regarding the fixation materials, such as wires, screws and hook plates for rigid coracoclavicular fixation, they are associated with a significant risk of migration, loosening and breakage. Other important complications of the hook plate include acromial osteolysis, dislocation of the hook and impingement due to plate. While comparing Polymer Cerclage Cable System (Ortholox) to rigid fixation materials, we can see same advantages of non-rigid group, such as reduced risk of migration and breakage.[5] According to the literature, non-rigid coracoclavicular fixation with synthetic materials can achieve similar outcomes to fixation with a hook plate, thus eliminate the necessity of secondary surgery to remove the plate. With similar thought ortholox system could be preferred to avoid hook plate specific complications like osteolysis, dislocation and impingement. Compared to other non-rigid fixations, in endobotton technique drill holes are used for fixation of sutures. This carries the risk of clavicle fracture. In our technique fixation is obtained without of the need for bone tunnels in the clavicle.[9] In CC ligament reconstruction Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

technique, as fixation material semitendinosus graft is used. We do not have and donor site morbidity compared to that reconstruction technique.[11] The strengths of this technique include that it is minimally invasive technique and only two small incisions are required. This Polymer Cerclage Cable System (Ortholox) technique also has the advantage of allowing for adjustable tension and a modifiable stitch placement. Functional outcomes (ASES, Constant, UCLA shoulder scores) are comparable to other reported techniques in the orthopaedic literature using endobutton fixation as well as the hook plate.[12,13] Some of the disadvantages of this technique include the potential for cerclage loosening with cyclical loading over time. Two patients in this series had cerclage loosening at their latest follow-up visit that did not affect functional outcomes. We did not observe clinical failure despite radiographic evidence of loss of fixation. Even one of our patients working as a heavy worker could perform his work without complaints. All patients successfully returned to their previous level of work without any problems. Our study had several limitations. One of them is we did not have a control group. We could only compare our results with the reported literature. Secondly, our patient population was small. Therefore, our results may not be generalized to all types of AC separations. Additional studies are required for determining functional outcomes and complication rates. In conclusion, we report a novel, minimally-invasive polymer cerclage technique that appears to be comparable to other reported arthroscopic and open techniques for the treatment of Rockwood Type 5 AC separations. Further analysis of this technique in the treatment of other high-grade AC separations in a larger cohort of patients with longer clinical and radiographic follow-up is warranted. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: G.H., J.C., E.M.; Design: G.H., E.Ö., J.C.; Supervision: G.H., E.M.; Materials: G.H., E.Ö., N.Z.; Data: G.H., E.Ö., N.Z., J.C., E.M.; Analysis: G.H., E.Ö., N.Z., J.C., E.M.; Literature search: G.H., E.Ö., N.Z., J.C., E.M.; Writing: G.H., E.Ö., N.Z., J.C., E.M.; Critical revision: G.H., J.C., E.M. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

REFERENCES 1. Babhulkar A, Pawaskar A. Acromioclavicular joint dislocations. Curr Rev Musculoskelet Med 2014;7:33–9. 2. Emery R. Acromioclavicular and sternoclavicular joints. In: Copeland S,

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Huri et al. Results of AC joint reconstruction using a novel minimally invasive technique editors. Shoulder surgery. London: WB Saunders; 1997. 3. Li X, Ma R, Bedi A, Dines DM, Altchek DW, Dines JS. Management of acromioclavicular joint injuries. J Bone Joint Surg Am 2014;96:73–84. 4. Rockwood CA Jr. Injuries to the acromioclavicular joint. In: In: Rockwood CA Jr, Green DP, editors. Fractures in adults, vol 1, 2nd ed. Philadelphia: JB Lippincott; 1984. p. 860−910. 5. Modi CS, Beazley J, Zywiel MG, Lawrence TM, Veillette CJ. Controversies relating to the management of acromioclavicular joint dislocations. Bone Joint J 2013;95-B:1595–1602. 6. Fraser-Moodie JA, Shortt NL, Robinson CM. Injuries to the acromioclavicular joint. J Bone Joint Surg Br 2008;90:697–707. 7. van Bergen CJA, van Bemmel AF, Alta TDW, van Noort A. New insights in the treatment of acromioclavicular separation. World J Orthop 2017;8:861–73. 8. Yoon JP, Lee YS, Song GS, Oh JH. Morphological analysis of acromion and hook plate for the fixation of acromioclavicular joint dislocation. Knee Surg Sports Traumatol Arthrosc 2017;25:980–6. 9. Martetschläger F, Horan MP, Warth RJ, Millett PJ. Complications after

anatomic fixation and reconstruction of the coracoclavicular ligaments. Am J Sports Med 2013;41:2896–2903. 10. Clavert P, Meyer A, Boyer P, Gastaud O, Barth J, Duparc F; SFA. Complication rates and types of failure after arthroscopic acute acromioclavicular dislocation fixation. Prospective multicenter study of 116 cases. Orthop Traumatol Surg Res 2015;101:S313−6. 11. Mazzocca AD, Santangelo SA, Johnson ST, Rios CG, Dumonski ML, Arciero RA. A biomechanical evaluation of an anatomical coracoclavicular ligament reconstruction. Am J Sports Med 2006;34:236–46. 12. Xue C, Song LJ, Zhang H, Tang GL, Li X, Fang JH. Truly anatomic coracoclavicular ligament reconstruction with 2 Endobutton devices for acute Rockwood type V acromioclavicular joint dislocations. J Shoulder Elbow Surg 2018;27:e196–202. 13. Arirachakaran A, Boonard M, Piyapittayanun P, Kanchanatawan W, Chaijenkij K, Prommahachai A, et al. Post-operative outcomes and complications of suspensory loop fixation device versus hook plate in acute unstable acromioclavicular joint dislocation: a systematic review and meta-analysis. J Orthop Traumatol 2017;18:293−304.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Minimal invaziv teknik ile akromioklaviküler eklem rekonstrüksiyonunun sonuçları Dr. Gazi Huri,1 Dr. Erdi Özdemir,1 Dr. Nezih Ziroğlu,2 Dr. John Costouros,3 Dr. Edward McFarland4 Hacettepe Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Ankara Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul, Türkiye Stanford Üniversitesi, Ortopedi ve Travmatoloji Departmanı, USA 4 Johns Hopkins Üniversitesi, Ortopedi ve Travmatoloji Departmanı, Omuz Bölümü, USA 1 2 3

AMAÇ: Akromiyoklaviküler (AC) eklem hasarı, 100.000’inde 3 ile 4 sıklığında görülen bir yaralanmadır. AC eklem yaralanmalarının tedavisi için optimal tedavi konusunda net bir fikir birliği olmadığından çok sayıda cerrahi teknik tanımlanmıştır. Çalışmamızda literatürde bildirilen diğer tekniklerle karşılaştırıldığında, minimal-invaziv polimer serklaj tel sistemi ile olumlu klinik sonuçlar elde edeceğimizi hipotez edilmiştir. GEREÇ VE YÖNTEM: Bölümümüzde 2014–2017 tarihleri ​​arasında subakut AC yaralanması olan tüm yetişkin hastalar geriye dönük olarak taranarak klinik ve radyografik olarak incelendi. Ameliyat öncesi ve sonrası klinik sonuçlar ASES skoru, Constant skoru ve UCLA omuz skoru ölçeği ile değerlendirildi. BULGULAR: Çalışmaya aynı minimal-invaziv tekniği kullanarak aynı cerrah tarafından cerrahi tedavi uygulanmış tip 5 AC yaralanması olan beş hasta dahil edildi. Ortalama takip süresi 22.4 aydı (18–29). Ameliyat öncesi ortalama korakoklavikular (CC) uzaklığı cerrahi tarafta 19.7 mm (16.4–24.5 mm), kontralateral tarafta 9.48 mm idi. Ameliyat sonrası erken dönemde ortalama CC mesafesi 7.1 mm (4.5–11.2 mm) idi. Son takipte, ortalama CC mesafesi 13.8 mm (7.3–21.2 mm) idi. Ameliyat öncesi ortalama Constant skoru 48, UCLA omuz skoru 14.8, ASES omuz skoru 49.26 idi. Hastaların son takiplerinde ortalama Constant skoru 91.6, UCLA omuz skoru 33.8, ASES omuz skoru 93.75 idi. Cerrahi sonrası nörovasküler komplikasyon görülmedi. Klinik veya radyografik implant yetersizliği veya fiksasyon kaybı görülmedi. Son takipte hiçbir hastada AC eklem artriti görülmedi. TARTIŞMA: Tip 5 AC eklem yaralanmaları için bildirilen diğer artroskopik ve açık teknikler ile karşılaştırılabilir sonuçlar sağlayan yeni bir minimalinvaziv polimer serklaj tel tekniği tanımlanmıştır. Anahtar sözcükler: Akromiklaviküler; akromiklaviküler eklemi; dislokasyon; omuz; yaralanma. Ulus Travma Acil Cerrahi Derg 2020;26(2):260-264

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ORIGIN A L A R T IC L E

Acetabular fractures treated surgically: Which of the parameters affect prognosis Utku Bilekdemir, M.D.,1

Osman Civan, M.D.,2

Ali Cavit, M.D.,3

Hakan Özdemir, M.D.4

1

Department of Orthopaedics and Traumatology, Silifke State Hospital, Mersin-Turkey

2

Department of Orthopaedics and Traumatology, Elmalı State Hospital, Antalya-Turkey

3

Department of Orthopaedics and Traumatology, Uludağ University Faculty of Medicine, Bursa-Turkey

4

Department of Orthopaedics and Traumatology, Akdeniz University Faculty of Medicine, Antalya-Turkey

ABSTRACT BACKGROUND: This study aims to evaluate the surgical approaches, complications, clinical and radiological findings in acetabular fractures treated with surgical methods and to determine the parameters affecting prognosis. METHODS: Out of 144 patients undergone surgical treatment with the diagnosis of displaced acetabular fractures between 1994 and 2014, a total of 103 patients with 75 male and 28 female with a mean age of 36.3 years (range 19–67 years) whom clinical and radiologic follow-ups (mean: 34 months, range 2–8 years) were performed at least for two years were included in this study. RESULTS: Clinically excellent to good outcomes were obtained in 64% of the patients and moderate to poor outcomes were recorded in 36% of the patients, while radiologically excellent to good outcomes were achieved in 57.3% of the patients and moderate to poor outcomes were recorded in 42.7% of the patients. Presence of one of the complications, creating mechanical block (chi-square p<0.001), complex fractures (chi-square p=0.023), increased duration between trauma and operation (p=0.039), operational time taking longer than six hours (chi-square p<0.001), more than 3 mm intra-articular step (Fisher’s p=0.033), avascular necrosis (p<0.001), arthritis (p=0.006) and heterotopic ossification (p=0.007) worsened the clinical outcomes (chi-square p<0.001). The age of the patient was not effective on the clinical outcome (p=0.461). CONCLUSION: It was found that three major parameters affecting the prognosis of acetabular fractures are as follows: type of fracture, operational time and reduction quality. The duration between trauma and operation indirectly affects the outcomes. Avascular necrosis, heterotopic ossification and arthritis may cause negative effects only on long term outcomes. Keywords: Acetabular fractures; acetabulum; fractures; pelvic fractures; prognosis of acetabular fractures; surgical treatment of acetabular fractures.

INTRODUCTION

MATERIALS AND METHODS

Surgical treatment techniques of acetabular fractures (AFs) are still one of the important and discussed topics due to the complex anatomy of this region, severity of complications and variety of factors affecting prognosis.[1–5]

Among 219 patients with 219 pelvic and AFs underwent surgical treatment between 1994 and 2014, out of 144 patients surgically treated for displaced AFs, a total of 103 patients (75 male, 28 female), mean age of 36.3 (range 19–67 years), were followed-up at least for two years (mean follow-up duration: 34 months; range 2–8 years) included in this study. Left acetabular fracture (AF) in 57 patients and right AF in 46 patients; 57 of the fractures caused by in-

The present study aims to investigate the factors affecting prognosis by evaluating: the surgical approaches applied for displaced AFs, complications and clinically and radiological results.

Cite this article as: Bilekdemir U, Civan O, Cavit A, Özdemir H. Acetabular fractures treated surgically: Which of the parameters affect prognosis. Ulus Travma Acil Cerrahi Derg 2020;26:265-273. Address for correspondence: Osman Civan, M.D. Elmalı Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Antalya, Turkey Tel: +90 242 - 618 83 00 E-mail: civanosman@gmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):265-273 DOI: 10.14744/tjtes.2019.88472 Submitted: 01.03.2019 Accepted: 02.07.2019 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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vehicle accident, 31 out-of-vehicle accidents and 15 falling from a height. Three radiographic series described by Judet used with Computerized Tomography (CT) and 3D reconstruction methods used for diagnosis, while the classification of the fractures was made according to the classification described by Judet and Letournel.[6] Surgical treatment was performed for the fractures with displacement >3 mm, roof arch angle <45°, intact posterior wall fragment <50%, in the presence of intra-articular free fragment, marginal impaction >3 mm and in femoral head fractures or the fractures accompanied by sciatic nerve lesions. The fourth author (H.Ö.) attended to all operations and worked for the follow-up of all patients. Low-molecular-weight heparin (LMWH) was used against the risk of thromboembolism from hospitalization of the patient up to the postoperative 6th week. Patients were put on compression socks up to the 3rd month for the same purpose. Infection prophylaxis was applied using 1st generation cephalosporin, beginning 12 hours before the surgery, repeating once every three hours during the surgery and three doses up to the postoperative 3rd day. Prophylaxis for heterotopic ossification (HO) was applied using Indometazine 75 mg, started on postoperative 1st day, and continued over six weeks. Displacement of the articular

surface was measured with postoperative acetabular graphy series and evaluated according to Matta criteria. A displacement of 0–1 mm was considered as anatomic, 1–3 mm acceptable and ≥3 mm as inadequate reduction. Knee and hip isometric exercises were initiated on the postoperative 2nd day. All of the patients were mobilized by a double crutch without weight-bearing in the same weeks after providing the security of the operation area. Clinical and radiological results were evaluated through the scoring system of Merle D’Aubigne modified by Matta[7] (Table 1). Statistical analysis was performed using SPSS (Statistical Package for Social Sciences for Windows 18.0) software. Spearman’s correlation test was used to investigate the relationships of the quantitative data with each other. Pearson’s chi-square test or Fisher’s exact test were used to evaluate the connections between categorical data. P-values less than 0.05 were considered as statistically significant results.

RESULTS Twenty-four (23.3%) of the patients had isolated AF, and 79 (76.7%) had AF accompanied with another injury (Table 2). Thirty-four (33%) of the fractures were simple and 69 (67%) were complex type fractures. Posterior wall fracture (16,6%) was the most common type among simple fractures; the most frequent type in both complex fractures and among all fractures was double-column AF (25.3%) (Table 3).

Table 1. Clinical and radiological criteria at fallow-up Clinical criteria

Pain

Walking

Range of motion

None

6 Normal

6 95%–100%

6

Slight or intermittent

5

No cane but slight limp

5

80%–94%

5

After walking but resolves

4

Long distance with cane or crutch

4

70%–79%

4

Moderately severe but patient is able to walk

3

Limited even with support

3

60%–69%

3

Severe, prevents walking

2

Very limited

2

50%–59%

2

Unable to walk

1

<50%

1

Clinical grade

Excellent: 18 Good: 17–16–15 Fair: 14–13 Poor: <13

Radiographic criteria Excellent

Normal appearance of the hip

Good

Small osteophytes, moderate (1 mm) narrowing of joint & minimum sclerosis

Fair

Intermediate changes, moderate osteophytes, Moderate (<50%) narrowing of

joint & moderate sclerosis

Poor

Advanced changes, large osteophytes, severe (>50%) narrowing of the joint,

collapse or wear of the femoral head, and acetabular wear. Collapse or wear

of the femoral head, and acetabular wear

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Table 2. Additional injuries to acetabulum fractures Additional injuries

n

%

Exremity injury

56

52.9

Hip luxation

23

21.6

Intracranial injury

8

7.6

Intra-abdominal injury

7

6.6

Chest injury

6

5.7

Nerve paralysis

3

2.8

Spinal injury

3

2.8

The posterior hip dislocation was found in 19 (17.9%) patients and central hip dislocation in four (3.7%) patients. Neurological deficit due to fracture was identified in two patients with the posterior hip dislocation (one sciatic and one peroneal nerve), and in one patient with transverse + posterior wall fracture (peroneal nerve). The duration between trauma and operation (T-O time) was between 0 and 28 days (mean 8.3 days). Surgical treatment was performed on the same day of the trauma in five patients, within one and 20 days after trauma (mean 8.3 days) in 96 patients and on the 21st and 28th days in each one patient (Table 4). Surgical procedures were performed using Kocher Langenbeck (K-L), Ilioinguinal (II), Iliofemoral (IF), Triradiate (TR), Modified Transtrochanteric (MT) and combined incisions (CI) (Table 3). The anatomic reduction was achieved in 78 (75.7%), acceptable reduction in 15 (14.6%) and non-acceptable reduction in 10 (9.7%) patients (Table 3).

served in 17 (16.5%) patients (Fig. 1). Meralgia due to postoperative lateral femoral cutaneous nerve damage was seen in 2 of 20 patients operated by II incision and 1 of 3 operated using IF incision. Relationship between paralysis, HO and type of fractures, type of incision were all introduced in Table 3. None of the patients who had paralysis showed complete healing. Symptomatic deep vein thrombosis and pulmonary embolism have not been observed except for a 63-year-old patient with posterior wall + column fracture. Excellent to good clinical outcomes were recorded in 79.4% of the simple fractures (Fig. 2) and 56.5% of the complex fractures (Fig. 3). A significant correlation was found between the type of fracture and clinical outcome. (chi-square=5.185 p=0.023). There was a significant correlation between T-O time and clinical outcomes (r=0.204 p=0.039). However, when T-O time was categorized as 0–7 days, 8–14 days and 15–28 days; it did not show a significant effect on clinical outcome (chisquare=1.365 p=0.505). Clinic outcomes were worsened by increasing at the operational time (r=0.318 p=0.001). When the operational time was categorized as 0–3 hours, 3–6 hours and >6 hours, it statistically significantly affected clinical outcomes of the groups (chi-square=15.752 p<0.001). The relationship of the groups with each other was examined in order to find out which group caused significant effect. An operational time between 0–3 hours and 3–6 hours did not significantly affect clinical outcomes (Fisher’s<0.999). However, there was a statistically significant correlation between clinical outcomes of the patients with an operational time of 0–3 hours and >6

Reconstruction plates with screws were used in 95 of 103 patients. Semi-tubular and reconstruction plates with screws were used together in seven patients and one patient was treated using only screws. These types of materials used in the surgical procedure had no significant effect on the clinical and radiological outcomes. Five patients had superficial and five patients had a deep infection during follow-up (Tables 3, 4). Infection was regressed with antibiotic therapy in patients who had a superficial infection and after repetitive debridements and antibiotherapy in those with deep infection. None of the patients required removal of the implant. Avascular necrosis (AVN) was found in 16 (15.5%) patients. AVN was seen in mean 22.8 months (range 6–52 months). The relationship between types of incision and types of fractures was reported in Table 3. Despite indomethacin prophylaxis, HO, varying between stages 1 and 4 according to Brooker classification[8] was obUlus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Figure 1. Heterotopic ossification (shown with arrow).

267

268

6

Transvers

2

Triradiate

100 103 103

MT

Displacement

Complication

2.6

2

2

4

202

6

1

1

4

1

2

10

1

4

1

1

3

15

1

1

1

1

1

315

460

330

450

445

540

365

482

360

600

450

600

473

241

338

296

248

542

385

212

5

1

1

10

7

3

1

1

1

1

1

1

1

7

1

1

1

1

2

1

1

11

1

1

10

1

1

1

2

2

1

1

1

1

2

1

1

1

2

3

1

2

1

3

2

1

1

2

2

2

2

1

1

2

1

1

1

1

2

1

1

1

1

1

3

2

17 51 23 78 15 10 16 17 19

2 9 7 3 1 3 2 4

1

2

2

3

270 1 4 2 6 1 3 1 2

280

276

240

245

236

7

LFCN

Peroneal

LFCN

Sciatic

Sciatic

LFCN

Peroneal

10

1

3

1

1

1

1

1

1

AVN: Avascular necrosis; HO: Heterotopic ossification; K-L: Kocher Langenbeck; II: Ilioinguinal; TO: Trochanteric osteotomy; MT: Modified transtrochanteric; LFCN: Lateral femoral cutaneous nerve.

Total

1 Iliofemoral

1

KL+TO

Triradiate

2

3

7

3.8

4

3

3

6

4

4

5.3

1.8

2

1.4

4.7

2

1

2.4

2

2,6

1

1

2

1.4

4,1

II

MT

II

II+KL

Operational time

Clinical outcome

Radiological outcome

23

1

2

1

1

1

1

1

1

3

3

1

2

5

3

2

1

1

1

3

1

1

1

1

2

3

1

2

1

1

1

43 18 19

1

3 3 4

4

1

1

2

3

7

1

4

2 1

1

18

1

2

1

1

1

1

1

1

3

1

1

1

1 1 2

1

5

1

1

7

2

1

4

1

1

1

2

1

2

1

1

1

2

1

1

3

3

1

1

1

1

2

41 20 24

1

2 3 5

1

1

2

2

8

4

2 1 1

4

1

2

11

Transfusion Mean 0-3 3-6 6-9 0-1 1-3 3< AVN HO Artrosis Paralysis Infection Excellent Good Fair Poor Excellent Good Fair Poor (RBC) (minutes) hour hour hour mm mm mm (nerve)

11 KL+II

25,3 26 8

2

Both column

1

1

1 II+Triradiate

Anterior column 5,8

KL

II

MT

Hemitranvers

1

4

6

1 Iliofemoral

6

5,8

T Type

5

KL

13

II

KL+II

20,4 21 1

1

Posterior wall

KL

6,8 7 7 KL

II

1 Iliofemoral

Posterior column 9,7 10 10

Transvers

Complex Posterior wall

Anterior column 5,8

5

II

1

KL

KL

1 Iliofemoral

2

3

1,9

Anterior wall

3

15,6 16 16

Posterior wall

Posterior column 2,9

Simple

Fracture % Approach

Table 3. Relationship between fracture type, incision, transfusion, surgical time, intra-articular stepping complication, clinical and radiological results

Bilekdemir et al. Acetabular fractures treated surgically: Which of the parameters affect prognosis

Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

{1}

x

x 0 4 3 0 2 3 2 6 1 0 {1} {0} {1}

4 2 5 3 0 2 8 5 1 0 {3} {4} {1} {1}

Clinical outcome was also worsened with the increase of the postoperative fracture displacement (r=0.248 p=0.011). When postoperative steps were categorized as 0–1 mm, 1–3 mm and >3 mm; no statistically significant difference was found between clinical outcomes of the patients with a step between 0–1 mm and a step between 1–3 mm (Fisher’s =0.232). When step groups were categorized as 0–3 and >3 mm, excellent to good outcomes were found in 67.7% of the patients with a step between 0–3 mm, while this rate is 30% in the patients with a step >3 mm (Fisher’s p=0.033).

T-O: Duration between trauma and operation time; AVN: Avascular necrosis; HO: Heterotopic ossification ND: mm: milimeter.

1 1 0 0 1 0 Infection 2 6 2 4 0

1

0 0 0 0 Paralysis 2 4 1 0 1

0

hours and those with an operational time of 3–6 hours and >6 hours (chi-square=7.378 p=0.007 and chi-square=14.010 p<0.001; respectively). Briefly, the clinical outcome was worsened with a surgery lasting longer than six hours.

2

{1} {1} 7 7 9 3 3 8 8 6 7 6 {3} {8} x

1

6 7 7 3 3 8 6 7 5 5 {4} x {8} {0} {4}

0 2 0 0 Arthrosis 1 12 5 1 1

0

2

4 1

1

5 9 6 1 1 6 9 12 4 0 x {4} {3} {1} {3} 3

1 1 0

0

0 0

1 9 6 1 0 HO

AVN

2 7 5 2 1

Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Complications

0 0 1 Poor

2 10 10 2

0

0

3

4 4

1

1 3 0

3 4 3 1

4 2

3

3

1 10 9 11 4 0 11 13 13 4 6 13 9 10 2

1 9 7 12 1 2 8 10 12 5 3 2 2 5 2 0 0 Fair

2 7 8 3 2

0

1

4 0

2

3

4

0 2

4 17 19 5 14 23 4 37 5 0 0 3 3

1 1

4 2

3 1 3

1 2

2 1 1 2

1 24 15 1 11 Good

Excellent 2 10 5 1

Radiological

0 0 Poor

3 6 8 2 1

4

3 0

2

10 2

3 1

1

3 12 6 0 1 13 4 16 1 1 1 3 1

3

2

1 2

7 7 8 4 0 8 11 12 2 4 12 7 7

5

1 8 7 10 1 4 5 9 11 5 3 3 4 5 0 1 0 0 Fair

0 10 7 1 3

0

4

3 2

1

3 8 15 23 5 8 27 8 34 7 2 0 2 6

0 2 3 16 7 0 5 15 3 21 1 1 1 4 1

2

1 1 4 3

1 1 1 7

6

1 2 5

2 22 15 4 Good

Excellent 2 13 8 0

0

3

11 2

10 7 19 26 45 48 10 17 55 31 78 15 10 16 17 6 6 21 10 7 6 2 3 16 7 51 38 7 Clinical

Patient

0-20 20-40 40-60 <60 Posterior Posterior Anterior Anterior Transvers Posterior Transvers T Hemitransvers Both 0-7 7-14 14-28 0-3 3-6 <6 0-1 1-3 <3 AVN HO Arthrosis Paralysis Infection wall column wall column wall posterior type anterior column days days days hour hour hour mm mm mm posterior wall column column

Operational time Displacement

T-O time

Complex Fracture type Simple Age

Table 4. The relationship between age, fracture type, duration between trauma and operation, surgical time and complications, clinical and radiological results

Complication

Bilekdemir et al. Acetabular fractures treated surgically: Which of the parameters affect prognosis

When the step increases, the incidence of arthritis and HO also increased. Arthritis was found in 14% of the patients with the step between 0–3 mm and 60% of those with the step >3 mm (Fisher’s p=0.002); while HO was observed in 12.9% of the patients with the step between 0–3 mm and 50% of those with the step >3 mm (Fisher’s p=0.010). A significant correlation was found between complication occurrence and type of fracture. Complications were developed in 23.5% of the simple fractures and 58% of the complex fractures (chi-square=10.857 p=0.001). Clinical outcomes were excellence to good in 74.7% of the patients without AVN (chisquare=27.519 p<0.001), 70.2% of the patients without arthritis (chi-square=7.508 p=0.006) and 69,8% of the patients without HO (chisquare=7.328 p=0.007). There was a significant correlation between clinical and radiological outcomes. Radiologically excellent to good outcomes were recorded in 83.3% of the patients with excellent to good and 10.8% of those with moderate to poor clinical outcomes (chi-square=50.959 p<0.001). It was determined that clinical and radiological outcomes were approximately 70% compatible with each other (kappa=0.696).

DISCUSSION Waiting for longer than 10 days for the surgical treatment of AFs causes difficulty in reduction due to the formation of granulation tissue, while 269

Bilekdemir et al. Acetabular fractures treated surgically: Which of the parameters affect prognosis

(a)

(b)

(c)

(d)

Figure 2. 42 years female, K-L incision, clinically excellent result; (a) Preoperative x-ray shows dislocated hip with posterior wall type acetabular fracture. (B) X-ray after reduction of the hip. (c) Preoperative CT. (d) 7th year, excellent radiological result.

(a)

(b)

(c)

(d)

Figure 3. 31 years old male, II incision, clinically good results; (a) Preoperative x-ray. (b) Preoperative CT. (c) Preoperative CT scan shows iliac fracture. (d) 5th year postoperative x-ray shows good radiological result.

delays for longer than three weeks lead to reduction and stabilization problems due to resorption.[9–11] The mean T-O time was 8.3 days in patients in our study groups. It was found that if T-O time is prolonged, clinical outcome was worsened and operational time was prolonged and likely to become an anatomic reduction decreased in the cases that T-O time exceeding 14 days. Although not statistically significant, an interesting result found regarding T-O time was as follows: extensile or combined incisions were needed in 38.8% of the patients with T-O time between 7–14 days and 55.5% in the patients with a operation time longer than 14 days. All these data are important in suggesting that performing surgery for AFs within the first two weeks would mean a smaller incision, shorter duration of anesthesia, less soft tissue damage and better clinical and radiological outcomes, and the vast majority of the literature is consistent with our data.[12,13] Although no randomized controlled trial was found in the literature to compare two different surgical approaches, recently, there is a tendency to shift from extensile or TR incisions toward K-L incisions,[9,14,15] whereas five different incisions were used in our study, the most commonly incisions used in the vast majority (84.5%) of the patients included KL, II and a combination of them. Surgeons trained in the last ten years may never have seen extensile approaches other than in a laboratory or book, and these approaches are likely to become historical within the next decade or two.[16] TR incision is a surgical approach that should be abondened due to the high incidence of HO and infections. MT incision 270

and its numerous disadvantages are reported in the literature, is not an approach that should be avoided as reported in the literature[8,17] because of leading shortened operational time, low incidence of HO and infections as demonstrated in the present study; also can be used as an alternative to extensile and combined approaches in fragmented, complicated fractures. Studies in the literature report localization and amount of the displacement, compliance between the femoral head and acetabulum and roof restoration as the most important prognostic indicators of AFs.[18,19] Rowe and Lowell[12] reported poor treatment results in cases of a displacement >3 mm, while Matta[15] reported the acceptable amount of displacement as 3 mm. In our study, clinical outcome was statistically worsened as the intra-articular step exceeds 3 mm while excellent to good outcomes were achieved in 70.5% of the patients could be reduced anatomically. Because of the 29.5% moderate to the poor rate of anatomically reduced fractures, it is important to show that anatomic reduction is not alone prognostic factor for AFs. In the literature, the infection rate after AFs treated surgically have been reported between 4–5% and 19% is the highest one.[9,20,21] Infection rate, 9.7% recorded in our study, is higher than the literature because of the use of combined or extensile incisions in one-third of the patients and prolonged operational time due to lack of experience, especially in the first years (operational time was over eight hours in almost all patients who developed infections). The finding which is needed to be deliberated is that the infection rate is higher Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Bilekdemir et al. Acetabular fractures treated surgically: Which of the parameters affect prognosis

in combined and extensile incisions by four times compared to single or limited incisions. This is meaningful for suggesting that single and limited incisions should be preferred, while extensile and combined incisions should be avoided. The literature reports the incidence of HO as 15–50% and HO blocking hip joint movement (Brooker type III-IV) as 7%, [8,22–23] while in our study, the incidence of HO was found as 16.5% (17 patients) and HO blocking hip joint movement as 4.9%. The incidence of HO increased in all extensile incisions except MT. The rate of HO was 15% in the patients operated within two weeks after the trauma, while this rate raised to 30% after the 2nd week. HO was observed in 15.2% of the patients with the operational time between 0–6 hours and 19.4% in those with operations ending longer than six hours. The incidence of HO was found to be significantly decreased in simple fractures and in the cases with a step <3 mm could be provided. These data indicate that operating patients within the first two weeks, operational times shorter than six hours and preference of limited surgical incisions are important to avoid HO. Another late complication of AFs is AVN. Letournel[24] reported the rate of AVN as 5.6%, Tile[5] as 18% and Alonso[4] as 2–25%. AVN is seen in a combination with arthrosis in the cases with delayed reduction and becomes radiologically marked within two years following injury. In our study, AVN was found in 15.5% of the patients. This rate was 26.3% in patients with posterior hip dislocation and 25% in those with central dislocation. Although not statistically significant, onethird of the patients who developed AVN had posterior dislocation and AVN was identified in one-third of the patients with posterior dislocation. These findings suggest a relationship between them. AVN was found in 20% of the patients operated within the first week after trauma; 12.5% of the patients operated between 1-2 weeks, and 10% of the patients operated after the 2nd week. Unlike information from the literature, in our study, prolonged T-O time did not increase the incidence of AVN. Posterior incisions (KL, MT, combined, TR) used in 15 of 16 patients developed AVN. AVN was found in 5.8% of the patients with an operational time between 0–3 hours, 10.9% of the patients with an operational time between 3–6 hours, and 29% of the patients with an operational time longer than six hours. The risk of AVN was increased by 2.7 times in the surgeries ending longer than six hours, compared to ending between 3-6 hours. These data demonstrate that the presence of dislocation, operational time and type of incision are parameters affecting the development of AVN. Although unlike the literature, increased T-O time was found as not increasing the incidence of AVN. It should be remembered that 98% of AVNs develop at the time of trauma and emergency reduction of the dislocation may prevent the development of AVN. Arthritis is one of the late complications of AFs. Several predisposing factors have been reported as the risk of arthritis, Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

including cartilage damage at the time of trauma, collapses that may develop at the late period, multi fragmentation of the fracture, localization, amount of the residual displacement and patients >40 years-old. The most important factor is residual displacement caused by inadequate reduction. There is a consensus on that displacement >3 mm would result in arthritis. [1,25,26] Tile reported the rate of arthrosis as 10% in anatomic reduction and 36% in inadequate reduction.[27] In our study, arthritis was identified in 18.5% of the patients. Of the patients with arthritis identified, 84.2% had complex and 15.8% had simple fractures. Arthritis was observed in 14% of the patients with a step between 0–3 mm and 60% of the patients with a step >3 mm (Fisher’s p=0.002). Although the incidence of arthritis is significantly increased when the amount of displacement exceeds 3 mm, arthritis was found in 7.7% of the patients with anatomic reduction provided, and these findings suggest that other predisposing factors also play a role. Arthritis was found in 17.2% of the patients operated within the first two weeks after the trauma, while this rate was found as 30% in those operated after two weeks. Although not statistically significant, 1.8 times, the difference between these two groups is obviously seen. Our statistical analysis indicates that the incidence of arthritis is significantly higher in the complex fractures than the simple fractures (chi-square p=0.077), and also arthritis was recorded in 66.6% of T type fractures and 26.9% of double-column fractures. The most remarkable point is that 57.9% of all identified arthritis cases were recorded in these two types of fractures. Based on this information, it can be said that the severity of trauma causing fracture is responsible for the type of fracture at least, T-O time, and reduction quality are responsible for the development of arthritis. In our study, clinical outcomes were statistically significantly worsened in cases of complex fractures, prolonged T-O time, surgeries taking longer than six hours, intra-articular step >3 mm and presence of any of AVN, arthritis and HO. However, the age of the patients had no significant effect on clinical outcomes. All these results indicate that evaluating patients’ pretraumatic functional status rather than age is more significant when making a decision for the surgical treatment of AFs. It should be kept in mind that technological developments could help us, especially for the treatment of complex type fractures. For example, 3D printing assisted surgical technique would be preferred for these types.[28] It is difficult to be sure, but one would hope that the advances made during this time have led to improvements in outcome and that if modern-day techniques had been available to Letournel, even better results would be seen.[16] Letournel pointed out that clinical outcomes are better than radiological ones. This is because of the late onset of patients’ complaints despite the earlier onset of radiographic arthrosis findings.[24] According to Matta, excellent anatomic reduction term is used based on radiologic imaging, which often causes misleading.[15] The results of our study support this information. 271

Bilekdemir et al. Acetabular fractures treated surgically: Which of the parameters affect prognosis

In conclusion, results obtained in this study demonstrated that type of fracture, operational time and reduction quality are the three major parameters affecting the prognosis of AFs that are surgically treated. T-O time indirectly affects the outcomes and avascular necrosis, heterotopic ossification and arthritis bring on negative effects only on long term outcomes. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: H.Ö., U.B., O.C; Design: H.Ö., U.B.; Supervision: H.Ö.; Materials: H.Ö., U.B.; Data: H.Ö., U.B., O.C., A.C.; Analysis: H.Ö., U.B., O.C., A.C.; Literature search: H.Ö., U.B., O.C., A.C.; Writing: H.Ö., U.B., O.C., A.C.; Critical revision: H.Ö., U.B., O.C., A.C. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

REFERENCES 1. Letournel E, Judet R. Surgical approaches to the acetabulum. In: Elson RA, editor. Fractures of the Acetabulum. Berlin, Heidelberg: Springer; 1993. p. 363−97. 2. Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach. A 10-year perspective. Clinical Orthopaedics and Related Research 1994;305:10−9. 3. Stannard JP, Alonso JE. Controversies in acetabular fractures. Clin Orthop Relat Res 1998;353:74–80. 4. Alonso JE, Davila R, Bradley E. Extended iliofemoral versus triradiate approaches in management of associated acetabular fractures. Clin Orthop Relat Res 1994;305:81–7. 5. Tile M. Fracture of the acetabulum. In: Rockwood CA, Green DP, editors. Rockwood and Green’s fractures in adults. 4th ed. Philadelphia: Lippincott-Raven; 1996. p. 1617−58. 6. Judet R, Judet J, Letournel E. Fractures of the Acetabulum: Classification and Surgical Approaches for Open Reduction. Preliminary Report. JBJS American Vol 1964;46:1615−46. 7. Qadir RI, Bukhari SI. Outcome of Operative Treatment of Acetabular Fractures: Short Term Follow-Up. J Ayub Med Coll Abbottabad 2015;27:287−91. 8. Ghalambor N, Matta JM, Bernstein L. Heterotopic ossification following operative treatment of acetabular fracture. An analysis of risk factors. Clin Orthop Relat Res 1994;305:96–105. 9. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the

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injury. J Bone Joint Surg Am 1996;78:1632–45. 10. Johnson EE, Matta JM, Mast JW, Letournel E. Delayed reconstruction of acetabular fractures 21-120 days following injury. Clin Orthop Relat Res 1994;305:20–30. 11. Nixon JR. Late open reduction of traumatic dislocation of the hip. Report of three cases. J Bone Joint Surg Br 1976;58:41–3. 12. Rowe CR, Lowell JD. Prognosis of fractures of the acetabulum. JBJS 1961;43:30−59. 13. Kınık H. Asetabulum Kırıkları. TOTBİD Derg 2002;1:45−59. 14. Letournel E. The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat Res 1993;292:62–76. 15. Matta JM, Anderson LM, Epstein HC, Hendricks P. Fractures of the acetabulum. A retrospective analysis. Clin Orthop Relat Res 1986;205:230–40. 16. Rickman M, Varghese VD. Contemporary acetabular fracture surgery: treading water or swimming upstream?. Bone Joint J 2017;99-B:1125– 31. 17. McDowell S, Mullis B, Knight BS, Dahners LE. Modified Ollier transtrochanteric approach for the treatment of acetabular fractures. Orthopedics 2012;35:e132–6. 18. Matta JM, Merritt PO. Displaced acetabular fractures. Clin Orthop Relat Res 1988;230:83–97. 19. Routt ML Jr, Swiontkowski MF. Operative treatment of complex acetabular fractures. Combined anterior and posterior exposures during the same procedure. J Bone Joint Surg Am 1990;72:897–904. 20. Matta JM, Letournel E, Browner BD. Surgical management of acetabular fractures. Instr Course Lect 1986;35:382–97. 21. Suzuki T, Smith WR, Hak DJ, Stahel PF, Baron AJ, Gillani SA, et al. Combined injuries of the pelvis and acetabulum: nature of a devastating dyad. J Orthop Trauma 2010;24:303−8. 22. Johnson EE, Kay RM, Dorey FJ. Heterotopic ossification prophylaxis following operative treatment of acetabular fracture. Clin Orthop Relat Res 1994;305:88–95. 23. Bosse MJ, Poka A, Reinert CM, Ellwanger F, Slawson R, McDevitt ER. Heterotopic ossification as a complication of acetabular fracture. Prophylaxis with low-dose irradiation. J Bone Joint Surg Am 1988;70:1231–7. 24. Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res 1980;151:81–106. 25. Letournel E. Diagnosis and treatment of nonunions and malunions of acetabular fractures. Orthopedic Clin North America 1990;21:769−88. 26. Tipton WW, D’Ambrosia RD, Ryle GP. Non-operative management of central fracture-dislocations of the hip. J Bone Joint Surg Am 1975;57:888–93. 27. Tile M. Fractures of the acetabulum. Rockwood and Green’s fractures in adults. 3rd ed. Philadelphia: Lipincott-Raven; 1991. p. 1442−79. 28. Shon HC, Choi S, Yang JY. Three-dimensional printing-assisted surgical technique with limited operative exposure for both-column acetabular fractures. Ulus Travma Acil Cerrahi Derg 2018;24:369–75.

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Bilekdemir et al. Acetabular fractures treated surgically: Which of the parameters affect prognosis

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Cerrahi olarak tedavi edilen asetabulum kırıkları: Prognozu hangi parametreler etkiler? Dr. Utku Bilekdemir,1 Dr. Osman Civan,2 Dr. Ali Cavit,3 Dr. Hakan Özdemir4 Silifke Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Mersin Elmalı Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Antalya Uludağ Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Bursa 4 Akdeniz Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Antalya 1 2 3

AMAÇ: Çalışmada, cerrahi yöntemlerle tedavi edilen asetabulum kırıklarında uyguladığımız cerrahi yaklaşımları, oluşan komplikasyonları ve elde edilen klinik ve radyolojik sonuçları değerlendirerek prognoz üstünde etkin olan parametreleri saptamak amaçlandı. GEREÇ VE YÖNTEM: Ocak 1994–Ocak 2014 tarihleri arasında deplase asetabulum kırığı tanısıyla cerrahi tedavi uygulanan 144 olgudan, en az iki yıl süreyle klinik ve radyolojik takipleri yapılan (ortalama takip süresi 34 ay, dağılımı 2–8 yıl) ve yaş ortalaması 36.3 yıl (19–67 yıl) olan 75’i erkek, 28’i kadın toplam 103 hasta çalışmaya alındı. BULGULAR: Hastaların klinik olarak %64’ünde mükemmel ve iyi, %36’sında orta ve kötü sonuç, radyolojik olarak ise %57.3’ünde mükemmel ve iyi, %42.7’sinde orta ve kötü sonuç elde edildi. Kırığın kompleks olması (ki-kare p=0.023), travma ile operasyon arası sürenin artması (p=0.039), cerrahi sürenin altı saatten uzun sürmesi (ki-kare p<0.001), eklem içi basamaklaşmanın 3 mm’den fazla olması (Fisher’s p=0.033), mekanik blok oluşturan komplikasyonların gelişmesi (ki-kare p<0.001) klinik sonuçları kötüleştirmekteydi. Hastaların yaşının klinik sonuç üzerine anlamlı etkisi yoktu (p=0.461). TARTIŞMA: Cerrahi olarak tedavi edilen asetabulum kırıklarının prognozuna etki eden üç temel parametrenin; kırık tipi, cerrahi girişim süresi ve redüksiyon kalitesi olduğu, travma ile operasyon arasında geçen sürenin sonuçları dolaylı olarak etkilediği, avasküler nekroz, heterotropik ossifikasyon ve artirtin ise sadece uzun dönem sonuçları üzerinde olumsuz etkiler yarattığı tespit edildi. Anahtar sözcükler: Asetabulum; asetabulum kırıkları; asetabulum kırıkları cerrahi tedavisi; asetabulum kırıkları prognozu; kırıklar; pelvis kırıkları. Ulus Travma Acil Cerrahi Derg 2020;26(2):265-273

doi: 10.14744/tjtes.2019.88472

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ORIGIN A L A R T IC L E

Comparison of caspase-8, granzyme B and cytochrome C apoptosis biomarker levels in orthopedic trauma patients Özhan Pazarcı, M.D.,1

Hüseyin Aydın, M.D.,2

Seyran Kılınç, M.D.1

1

Department of Orthopaedics and Traumatology, Cumhuriyet University Faculty of Medicine, Sivas-Turkey

2

Department of Biochemistry, Cumhuriyet University Faculty of Medicine, Sivas-Turkey

ABSTRACT BACKGROUND: The primary objective of this study was to investigate whether or not apoptosis is induced following bone fracture, and if so, to investigate whether the extrinsic or intrinsic pathway of cell death is stimulated. METHODS: A total of 30 patients who presented at our clinic and were diagnosed with bone fracture following trauma were included in the study group. A control group was formed of 37 age and gender-matched volunteers. On the day after the fracture, blood samples taken from the patients were examined for cytochrome C, granzyme B and caspase-8 with the ELISA method. RESULTS: A total of 67 individuals were evaluated (fracture group: 30, control group: 37) in this study. Caspase-8 was found to be statistically significantly high in the patient group (0.37±0.06 ng/mL, p=0.002). No significant difference was determined between the groups in respect to cytochrome C values (p=0.173). The granzyme B values were determined to be significantly high in the patient group (52.56±8.51 pg/mL, p=0.007). CONCLUSION: These results obtained from patients with a long bone fracture demonstrated that serum caspase-8 and granzyme B levels were higher in patients than in the control group, thereby showing activation of the extrinsic pathway. However, no significant difference was determined between the groups concerning serum cytochrome C levels. This study may guide future studies designed for better understanding of the molecular pathways that govern the events during a fracture, which will be important for the future advancement of fracture treatment. Keywords: Apoptosis; caspase-8; cytochrome C; fracture; granzyme B.

INTRODUCTION Fracture healing stages following trauma are separated into the phases of hematoma, inflammation, and remodelling. However, the healing process that starts in damaged tissue after trauma is more complex than this.[1] Relationships between several different molecules and cellular activities are involved in this process.[2] New cells entering the fracture site, cell proliferation, cell differentiation and cell death are a part of fracture healing.[3] Apoptosis is controlled and selective cell death for the elimination of cells in multi-cellular organisms. Apoptosis has an important role in the elimination

of infected and damaged cells, which are differentiated from normal cells by vital components and have undergone mutation in development and tissue hemostasis.[4] Caspases are the primary enzymes found in the cytoplasm that have an important role in apoptotic cell death. Caspases are members of the cysteine protease family. These proteins are inactive when synthesized and are activated with the occurrence of several cellular and morphological changes during cell death. They are activated by intrinsic or extrinsic pathways, which include events, such as endoplasmic reticulum stress, metabolic stress, excessive reactive oxygen and

Cite this article as: Pazarcı Ö, Aydın H, Kılınç S. Comparison of caspase-8, granzyme B and cytochrome C apoptosis biomarker levels in orthopedic trauma patients. Ulus Travma Acil Cerrahi Derg 2020;26:274-279. Address for correspondence: Özhan Pazarcı, M.D. Cumhuriyet Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, 58000 Sivas, Turkey Tel: +90 346 - 258 06 38 E-mail: dr.pazarci@gmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):274-279 DOI: 10.14744/tjtes.2019.02680 Submitted: 14.05.2019 Accepted: 19.12.2019 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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DNA damage.[5] Caspase-8 is among the activation caspases involved in signal transmission and activating killer caspases. Caspase-8 is a member of the cysteine proteases involved in apoptosis and cytokine processing. As is the case for all caspases, caspase-8 is synthesised when inactive as a zymogen procaspase single polypeptide chain and is activated with proteolytic cleavage.[4] Granzyme B is the most important of the serine proteases stored in natural killer (NK) and cytotoxic T lymphocytes (CTL). Activated T lymphocytes express granzyme B, exposing serine proteases from granulation of cytotoxic T cells, and target cell death is induced.[6] Caspases are granzyme B substrates and their activation leads to cell death with apoptosis. In cell death induced by granzyme B, elimination of the damaged target cell occurs through a mechanism driven by NKs and CTLs.[7] Cytochrome C is a mitochondrial protein providing vital support functions by transferring electrons to the respiratory chain to maintain ATP production. However, during the activation of apoptotic mechanisms, it is expressed from the mitochondria and activates the caspase cascade while in the cytoplasm or in the intrinsic apoptotic pathway, or provides amplification of the extrinsic apoptotic signals.[8] When cytochrome C is expressed from the mitochondria to the cytoplasm, it is an essential mediator of apoptosis. Under normal conditions, this process occurs in response to DNA damage, but because of various mechanisms, it does not function in several cancer cells.[9] While caspase-8 and granzyme B are biomarkers of the extrinsic apoptotic pathway, cytochrome C is a biomarker showing the intrinsic apoptosis pathway. To our knowledge, there have been no previous studies in literature that have shown the above-mentioned apoptosis markers in vivo in patients with bone fracture following trauma. This study aims to investigate whether or not apoptosis is induced following bone fracture, and if so, to investigate whether the extrinsic or intrinsic pathway of cell death is stimulated.

MATERIALS AND METHODS Patients in the study group were selected from the patients who presented at our clinic and were diagnosed with bone fracture caused by trauma. Exclusion criteria were defined as smoking, the use of alcohol or substances, concomitant psychiatric disease, acute or chronic disease (diabetes mellitus, hypertension, chronic renal failure etc) or the presence of a focus of infection. Informed consent was obtained from all the study participants, and approval for this study was granted by the Local Ethics Committee. Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

On the basis of α=0.005, β=0.10, (1-β=0.9), it was deemed necessary to have at least 30 individuals in each group. A total of 30 adult patients were selected at random from the patients requiring surgical treatment for a diagnosis of bone fracture. For each patient in the fracture group, a record was made of the cause of trauma and information about the fracture region, in addition to other blood parameters of Wbc, Hb, Plt and blood glucose. The control group was formed of 37 healthy volunteers, age and gender-matched to the patient group, who had no chronic disease, malignancy, autoimmune disease, or systemic infection. On the first day of hospitalisation, blood samples of approximately 5 ml were taken from the patients. The blood samples of both the patient and control groups were kept at room temperature for 5 mins, then, centrifuged at 4000 rpm for 5 mins. The serum which formed uppermost was withdrawn and portioned into at least two Eppendorf tubes, which were stored at -80˚C until assay. When the number of patients required for this study was reached, all the samples were thawed then assayed in a single session in an ELISA device with human CYCS (cytochrome C), human granzyme B, and human caspase-8 tests (ELISA kits, FineTest® produced by Wuhan Fine Biological Technology, China).

Statistical Analysis Data obtained in the study were analysed statistically using SPSS (vn 22.0 for Windows) software. For data that met parametric assumptions, the Kolmogorov Smirnov test was applied to independent groups to determine the significance between two mean values. When parametric test assumptions were not met, the Mann-Whitney U test was applied. Correlation analysis was applied and in the evaluation of the results obtained, the Chi-square test was used. A value of p<0.05 was accepted as statistically significant.

RESULTS A total of 67 individuals were evaluated, comprising 40 (59.7%) males and 27 (40.3%) females with a mean age of 62.03 years (range, 18–91 years) in the patient group and 61.62 years (range, 25–90 years) in the control group. Fracture localisation distribution was determined as humerus in three (10%) patients, femur in 21 (70%) patients, and tibia in six (20%) patients. The mechanism of trauma was a fall in 23 (76.7%) patients, traffic accident in four (13.3%) patients, and other reasons in 3 (10%) patients. Blood parameters in the patient group were determined as Wbc: 11.26±2.98, Hb: 11.58±1.88, Plt: 246.16±81.06, and non-fasting blood glucose: 122.76±34.83 (Table 1). No significant difference was determined between males and females. Caspase-8 was found to be significantly high in the patient group (p=0.002) (Fig. 1). No significant difference was determined between the groups in respect of cytochrome C 275

PazarcÄą et al. Comparison of caspase-8, granzyme B and cytochrome C apoptosis biomarker levels in orthopedic trauma patients

Table 1. Fracture localisations, mechanisms of trauma, and blood parameter results of the fracture group

n % Mean SD

Fracture localisation Humerus

3 10

Femur

21 70

Tibia

6 20

DISCUSSION Following trauma, several mechanisms are triggered in the body. This study aims to investigate apoptosis in patients with a bone fracture following trauma and to investigate by which pathway apoptosis was activated. The results of this study demonstrated that both granzyme B and caspase-8 levels were higher in patients with long bone fractures than in the control group and no difference was determined be-

Mechanism of trauma Fall

23 76.7

4 13.3

Traffic accident

Other

1.8

3 10

White blood cells

11.26

2.98

Hemoglobin 11.58 1.88

ng/mL

Blood parameters*

1.4

Platelet 246.16 81.06

Postprandial blood glucose

122.76 34.83

SD: Standard deviation. 1.0

values (p=0.173) (Fig. 2). The granzyme B values were determined to be significantly high in the patient group (p=0.007) (Fig. 3, Table 2).

1

Cytochrome C

2

Figure 2. Box plot graph showing serum levels of cytochrome C in the fracture group (1) and the control group (2).

65

0.45

pg/mL

ng/mL

55 0.35

45

0.25

35 1

Caspase-8

1

2

Figure 1. Box plot graph showing serum levels of caspase-8 in the fracture group (1) and the control group (2).

Granzyme B

2

Figure 3. Box plot graph showing serum levels of Granzyme B in the fracture group (1) and the control group (2).

Table 2. Comparison of serum caspase-8, cytochrome C and granzyme B levels between groups

Group

Minimum

Maximum

Mean

Standard deviation

p

Caspase-8 (ng/mL)

Fracture

0.26

0.47

0.37

0.06

0.002

Control 0.23 0.40 0.33

0.04

Cytocrome C (ng/mL)

Fracture

0.18

Control 1.01 2.02 1.37

0.19

Granzyme B (pg/mL)

Fracture

8.51

Control 33.19 62.84 46.67

276

1.13 34.76

1.78 66.09

1.44 52.56

0.173 0.007

8.80

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tween the groups in respect of cytochrome C. In a previous study that examined cell proliferation and apoptosis in a mouse femoral fracture model, it was seen that despite being opposing processes, these two events were coupled in fracture healing.[10] It has been reported that inhibition of apoptosis signal-regulating kinase 1 (ASK1) could be a potential therapeutic option for fracture healing and the prevention of osteoarthritis progression.[11] The data of those studies partly support the findings of the current study. Both previous research and the current study show that apoptosis is a part of the healing processes following trauma or fracture. Although there have been many previous studies on apoptosis during fracture healing, those reports have been in vitro or experimental animal models. The current study was especially designed to compare orthopaedic trauma patients with a control group. Apoptosis is a fundamental biochemical process for the selective and controlled elimination of cells within multicellular organisms.[4] Previous studies have demonstrated that apoptosis plays a critical role during embryonic limb development, skeletal maturation, and adult bone turnover through modelling and remodelling processes, and during fracture healing and bone regeneration. In humans, increased osteocyte apoptosis has been correlated with sites of rapid bone turnover, and osteoblast apoptosis plays an important role in bone development and maintenance.[12] It is estimated that 60–80% of the osteoblasts that originally assemble at the resorption pit die by apoptosis.[13] Moreover, chondrocyte apoptosis is an important event in the transition from cartilage to bone during fracture healing and the growth of long bones.[14] The two major pathways of apoptosis are the extrinsic and intrinsic pathways.[15] The results of the blood samples taken on the first day from the patients with long bone fracture were important in respect of showing that the extrinsic pathway of apoptosis was active. Kim et al.[16] observed high levels of chondrocyte apoptosis following intra-articular fracture, and they suggested that apoptosis inhibition may be effective in the setting of acute trauma to prevent chondrocyte loss. In a study by Li et al.,[10] the relationship between cell proliferation and apoptosis during fracture healing was demonstrated in a mouse femoral fracture model. Cell proliferation and apoptosis were stated to be indispensable components of fracture repair. These findings are consistent with the results obtained in this study. The apoptosis mechanism following musculoskeletal system trauma has not been fully explained.[17] However, apoptosis is known to be a critical part of the pathological and physiological processes in bone, just as it is for all tissues. The apoptotic process is triggered by two pathways; the intrinsic pathway and the extrinsic pathway.[18] Once granzyme B is delivered into the cytosol, it can proteolytically attack different protein substrates and initiate Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

programmed cell death.[6] When granzyme B has entered the cell, it activates apoptotic procaspases, including caspase-8, which is an important regulator of cell viability. [19] Several diseases are associated with aberrant apoptosis. Caspases undertake a key role in osteoblast apoptosis. [18] Cytochrome C is a well-known mitochondrial protein with significant roles within the mitochondria, including in the electron transport chain, antioxidant defenses, and cell death.[20] The function of cytochrome C changes radically when apoptosis starts.[8] By stimulating different pathways, apoptosis affects bone diseases, such as osteoporosis, Paget’s disease, osteoarthrosis, hyperparathyroidism and malignant osteolysis.[18] There has been shown to be an increase in apoptosis following intra-articular fractures or in chondrocytes exposed to high-energy trauma.[21] A good understanding of apoptosis is important to resolve the problems brought by these diseases. The present study is important in respect of showing which pathway was active on the first day after trauma. A better understanding of the mechanism of bone apoptosis is important for bone health and to reduce the effects of aging.[13] The use of anti-apoptotic after muscle injury has been shown to have a positive effect on healing.[22] It is possible that in the future, the intra-operative use of apoptosis inhibitor agents could be a treatment option,[21] such as biphosphonates as anti-apoptotic drugs in the treatment of bone loss.[18] Prevention of osteoblast apoptosis is a crucial mechanism for the anabolic effects of PTH on the bone.[23] In the light of all this information, the results of the blood samples taken from the patients with long bone fractures on the day after the trauma showed that the apoptosis extrinsic pathway was active. Several studies have revealed that apoptosis is an essential process of the human body. However, in this highly sophisticated series of physiological events, as occurs in patients with long bone fractures, the complicated activation processes have not yet been fully understood. Furthermore, this study also highlights the difference in the extrinsic and intrinsic pathways. There were some limitations to this study primarily that this study was conducted in a single centre and small groups were compared. There is a need for further studies of larger patient populations. More importantly, only a single measurement was taken following the trauma. With repeated measurements, changes in the serum levels could be observed, but the surgical treatment and drugs administered could also affect the serum levels of apoptosis markers. Therefore, it was decided to evaluate serum apoptosis marker levels on the first admission and to compare these with a matched control group to determine the serum apoptosis marker levels. The main strength of this study was that, to our knowledge, this is the first in vivo study in the literature to determine serum 277

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apoptosis marker levels in trauma patients in comparison to healthy individuals. Further studies of large cohorts are needed to reach a better level of evidence.

Conclusion The results of this study demonstrated that serum caspase and granzyme levels were higher in patients with long bone fracture, thereby showing the activation of the apoptosis extrinsic pathway. However, no significant difference was determined between the groups concerning serum cytochrome C levels. This study may guide future studies designed to better understand the molecular pathways that govern the events during fracture, which will be important for the future advancement of fracture treatment. Elucidation of these mechanisms and the development of new therapeutic agents to control apoptosis may play an important role in the future of fracture management. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: O.P., H.A.; Design: O.P., H.A.; Supervision: O.P., S.K.; Fundings: O.P., S.K., H.A.; Materials: O.P., S.K.; Data: H.A., O.P.; Analysis: O.P.; Literature search: O.P., S.K.; Writing: O.P.; Critical revision: S.K., H.A. Conflict of Interest: None declared. Financial Disclosure: This study was wholly funded by the authors.

REFERENCES 1. Dimitriou R, Tsiridis E, Giannoudis PV. Current concepts of molecular aspects of bone healing. Injury 2005;36:1392–404. 2. Einhorn TA. The science of fracture healing. J Orthop Trauma 2005;19:S4–6. 3. Bielby R, Jones E, McGonagle D. The role of mesenchymal stem cells in maintenance and repair of bone. Injury 2007;38:S26–32. 4. Kruidering M, Evan GI. Caspase-8 in apoptosis: the beginning of “the end”?. IUBMB Life. 2000;50:85–90. 5. van der Kallen CJ, van Greevenbroek MM, Stehouwer CD, Schalkwijk CG. Endoplasmic reticulum stress-induced apoptosis in the development of diabetes: is there a role for adipose tissue and liver?. Apoptosis 2009;14:1424–34. 6. Abu M, Muhamad M, Hassan H, Zakaria Z, Ali SAM. Proximity coupled antenna with star geometry pattern amc ground plane. ARPN J Eng

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Appl Sci 2016;11:8822–8. 7. Paul S, Lal G. The Molecular Mechanism of Natural Killer Cells Function and Its Importance in Cancer Immunotherapy. Front Immunol. 2017;8:1124. 8. Kulikov AV, Shilov ES, Mufazalov IA, Gogvadze V, Nedospasov SA, Zhivotovsky B. Cytochrome c: the Achilles’ heel in apoptosis. Cell Mol Life Sci 2012;69:1787–97. 9. Morales-Cruz M, Figueroa CM, González-Robles T, Delgado Y, Molina A, Méndez J, et al. Activation of caspase-dependent apoptosis by intracellular delivery of Cytochrome c-based nanoparticles. J Nanobiotechnology 2014;12:33. 10. Li G, White G, Connolly C, Marsh D. Cell proliferation and apoptosis during fracture healing. J Bone Miner Res 2002;17:791–9. 11. Eaton GJ, Zhang QS, Diallo C, Matsuzawa A, Ichijo H, Steinbeck MJ, et al. Inhibition of apoptosis signal-regulating kinase 1 enhances endochondral bone formation by increasing chondrocyte survival. Cell Death Dis 2014;5:e1522. 12. Hock JM, Krishnan V, Onyia JE, Bidwell JP, Milas J, Stanislaus D. Osteoblast apoptosis and bone turnover. J Bone Miner Res 2001;16:975–84. 13. Moriishi T, Maruyama Z, Fukuyama R, Ito M, Miyazaki T, Kitaura H, et al. Overexpression of Bcl2 in osteoblasts inhibits osteoblast differentiation and induces osteocyte apoptosis. PLoS One 2011;6:e27487. 14. Lee FY, Choi YW, Behrens FF, DeFouw DO, Einhorn TA. Programmed removal of chondrocytes during endochondral fracture healing. J Orthop Res 1998;16:144–50. 15. Schultz DR, Harrington WJ Jr. Apoptosis: programmed cell death at a molecular level. Semin Arthritis Rheum 2003;32:345–69. 16. Kim HT, Lo MY, Pillarisetty R. Chondrocyte apoptosis following intraarticular fracture in humans. Osteoarthritis Cartilage 2002;10:747–9. 17. Merrick MA. Secondary injury after musculoskeletal trauma: a review and update. J Athl Train 2002;37:209–17. 18. Mollazadeh S, Fazly Bazzaz BS, Kerachian MA. Role of apoptosis in pathogenesis and treatment of bone-related diseases. J Orthop Surg Res 2015;10:15. 19. Haile Y, Simmen KC, Pasichnyk D, Touret N, Simmen T, Lu JQ, et al. Granule-derived granzyme B mediates the vulnerability of human neurons to T cell-induced neurotoxicity. J Immunol 2011;187:4861−72. 20. Mavridou DA, Ferguson SJ, Stevens JM. Cytochrome c assembly. IUBMB Life 2013;65:209–16. 21. Prince DE, Greisberg JK. Nitric oxide-associated chondrocyte apoptosis in trauma patients after high-energy lower extremity intra-articular fractures. J Orthop Traumatol 2015;16:335–41. 22. Stratos I, Li Z, Rotter R, Herlyn P, Mittlmeier T, Vollmar B. Inhibition of caspase mediated apoptosis restores muscle function after crush injury in rat skeletal muscle. Apoptosis 2012;17:269–77. 23. Jilka RL, Weinstein RS, Bellido T, Roberson P, Parfitt AM, Manolagas SC. Increased bone formation by prevention of osteoblast apoptosis with parathyroid hormone. J Clin Invest 1999;104:439–46.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Ortopedik travma hastalarında kaspas-8, granzim B ve sitokrom C apoptoz biyobelirteçlerin düzeylerinin karşılaştırılması Dr. Özhan Pazarcı,1 Dr. Hüseyin Aydın,2 Dr. Seyran Kılınç1 1 2

Cumhuriyet Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Sivas Cumhuriyet Üniversitesi Tıp Fakültesi, Biyokimya Anabilim Dalı, Sivas

AMAÇ: Bu çalışmanın amacı kırık sonrası apoptozisin indüklenip indüklenmediğinin belirlenmesi ve eğer öyleyse ekstrensek ya da intrensek hangi apoptotik yolağın aktif olduğunun gösterilmesidir. GEREÇ VE YÖNTEM: Kliniğimize başvuran ve travma nedeniyle kırık tanısı konulmuş olan 30 kişi, hasta grubu ve hasta grubu ile benzerlik gösteren gönüllülerden oluşan sağlıklı 37 bireyden kontrol grubu oluşturuldu. Kırık sonrası birinci gün hastalardan alınan kanlardan ELISA yöntemi ile sitokrom C, granzim B ve kaspas-8 testleri çalışıldı. BULGULAR: Çalışmaya toplam 67 kişi dahil edildi (kırık grubunda 30, kontrol grubunda 37 kişi). Hasta grubunda ortalalama yaş 62.03 (min: 18, maks: 91), kontrol grubu ortalama yaşı 61.62 (min 25, maks: 90). Kaspas-8 hasta grubunda anlamlı yüksek bulundu 0.37 ng/mL (Std: 0.06), (p=0.002); gruplar arasına sitokrom C ölçüm değerleri arasında fark izlenmedi (p=0.173). Granzim B hasta grubunda anlamlı olarak daha yüksek ölçüldü 52.56 pg/mL (Std: 8.51), (p=0.007). TARTIŞMA: Uzun kemik kırıkları olan hastalarda ekstrensek apoptotik yolak aktivasyonunu gösteren serum kaspas-8 ve granzim B düzeyleri yüksektir. Ancak, serum sitokrom C düzeyleri açısından gruplar arasında anlamlı bir fark bulunamadı. Bu çalışma, kırık sonrası olayları yöneten moleküler yolakların daha iyi anlaşılması için tasarlanacak gelecek çalışmalara rehber olabilir ve kırık tedavisinin gelecekteki ilerlemesi için önemlidir. Anahtar sözcükler: Apoptoz; granzim B; kaspas-8; kırık; sitokrom C. Ulus Travma Acil Cerrahi Derg 2020;26(2):274-279

doi: 10.14744/tjtes.2019.02680

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ORIGIN A L A R T IC L E

Is electromagnetic guidance system superior to a free-hand technique for distal locking in intramedullary nailing of tibial fractures? A prospective comparative study Ahmet Aslan, M.D.,1

Mehmet Nuri Konya, M.D.,2

Anıl Gülcü, M.D.,1

Serdar Sargın, M.D.3

1

Department of Orthopedics and Traumatology, Alanya Alaaddin Keykubat University Faculty of Medicine, Antalya-Turkey

2

Department of Orthopedics and Traumatology, Afyon Health Science University Faculty of Medicine, Afyonkarahisar-Turkey

3

Department of Orthopedics and Traumatology, Balikesir University Faculty of Medicine, Balikesir-Turkey

ABSTRACT BACKGROUND: Intramedullary nailing (IMN) technique is the gold standard for the treatment of closed fractures of the lower extremity long bones. For orthopedic surgeons, one of the most important problems in IMN procedures is the fixation of distal locking screws (DLS). Accurate and rapid placement of DLSs with minimal radiation exposure is crucial. In this study, we aimed to compare the results of two different distal locking methods concerning surgery duration and radiation exposure in patients who underwent osteosynthesis of tibia fractures with IMN. METHODS: In this prospective study, the results of 56 patients who met the inclusion and exclusion criteria from 72 patients were evaluated. Patients were divided into two groups according to the distal screwing method. Group 1 (n=29) comprised patients who used free-hand technique (FHT) for distal locking, while Group 2 (n=27) consisted of patients who used electromagnetic guidance system (EMGS) for distal locking. Demographic and medical data of the patients, duration of surgery time, amount of bleeding, total fluoroscopy counts, the time elapsed for distal locking, the measure of radiation exposure, number of attempts for distal screw locking, incorrect screw placements, complications and follow-up time were recorded. The groups were compared concerning demographic data and clinical results. RESULTS: There was no statistically significant difference between the groups about gender and side (p=0.928 and p=0.432, respectively). The mean age in Group-1 was higher than that of Group-2, and the difference was statistically significant (p=0.012). However, there was no statistically significant difference in length of hospital stay in Group-1 (p=0.140). On the other hand, in Group-2, the number of distal shots, fluoroscopy duration, effective radiation dose and operation duration were lower compared to Group-1, although this difference was not statistically significant (p=0.057, 0.073, 0.058 and 0.056, respectively). Failure was encountered in distal locking during the first attempt in three cases in Group-1 and in two cases in Group-2. Aseptic nonunion was observed in one patient in both groups. CONCLUSION: Both the FHT distal screwing technique and the EMGS distal screwing technique are highly effective methods for distal locking. The duration of operation, the duration of the fluoroscopy and radiation exposure were similar. FHT can be preferred for distal locking in conventional intramedullary nail applications, as it is effective, easy and inexpensive. Keywords: Distal screw locking; intramedullary nailing; radiation exposure; tibial fracture.

INTRODUCTION Intramedullary nailing (IMN) technique is the gold standard for the treatment of closed fractures of the lower extremity

long bones. For orthopedic surgeons, one of the most important problems in IMN procedures is the fixation of distal locking screws (DLS). The placement of the screws can be time-consuming and challenging due to the placement of the

Cite this article as: Aslan A, Konya MN, Gülcü A, Sargın S. Is electromagnetic guidance system superior to a free-hand technique for distal locking in intramedullary nailing of tibial fractures? A prospective comparative study. Ulus Travma Acil Cerrahi Derg 2020;26:280-286. Address for correspondence: Anıl Gülcü, M.D. Alladin Keykubat Üniversitesi Tıp Fakültesi, Alanya Eğitim ve Araştırma Hastanesi, 07100 Alanya, Antalya, Turkey Tel: +90 242 - 513 48 69 E-mail: anilgulcu@gmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):280-286 DOI: 10.14744/tjtes.2020.94490 Submitted: 21.06.2019 Accepted: 19.01.2020 Online: 02.03.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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distal lock holes. Various problems can be encountered in DLS fixation, such as prolongation of the operation time, the lock screw missing the nail, formation of stress points in the bone cortex due to repeated attempts, and radiation exposure due to recurrent fluoroscopy use. For orthopedists dealing with trauma, accurate and rapid placement of DLSs with minimal radiation exposure is crucial. The conventional approach for detecting the correct point when placing DLS involves fluoroscopic free-hand technique (FHT). However, the most important disadvantage of this method is high radiation exposure.[1–4] Therefore, new methods are needed and new guidance systems have been developed to reduce radiation exposure.[5,6] A variety of technological methods have been developed in the treatment of lower extremity long bone fractures with IMN, such as navigation systems, laser marking, computer-aided guiders, and mechanical systems mounted proximally or distally to reduce radiation exposure when locking screws are applied.[7–11] Electromagnetic guidance system (EMGS) is one of the methods developed to solve this problem. There are different results in the literature regarding radiation dose and surgery durations with the use of EMGS in DLS application. There are studies suggesting that DLS reduces operation duration radiation exposure despite studies reporting that it does not make a difference. [4,12] The current literature suggest that the EMGS is a better alternative for distal locking in the IMN procedure.[1,12,13] However, IMNs with EMGSs have the disadvantages of requiring technical skills, having a long learning curve and being uneconomical and unpractical.[2,3] On the other hand, inexpensive and simple FHTs, which reduce radiation exposure in distal screwing, have been described.[2,14] In this study, we aimed to compare the results of FHT and EMGS results of the distal locking method concerning surgery duration and radiation exposure in patients who underwent osteosynthesis of tibia fractures with IMN.

MATERIALS AND METHODS Study Design Local Ethics Committee approval was obtained for this prospective study (B.30.2.AKÜ.0.20.05.04/06-2013/1). The sample of the study consisted of patients who underwent IMN procedure for tibial fractures between January 2013 and January 2015 in Afyonkarahisar State Hospital, Orthopedics and Traumatology Clinics. The results of a total of 53 cases were evaluated according to the exclusion and inclusion criteria from 72 patients. The patients enrolled in this study were informed that their medical records would be used in the scientific study.

Inclusion Criteria 1- Closed tibia fracture cases according to AO/OTA classification,[15] 2- Cases treated with closed carved IMN and underwent FHT or EMGS-assisted distal locking, 3-Patients whose Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

data were recorded during the surgery and followed up for at least one year after the operation.

Exclusion Criteria 1-Proximal and distal femur/tibia fractures, 2-Cases with incomplete skeletal maturation, 3- Old age and osteoporotic cases, 4- Secondary operations due to any complication, 5Morbidly obese patients, 6- Patients with additional trauma affecting the postoperative mobilization were excluded from this study.

Data Collection For the above-mentioned purposes, 1- Demographic and medical information of the patients were recorded, 2- Duration of surgery and the amount of bleeding were recorded. 3-Total duration of fluoroscopy (insertion of the guidewire, confirmation of the nail placement, and distal and proximal screws) and duration of the distal locking (confirmation regarding insertion of the screws, re-insertion in case of incorrect placement), and the radiation dose emitted was measured and recorded, 4- Number of distal screw locking attempts and incorrect screw placement was recorded. 5-Complications and follow-up periods were recorded.

Surgical Technique All surgeries were performed by three surgeons (MNK, SS, AA). All three surgeons had sufficient experience with IMN and osteosynthesis and had previously performed both of the techniques mentioned. Patients who underwent osteosynthesis with IMN were divided into two groups according to the distal locking method used. Following the antiseptic preparations, the knee was flexed to 90–100° in supine position under spinal anesthesia and the tibia was prepared so that it was completely hanging down. A standard parapatellar incision was done, and closed fracture reduction was performed. The length of the nail was determined by the guidewire and the width with the reamer. IMN was performed in an antegrade and carved manner in all cases. Intraoperative rotation and alignment were calibrated according to definitions made by Krettek et al.[16]

Group-1 and Distal Locking Technique Classic intramedullary locked nails (Tıpmed® IM/tibia, Turkey) were used in this group. Distal locking screws were placed using the free hand technique, as described by Aldemir et al.[2] Surgical techniques: 1. Bone centering technique, 2. Malleolar centering technique, 3.Aspiration technique. Control methods: 1. Length measurement by the guidewire, 2. Metallic sound control method. For distal locking, the drill bit was first forwarded to the most-distal hole using the bone centering and medial malleolar centering technique. With the guidewire, it was checked whether the drill bit was in the lock screw hole using length measurement with the guidewire or metallic sound control method. If the drill bit was not in place, the aspiration technique was initiated (Fig. 1a). 281

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(a)

(b)

Figure 1. (a) Insertion of distal locking screws with free-hand method (FHT). (b) Insertion of distal locking screws with electromagnetic guidance (EMGS).

Group-2 and Distal Locking Technique: SpectruM®Tibia (Art Metal, Hungary) electromagnetic tibial IMN was used in this group. This nailing system consists of three parts. The first part contains the computerized control unit, the second part consists of the electromagnetic field producing handheld and the third part contains the sensory probe. Electromagnetic-assisted distal locking screws were placed with the method described in Uruç et al.[5] (and manufacturer’s manual) (Fig. 1b).

Determination of Fluoroscopy Duration Samsung® 03345209 Fluoroscopy equipment was used as a portable imaging device. After starting the distal locking, the number of fluoroscopy shots, radiation exposure measurement and locking time for all screws were compared between the two groups (Table 1).

Measurement of Radiation Exposure During the intramedullary nail application, the settings of the fluoroscopy device were set to 100 kVp and 50mAs. The fluoroscopy device was used by the same trained technician. The exposure dose was measured with NEB.223 RADIACMETER® obtained from the Turkish Civil Defense Directorate. A single shot of the fluoroscopy device lasted an average of two seconds and the radiation dose was 27.3 RA. Fluoroscopy time was calculated by multiplying the total number of shots and the average shooting time (2 sec). The operation time

was calculated as minutes. Using the measurements calculated as microrad ( RA) with NEB.223 RADIACMETER®, the radiation dose emitted first (mGy.m2) was calculated. The effective dose (mSv) was finally calculated. Measurement of radiation exposure were calculated using the methods described in the previous studies.[4,17–20]

Statistical Analysis SPSS 20.0 package program was used to analyze the data. The conformity of the data to the normal distribution was checked using the Kolmogorov-Smirnov test. A chi-squared test was used to compare categorical data between the groups, and the Mann-Whitney U test was used to compare mean values. P<0.05 was considered significant.

RESULTS The results of 56 patients were evaluated. There were 29 patients (10 females/19 males) in Group-1, of whom 17 had a fracture in the right tibia and 12 in the left tibia. In Group-2, there were 27 patients (9 females/18 males), of whom 13 had right tibia fracture and 14 had left tibia fracture. There was no statistically significant difference between the groups concerning gender and side (p=0.928 and p=0.432, respectively, Table 1). The mean age in Group-1 was higher than that of Group-2 and the difference was statistically significant (p=0,012, Table 1). However, there was no statistically significant difference in length of hospital stay in Group-1 (p=0.140,

Table 1. Comparison of the demographic data and clinical outcomes according to groups Parameter Gender (female/male) Side (right/left)

Group I 10/19

Group II

p

9/18

0.928

17/12

13/14

0.432

Age (years)

47.86±9.77

39.56±13.89

0.012

Hospitalization (day)

5.17±2.14

4.44±1.40

0.140

Fluoroscopic shooting number at distal locking

5.79±1.72

4.89±1.76

0.057

Fluoroscopy time (sec.)

53.17±26.56

40.41±25.55

0.073

Operation time (min.)

68.52±8.14

64.63±6.64

0.056

Effective radiation (mSv)

35.94±27.67

22.69±23.15

0.058

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Table 1). On the other hand, in Group-2, the number of distal shots, fluoroscopy duration, effective radiation dose and operation duration were lower compared to Group-1, although this difference was not statistically significant (p=0.057, 0.073, 0.058 and 0.056, respectively, Table 1). A single shot lasted two seconds with the fluoroscopy device we used in the operating room, and the radiation dose was 27.3 RA. Fluoroscopy duration was calculated by multiplying the total number of shots by the mean duration (2 sec). The operation duration was calculated as minutes. Measurements were performed in RA as described in the previous studies [4,17,18] with the device we used; first, the radiation dose (mGy.

(a)

(b)

m2) emitted to the environment was calculated, followed by the effective dose (mSv).

Complications Failure was encountered in distal locking during the first attempt in three cases in Group-1 and in two cases in Group-2. Aseptic nonunion was observed in one patient in both groups. The revision was not performed due to rotation or extremity inequality in any case. There were no neurovascular deficits and compartment syndrome. On the other hand, in the years when this study was carried out, the cost of EM nail was twice as a conventional nail. Some of our cases from Group-1 and 2 are presented in Figures 2 and 3.

(c)

Figure 2. Preoperative anteroposterior-lateral x-ray (a), postoperative anteroposterior-lateral (b) and last follow-up anteroposterior-lateral x-ray (c) images of a surgically treated patient, a 42 years old female, right tibia, from group 1.

(a)

(b)

(c)

Figure 3. Preoperative anteroposterior-lateral x-ray (a), postoperative anteroposterior-lateral (b) and last follow-up anteroposterior-lateral x-ray (c) images of a surgically treated patient, a 22 years old male, left tibia, from group 2.

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DISCUSSION Various technological methods have been developed for intramedullary nailing treatment of lower extremity long bone fractures to reduce radiation exposure when locking screws are applied: navigation systems, laser marking, computeraided guiding and mechanical systems mounted proximally or distally.[7–11] On the other hand, many free hand techniques are known in distal screwing, as described in previous studies. [21] In addition, inexpensive and simple methods that reduce radiation exposure and do not require fluoroscopy have also been described.[2,14] Soni RK et al.[14] reported that 45 of 47 tibial shaft fractures that they operated with an easy, applicable and no-radiation distal locking screw insertion technique showed complete union and no complications occurred during six months of follow-up. Aldemir et al.[2] reported that they operated on 578 tibial fractures without using fluoroscopy with three locking techniques and two control methods, which they described with long years of experience in a very large series, and that failure in the distal locking was seen in only one patient. In our study, patients in Group 1 underwent distal locking with the technique described by Aldemir et al.,[2] and we experienced failure in three of 29 cases at the first attempt. The complete union was achieved in all patients except two cases during at least one year of follow up. The difference from the studies that mentioned above may have resulted from the experience. In long bone fractures of the lower extremities, there are studies indicating that the distal locking method with electromagnetic guidance (EMG) system does not make a difference despite studies reporting that it reduces operative time and radiation exposure.[4–6,12,13] Studies on distal free hand and magnetic locking intramedullary nails have reported different results concerning operative time, duration of fluoroscopy and radiation exposure. Kirousis et al.[18] reported that the mean fluoroscopy duration was 71 seconds (19–141) in whole intramedullary nailing procedure with free hand technique. Levin et al.[22] reported that fluoroscopy-guided free hand-held required 60–307 seconds of fluoroscopy duration for insertion of distal locking screws. Hoffmann et al.[23] reported that they gained 244 seconds of time with electromagnetic navigation system (without ionizing radiation) compared to the free hand fluoroscopy technique. Stathopoulos et al.[6] reported an average distal locking time of 219 seconds (200–250) in tibial fractures using the electromagnetic-assisted computer system (SURESHOTTM). Uruc et al.[5] reported that the electromagnetic-based targeting significantly reduced the fluoroscopy duration and operative time compared to the free hand technique. They reported that the mean operative time in the free hand group was 108 minutes, and the mean duration of the fluoroscopy was 47.77 seconds, while in the EMG group, the mean operative time was 80.96 minutes, and the mean duration of fluoroscopy was 22.59 seconds. 284

In our study, we could not find a significant difference concerning duration of fluoroscopy use, radiation dose and operative time in tibial fractures between electromagnetic nailing and nailing by the free-hand method, which we described. In their free hand technique, Aldemir et al.[2] reported failure in only one case in distal screwing. In their comparative study, Suhm et al.[8] reported failure in one case in the group that they used the optoelectronic targeting surgical navigation system (SurgiGATE). Langfitt et al.[24] reported that the EM-assisted system was more rapid than the free hand technique in the IMN operations of the tibia and femur fractures and resulted in fewer screw problems. Uruc et al.[5] reported no failure of free hand technique and EM- assisted distal screwing in any of the patients. Dursun et al.[25] reported that the magnetic locking system was as accurate as the standard hand technique for distal locking during tibial intramedullary nailing, and no failure in distal screwing was encountered in both groups. In our study, failure was encountered at the first attempt in distal screwing in three cases in Group-1 and in 2 cases in Group-2. As discussed above, current literature suggests that the EM technique is a better alternative for distal locking in the intramedullary nailing procedure.[1,12,13] However, devices accompanying the EMG-assisted distal screwing systems have the disadvantages of requiring technical skills, a long learning curve, and being uneconomic and unpractical.[2,3] The results of our study showed no difference between the EMG and FHM in tibia fractures. In addition, the price of EMK nails was twice as expensive as the conventional nail at the time of our study. In the literature, the effective dose detected during intramedullary nailing in several studies has been reported between 2.5 and 87.6 microSv.[18,26–30] In our study, the mean effective radiation dose was 35.94 in Group-1 and 22.69 in Group-2. The difference between the groups was not significant. The effective radiation doses in both groups were consistent with the literature. Moreover, when evaluated cumulatively, they were not high enough to affect human health.

Strengths and Limitations of this Study Although there are similar comparative studies,[5,8,12,13] the free hand technique described in the studies is different. On the other hand, the study of Aldemir et al.[2] which we used the free hand technique’s, is not comparative and it was written in Turkish. Therefore, we believe that our results regarding a simple, inexpensive, accessible technique described in our country with a comparative study will contribute to the literature. The inadequacy of the number of cases and the Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

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lack of homogeneous distribution among the groups can be considered as the limitations of our study.

Conclusion Both the FHT distal screwing technique and the EMGS distal screwing technique are highly effective methods for distal locking. The duration of operation, the duration of the fluoroscopy use and radiation exposure were similar. FHT can be preferred for distal locking in conventional intramedullary nail applications, as it is effective, easy and inexpensive. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: A.A.; Design: A.A.; Supervision: A.A., M.N.K., S.S.; Fundings: A.A., M.N.K., S.S., A.G.; Materials: M.N.K., S.S., A.G.; Data: A.A., M.N.K., S.S.; Analysis: A.A., A.G.; Literature search: S.S., A.G.; Writing: A.A., S.S., A.G.; Critical revision: A.A., M.N.K. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Zhu Y, Chang H, Yu Y, Chen W, Liu S, Zhang Y. Meta-analysis suggests that the electromagnetic technique is better than the free-hand method for the distal locking during intramedullary nailing procedures. Int Orthop 2017;41:1041–8. 2. Aldemir C, Doğan A, İnci F, Sertkaya Ö, Duygun F. Distal locking techniques without fluoroscopy in intramedullar nailing. Eklem Hastalik Cerrahisi 2014;25:64–9. 3. Whatling GM, Nokes LD. Literature review of current techniques for the insertion of distal screws into intramedullary locking nails. Injury 2006;37:109–19. 4. Konya MN, Kaya ÖA. Can radiation exposure be reduced in the treatment of femur fractures with the Intrameduller nail? Acta Med Alanya 2017;1:22−3. 5. Uruc V, Ozden R, Dogramacı Y, Kalacı A, Dikmen B, Yıldız OS, et al. The comparison of freehand fluoroscopic guidance and electromagnetic navigation for distal locking of intramedullary implants. Injury 2013;44:863−6. 6. Stathopoulos I, Karampinas P, Evangelopoulos DS, Lampropoulou-Adamidou K, Vlamis J. Radiation-free distal locking of intramedullary nails: evaluation of a new electromagnetic computer-assisted guidance system. Injury 2013;44:872–5. 7. Abdlslam KM, Bonnaire F. Experimental model for a new distal locking aiming device for solid intramedullary tibia nails. Injury 2003;34:363–6. 8. Suhm N, Messmer P, Zuna I, Jacob LA, Regazzoni P. Fluoroscopic guidance versus surgical navigation for distal locking of intramedullary implants. A prospective, controlled clinical study. Injury 2004;35:567–74. 9. Malek S, Phillips R, Mohsen A, Viant W, Bielby M, Sherman K. Computer assisted orthopaedic surgical system for insertion of distal locking screws in intra-medullary nails: a valid and reliable navigation system. Int J Med Robot 2005;1:34–44. 10. Zirkle LG Jr, Shearer D. SIGN technique for retrograde and antegrade approaches to femur. Tech Orthop 2009;24:247−52.

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11. Ricci WM, Russell TA, Kahler DM, Terrill-Grisoni L, Culley P. A comparison of optical and electromagnetic computer-assisted navigation systems for fluoroscopic targeting. J Orthop Trauma 2008;22:190–4. 12. Han B, Shi Z, Fu Y, Ye Y, Jing J, Li J. Comparison of free-hand fluoroscopic guidance and electromagnetic navigation in distal locking of femoral intramedullary nails. Medicine (Baltimore) 2017;96(:e7450. 13. Moreschini O, Petrucci V, Cannata R. Insertion of distal locking screws of tibial intramedullary nails: a comparison between the free-hand technique and the SURESHOT™ Distal Targeting System. Injury 2014;45:405–7. 14. Soni RK, Mehta SM, Awasthi B, Singh JL, Kumar A, Thakur L, et al. Radiation-free Insertion of Distal Interlocking Screw in Tibial and Femur Nailing: A Simple Technique. J Surg Tech Case Rep 2012;4:15−8. 15. Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma 2018;32 Suppl 1:S1–S170. 16. Krettek C, Miclau T, Grün O, Schandelmaier P, Tscherne H. Intraoperative control of axes, rotation and length in femoral and tibial fractures. Technical note. Injury 1998;29 Suppl 3:C29–C39. 17. Müller MC, Welle K, Strauss A, Naehle PC, Pennekamp PH, Weber O, et al. Real-time dosimetry reduces radiation exposure of orthopaedic surgeons. Orthop Traumatol Surg Res 2014;100:947−51. 18. Kirousis G, Delis H, Megas P, Lambiris E, Panayiotakis G. Dosimetry during intramedullary nailing of the tibia. Acta Orthop 2009;80:568–72. 19. Ehlinger M, Dillman G, Czekaj J, Adam P, Taglang G, Brinkert D, et al. Distal targeting device for long Gamma nail(®). Monocentric observational study. Orthop Traumatol Surg Res 2013;99:799−804. 20. Lee YS, Lee HK, Cho JH, Kim HG. Analysis of radiation risk to patients from intra-operative use of the mobile X-ray system (C-arm). J Res Med Sci 2015;20:7–12. 21. Tyropoulos S, Garnavos C. A new distal targeting device for closed interlocking nailing. Injury 2001;32:732–5. 22. Levin PE, Schoen RW Jr, Browner BD. Radiation exposure to the surgeon during closed interlocking intramedullary nailing. J Bone Joint Surg Am 1987;69:761–6. 23. Hoffmann M, Schröder M, Lehmann W, Kammal M, Rueger JM, Herrman Ruecker A. Next generation distal locking for intramedullary nails using an electromagnetic X-ray-radiation-free real-time navigation system. J Trauma Acute Care Surg 2012;73:243–8. 24. Langfitt MK, Halvorson JJ, Scott AT, Smith BP, Russell GB, Jinnah RH, et al. Distal locking using an electromagnetic field-guided computer-based real-time system for orthopaedic trauma patients. J Orthop Trauma 2013;27:367−72. 25. Dursun M, Kalkan T, Aytekin MN, Celik I, Uğurlu M. Does the magnetic-guided intramedullary nailing technique shorten operation time and radiation exposure?. Eur J Orthop Surg Traumatol 2014;24:1005–11. 26. Muzaffar TS, Imran Y, Iskandar MA, Zakaria A. Radiation exposure to the surgeon during femoral interlocking nailing under fluoroscopic imaging. Med J Malaysia 2005;60 Suppl C:26–9. 27. Blattert TR, Fill UA, Kunz E, Panzer W, Weckbach A, Regulla DF. Skill dependence of radiation exposure for the orthopaedic surgeon during interlocking nailing of long-bone shaft fractures: a clinical study. Arch Orthop Trauma Surg 2004;124:659–64. 28. Fuchs M, Schmid A, Eiteljörge T, Modler M, Stürmer KM. Exposure of the surgeon to radiation during surgery. Int Orthop 1998;22:153–6. 29. Coetzee JC, van der Merwe EJ. Exposure of surgeons-in-training to radiation during intramedullary fixation of femoral shaft fractures. S Afr Med J 1992;81:312–4. 30. Kim KP, Miller DL, Berrington de Gonzalez A, Balter S, Kleinerman RA, et al. Occupational radiation doses to operators performing fluoroscopically-guided procedures. Health Phys 2012;103:80−99.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Tibia kırıklarının intramedüller çivilemesinde, distal kilitleme için elektromanyetik yönlendirme sistemi, serbest el tekniğinden üstün müdür? İleriye yönelik karşılaştırmalı bir çalışma Dr. Ahmet Aslan,1 Dr. Mehmet Nuri Konya,2 Dr. Anıl Gülcü,1 Dr. Serdar Sargın3 1 2 3

Alanya Alaaddin Keykubat Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Antalya Afyon Sağlık Bilimleri Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Afyonkarahisar Balıkesir Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Balıkesir

AMAÇ: İntramedüller çivileme (İMÇ) tekniği, alt ekstremite uzun kemiklerinin kapalı kırıklarının tedavisinde altın standarttır. Ortopedik cerrahlar için İMÇ prosedürlerindeki en önemli sorunlardan biri distal kilitleme vidalarının (DKV) yerleştirilmesidir. DKV’ların en az radyasyona maruz kalma ile doğru ve hızlı bir şekilde yerleştirilmesi çok önemlidir. Bu çalışmada, tibia kırıklarında İMÇ ile osteosentez uygulanan hastalarda ameliyat süresi ve radyasyon maruziyeti açısından iki farklı distal kilitleme yönteminin sonuçlarını karşılaştırmayı amaçladık. GEREÇ VE YÖNTEM: İleriye yönelik yapılan bu çalışmada toplamda 72 hastadan dahil etme ve dışlama kriterlerini karşılayan 56 olgunun sonuçları değerlendirildi. Hastalar distal vidalama yöntemine göre iki gruba ayrıldı. Grup-1 (n=29) distal kilitleme için serbest el tekniği (SET) kullanılan hastaları, Grup-2 (n=27) distal kilitleme için elektromanyetik yönlendirme sistemi (EMYS) kullanılan hastaları içeriyordu. Hastaların demografik ve tıbbi bilgileri, ameliyat süreleri, kanama miktarları, toplam floroskopi süreleri, distal kilitleme için geçen süreler, maruz kalınan radyasyon dozu ölçümleri, distal vida kilitleme için teşebbüs sayıları, hatalı vida yerleşimleri, komplikasyonlar ve takip süreleri kaydedildi. Gruplar demografik veriler ve klinik sonuçlar açısından karşılaştırıldı. BULGULAR: Gruplar arasında cinsiyet ve taraf açısından istatistiksel olarak anlamlı fark yoktu (sırasıyla, p=0.928 ve p=0.432). Grup 1’deki yaş ortalaması Grup-2’den daha yüksekti ve fark istatistiksel olarak anlamlı idi (p=0.012). Ancak, Grup-1’de hastanede kalış süresi açısından istatistiksel olarak anlamlı bir fark yoktu (p=0.140). Diğer taraftan Grup-2’de distal atım sayısı, floroskopi süresi, etkili radyasyon dozu ve operasyon süresi Grup-1’e göre daha düşüktü, ancak bu fark istatistiksel olarak anlamlı değildi (sırasıyla, p=0.057, 0.073, 0.058 ve 0.056). Grup-1’deki üç olguda ve Grup-2’deki iki olguda ilk denemede distal kilitlemede başarısızlıkla karşılaşıldı. Her iki grupta bir hastada aseptik kaynamama gözlendi. TARTIŞMA: Hem SET hem de EMYS distal vidalama tekniği, distal kilitleme için oldukça etkili yöntemlerdir. Ameliyat süresi, floroskopi süresi ve radyasyona maruz kalma benzerdir. Geleneksel İMÇ uygulamalarındaki distal kilitlemelerde, etkili, kolay ve ucuz olduğu için SET tercih edilebilir. Anahtar sözcükler: Distal vida kilitleme; intramedüller çivileme; radyasyon maruziyeti; tibia kırığı. Ulus Travma Acil Cerrahi Derg 2020;26(2):280-286

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doi: 10.14744/tjtes.2020.94490

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ORIGIN A L A R T IC L E

A bibliometric analysis of publications on trauma in critical care medicine during 1980–2018: A holistic view Onur Karaca, M.D.,1

Cem Emir Güldoğan, M.D.2

1

Depatment of Anesthesiology and Reanimation, Aksaray University Training and Research Hospital, Aksaray-Turkey

2

Department of General Surgery, İstinye University Liv Hospital Ankara, Ankara-Turkey

ABSTRACT BACKGROUND: There is not a holistic bibliometric study evaluating the publications in the literature even though trauma is a paramount subject in the field of critical care. This study aimed to investigate the important articles and journals receiving the most citations and publishing the most articles, revealing international cooperation and uncovering trend topics in this subject as a consequence of analyzing articles on trauma in the field of critical care published between 1980 and 2018 using bibliometric analysis methods. METHODS: Publication scan in this study was performed using Web of Science (WoS) database. Literature review was limited to only publications indexed in the field of Critical Care. “Trauma” was used as the keyword to reach relevant publications. Linear regression analysis was performed to predict the number of articles foreseen to be published in the upcoming years in the subject of trauma. RESULTS: As a result of the literature review, a total of 10851 publications were found. Six thousand four hundred and eighty-nine (59.8%) of these publications were under the category of article. First three countries with the most publications were respectively as the United States of America (4096) (63.1%), Canada (401) and Germany (380). Turkey ranked 21 with 41 publications. The article titled “Evaluating trauma care - the triss method” published in 1987 had received the most citations. The journal with the most publications and citations was “Journal of Trauma Injury Infection and Critical Care”. CONCLUSION: This study will be a useful guide to all scientists and clinicians conducting research on trauma in critical care. Keywords: Bibliometric analysis; critical care; trauma; trends.

INTRODUCTION Trauma can be defined as injury that arises from an acute exposure to mechanic, thermal, electric or chemical energy. [1,2] Trauma maintains a significant health issue rising mortality and morbidity rates with the contribution in technological advancements, accidents and acts of violence. Some studies have indicated that trauma-related deaths rank fifth in all-cause deaths for every age group in the United States of America.[3] Critical care units, which are vital centers to prevent primary and secondary damage infliction at the time of trauma and as a direct result of trauma itself, are multidisciplinary structures dealing with potentially life-threatening diseases and conditions. These units are special with

airway support, mechanical ventilation, current treatment methods, efficient application of drugs, and monitorization techniques.[4] Bibliometry can be defined as a holistic analysis of written publications like books or articles using various statistical methods.[5,6] Parallel to the gradual increase in the number of publications on worthy databases, such as Web of Science, Pubmed, and Scopus, the value of bibliometric analyses ensuring the evaluation of the publications holistically rises every passing day.[7,8] The most impactful publications, institutions, active journals, international cooperation and trend topics in one subject are revealed, and these studies act as a guide to researchers.[9–10] Thanks to bibliometric studies, researchers

Cite this article as: Karaca O, Güldoğan CE. A bibliometric analysis of publications on trauma in critical care medicine during 1980–2018: A holistic view. Ulus Travma Acil Cerrahi Derg 2020;26:287-295. Address for correspondence: Onur Karaca, M.D. Aksaray Üniversitesi Eğitim ve Araştıma Hastanesi, Anesteziyoloji Anabilim Dalı, 68200 Aksaray, Turkey Tel: +90 382 - 212 91 09 E-mail: asalkaraca@gmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):287-295 DOI: 10.14744/tjtes.2020.61595 Submitted: 07.02.2020 Accepted: 28.02.2020 Online: 04.03.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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can access information on a subject in a short time through these studies summarizing the literature.[11]

(59.8%) of these publications were indexed under the category of article, 2194 (20.2%) under meeting abstracts, 1502 (13.8%) under proceedings papers, 1124 (10.3%) under editorial materials, 460 (4.2%) under reviews, and 634 (6%) under other categories (such as letter, book chapter, book review, note, correction, discussion, biographical item). Only 6489 papers published under the category of the article were downloaded through WoS and analyzed using bibliometric methods.

There is not a holistic bibliometric study evaluating the publications in the literature although trauma is a paramount subject in the field of critical care. This study aimed to investigate the important articles and journals receiving the most citations and publishing the most articles, revealing international cooperation and uncovering trend topics in this subject in consequence of analyzing articles on trauma in the field of critical care published between 1980 and 2018 using bibliometric analysis methods.

Ninety-eight point seventy-five percent (n=6408) of the articles were published in English and the rest of the articles was published in other languages (German: n=55, Spanish: n=25, Turkish: n=1). Six thousand four hundred and eighty-nine publications received 195429 citations in total. Mean citation count per article was 30. The h-index value of all articles was 144.

MATERIALS AND METHODS Publication scan in this study was addressed using the Web of Science (WoS) database. Literature review was limited to only publications indexed in the field of Critical Care. “Trauma” was used as the keyword to reach relevant publications (Title: (trauma) Refined by Web of Science Categories: (Critical Care Medicine) Timespan: 1975–2018. Indexes: SCI-Expanded, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI).

Active Institutions The highest number of publications was produced in the following institutions: Washington University (n=238), Maryland University (n=195), Pittsburgh University (n=165), Toronto University (n=154), California San Francisco University (n=140), and Colorado University (n=140). Our most active institutions in Turkey were Ankara Numune Training and Research Hospital (n=5) and Selcuk University (n=5), respectively.

Bibliometric analyses and network visualization were performed using VOSviewer (Version 1.6.10) package program. [12] “Gunn Map” (http://lert.co.nz/map/) online world map was used to show the publication distribution of world countries. SPSS (Version 22.0, SPSS Inc., Chicago, IL, ABD, License: Hitit University) program was used for statistical analyses. Data distribution was evaluated using the Shapiro-Wilk test. Linear regression analysis was performed to predict the number of articles foreseen to be published in the upcoming years in the subject of trauma. P<0.05 was accepted as statistically significant.

Active Authors The first five authors contributing vastly to the literature concerning publication number were found respectively as follows: Moore EE. (n=124), Inaba K. (n=97), Demetriades D. (n=93), Scalea TM. (n=84), and Jurkovich GJ. (n=81). The most active writers in Turkey Ustun M. E. (n=5), followed by Duman A. (n=4) and Gurbilek M (n=4), respectively.

Distribution of the Publications According to Years

RESULTS

Figure 1 shows the distribution of the articles published on trauma according to years. 5-year (2019–2023) publication prediction numbers obtained by linear regression analysis are

As a result of the literature review, a total of 10851 publications were found. Six thousand four hundred and eighty-nine Number of publications

Estimated value

Lower confidence limit

Upper confidence limit

450 400 349

350 313

Number of articles

309

300

270

200

177 174

150

142 118 121

100

99

86 61

0

240

217

41

1980

43

39

1982

37

43

1984

46

1986

106

115

154

189 175

191 187

311

290

289 254

250

50

312

270

267

274

366

357

326

319 280

287

374

334

293

383

341

300

245 227

197

145

122 124

54

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

2016

2018

2020

2022

Years

Figure 4. Distribution of the articles on trauma in critical care according to years.

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also given in Figure 1. It was predicted that there would be 311 articles published in 2019 (95% CI: 274–349) and 341 articles (95% CI: 300–383) published in 2022.

Articles Receiving Most Citations The first 15 articles on trauma receiving the most citations are given in Table 1. In Turkey, the most cited study with a

total of 61 citations was “Prospective study investigating routine usage of ultrasonography as the initial diagnostic modality for the evaluation of children sustaining blunt abdominal trauma” that was published by Akgür et al.

Active Countries The country with the highest number of publications was

Table 1. The 15 most cited manuscripts on trauma in critical care medicine No Article

Author

1

Boyd, CR. et al.

Evaluating trauma care - the triss method

2

Epidemiology of trauma deaths - a reassessment

Sauaia, A. et al.

3

A revision of the trauma score

Champion, HR. et al.

4

The major trauma outcome study - establishing

national norms for trauma care

Champion, HR. et al.

5

Early coagulopathy predicts mortality in trauma

MacLeod, JBA. et al.

Journal Journal of Trauma-Injury

PY TC AC 1987 1338 40,55

Infection and Critical Care Journal of Trauma-Injury

1995 1193 47,72

Infection and Critical Care Journal of Trauma-Injury

1989 1134 36,58

Infection and Critical Care Journal of Trauma-Injury

1990

793 26,43

2003

691 40,65

Infection and Critical Care Journal of Trauma-Injury Infection and Critical Care

6

Trauma score

Champion, HR. et al.

Critical Care Medicine

1981

636 16,31

7

Impact of hemorrhage on trauma outcome:

Kauvar, DS. et al.

Journal of Trauma-Injury

2006

618 44,14

an overview of epidemiology, clinical

presentations, and therapeutic considerations 1989

570 18,39

2005

526 35,07

8

Ten versus tpn following major abdominal-

trauma - reduced septic morbidity

Moore, FA. et al.

9

Recombinant factor via as adjunctive therapy

for bleeding control in severely injured trauma

patients: two parallel randomized, placebo-

controlled, double-blind clinical trials

10

Management of bleeding and coagulopathy

following major trauma: an updated

European guideline

11

The effect of selective decontamination of the

digestive-tract on colonization and

infection-rate in multiple trauma patients

Boffard, KD. et al.

Infection and Critical Care Journal of Trauma-Injury Infection and Critical Care Journal of Trauma-Injury Infection and Critical Care

Spahn, DR. et al.

Critical Care

2013

510 72,86

Stoutenbeek, CP. et al.

Intensive Care Medicine

1984

474 13,17

Journal of Trauma-Injury

1997

471 20,48

2008

460 38,33

Critical Care

2010

458

Journal of Trauma-Injury

2003

437 25,71

12

Prospective study of blunt aortic injury:

multicenter trial of the American

Fabian, TC et al.

association for the surgery of trauma

13

Acute coagulopathy of trauma: hypoperfusion

induces systemic anticoagulation and

Brohi, K. et al.

Infection and Critical Care Journal of Trauma-Injury Infection and Critical Care

hyperfibrinolysis 14

Management of bleeding following major trauma:

an updated European guideline

Rossaint, R. et al.

15

Blood transfusion, independent of shock severity,

is associated with worse outcome in trauma

Malone, DL. et al.

45,8

Infection and Critical Care

PY: Publication Year; TC: Total Citation; AC: Average Citations per Year.

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the United States of America with 4096 publications (63.1%). The United States of America was followed respectively by Canada (401), Germany (380), England (377), Australia (239), the Netherlands (163), France (137), Japan (111), China (103), Italy (96), Austria (82), South Africa (76), Switzerland (76), Israel (75), Sweden (72), Spain (69), Taiwan (56), Norway

(48), Scotland (48), Denmark (44), and Turkey (41). The distribution of the publications according to world countries is shown in Figure 2. Six thousand four hundred and eighty-nine articles were written by authors from 111 world countries. Figure 3 shows the network map of international cooperation among 53 world authors who have at least five publications.

Figure 2. Distribution of the articles on trauma in critical care according to world countries. Footnote: In the indicator given at the bottom left of the figure, productivity increases from green to red.

Figure 3. Network visualization map for international cooperation of world countries publishing articles on trauma in critical care. Footnote: The size of the circle shows a large number of articles. The colors indicate the clusters and the thickness of the lines indicates the strength of the relationship.

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Active Journals

There were a total of 60 journals publishing the highest number of articles on trauma. Table 2 gives the first 35 journals among the 60 publishing at least five articles. Figure 4 demonstrates the citation network map among these journals.

Trend Topics Eight thousand thirty-five keywords were used in 6489 articles. One hundred and seven keywords used at least 20 times are shown in Table 3. The network map obtained as a result of the clustering analysis for these keywords is presented in Figure 5 (Footnote: Indicator shows current publications from blue to red). Figure 6 demonstrates the network map of the trend topics according to the years of the keywords used. Moreover, the network map obtained according to the citation count of the articles with these keywords is given in Figure 7.

DISCUSSION We presented summarized information of 6489 articles published in a long time (1975–2018) on the subject of trauma in critical care in this comprehensive bibliometric study. The

most active institution was determined as the Washington University, and the most actively producing author was found as Moore EE. When the publications were investigated according to years, publication trends that started to increase in 1988 demonstrated a linear increase and have reached approximately 300 articles in recent years. According to the result of the regression analysis, it is seen that research conducted on this subject will increase every passing day. The articles receiving the most citations on this subject were that of Boyd et al. titled “Evaluating trauma care - the triss method” published in 1987 in the Journal of Trauma-Injury Infection and Critical Care and that of Sauaia et al. titled “Epidemiology of trauma deaths - a reassessment” published in 1995. Furthermore, salient studies as regards mean citation count were that of Spahn et al. (2013) titled “Management of bleeding and coagulopathy following major trauma: an updated European guideline” and that of Rossaint et al. (2010) titled “Management of bleeding following major trauma: an updated European guideline”. We are of the opinion that these are studies that should be primarily read by researchers interested in this subject.

Table 2. Active journals on trauma in critical care medicine Journals Journal of Trauma Injury Infection

RC % C Journals

RC % C

3109

47.9

131167

Anaesthesia and Intensive Care

18

0.2

266

962

14.8

14253

Pediatric Critical Care Medicine

17

0.2

354

908

13.9

12791

Essentials of Trauma Anesthesia

15

0.2

9

Shock

225

3.4

6660

Indian Journal of Critical Care Medicine

14

0.2

18

Critical Care Medicine

211

3.2

9748

Neurocritical Care

13

0.2

120

Journal of Neurotrauma

147

2.2

4595

Anasthesiologie Intensivmedizin

12

0.1

8

Journal of Trauma Nursing

137

2.1

364

Minerva Anestesiologica

12

0.18

100

Intensive Care Medicine

90

1.3

3651

Critical Care Nurse

11

0.17

50

Critical Care

86

1.3

4971

American Journal of Respiratory

9

0.13

729

and Critical Care Injury International Journal of The Care of the Injured Journal of Trauma and Acute Care Surgery

And Critical Care Medicine

Resuscitation

75

1.1

2004

Journal of Acute Disease

9

0.13

3

Critical Care Clinics

55

0.8

553

Trauma Critical Care and Surgical Emergencies

9

0.13

3

A Case and Evidence-Based Textbook

Journal of Critical Care

48

0.7

537

European Manual of Medicine

8

0.12

10

Burns

45

0.6

507

General Trauma Care And Related Aspects

8

0.12

10

Trauma Surgery II

Anasthesiologie Intensivmedizin

40

0.6

143

American Journal of Critical Care

7

0.10

72

Current Trauma Reports

40

0.6

37

Annals of Intensive Care

7

0.10

54

Chest

32

0.4

1204

Anaesthesia Critical Care Pain Medicine

6

0.09

20

Medicina Intensiva

27

0.4

164

Journal of Intensive Care Medicine

5

0.07

14

Journal of Burn Care Research

20

0.3

167

Notfallmedizin Schmerztherapie

RC: Record Count; C: Number of Citation.

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Figure 4. Network visualization map for citation analysis of active journals publishing articles on trauma in critical care. Footnote: The size of the circle shows a large number of articles. The colors indicate the clusters and the thickness of the lines indicates the strength of the relationship.

Figure 5. Clustering network visualization map for keyword analysis used in articles on trauma in critical care. Footnote: Indicator shows current publications from blue to red.

When the countries producing publications were assessed, economically developed countries were found to be more efficient. A significant correlation between academic productivity and economic development has been shown in many studies 292

in the literature.[7,8,10] Dokur et al.[13] (2018) have indicated in a bibliometric study determining the 100 most cited articles in traumatology that 70 of the first 100 cited articles were supported by institutions providing funds. We are of the opinion Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Karaca et al. A bibliometric analysis of publications on trauma in critical care medicine during 1980–2018: A holistic view

Table 3. The first 107 trend keywords on trauma in critical care medicine Keyword

O Keyword

O Keyword

O Keyword

O

trauma

1367 trauma centers

56

hypothermia

30

damage control

23

mortality

259

trauma system

56

blood transfusion

29

geriatric

23

outcome

153

transfusion

53

brain injury

29

length of stay

23

injury

121

complications

52

cervical spine

29

prehospital care

23

outcomes

121

prehospital

52

mechanical ventilation

29

rat

23

resuscitation

115

blunt abdominal trauma

51

multiple organ failure

29

rehabilitation

23

traumatic brain injury

112

cytokines

49

pulmonary embolism

29

severe trauma

23

blunt trauma

97

trauma registry

47

screening

29

trauma patients

23

multiple trauma

95

head injury

46

acute respiratory

28

burns

22

28

emergency medicine

22

distress syndrome trauma systems

87

penetrating trauma

45

survival

computed tomography

85

alcohol

43

injury severity score

28

laparotomy

22

coagulopathy

79

children

41

intensive care unit

27

pulmonary contusion

22

hemorrhage

78 polytrauma

41 lactate

27 ct scan

shock

76

ultrasound

40

abdominal trauma

26

deep venous thrombosis 21

21

critical care

72

ventilator-associated

39

quality of life

26

education

25

fracture

21

25 pediatrics

21

21

pneumonia Äąnjury

72

sepsis

68 quality improvement

emergency medical services 37

ards

37 atls

pediatric

66

major trauma

36

geriatric trauma

25

penetrating

21

pediatric trauma

66

trauma care

36

hypotension

25

prognosis

21

triage

65

venous thromboembolism

36

morbidity

25

trauma surgery

21

wounds and injuries

65

head trauma

35

pelvic fracture

25

Äąss

21

trauma center

60

blunt chest trauma

34

performance improvement

25

base deficit

20

elderly

57

risk factors

34

acute lung injury

24

infection

20

epidemiology

57

surgery

33

injury severity score

24

intensive care

20

hemorrhagic shock

57

critical illness

32

multiple injuries

24

pregnancy

20

inflammation

57 pneumonia

32 trauma outcomes

24 training

massive transfusion

56

32

24

thoracic trauma

triss

20

O: Number of occurrences.

that the contribution of South Africa and Turkey, two developing countries, is related to the high rate of trauma prevalence in these countries. Especially from developing countries, it has been determined that Turkey was not involved in the first twenty countries. Considering international cooperation, regional cooperation was found to be made geographically. Active journals producing the most publications were determined as the Journal of Trauma Injury Infection and Critical Care, Injury International Journal of The Care of the Injured and the Journal of Trauma and Acute Care Surgery. However, impactful journals receiving citations were as follows: Trauma Injury Infection and Critical Care, Critical Care Medicine, Critical Care, Intensive Care Medicine, Chest, and American Journal of Respiratory and Critical Care Medicine. Researchers wishing to publish studies in this subject are advised to consider these journals. Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

The results of keyword analysis revealed that although subjects, such as brain injury, head injury, and chest injury, were studied in first years, subjects, such as cytokines, acute respiratory distress syndrome, pneumonia, pulmonary embolism, inflammation, and hemorrhagic shock, were researched in subsequent years, and trend topics in recent years were determined to be outcomes, geriatric trauma, quality improvement, education, venous thromboembolism, transfusion, and coagulopathy. Outcomes and transfusion subjects preserved their significance in all years. Topics with the highest citation rates were detected as transfusion, coagulopathy, hemorrhage and ultrasound. Our study is the first comprehensive bibliometric study conducted on this subject. Literature review put forth that Zhang et al.[14] (2018) have determined at least 2000 cited articles on critical care as a result of the bibliometric analyses they con293

Karaca et al. A bibliometric analysis of publications on trauma in critical care medicine during 1980–2018: A holistic view

ducted. Li et al.[15] (2018) have determined the most cited 100 articles on Severe Traumatic Brain Injury in their bibliometric study. In this study, all articles published between 1980 and 2018 on the subject of trauma in the field of critical care were analyzed and the publications were evaluated holistically with

analyses, such as international cooperation, journal analyses, and trend topic analyses in addition to citation analyses. A limitation to our study was that only the WoS database was used for article retrieval. Other databases, like PubMed

Figure 6. Network visualization map for trend words of the keywords used in articles on trauma in critical care. Footnote: Indicator shows current publications from blue to red.

Figure 7. Network visualization map for most cited words of the keywords used articles on trauma in critical care. Footnote: The number of citations from blue to red (blue-green-yellow-red) increases.

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and Scopus, were not considered. In analyses conducted with more than one database, there is an issue of including the same articles more than once to the analyses. Moreover, it can be said that WoS is a relatively important database since it indexes articles published in journals with high impact scores.

Conclusion

Summarized information was provided to researchers on trauma in critical care in this study. Bibliometric analyses demonstrated the most important articles cited and the journals receiving citation on the subject “trauma in critical care” and those producing the highest number of publications and indicated international cooperation and trend topics on this subject. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: O.K., C.E.G.; Design: O.K., C.E.G.; Supervision: O.K., C.E.G.; Fundings: O.K., C.E.G.; Materials: O.K., C.E.G.; Data: O.K., C.E.G.; Analysis: O.K., C.E.G.; Literature search: O.K., C.E.G.; Writing: O.K., C.E.G.; Critical revision: O.K., C.E.G. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma 1987;27:370–37. 2. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, et al. Epidemiology of trauma deaths: a reassessment. J Trauma 1995;38:185−93. 3. Adıyaman E, Tokur ME, Mermi Bal Z, Gökmen AN, Koca U. Retro-

spective analysis of trauma patients who were treated and followed in anesthesia intensive care unit. Turk J Intensive Care 2019;17:146–53. 4. George WW. Common Clinical Concerns in Critical Care Medicine. In: Butterworth IV JF, Mackey DC, Wasnick JD, editors. Morgan and Mikhail’s Clinical Anesthesiology. 6th ed. New York: McGraw-Hill; 2018 p. 2097−145. 5. Ozsoy Z, Demir E. Correction to: Which Bariatric Procedure Is the Most Popular in the World? A Bibliometric Comparison. Obes Surg 2018;28:2353. 6. Demir E. The Evolution of Spirituality, Religion and Health Publications: Yesterday, Today and Tomorrow. J Relig Health 2019;58:1–13. 7. Doğan G, Kayır S. Global Scientific Outputs of Brain Death Publications and Evaluation According to the Religions of Countries. J Relig Health 2020;59:96–112. 8. Demir E, Comba A. The evolution of celiac disease publications: a holistic approach with bibliometric analysis. Ir J Med Sci 2020;189:267–76. 9. Doğan G, İpek H. The Development of Necrotizing Enterocolitis Publications: A Holistic Evolution of Global Literature with Bibliometric Analysis. Eur J Pediatr Surg 2019 Nov 27. doi:10.1055/s-0039-3400514. [Epub ahead of print]. 10. Demir E, Yaşar E, Özkoçak V, Yıldırım E. The evolution of the field of legal medicine: A holistic investigation of global outputs with bibliometric analysis. J Forensic Leg Med 2020;69:101885. 11. Yıldırım E, Demir E. Comparative bibliometric analysis of fertility preservation. Ann Med Res 2019;26:1622−8. 12. Van Eck NJ, Waltman L. Software survey: VOS viewer, a computer program for bibliometric mapping. Scientometrics 2010;84:523−38. 13. Dokur M, Uysal E. Top 100 cited articles in traumatology: A bibliometric analysis. Ulus Travma Acil Cerrahi Derg 2018;24:294–302. 14. Zhang Z, Van Poucke S, Goyal H, Rowley DD, Zhong M, Liu N. The top 2,000 cited articles in critical care medicine: a bibliometric analysis. J Thorac Dis 2018;10:2437–47. 15. Li L, Ma X, Pandey S, Deng X, Chen S, Cui D, et al. The Most-Cited Works in Severe Traumatic Brain Injury: A Bibliometric Analysis of the 100 Most-Cited Articles. World Neurosurg 2018;113:e82−7.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Yoğun bakım alanında travma konusunda 1980–2018 yılları arasında yapılan yayınların bibliyometrik analizi: Bütünsel yaklaşım Dr. Onur Karaca,1 Dr. Cem Emir Güldoğan2 1 2

Aksaray Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, Aksaray İstinye Üniversitesi Tıp Fakültesi Liv Hospital Ankara, Genel Cerrahi Anabilim Dalı, Ankara

AMAÇ: Yoğun bakım alanında travma konusunun önemli bir yeri olmasına rağmen halen bu konuda literatürdeki yayınların bütünsel olarak değerlendirildiği bir bibliyometrik araştırma bulunmamaktadır. Bu çalışmada 1980 ve 2018 yılları arasında yoğun bakım araştırma alanında yayınlanmış travma konusundaki makalelerin bibliyometrik analiz yöntemleri kullanılarak analiz edilmesi sonucunda; en fazla alıntı yapılan önemli makalelerin ve bu konudaki en fazla atıf alan ve yayın üreten dergilerin belirlenmesi, ülkelerarası işbirliklerinin ortaya konulması ve bu konudaki trend konuların ortaya çıkarılması amaçlanmıştır. GEREÇ VE YÖNTEM: Araştırmamızda yayın taraması Web of Science (WoS) veri tabanı kullanılarak gerçekleştirildi. Literatür taraması sadece Yoğun Bakım araştırma alanında indekslenen yayınlarda yapıldı. İlgili yayınlara ulaşmak için arama anahtar kelimesi olarak “trauma” kullanıldı. Travma konusunda gelecek yıllarda yayınlanması öngörülen makale sayısını tahmin etmek amacıyla doğrusal regresyon analizi gerçekleştirildi. BULGULAR: Literatür taraması sonucunda toplam 10.851 yayın bulundu. Bu yayınların 6.489’u (59.8%) makale kategorisinde idi. En fazla yayın yapan ilk üç ülke Amerika Birleşik Devletleri 4.096 (%63.1) Kanada (401) ve Almanya (380) idi. Türkiye 41 yayınla 21. sırada idi. En fazla atıfı 1987 yılında yayınlanan “Evaluating trauma care - the triss method” başlıklı makale almıştı. En fazla yayın üreten ve en çok atıf alan dergi “Journal of Trauma Injury Infection and Critical Care” idi. TARTIŞMA: Bu çalışma yoğun bakımda travma konusunda araştırma yapan klinisyenler ve bilim adamları için faydalı bir rehber olacaktır. Anahtar sözcükler: Bibliyometrik analiz; travma; trendler; yoğun bakım. Ulus Travma Acil Cerrahi Derg 2020;26(2):287-295

doi: 10.14744/tjtes.2020.61595

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ORIGIN A L A R T IC L E

Evaluation of the patients admitted to the pediatric emergency service: Cross-sectional analysis of the pediatric emergency and trauma clinic of a tertiary training hospital in Turkey Ahu Pakdemirli, M.D., Ph.D.,1

Dilek Orbatu, M.D.,2

Emel Berksoy, M.D.3

1

Department of Physiology, University of Health Sciences, Gülhane Facult of Medicine, Ankara-Turkey

2

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

3

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

ABSTRACT BACKGROUND: This study aims to carry out a cross-sectional analysis of the applications during three months to the Pediatric Emergency Service of İzmir University of Health Sciences, Tepecik Training and Research Hospital and determination of demographical features and distribution of cases in line with provided data and planning the positive changes and innovations in the current service and functioning of the Pediatric Emergency Service. METHODS: The file records of 46038 patients between the ages of 0–18 who applied to the University of Health Science, Tepecik Training and Research Hospital Pediatric Emergency Training Clinic between 01.12.2019 and 01.03.2020 were examined retrospectively in this study. RESULTS: A total of 46038 patients (53.6% male) applied to the emergency service. The average age was 7.07 for both genders. In the application, the average age of the patients with a history of trauma was 9.3, whereas the average age of the patients without a history of trauma is 6.7. While 82.7% of the patients was male with no trauma history, 86.9% was female without a history of trauma. When the application diagnoses were examined, the most common diagnosis was Upper Respiratory Infection (58.5%). More than half of the applications were monitored in the emergency observation unit (62.5%). When the patients were evaluated according to age groups, 49.2% of them were the children aged between 1–6. While 10.5% of the applicants were infants, and 38.7% were game children, it was noteworthy that the number of male patients was higher in the 1–6 age group, with 54.7%. There was no trauma in 49.5% of the cases. 78,3% of the cases were applied directly to the Paediatric Emergency. Secondly, 16.6% were to the Green Area-1 and Green Area-2. 98.2% of the cases were applied to the Emergency Service for ambulatory care. The 48.8% of the applications were made out of working hours. 97.6% of the cases were not hospitalized for the treatment and were addressed to home. The average staying period of the hospitalized cases in the Service was 4.53 days. Among applications, seven cases died. CONCLUSION: Most of the patients admitted to pediatric emergency service for non-urgent reasons which can be managed in primary care services. Keywords: Cross-sectional analysis; pediatric emergency; trauma.

INTRODUCTION Emergency Services are the most important departments of the hospitals which the health service are provided for

twenty-four hours without any interruption and with intensive stress for both side and they are the entrance doors and windows of the hospitals which the patients are admitted without any order or any appointment.

Cite this article as: Pakdemirli A, Orbatu D, Berksoy E. Evaluation of the patients admitted to the pediatric emergency service: Cross-sectional analysis of the pediatric emergency and trauma clinic of a tertiary training hospital in Turkey. Ulus Travma Acil Cerrahi Derg 2020;26:296-300. Address for correspondence: Ahu Pakdemirli, M.D., Ph.D. Sağlık Bilimleri Üniversitesi, Gülhane Tıp Fakültesi, Fizyoloji Anabilim Dalı, Keçiören, Ankara, Turkey Tel: +90 312 - 304 20 00 E-mail: ahu@pakdemirli.com Ulus Travma Acil Cerrahi Derg 2020;26(2):296-300 DOI: 10.14744/tjtes.2020.80079 Submitted: 01.03.2020 Accepted: 07.03.2020 Online: 11.03.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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Pakdemirli et al. Evaluation of the patients admitted to the pediatric emergency service

Emergency Service is one of the most exhausting and chaotic units of hospitals concerning working conditions and it needs to continue to provide the best service under these conditions. Especially in training and research hospitals, all medical units have the capacity of serving 24 hours. Moreover, under country conditions, pediatric trauma patients are directly admitted by pediatric emergency service. It is not common for paediatric intensive care and/or paediatric surgery service to be followed and treated within the same hospital. In this sense, our hospital serves as a trauma centre in the Aegean Region as a public hospital that provides the abovementioned services. As our pediatric emergency service is a training and research hospital, patients are oriented to our hospital for various consultations and medical radiological examination or families apply directly apply to our hospital with this awareness. Our hospital takes place on the top, in which patients and their relatives can make a positive or negative decision and complaints are concentrated.[1] Definition of the emergency case, it should be considered as unusual events which happen suddenly, endangers life and/or impair the quality of life and cannot be resolved by patient relatives in a short time. Only injuries: It causes the death of more than five million people in the world every year and millions of people apply to emergency clinics.[2] The number of patients who apply to the paediatric emergency services is increasing even outside working hours. However, because of the nonstop working hours of the emergency services, the patients’ relatives may able to see emergency services as a means of receiving fast care in the hospital.[3–5] The most important features that affect people who apply to the emergency policlinics are the sociocultural level of the patients’ relatives, the closeness of the emergency services centres, the differences of the working conditions and working hours. The situation in pediatric emergency services is the same as in adult emergency services. The increased anxiety level of pediatric patients, their parents, and clinical, seasonal differences in childhood diseases also increase applications to pediatric emergency services. In recent years, because of the effects of changing sociocultural differences in addition to population growth and internal migration, excessive patient density has been observed in emergency services of training and research hospitals, which may lead to inadequacies in health services. [6] When it comes to insufficient service, it should be understood that there are situations will cause patients to wait longer in the emergency room that even more serious patients may have delay in their treatment, decrease in patient satisfaction and decrease in the quality of service and a safe working environment, unwilling-and unavoidable situations, such as inefficiency in staff.[7] Knowing the characteristics of the emergency applications, the frequency and density of the cases and the socio-demographic characteristics of the region served will provide resource data for planning effective service delivery. The three-month cross-sectional analysis of the applications made to the Health Science University, Pediatric Emergency Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Clinic of Tepecik Training and Research Hospital within three months is to plan the changes and innovations that can be made positively in the current service and operation in our pediatric emergency clinic.

MATERIALS AND METHODS The file records of 46038 patients between the ages of 0-18 who applied to the Pediatric Emergency Clinic of Tepecik Training and Research Hospital between 01.12.2019 and 01.03.2020 were examined retrospectively in this study. The demographic and medical information of the patients who applied to the pediatric emergency service were obtained retrospectively from the hospital automation system. ICD-10 diagnostic code system was used for diagnoses. Demographic information, types of application to the hospital, application times, medical diagnoses and results of the procedures (observation, hospitalization) of patients who applied to the pediatric emergency service within the specified time interval were evaluated. In our hospital, the cases are coded according to the International Classification of Disease 10=ICD-10 system. All medical and surgical emergencies, trauma and poisoning cases are accepted to the pediatric emergency service. Our hospital has 24-hour uninterrupted service in radiology, biochemistry and microbiology units serving only for emergency clinics. The research type is cross-sectional. All data obtained from the automation system were analyzed using SPSS 24.0 program. Variables indicated by count were summarized by percentage distribution and variables indicated by measurement were summarized by mean standard deviation, median minimum and maximum values. Chi-square test was used for the analysis of variables indicated by count, and a t-test was used for the variable analysis indicated by measurement. The statistical significance level was accepted as p<0.05. Categorical data were expressed in numbers (n) and percentages (%).

RESULTS According to our records, it was learned that during the last one year, there was an average of 170,000 patient applications to our unit. In a 3-month cross-sectional examination, a toTable 1. Distribution of the patients attending the pediatric emergency clinic concerning gender and age groups

n %

Male

24661 53.6

Female

21377 46.4

Newborn–11 months

2727

5.9

1–6 ages

21703

47.1

7–12 ages

12606

27.4

13–18 ages

9002

19.6

Total

46038 100.0

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Pakdemirli et al. Evaluation of the patients admitted to the pediatric emergency service

tal of 46038 patients (53.6% male, n=24661) applied to the emergency service. The mean age was 7.07 years for both genders (Table 1). The average age of the patients with a history of trauma in their application was 9.3, while without was 6.7. Among the cases, 82.7% of male cases, and 86.9% of female cases were with no trauma history. The most common diagnosis was Upper Respiratory Tract Infection (58.5%, n=25506) (Table 2). More than half of the applications were monitored in the emergency observation unit (62.5%, n=27270). When patients were examined according to age groups (n=21703), it was determined that 47.1% of the children were 1–6 years old (Table 1). About the number of cases, n=46038, 10.5% of was infant, n=16891, 38.7% of were children, and in the 1-6 age group, the number of male patients (n=11868, 54.7%) was higher. The patient who was observed and followed up (n=27270, 62.5%), the outpatient was (n=15.352, 35.2%). In 49.5% of these cases, there was no trauma. It was observed that 78.3% of the cases applied directly to the Pediatric Emergency Service, and secondly, 16.6% of the cases was applied to the green field 1–2. 98.2% of the cases were outpatient applications. More than half of the applications (48.8%) were out of the working hours. During the continuing treatment, the hospitalization of the applicants was not considered (n=44954, 97.6%) and sent home. The duration of stay in the hospital of the patients to be of the planned to hospitalize was 4.53 days; 5.8% of the applicants (n=2568,) were trauma patients, 0.001% (n=7), of the cases was decease. Table 2. Distribution of the patients attending the pediatric emergency clinic concerning major diagnosis

According to the disease distribution

%

Upper respiratory disease

25506

57.53

Trauma

6790 15.32

Gastroenteritis

2203 4.97

Lower respiratory disease

835

Newborn

175 0.39

Allergic diseases

314

Bites

173 0.39

Neurological

149 0.34

Poisoning

137 0.31

Cardiovascular

45 0.10

1.88 0.71

Urinary system

1536

Syncope

348 0.78

Skin

484 1.09

Child surgery

48

Other

298

3.46

0.11

5592 12.61

Ages by gender in trauma 12000

Trauma+ Trauma–

10000 8000 6000 4000 2000 0 Infant

1–6 age 7–12 age 13–18 age

Men

Infant

1–6 age

7–12 age 13–18 age

Women

Figure 1. Trauma patients according to gender and age groups.

Trauma was not present in 49.5% of these cases. Among the cases, it was observed that 78.3% directly attended paediatric emergency service, while 16.6% of the patients attended green zones 1–2. 98.2% of the cases were outpatients. Almost half of the cases (48.8%) attended the hospital after the working hours. Among the cases (n=44954), 97.6% were not considered for further hospitalization and were discharged. Among the cases that were considered for hospitalization, the average time of staying at the service was 4.53 days. Among the cases who attended the hospital (n=2568), 5.8% of them was trauma patients. Distribution of trauma patients by age and gender groups is shown in Figure 1. Seven of the cases who attended the hospital (0.001%) died.

DISCUSSION The findings suggest that paediatric emergency clinic of our hospital serves a remarkably high number of patients. Our hospital admits pediatric trauma patients to the pediatric emergency service, and it serves as a trauma centre in the Aegean Region on a 24-hour non-stop basis with a multidisciplinary approach. In our pediatric emergency service, which admits 170000 patients on average, experienced nurses are implementing a 3-phase triage system. In our study, 53.6% of the patients was male, while 46.4% was female. This result was similar in studies that were carried out in countries with limited or rich sources.[8–11] The findings suggest that boys are more biologically susceptible to diseases and/or more mobile and susceptible to external effects, such as trauma. However, further studies are needed to explain this gender difference and its reasons in the frequency of applications to pediatric emergency services. More than half of our total patients were monitored in the emergency observation unit. Another study conducted in our country showed that only 1/3 of the patients admitted to pediatric emergency services were monitored in the observation unit.[1] This may be because we are the only pediatric trauma centre in our province as a training hospital of Ministry of Health, and due to lack of equipment and specialists, pediatric surgery, pediatric intensive care, pediatric side branches and emergency patients are accepted from surrounding districts. However, according to the data of our hospital from the year 2011, only 10% of pediatric emergency Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Pakdemirli et al. Evaluation of the patients admitted to the pediatric emergency service

applications were monitored in the emergency observation unit.[12] Although there is no change in the number of patient applications during these years, the increase in the patients who are monitored in the observation unit can be explained by the decrease in patient applications that are not suitable for the emergency service, or the increase in the knowledge and skills of the emergency healthcare professionals to recognize the patients in critical condition or requiring observation. Comprehensive and multicentre studies are needed to explain these differences. Approximately 1/3 of the patients after first doctor examination and more than half them within 12 hours monitoring period at emergency observation unit have been sent home after followed up and treated. Finally, 97.5% of the patients have been sent home and this finding is an important reality of our study. In our study, admissions from emergency to hospitalization are found lower than the studies conducted in other centres in our country.[13,14] Since we have limited bed capacity but intense examination and treatment patients, this situation can be explained with offering daily hospitalization to some of the patients which are planned to hospitalize for a short time at emergency observation unit. When epidemiological data in paediatric emergency submissions are looked into, it can be seen that nearly half of the patients are infants.[11,15,16] In our study, our patients comprise of 10.5 infants and 38.7% play children age group which is similar to Atabek et al.’s study.[17] Prospective multicentre studies comparing epidemiological data of our country and child emergency applications of developed or underdeveloped countries may reveal age group differences and reasons in child emergency applications. Another striking point in our study is that more than half of the applications are concentrated outside working hours in accordance with the literature.[13,14,18,19] Reasons, such as working parents, disruptions in the appointment system and fast operation in the emergency room, may be influential in this result. However, in our study, one of the most important factors that constitute overtime patient density is service provided in two emergency green area two clinics located close to the emergency to reduce the patient density of the emergency service. Patients who receive the green code from triage can also receive service at these outpatient clinics during off-hours. In our study, it was observed that the most common diagnosis in pediatric emergency applications was upper respiratory tract infection, similar to the data of other centres in our country. This shows that more than half of the patients applying to the emergency service can receive services in 1st step health care facilities. Every patient admitted to the pediatric emergency service is regarded as an “urgent patient” until proven otherwise. Therefore, the occupation of emergency services with non-emergency situations causes high costs and increased workload on employees. Trauma, which is one of Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

the most urgent emergencies, was the second most common pediatric emergency service after upper respiratory tract infections. The Institution, affiliated to the Ministry of Health, being the pediatric emergency clinic that meets the region’s most intense and single child trauma patient, when respiratory diseases are most intense in winter, it has caused trauma to take the first place in ‘emergencies’. Bulut et al.[20] showed that the most common cause of pediatric trauma was the falls, while Gürses et al.[21] reported the most common cause of trauma as traffic accidents. In this study, the most common cause of trauma was soft tissue and minor injuries and falls, respectively. On the other hand, inside and outside traffic accidents constituted only 3.7% of all trauma patients. It can be explained that soft tissue traumas and falls constitute the majority in trauma applications, our hospital is easy and centrally located concerning transportation, and patients with minor trauma can easily apply to the pediatric emergency. When one-year data of the previous study from the same centre were examined, it was observed that trauma applications were again at the second place with 12.6% after upper respiratory tract infections.[12] In the same study, the most common trauma application month was reported as July. As this study examined applications within the 3-month winter season, our rates of high energy trauma and traffic accidents may be low. There are some limitations in our study. One of the most important limitations is that this study is retrospective and there are deficiencies in some records and at least one year of data that could reveal the seasonal characteristics of the applications are not received. Diagnosis and demographic data of patients who were followed up in the observation and hospitalized in intensive care and service were not examined.

Conclusion Most patients admitted to pediatric emergency service for non-urgent reasons which can be managed in primary care services. Multicentre pediatric emergency epidemiological research is needed to produce healthy solutions to the problems of emergency room operation in our country. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: A.P.; Design: D.O.; Supervision: A.P.; Fundings: D.O.; Materials: E.B.; Data: D.O.; Analysis: A.P.; Literature search: E.B.; Writing: A.P.; Critical revision: E.B. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Araslı Yılmaz A, Köksal AO, Özdemir O, Yılmaz Ş, Yıldız D, Koçak M, et al. An Evaluation of Cases Presenting to the Pediatric Emergency

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Pakdemirli et al. Evaluation of the patients admitted to the pediatric emergency service Department of a Training and Research Hospital. Turkish J Pediatric Disease 2015;9:18−21. 2. WHO. Injuries and violence: the facts 2014. World Health Organization; 2014. 3. Liu T, Sayre MR, Carleton SC. Emergency medical care: types, trends, and factors related to nonurgent visits. Acad Emerg Med 1999;6:1147– 52. 4. Brousseau DC, Mistry RD, Alessandrini EA. Methods of categorizing emergency department visit urgency: a survey of pediatric emergency medicine physicians. Pediatr Emerg Care 2006;22:635–9. 5. Pope D, Fernandes CM, Bouthillette F, Etherington J. Frequent users of the emergency department: a program to improve care and reduce visits. CMAJ 2000;162:1017–20. 6. Derlet RW, Kinser D, Ray L, Hamilton B, McKenzie J. Prospective identification and triage of nonemergency patients out of an emergency department: a 5-year study. Ann Emerg Med 1995;25:215–23. 7. Andrulis DP, Kellermann A, Hintz EA, Hackman BB, Weslowski VB. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med 1991;20:980–6. 8. Kılıçaslan İ, Bozan H, Oktay C, Göksu E. Türkiye’de acil servise başvuran hastaların demografik özellikleri. Turk J Emerg Med 2005;5:5−13. 9. McCaig LF, Nawar EW. National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary. Adv Data 2006;372:1– 29. 10. Ayvaz A, Gungor N, Topbas M, Yildizlar O, Emine CE, Akkol N. Characteristic of the child patients admitted to emergency department in Surmene Government Hospital, Trabzon. C.Ü. Tıp Fakültesi Derg 2007;29:156−62. 11. Singhi S, Jain V, Gupta G. Pediatric emergencies at a tertiary care hospital

in India. J Trop Pediatr 2003;49:207–11. 12. Anıl M, Anıl AB, Köse E, Akbay S, Helvacı M, Aksu N. The Evaluation of the Patients Admitted to the Pediatric Emergency Department in a Training and Research Hospital. CAYD 2014;1:65−71. 13. Derinöz O, Tunaoğlu FS. Usage of pediatric emergency department observation unit for children: observations in a university hospital. Turk Arch Ped 2007;42:61−4. 14. Temizkan RC, Büyük N, Kılıçaslan Ö, Ankaralı H, Kocabay K. Characteristics of Patients Visiting the Pediatric Emergency Department of a Medical Faculty Hospital. Anadolu Kliniği Tıp Bilimleri Dergisi 2019;24:122−31. 15. Kelley BK. Gender and disease. Acta Pediatr 1999;88:921−2. 16. Rajnil L, Fernendez E, Solas T, Barba G, Raspall F, Vila C, et al. Gender differences in children’s hospital in Catatonia; another inequality? Acta Pediatr 1999;88:990–7. 17. Atabek ME, Oran B, Çoban H, Erkul İ. Çocuk acile başvuran hastaların özellikleri. Selcuk Med J 1999;15:89–92. 18. Yurtseven A, Özcan G, Ulas Saz E. Comparison of between Syrian patients and Turkish patients who admitted to the pediatric emergency department: Experince of Ege University. CAYD 2015;2:133−6. 19. Boran P, Tokuç G, Çoban Büyükkalfa D, Taşkın B, Pişkin B. Evaluation of the Patients Admitted to the Pediatric Emergency Department. J Child 2008;8:114−6. 20. Bulut M, Korkmaz A, Akköse Ş, Balcı V, Özgüç H, Tokyay R. Epidemiologic and clinical features of childhood falls. Ulus Travma Acil Cerrahi Derg 2002;8:220−3. 21. Gürses D, Sarıoğlu Büke A, Başkan M, Herek Ö, Kılıç İ. Epidemiologic evaluation of trauma cases admitted to a pediatric emergency service. Ulus travma acil cerrahi derg 2002;8:156–9.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Çocuk acil servise başvuran hastaların gözden geçirilmesi: Türkiye’deki bir üçüncü basamak hastane çocuk acil eğitim kliniğinin kesitsel analizi Dr. Ahu Pakdemirli,1 Dr. Dilek Orbatu,2 Dr. Emel Berksoy3 Sağlık Bilimleri Üniversitesi Gülhane Tıp Fakültesi, Fizyoloji Anabilim Dalı, Ankara Sağlık Bilimleri Üniversitesi Tepecik Eğitim ve Araştırma Hastanesi, Çocuk Sağlığı ve Hastalıkları Kliniği, İzmir 3 Sağlık Bilimleri Üniversitesi Tepecik Eğitim ve Araştırma Hastanesi, Çocuk Acil Eğitim Kliniği, İzmir 1 2

AMAÇ: Bu çalışmada, S.B. İzmir Tepecik Eğitim ve Araştırma Hastanesi Çocuk Acil Servisi’ne son üç ayda başvuran hastaların kesitsel analiz çalışması ile travma olgularının değerlendirilmesi amaçlanmıştır. GEREÇ VE YÖNTEM: İzmir S.B.Ü. Tepecik Eğitim ve Araştırma Hastanesi Çocuk Acil Eğitim Kliniği’ne 01.12.2019 ile 01.03.2020 tarihleri arasında başvuran 0–18 yaş arası 46038 hastanın dosya kayıtları geriye dönük olarak incelendi. BULGULAR: Toplam 46,038 hasta (%53.6 erkek) acil servise başvurmuştur. Ortalama yaş her iki cinsiyet içinde 7.07 olarak saptandı. Başvurusunda travma öyküsü olguların yaş ortalaması 9.3 iken travma öyküsü olmayanlar olguların yaş ortalaması 6.7 olduğu görüldü. Hastaların %82.7’sini travma öyküsü olmayan erkek olgu oluştururken %86.9’unu travma öyküsü olmayan kız olgular oluşturmaktadır. Başvuru tanıları incelendiği zaman en sık görülen tanı üst solunum yolu enfeksiyonudur (%58.5). Başvuruların yarısından fazlası acil gözlem ünitesinde izlenmiştir (%62.5). Hastalar yaş gruplarına göre değerlendirildiğinde, %49.2’sini 1–6 yaş grubu çocukların oluşturduğu saptandı. Başvuran olguların %10.5’i infant ve %38.7’si oyun çocuğu iken, 1–6 yaş grubunda %54.7 ile erkek hasta başvuru sayısı fazla olduğu dikkat çekmektedir. Bu olguların %49.5’inde travma yoktu. Olguların %78.3’ünün direkt çocuk acile, ikinci sıklıkla %16.6 ile yeşil alan 1 ve yeşil alan 2’ye başvurduğu görülmektedir. Olguların %98.2’si ayaktan acil servise başvurmaktadır. Başvuruların %48.8’inin mesai saati dışında olduğu görülmektedir. Başvuran olguların %97.6’sının tedavisinin devamı amacıyla yatışı düşünülmemiş eve gönderilmiştir. Yatışı planlanan olguların ise ortalama serviste kalış zamanı 4.53 gündür. Başvuran yedi olgu hayatını kaybetmiştir. TARTIŞMA: Hastaların çoğunluğu birinci basamak sağlık hizmetlerinde yönetilebilen acil olmayan nedenlerle çocuk acil servise başvurmuştur. Anahtar sözcükler: Kesitsel analiz; pediatrik acil; travma. Ulus Travma Acil Cerrahi Derg 2020;26(2):296-300

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ORIGIN A L A R T IC L E

Assessment of firearm injuries undergoing advanced airway management: Role II hospital experience Sami Eksert, M.D.,1

Mehmet Burak Aşık, M.D.,2

Murtaza Kaya, M.D.3

1

Department of Anesthesia and Reanimation, University of Health Sciences, Gülhane Training and Research Hospital, Ankara-Turkey

2

Department of Otolaryngolog, University of Health Sciences, Gülhane Training and Research Hospital, Ankara-Turkey

3

Department of Emergency Medicine, Kütahya University of Health Sciences Faculty of Medicine, Kütahya-Turkey

ABSTRACT BACKGROUND: Airway problems are one of the most important factors affecting mortality in firearm injuries. The present study aims to examine the data of patients who underwent advanced airway support due to explosion and bullet injuries in a Role II hospital. METHODS: Ninety three patients who underwent advanced airway support due to gunshot wounds in a Role II hospital between January 2015 and September 2016 were included in this study. The patients were divided into two groups as blast (Group A) (handmade explosives, rocket, and mine) and bullet (Group B) (rifle and pistol bullet) trauma injuries. The groups were compared regarding pre-hospital intubation, NISS (New Injury Severity Score), cardio-pulmonary resuscitation (CPR), emergency surgical intervention and mortality rates. RESULTS: There was no difference between the patient groups concerning demographic and clinical features. Thirty-six patients were included in group A, and 57 patients were included in group B. There was no statistically significant difference between the groups about emergency surgical intervention rates (p=0.42). However, a statistically significant difference was observed between the groups in terms of pre-hospital intubation (p=0.001), CPR application (p=0.001), mortality (p=0.001) rates and NISS (p=0.002) scores. CONCLUSION: Bullet injuries that require advanced airway are more destructive and more deadly than explosion injuries. This may be due to direct airway or organ damage in bullet gunshot wounds. Keywords: Airway management; combat; firearm; hospital; gunshot; mortality; Role II; weapon.

INTRODUCTION Injuries via firearms and explosives may result in many lifethreatening situations.[1] These include hypovolemia due to blood loss, hypotension, hypoventilation, shock, respiratory, and cardiac arrest.[2–5] Among these, failure to maintain airway management in firearm injuries is the second leading cause of death after bleeding.[6] Thus, it is vital that the casualty’s airway management and bleeding control must be carefully carried out, in the conflict area and the hospital. In the US there are four main “role” levels in the military trauma center designation. These levels begin in the field of a combat zone with Role I. Accordingly, Role I care encompasses

first aid at the point of injury by the wounded people themselves, colleagues or emergency teams in the fire zone. The Role I also includes triage, treatment, and transfer by doctors/ healthcare personnel at accident collection areas or battalion first-aid stations. Here, the aim is to separate the person who can return to the task and transfer the wounded who need advanced life support to the next level, healthcare center. Role II includes hospitals within the area of battleground where limited interventional and surgical procedures can be performed. Role III defines hospitals within or close to the combat region wherein advanced surgical support can be obtained. Role IV represents advanced regional medical centers.[7]

Cite this article as: Eksert S, Aşık MB, Kaya M. Assessment of firearm injuries undergoing advanced airway management: Role II hospital experience. Ulus Travma Acil Cerrahi Derg 2020;26:301-305. Address for correspondence: Sami Eksert, M.D. Sağlık Bilimleri Üniversitesi, Gülhane Eğitim ve Araştırma Hastanesi Anestezi ve Reanimasyon Anabilim Dalı, Ankara, Turkey Tel: +90 312 - 304 59 07 E-mail: exert79@yahoo.com Ulus Travma Acil Cerrahi Derg 2020;26(2):301-305 DOI: 10.14744/tjtes.2020.59956 Submitted: 26.07.2019 Accepted: 04.03.2020 Online: 11.03.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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Eksert et al. Assessment of firearm injuries undergoing advanced airway management: Role II hospital experience

first intervention in the field, the patients were transferred to the Role II hospital, which was 5–10 minutes away by ambulance. Patients were divided into two groups. Handmade explosives, rocket, and mine injuries were considered as blast injury (Group A). Rifle and pistol injuries were defined as bullet injuries (Group B). Patients’ age, type of trauma, prehospital intubation status, Glasgow Coma Scale (GCS) score, cardiopulmonary resuscitation (CPR) status, emergency surgical intervention requirements, need for postoperative intensive care, and tracheotomy requirements were assessed. Groups were compared concerning prehospital intubation rates, NISS (New Injury Severity Score), mortality, follow-up periods, and injury sites.

Since the tissue destruction mechanism is different in bullet and blast injuries, the treatment principles of these two types of injury are also individual.[8] Blast injuries occur due to handmade explosives (HME), mines and shrapnel, and rockets that cause very dramatic injuries because of the high impact power due to sudden explosion at close range. Trauma that arises from handmade explosives generally affects a lot of military staff in the region and involves metal fragments in the wound.[9] Bullet injuries occur in personnel directly targeted by a gun or rifle. Military rifles and guns have lower kinetic energy than explosives. Thus, although blast trauma may cause severe injuries at close distances, bullet injuries may result in more advanced airway requirements and mortality as a result of direct trauma to the neck and thorax region.

Statistical Analysis

In this study, the data of patients who received advanced airway support due to explosion and bullet injuries in a Role II hospital between 2015 and 2016 were analyzed to compare the differences between mortality and severity of the injury.

Patients’ data were analyzed using SPSS 21.0 (SPSS Inc., Chicago, IL., USA). Descriptive statistics were given as a number, percentage, mean and standard deviation. Discrete data were compared with Fisher’s Exact Test and continuous data in the Mann-Whitney U test in pairs that did not conform to normal distribution. The level of significance was set at p<0.05.

MATERIALS AND METHODS Patients who were admitted to the Department of Emergency of our Role II hospital between January 2015 and September 2016 and who received advanced airway support were included in this study. This study received the necessary ethics committee permission from the Institutional Review Board (2018/15, 18/204). Patients who underwent advanced airway support were those who underwent endotracheal intubation and tracheotomy. Patients who died in the combat area were excluded from this study. Immediately after the

RESULTS This study included 93 patients and all of the casualties were male. There were 36 patients (38.7%) in group A, and 57 patients (61.3%) in Group B. The mean age was 28.3±8.1 (Mean±SD) in group A, and 29.3±8.2 in group B (total 28.9±8.1). Clinical features of patients are given in detail in Table 1.

Table 1. Clinical features of the patients

Group A (n=36)

Group B (n=57)

Total (n=93)

p

Glasgow Coma Scale (Mean±SD)

7.8±3.7

5.4±3.3

6.33±3.64

0.016*

Prehospital intubation, n (%)

9 (25.0)

34 (59.6)

43 (46.2)

0.001*

Follow-up with intubation, n (%)

8 (22.2)

14 (24.6)

22 (23.7)

0.796**

Tracheotomy intervention, n (%)

5 (13.9)

6 (10.5)

11 (11.8)

0.127**

Intensive care monitoring , n (%)

23 (63.9)

28 (49.1)

51 (54.8)

0.163*

21.27±22.26

36.12±26.87

28.69±24.43

0.002***

New Injury Severity Score (Mean±SD)

Group A (blast trauma injuries), Group B (bullet trauma injuries). *Chi-square Test; **Fisher’s Exact Test; ***Mann-Whitney U Test. SD: Standard deviation.

Table 2. Comparison of the cases with Group A (blast trauma injuries) and Group B (bullet trauma injuries)

Group A (n=36)

Group B (n=57)

p

n % n %

Cardiopulmonary resuscitation

6

16.7

28

49.1

0.001*

Emergency surgical ıntervention

31

86.1

44

77.2

0.420**

Mortality

10 25.6 29 74.4 0.028*

*Chi-square Test; **Fisher’s Exact Test.

302

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Eksert et al. Assessment of firearm injuries undergoing advanced airway management: Role II hospital experience

Table 3. Injury sites of the casualties

Group A Group B Total (n=36) (n=57) (n=93)

Head

13 16 29

Thorax

4 21 25

Pelvis

2 3 5

Abdomen

7 6 13

Neck

1 4 5

Extremity

2 1 3

Thorax and limb

2

3

5

Thorax and abdomen

3

2

5

Head and thorax

1

0

1

Abdomen and neck

1

0

1

Head and neck

0

1

1

Craniotomy n=20 (19.2%)

Thoracotomy n=32 (30.8%)

Laparotomy n=20 (19.2%)

Other surgery Extremity n=6 n=[VALUE] (5.8%) (7.7%)

Face and Neck n=[VALUE] (17.3%)

Figure 1. Distribution of the emergency surgical interventions of the patients.

When compared with group A, patients in Group B had significantly high prehospital intubation, CPR, and mortality rates (p<0.05). Also, the NISS value was significantly higher in group B patients (p<0.05). However, the difference in the emergency surgical intervention rates between the groups was statistically insignificant (p=0.420) (Table 2). The injury sites of the causalities are demonstrated in Table 3. In Group A, the most common injury site was the head region, while in Group B, the thorax area. Emergency surgical interventions (craniotomy, laparotomy, thoracotomy, extremity, face-neck and other surgery) are presented in the Figure 1.

DISCUSSION In this study, the difference in mortality rate and injury severUlus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

ity score was investigated in patients with advanced airway support (endotracheal intubation and tracheostomy) with a bullet or blast injuries. Contrary to the prediction, we found that mortality rates in Group B were much higher than the mortality rates in Group A. In the battlefield, gunshot injuries have become the leading cause of death in recent years due to advances in weapon industry technology. Contemporarily, war and conflicts are taking place on the urban terrain, not on the battlefields. Differences have been observed in injury sites with the change of weapon technology and combat style. In the study conducted by Güven et al.,[9] extremities were the most frequently affected site in bullet injuries, while head and neck injuries were observed in blast injuries along with extremities. In our study, the thorax region was most commonly affected in bullet injuries, while the head and neck region was affected in blast injuries. Eastridge et al.’s[6] study examined the data about 4596 patients who were fatally wounded between 2001 and 2011on the battlefield. Of these injuries, 73.7% were due to explosives, and 22.1% were due to pistol and rifle injuries. Accordingly, in another study, the injury rate that occurred due to blast trauma was 58.3%.[9] However, in the present study, the pistol-rifle/explosive ratio was found to be 38.7%, as opposed to the previous ones. This may be due to the inclusion of only those cases who could reach the Role II hospital alive. Deaths from injuries that arise from blast trauma are usually on the battlefield or at the Role I level before reaching the Role II hospital. The injuries affecting the respiratory system result in ventilation failure and hypoventilation. Airway management is vitally important in monitoring these critical trauma patients.[10,11] Studies have defined that ensuring sufficient ventilation and oxygenation of trauma patients before hospital admission is associated with an increase in survival and discharge rates. [12,13] Failure to provide a safe airway is the second leading potentially preventable cause of death after bleeding in combat settings.[6] Only a few studies to date have investigated the airway management during and after combat operations by evaluating the rate of accurate insertion of the airway, frequency of cricothyroidotomy, and incidence of maxillofacial traumas.[13–18] However, none of these studies about airway management in combat zones and afterward have evaluated the effects of the mechanism of the trauma on mortality in these patients. In the current study, when the patients who needed endotracheal intubation and tracheotomy were evaluated, it was observed that mortality rates were higher in pre-hospital intubated patients. Also, the mortality rates are found to be higher among the patients brought to the emergency service with bullet trauma injuries. In this regard, similar results were obtained in studies conducted in a civilian environment.[6,10] 303

Eksert et al. Assessment of firearm injuries undergoing advanced airway management: Role II hospital experience

The high mortality rate in pre-hospital intubated patients may possibly be due to excessive severity of injury or the presence of airway injury in these patients. When the presence of a correlation between weapon type and NISS values is examined, relatively old literature presents comparatively more pistol and rifle injuries in previous studies. However, in recent studies, injuries due to explosives were reported more.[19] Also, injuries due to explosives were determined to have higher severity scores. In our study, injuries occurring due to bullet trauma injuries were found to have higher injury severity scores. This difference may be because the majority of blast trauma injuries cannot reach Role II. In patients with bullet injuries, insufficient attention to the existing wound, ongoing bleeding and body compensation may prevent an understanding of the severity of the injury. In the literature, mortality rates in this study were much higher when compared to relevant studies. One study using 10-year data in the Role IV area found mortality rates in the Afghanistan and Iraq wars were 2/167 and 2/224, respectively. [20] In our study, when the mortality rates were evaluated, the general rate was 39/93. In this study, the higher mortality rates may be because patients presenting to Role II were newly injured and not yet stabilized. Additionally, the low number of people reaching the Role II area among those with injury occurring due to blast trauma injuries leads to the consideration that mortality occurs more in the field of conflict for these injuries. The most important limitation of our study was that the design was retrospective, and the number of patients was relatively low. The reason for the low number of patients is that the data obtained from a hospital located in a certain conflict area, not in a wide battlefield, were used. Another limitation was that the causes of death of the deceased patients could not be revealed from the patient records.

Conclusion Patients in need of prehospital advanced airway support were found to have high mortality rates for both bullet and blast trauma injuries. Although blast injuries involve risk of multiorgan traumas, the reason for high mortality from bullet injuries is considered to be because of direct destruction of the projectile to the airway or the vital organs. To conclude, the high mortality rates associated with bullet trauma injuries require special attention. To generalize the results of our study, large series are needed. Ethics Committee Approval: This study received the necessary ethics committee permission from the Institutional Review Board (2018/15, 18/204). Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: S.E., M.B.A.; Design: S.E., M.B.A.; Supervision: S.E., M.B.A.; Fundings: S.E.; Materi304

als: S.E., M.B.A., M.K.; Data: S.E., M.K.; Analysis: S.E., M.K.; Literature search: S.E., M.B.A., M.K.; Writing: S.E., M.K.; Critical revision: S.E., M.K. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Bellamy RF. The medical effects of conventional weapons. World J Surg 1992;16:888–92. 2. Dunn JC, Kusnezov N, Schoenfeld AJ, Orr JD, Cook PJ, Belmont PJ Jr. Vascular Injuries in Combat-Specific Soldiers during Operation Iraqi Freedom and Operation Enduring Freedom. Ann Vasc Surg 2016;35:30–7. 3. Eksert S, Sır E. Incidence of hypothermia and analgesic use in the postanesthesia care unit. Gulhane Med J 2019;61:69−72. 4. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg 2011;253:1184–9. 5. Buckenmaier CC 3rd, Rupprecht C, McKnight G, McMillan B, White RL, Gallagher RM, et al. Pain following battlefield injury and evacuation: a survey of 110 casualties from the wars in Iraq and Afghanistan. Pain Med 2009;10:1487−96. 6. Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg 2012;73:S431−7. 7. Borden Institute, USA. Emergency War Surgery. Fourth United States Revision. Fort Sam Houston; TX: US Army Medical Department Center and School, Borden Institute; 2013. 8. Ozer MT. Wound Ballistic of Gunshot Injuries with High Kinetic Energy and Reflections to the Surgical Treatment. Eur Arc Med Res 2017;33:40−7. 9. Güven HE, Bilge S, Aydın AA, Eryılmaz M. Comparison of the nonmortal gunshot and handmade explosive blast traumas during a low-intensity conflict on urban terrain. Turk J Surg 2018;34:221–4. 10. Walker JJ, Kelly JF, McCriskin BJ, Bader JO, Schoenfeld AJ. Combat-related gunshot wounds in the United States military: 2000-2009 (cohort study). Int J Surg 2012;10:140–3. 11. Hardy GB, Maddry JK, Ng PC, Savell SC, Arana AA, Kester A, et al. Impact of prehospital airway management on combat mortality. Am J Emerg Med 2018;36:1032−5. 12. Bossers SM, Schwarte LA, Loer SA, Twisk JW, Boer C, Schober P. Experience in Prehospital Endotracheal Intubation Significantly Influences Mortality of Patients with Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis. PLoS One 2015;10:e0141034. 13. Davis DP, Peay J, Sise MJ, Kennedy F, Simon F, Tominaga G, et al. Prehospital airway and ventilation management: a trauma score and injury severity score-based analysis. J Trauma 2010;69:294−301. 14. Adams BD, Cuniowski PA, Muck A, De Lorenzo RA. Registry of emergency airways arriving at combat hospitals. J Trauma 2008;64:1548–54. 15. Mabry RL, Frankfurt A. Advanced airway management in combat casualties by medics at the point of injury: a sub-group analysis of the reach study. J Spec Oper Med 2011;11:16–9. 16. Mabry RL. An analysis of battlefield cricothyrotomy in Iraq and Afghanistan. J Spec Oper Med 2012;12:17–23. 17. Schauer SG, Bellamy MA, Mabry RL, Bebarta VS. A comparison of the incidence of cricothyrotomy in the deployed setting to the emergency department at a level 1 military trauma center: a descriptive analysis. Mil

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Eksert et al. Assessment of firearm injuries undergoing advanced airway management: Role II hospital experience Med 2015;180:60–3. 18. Keller MW, Han PP, Galarneau MR, Brigger MT. Airway Management in Severe Combat Maxillofacial Trauma. Otolaryngol Head Neck Surg 2015;153:532–7. 19. Belmont PJ, Schoenfeld AJ, Goodman G. Epidemiology of combat

wounds in Operation Iraqi Freedom and Operation Enduring Freedom: orthopaedic burden of disease. J Surg Orthop Adv 2010;19:2–7. 20. Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK Jr, Mabry RL, et al. Eliminating preventable death on the battlefield. Arch Surg 2011;146:1350−8.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

İleri hava yolu yönetimi uygulanan ateşli silah yaralanmalarının değerlendirilmesi: Role II hastane deneyimi Dr. Sami Eksert,1 Dr. Mehmet Burak Aşık,2 Dr. Murtaza Kaya3 1 2 3

Sağlık Bilimleri Üniversitesi, Gülhane Eği̇ ti̇ m ve Araştırma Hastanesi̇ , Anestezi ve Reanimasyon Anabilim Dalı, Ankara Sağlık Bilimleri Üniversitesi, Gülhane Eği̇ ti̇ m ve Araştırma Hastanesi, Kulak Burun Boğaz Anabilim Dalı, Ankara. Kütahya Sağlık Bilimleri Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Kütahya

AMAÇ: Havayolu sorunları, ateşli silah yaralanmalarında mortaliteyi etkileyen en önemli faktörlerden biridir. Bu çalışmanın amacı, bir Rol II hastanesinde patlama ve mermi yaralanmaları nedeniyle ileri hava yolu desteği uygulanan hastaların verilerini incelemektir. GEREÇ VE YÖNTEM: Çalışmaya, Ocak 2015 ile Eylül 2016 tarihleri arasında bir Role II hastanesinde ileri hava yolu desteği uygulanan 93 hasta dahil edildi. Hastalar patlayıcı (Grup A) (el yapımı patlayıcılar, roket ve mayın) ve mermi (Grup B) yaralanmaları olarak iki gruba ayrıldı (tüfek ve tabanca mermi) travma yaralanmaları. Gruplar hastane öncesi entübasyon, NISS (Yeni Yaralanma Şiddeti Skoru), kardiyopulmoner resüsitasyon (CPR), acil cerrahi müdahale ve mortalite oranları açısından karşılaştırıldı. BULGULAR: Hasta grupları arasında demografik ve klinik özellikler açısından fark yoktu. Otuz altı hasta A grubuna, 57 hasta B grubuna alındı. Acil cerrahi müdahale oranları açısından gruplar arasında istatistiksel olarak anlamlı fark yoktu (p=0.42). Ancak gruplar arasında hastane öncesi entübasyon (p=0.001), CPR uygulaması (p=0.001), mortalite (p=0.001) oranları ve NISS (p=0.002) skorları arasında istatistiksel olarak anlamlı bir fark gözlendi. TARTIŞMA: İleri hava yolu gerektiren mermi yaralanmaları, patlama yaralanmalarından daha yıkıcı ve daha ölümcüldür. Bunun nedeni, mermi ile ateşli silah yaralarında doğrudan hava yolu veya organ hasarı oluşması olabilir. Anahtar sözcükler: Ateşli silah; hastane; havayolu yönetimi; mortalite; Rol II; savaş; silah; tabanca atışı. Ulus Travma Acil Cerrahi Derg 2020;26(2):301-305

doi: 10.14744/tjtes.2020.59956

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305

ORIGIN A L A R T IC L E

Diagnostic accuracy of ultrasonography and scoring systems: The effects on the negative appendectomy rate and gender Rahman Şenocak, M.D.,

Şahin Kaymak, M.D.

Department of General Surgery, Health Science University Gülhane Training and Research Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: Despite the development of clinical, laboratory, and imaging methods, the diagnosis of acute appendicitis is not always easy, and negative appendectomy rates are still high. This study aims to reveal the effects of different scoring systems on the diagnostic accuracy of acute appendicitis and negative appendectomy rates, alone or when evaluated together with ultrasonography. METHODS: In this study, 202 consecutive patients who underwent emergency appendectomy for acute appendicitis were included. Clinical scores of all patients were preoperatively calculated using Ohmann, Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA), Lintula, Eskelinen, and Alvarado scoring systems. Abdominal ultrasonography (USG) was performed randomly in all cases. The sensitivity and specificity of scoring systems were calculated according to the threshold values. The area under the curve (AUC) was calculated using ROC analysis. In the regression model, histological diagnosis of appendicitis was used as the dependent variable, while scoring systems and USG were preferred as independent variables. RESULTS: The negative appendectomy rate was 15.8%. In the diagnosis of acute appendicitis, Ohmann was the most predictive for both genders (DOR=24.2, 95% CI 6.98–84.44). Similarly, the lowest negative appendectomy rates were obtained with the Ohmann score as 6.9% in females and 3.4% in males. When the scores were combined with USG, the rate of diagnostic accuracy for acute appendicitis was not increased. However, when Ohmann and USG were combined, negative appendectomy rates were further reduced for women from 6.9% to 4%. CONCLUSION: In addition to being a good diagnostic predictor of acute appendicitis in male and female patients, Ohmann score provides the best negative appendectomy rates. The combination of USG and scoring systems does not increase the diagnostic accuracy of acute appendicitis. However, negative appendectomy rates are significantly reduced when the USG and Ohmann scale are used together in females, while this reduction is minimal in men. Keywords: Alvarado; Eskelinen; Lintula; negative appendectomy rate; Ohmann; RIPASA; USG.

INTRODUCTION Acute appendicitis (AA) is the most common cause of emergency abdominal surgery. To prevent serious complications up to 17–33% perforation rates, rapid and early diagnosis should be made.[1] Occasionally, the decision of surgical indication in atypical acute appendicitis may be difficult due to the incomplete clinical findings.[2] Therefore, the main objective is to achieve the lowest negative appendectomy rates (NARs),

while reducing morbidity and hospital cost without diagnostic delay. Various scoring systems have been developed to support diagnosis in suspected cases for AA.[3–7] Some of these systems target pediatrics or female populations;[4,5] other systems target the general population.[7] Positive and negative predictive values were reported to differ between the results,[8] and it was suggested that accurate diagnosis rates could be in-

Cite this article as: Şenocak R, Kaymak Ş. Diagnostic accuracy of ultrasonography and scoring systems: The effects on the negative appendectomy rate and gender. Ulus Travma Acil Cerrahi Derg 2020;26:306-313. Address for correspondence: Şahin Kaymak, M.D. Sağlık Bilimleri Üniversitesi Gülhane Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Ankara, Turkey Tel: +90 312 - 304 51 12 E-mail: sahinkaymak@hotmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):306-313 DOI: 10.14744/tjtes.2019.86717 Submitted: 08.12.2019 Accepted: 31.12.2019 Online: 11.03.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

306

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Şenocak et al. Diagnostic accuracy of USG and scoring systems: The effects on the negative appendectomy rate and gender

creased and NARs could be reduced with integration scoring systems and imaging methods.[9,10] However, in the literature, studies on the superiority between appendicitis scoring systems are limited and the results are controversial.

on. Negative appendectomy was defined by postoperative histopathologic examination as no evidence of inflammation in the appendix wall or absence of polymorphonuclear leukocytes.

Diagnostic imaging of acute appendicitis has improved in recent years. Although the sensitivity and specificity of computed tomography (CT) in the diagnosis of appendicitis is known to be as high as 94%,[11] it is not preferred in all routine cases because it contains ionized radiation, increases the cost of routine health, and may delay the emergency appendectomy. Ultrasonography (USG) is still the most widely used diagnostic method in the diagnosis of acute appendicitis in many centers due to its rapid and practical application and its good tolerability by the pediatric population.[1] However, despite these advances in diagnostic methods, to our knowledge, there is no information in the literature that NARs have been reduced to the desired level.[12] Therefore, this study aims to determine the effects of various appendicitis scoring systems on the diagnostic accuracy of AA and NARs, alone or when evaluated together with USG.

Data analysis was performed using SPSS version 15.0 (IBM®, Chicago, USA). The sensitivity, specificity of RIPASA, Alvarado, Ohmann, Lintula and Eskelinen scoring systems were calculated according to the threshold values reported in the literature. In addition, the area under the curve (AUC) was calculated using ROC analysis. The values with the best sensitivity and specificity were defined by the likelihood ratio. The combination of the score with USG was defined as the presence of positive USG findings in patients whose scoring systems exceeded the threshold. Negative appendectomy rates, sensitivity and specificities of scoring systems were analyzed separately and in combination with USG. Pairwise comparisons of ROC analysis were used to analyze the superiority of scoring systems. Also, binary logistic regression analysis was preferred for comparison of scoring systems. In the regression model, histological appendicitis diagnosis was used as the dependent variable, while scoring systems and USG were preferred as independent variables. Results were expressed as Diagnostic Odds Ratio (DOR) at 95% Confidence Interval (95% CI). In statistical analysis, the p-value was considered significant below 0.05.

MATERIALS AND METHODS A total of 202 consecutive patients, who were admitted to the emergency ward of Gülhane Training and Research Hospital in Ankara, Turkey, and were operated on in the general surgery clinic with the diagnosis of acute appendicitis between 01 January 2017 and 31 December 2017, were included in this study. This was a retrospective cross-sectional study. The Ethical Committee of Clinical Research found no ethical problem in carrying out the present study because this study did not involve a prospective evaluation of a new method and only involved research showing standard clinical practices or advancement of practices. Demographic characteristics, age and gender of the cases were recorded. Physical examinations were performed randomly by five general surgeons from the same clinic, and the clinical parameters of all patients were recorded in a prospective manner using a previously prepared form on admission, according to the RIPASA,[3] Alvarado,[7] Ohmann,[6] Lintula,[5] and Eskelinen[4] scoring systems (Table 1). Thus scores were preoperatively calculated. Due to the design of this study, abdominal ultrasonography was performed randomly by four separate radiologists working in the same department. USG examination was performed with a Toshiba Fomio 8, using the 3.75 and 8 Mhz linear probes. The diagnosis of appendicitis was based on the visualization of the blind-ending tubular structure in the right lower quadrant of the abdomen with a diameter greater than 6 mm, indicating a non-compressible intestinal structure. In this study, patients with a score equal to or above the threshold according to scoring systems, or patients whose diagnosis of acute appendicitis was supported by USG were operated Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

RESULTS The mean age of 202 patients who underwent laparotomy for acute appendicitis was 25.6±8.8 years (range between 14-69 years). The majority of patients were male. The male/female ratio was 1/0.3. Mean RIPASA score was 9.8±2.1 (range between 4.5–15), Ohmann score was 13.5±2.1 (range between 8-16), Lintula score was 21.5±5.2 (range between 4–32). The Eskelinen score was 59.6±5.7 (range between 44.7–67.7), and the Alvarado score was 7.3±1.7 (range between 2–10). Acute appendicitis was detected in 79.7% of the patients by USG. Histological examination revealed acute appendicitis in 84.2% (n=170) of the patients. The NAR was 15.8% (n=32). Table 2 shows the sociodemographic characteristics, clinical characteristics, and scores of the patients. When the thresholds previously reported in the literature were used for the diagnosis of acute appendicitis, Sensitivity of RIPASA, Ohmann, Lintula, Eskelinen, and Alvarado was 83.5%, 82.3%, 69.4%, 76.4%, and 75.8% (respectively), and specificity was 37.5%, 81.2%, 50%, 65.6%, 65.6% (respectively). NARs were 12.3%, 4.1%, 11.9%, 7.8%, 7.9% respectively. In all scoring systems, NARs tended to be lower in male patients than in female patients. The lowest NARs were obtained with Ohmann scoring in both female (6.9%) and male (3.4%) patients. In the logistic regression model, the most predictive scale for acute appendicitis was Ohmann (DOR=24.2, 95% CI 307

Şenocak et al. Diagnostic accuracy of USG and scoring systems: The effects on the negative appendectomy rate and gender

6.98–84.44), and the second was Alvarado (DOR=2.5, 95% CI 0.85–7.88) (Table 3). Similarly, when divided by gender, the most predictive method of diagnosis for acute appendicitis in females (DOR=60.2, 95% CI 2.84–1274) and in males (DOR=30.5, 95% CI 6.54–142.75) was Ohmann. Also, USG’s sensitivity was 91.9%, and specificity was 23%, and its effectiveness in the diagnosis of acute appendicitis was observed to be low (DOR=1.7, 95% CI 0.55–5.44).

Although all scoring systems for acute appendicitis were determinative in ROC analysis, the highest AUC (accuracy in predicting acute appendicitis) value was observed in Ohmann scoring (AUC=0.818, p<0.001, 95% CI=0.758–0.869) (Table 4, Fig. 1). In the comparison of the pairwise ROC curves for the diagnosis of acute appendicitis, the Ohmann scale was more predictive than Lintula (p<0.001), Eskelinen (p=0.012), RIPASA (p<0.001), and Alvarado (p=0.040).

Table 1. RIPASA, Ohmann, Lintula, Eskelinen and Alvarado evaluation tables RIPASA Score

Alvarado

Male

Migratory RIF pain

1

Anorexia

1

Female Age <39.9

1 0.5 1

Score

Nausea & Vomiting

1

Age >40

0.5

Tenderness in RIF

2

RIF pain

0.5

Rebound tenderness in RIF

1

Pain migration to RIF

0.5

Elevated temperature

1

Anorexia

1

Leucocytosis

2

Nausea & Vomiting

1

Shift to the left of neutrophils

1

Duration of symptoms <48 h

1

Cut off scoring for acute appendicitis

≥7

Duration of symptoms >48 h

0.5

Ohmann

Score

RIF tenderness

1

Guarding

2

Pain in the lower right quadrant

4.5

Rebound tenderness

1

Rebound tenderness

2.5

Roving sign

2

Absence of urinary symptoms

Fever

1

Continuous pain

Raised WBC

1

WBC count >10000/µIL

1.5

Negative urine analysis

1

Age <50

1.5

Foreign

1

Involuntary muscular defense

>7.5

Migration of pain to the RIF

Probability of acute appendicitis is high

Lintula Score

2 2

1 1

Cut off scoring for acute appendicitis Eskelinen

Score criterion

Score

2- RIF

11.41

Male

2

Intensity of pain

2

Pain

Migration of pain

4

Right lower quadrant pain

4

Rigidity

Vomiting

2

Body temperature >37.5°C

3

WBC count (/µIL)

2- >10000

Guarding

4

1- <10000

Bowel sounds (absent, tinkling or high pitched)

4

Rebound tenderness

2- Yes

Rebound tenderness

7

1- No

Pain upon arrival

2- RIF

Cut off scoring for acute appendicitis

≥21

>12

1- Any other location 2- Yes

6.62

1- No

5.88 4.25 3.51

1- Any other location

Duration of pain

2- >48 h

1- <48 h

2.13

Cut off scoring for acute appendicitis ≥57 RIPASA: Raja Isteri Pengiran Anak Saleha Appendicitis; WBC: White blood cell; RIF: Right Iliac Fossa; NRIC: National record of identity card;

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By combining USG with scoring systems, the highest predictivity was obtained by Ohmann+USG combination. However, for acute appendicitis, the USG combination Table 2. Socio-demographic and clinical characteristics of the patients

n

%

Mean±SD

Age

25.6±8.8

Gender

Female

50

Male

24.8

152 75.2

RIPASA 9.8±2.1

with Ohmann (DOR=17.5, 95% CI 4.35–70.75) was found to have lower predictivity compared to the Ohmann scale alone (DOR=24.2, 95% CI 6.98–84.44) (Table 5). On the other hand, the lowest NARs (4%) were achieved in women when Ohmann was combined with USG. In ROC analysis, the highest AUC value was observed in Ohmann scoring (AUC=0.748, p<0.001, 95% CI=0.683–0.807) (Table 6). When the ROC analyses obtained with using scoring systems alone or in combination with USG were compared, the AUC for acute appendicitis was decreased with the USG combination with the scoring systems, but no statistical difference was in found two analyses.

Ohmann 13.5±2.1

Table 4. ROC analysis of scoring systems in the diagnosis of the AA

Lintula 21.5±5.2 Eskelinen 59.6±5.7 Alvarado 7.3±1.7 Abdominal ultrasonography

Positive (+)

161

79.7

Negative (-)

41

20.3

White blood cell count

13.5±3.9

Pathology report

Positive (+)

170

84.2

Negative (-)

32

15.8

AUC

SD

p

%95 CI

RIPASA

0.605 0.046 0.021 0.534–0.673

Ohmann

0.818

0.038

<0.001

0.758–0.869

Lintula

0.597

0.048

0.044

0.526–0.665

Eskelinen

0.710

0.046

<0.001

0.643–0.772

Alvarado

0.708

0.046

<0.001

0.640–0.769

AUC: Area under the curve; SD: Standard deviation; CI: Confidence interval; ROC: Receiver Operating Characteristic; AA: Acute appendicitis; RIPASA: Raja Isteri Pengiran Anak Saleha Appendicitis.

RIPASA: Raja Isteri Pengiran Anak Saleha Appendicitis; SD: Standard deviation.

Table 3. Diagnostic performance parameters of scoring systems and ultrasonography in the diagnosis of the acute appendicitis

Sensitivity

Specificity

PPV

NPV

%95 CI

NAR

0.4

0.12–1.42

12.3

RIPASA

83.5

37.5

87.6

Female

64.8

46.1

77.4

Male

88.7

31.5 90 28.6 0.6 0.14–3.17 9.9

Ohmann

82.3

81.2

95.8 46.4 24.2 6.98–84.44 4.1

Female

72.9

84.6

93.1 52.3 60.2 2.84–1274 6.9

79

96.6 42.9 30.5 6.54–142.75 3.4

Male

85

50

31.5

<0.1

0–1.15

22.6

Lintula

69.4

Female

56.7

61.5

Male

72.9

42.1

Eskelinen

76.4

65.6 92.2 34.4 2.1 0.53–8.26 7.8

Female

64.8

84.6 92.3 45.8 7.4 0.45–122.3 7.7

Male

79.7

52.6 92.1 27 0.9 0.16–5.77 7.8

Alvarado

75.8

65.6

92.1

33.8

2.5

0.85–7.88

7.9

Female

78.3

69.2

87.8

52.9

3.2

0.37–27.5

12.1

Male

75.1

63.1 93.4 26.6 2.6 0.63–11.03 6.5

Ultrasonography

81.1

28.1

Female

91.9

Male

78.2

23 31.5

88

30

DOR

23.5

0.4

0.10–1.47

11.9

80.7

33.3

1.1

0.11–11.66

19.2

89.8

18.1

0.3

0–1.71

10.2

85.7

21.9

1.7

0.55–5.44

14.3

77.2 50 11.1 0.42–291.64 22.7 88.8

17.1

1.5

0.42–5.83

11.1

PPV: Positive predictive value; NPV: Negative predictive value; DOR: Diagnostic Odds Ratio; CI: Confidence interval; NAR: Negative appendectomy ratio.

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Table 5. Diagnostic performance parameters of scoring systems and USG combination in the diagnosis of the acute appendicitis USG+Ripasa >7.5

Sensitivity

Specificity

PPV

NPV

DOR

%95 CI

NAR

65.9

53.1

88.1

22.6

0.2

0–0.83

11.8

Female

59.5

61.5

81.5

34.8

0

0–1.48

18.5

Male

67.7

47.4

90

17.3

0.2

0–1.59

10

USG+Ohmann >12 65.2

84.3

95.6 31.4 17.5 4.35–70.75 4.3

Female

64.9

92.3

96

48

34.7

1.84–655.21

4.0

Male

65.4

79

95.7

24.6

17.2

3–97.92

4.4

USG+Lintula ≥21 55.8

68.7 90.4 22.6 0.5 0.12–2.63 9.5

Female

54.1

84.6

90.9

39.2

1.7

0.16–19.91

9.1

Male

56.4

57.9

90.4

15.9

0.2

0–2.50

9.6

USG+Eskelinen ≥57 61.7

71.8 92.1 26.1 1.6 0.33–8.60 7.9

Female

59.5

84.6

91.7

42.3

4.1

0.26–66.88

8.3

Male

62.4

63.1

92.2

19.3

1.2

0.1–12.21

7.8

USG+Alvarado ≥7

61.1

71.8

92

25.8

2.5

0.74–8.97

8

Female

70.2

69.2

86.7

45

2.5

0.34–18.13

13.3

Male

58.6

73.7

94

20.2

3.7

0.78–18.46

6.0

USG: Ultrasonography; PPV: Positive predictive value; NPV: Negative predictive value; DOR: Diagnostic Odds Ratio; CI: Confidence interval; NAR: Negative appendectomy ratio.

Table 6. ROC analysis of scoring systems and USG combination in the diagnosis of the AA

AUC

SD

p

ROC Curve

1.0

%95 CI 0.8

RIPASA+USG 0.595 0.048 0.049 0.524–0.663 Lintula+USG 0.623 0.046 0.007 0.552–0.690 Eskelinen+USG 0.668 0.044 0.001 0.599–0.733 Alvarado+USG 0.665 0.044 0.001 0.596–0.730 AUC: Area under the curve; SD: Standard deviation; CI: Confidence interval; ROC: Receiver Operating Characteristic; AA: Acute appendicitis; RIPASA: Raja Isteri Pengiran Anak Saleha Appendicitis; USG: Ultrasonography;

DISCUSSION Despite the development of clinical and diagnostic methods in acute appendicitis, difficulties in making the correct diagnosis remain. While morbidity rates due to diagnostic delays increase, NARs are still seen between 15–23%.[13] In this study, the NARs were 15.8% comparable with other studies. Various non-invasive and cost-effective scoring systems have been developed to minimize morbidity and negative appendectomy. In this study, the sensitivity and specificity of the Ohmann scoring system were highest among all scoring systems and it was found to be more predictive in the diagnosis of acute appendicitis in the regression model compared to other scoring systems. In all scoring systems, the rate of a negative appendectomy was lower in male patients than in female patients. When scoring systems were combined with 310

Sensitivity

Ohmann+USG 0.748 0.037 <0.001 0.683–0.807

0.6

0.4 Source of the Curve

0.2

0.0 0.0

RIPASA Ohmann Lintula Eskelinen Alvarado

0.2

0.4 0.6 0.8 1 - Specificity Diagonal segments are produced by ties

1.0

Figure 1. ROC curves of scoring systems.

USG, it was seen that the diagnostic accuracy of acute appendicitis and DOR were not increased, whereas when Ohmann scoring system was combined with USG, the lowest NAR was obtained, especially in women. It is stated in some of the literature that the Ohmann scoring system is superior to other scoring systems in the diagnosis of acute appendicitis. In the study of Rastović et al.[14] comparing Modified Alvarado, Ohmann, and Eskelinen scoring systems in the diagnosis of acute appendicitis, it was stated that the scoring system with the best sensitivity and speciUlus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Şenocak et al. Diagnostic accuracy of USG and scoring systems: The effects on the negative appendectomy rate and gender

ficity was Ohmann. Similarly, Erdem et al.[2] reported that among Alvarado, Eskelinen, Ohmann, and RIPASA, the best scoring system was the Ohmann scoring system with 83.1% sensitivity and 80.6% specificity. Zielke et al.[15] reported that the sensitivity and specificity of the Ohmann scoring system were 63% and 93% in a study of 2359 patients with acute appendicitis. In this study, the sensitivity and specificity of the Ohmann scoring system were 82.3% and 81.2%, respectively. In addition, the highest AUC was observed via the Ohmann scoring system, although Lintula and Ripasa were weak, and all other scoring systems have strong diagnostic accuracy for acute appendicitis. Although some prospective studies have shown that scoring systems may be insufficient as a diagnostic test alone, it has been reported that good results can be obtained by combining clinical evaluation with either USG or Ohmann scoring.[15] Although USG has been shown to have more than 70% sensitivity and specificity in the diagnosis of acute appendicitis, and it has been shown to have high diagnostic accuracy in acute appendicitis, the method depends largely on the user’s experience and knowledge.[16–18] In the study conducted by Hosseini et al.,[19] the sensitivity and specificity of USG were reported as 37.1% and 87.2%, respectively, in tertiary health care centers. Due to its low negative predictive value (11.7%), USG was recommended for differential diagnosis and complicated cases of appendicitis rather than routine use. In a review by Pinto et al.,[20] it was stated that USG had highly variable sensitivity and specificity. In this study, sensitivity, specificity and Negative Predictive Value (NPV) of USG were 81.1%, 28.1%, and 21.9%, respectively. In addition, the scoring systems had similar sensitivity to USG and higher specificity than USG, and the combination of scoring systems with USG did not increase the diagnostic accuracy of acute appendicitis. These results were consistent with the recommendations in the literature stating that USG needs to be used in differential diagnosis or suspicious cases rather than routinely. It is demonstrated in a study that acute appendicitis might be overlooked in 33% of premenopausal women, the NARs were 45% and gynecological causes constituted more than half of the cases in the premenopausal period. Additionally, the sensitivity of diagnosis of acute appendicitis by USG was 65%, with a specificity of 41%, which was lower than reported. USG had a 65% sensitivity and 41% specificity. Althoubaity et al.[21] concluded that negative appendectomy rates did not decrease with USG and could be decreased to a minimum of 8.3% by CT. In this study, the higher detection rate of negative appendectomy (22%) using only USG in female patients indicated that USG and scoring systems were more important in females. On the other hand, it was reported that scoring systems were also affected by age group, gender, and geographical population.[22] In our study, the integration of USG with the scoring systems did not change the DOR of Alvarado and Lintula, regardless of gender, but decreased the others. Similarly, it did not significantly reduce Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

the NARs. In other words, the combination of the scoring systems with USG did not contribute positively to diagnostic accuracy and NARs. However, when analyzed by gender, NARs decreased in Lintula, Ripasa, and Ohmann scoring systems in female patients, yet did not change significantly in male patients. In conclusion, combining Ohmann, Lintula, and Ripasa scoring systems with USG can reduce NARs down to 4% in female patients. Regression analysis showed that the combination of scoring systems with USG reduced the AUC value in the diagnosis of acute appendicitis and the lowest NAR was obtained in female patients who were evaluated by a combination of USG and Ohmann. Similarly, Horzić et al.[23] stated that NARs were reduced by using Ohmann and Alvarado scores in female patients, while Althoubaity[21] stated that the Alvarado score in women had 89% sensitivity and 40% specificity and could have an effect on reducing NAR in female patients. It has been reported in previous studies that scoring systems reduce NARs or increase diagnostic accuracy. These scoring systems include Alvarado[10,24] RIPASA,[25] Ohmann,[14] Eskelinen,[26] Lintula[27] and Adult Appendicitis Score.[28] However, the number of studies in which these systems were evaluated on a large scale and with imaging methods was quite limited. Mariadason et al.[9] found that in 76.1% of patients with positive Alvarado score 1.9% NARs were obtained, in 82.4% of patients in appendicitis detected with CT 1.3% NARs were obtained, especially male patients had minimal benefit from CT, and that CT would not be needed for many patients. Genzor et al.[10] reported that NAR rates decreased from 5.2% to 4.3% when Alvarado score above 5 and USG were evaluated together. Jha et al.[29] suggested that performing CT after USG can only benefit 3.1% of false-negative USG patients. Therefore, the patients can be evaluated with scoring systems without a CT scan. In this study, it was seen that more accurate results were obtained with Ohmann scoring rather than Alvarado scoring which is preferred more frequently in surgical practice, NARs were lowered, and for female patients, the lowest NAR was obtained when Ohmann was combined with USG. Our study had some limitations. First, the effects of CT imaging could not be evaluated, but it was aimed to analyze the effects of USG which were more accessible and more applicable. Second, scoring systems were evaluated only in patients who underwent the appendectomy. Therefore, the sensitivity and specificity of scoring systems in the diagnosis of acute appendicitis may be overestimated. In conclusion, the use of scoring systems in the diagnosis of acute appendicitis not only increases the accuracy of the diagnosis but also reduces the NARs. Among the scoring systems in which the results differ geographically, Ohmann scoring gave the best results considering the NARs and DOR in the patients. To decrease NAR, especially in female patients, USG is recommended to be evaluated together with scoring sys311

Şenocak et al. Diagnostic accuracy of USG and scoring systems: The effects on the negative appendectomy rate and gender

tems. With the quick and easy application of Ohmann scoring, diagnosis of acute appendicitis can be supported in cases where CT or USG facilities are limited, the need for tests that contains ionizing radiation, such as CT can be reduced, and unnecessary health costs, can be prevented by facilitating the early diagnosis of acute appendicitis. Ethics Committee Approval: Retrospective study. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: R.Ş., Ş.K.; Design: R.Ş., Ş.K.; Supervision: R.Ş., Ş.K.; Fundings: R.Ş., Ş.K.; Materials: R.Ş., Ş.K.; Data: R.Ş., Ş.K.; Analysis: R.Ş., Ş.K.; Literature search: R.Ş., Ş.K.; Writing: R.Ş., Ş.K.; Critical revision: R.Ş., Ş.K. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Toprak H, Kilincaslan H, Ahmad IC, Yildiz S, Bilgin M, Sharifov R, et al. Integration of ultrasound findings with Alvarado score in children with suspected appendicitis. Pediatr Int 2014;56:95−9. 2. Erdem H, Çetinkünar S, Daş K, Reyhan E, Değer C, Aziret M, et al. Alvarado, Eskelinen, Ohhmann and Raja Isteri Pengiran Anak Saleha Appendicitis scores for diagnosis of acute appendicitis. World J Gastroenterol 2013;19:9057−62. 3. Chong CF, Adi MI, Thien A, Suyoi A, Mackie AJ, Tin AS, et al. Development of the RIPASA score: a new appendicitis scoring system for the diagnosis of acute appendicitis. Singapore Med J 2010;51:220−5. 4. Eskelinen M, Ikonen J, Lipponen P. Sex-specific diagnostic scores for acute appendicitis. Scand J Gastroenterol 1994;29:59–66. 5. Lintula H, Kokki H, Pulkkinen J, Kettunen R, Gröhn O, Eskelinen M. Diagnostic score in acute appendicitis. Validation of a diagnostic score (Lintula score) for adults with suspected appendicitis. Langenbecks Arch Surg 2010;395:495–500. 6. Ohmann C, Franke C, Yang Q, Margulies M, Chan M, van Elk PJ, et al. Diagnosescore für akute Appendicitis [Diagnostic score for acute appendicitis]. Chirurg 1995;66:135-41. 7. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557–64. 8. Xingye W, Yuqiang L, Rong W, Hongyu Z. Evaluation of Diagnostic Scores for Acute Appendicitis. J Coll Physicians Surg Pak 2018;28:110– 4. 9. Mariadason JG, Wang WN, Wallack MK, Belmonte A, Matari H. Negative appendicectomy rate as a quality metric in the management of appendicitis: impact of computed tomography, Alvarado score and the definition of negative appendicectomy. Ann R Coll Surg Engl 2012;94:395–401. 10. Genzor Ríos SJ, Rodríguez Artigas JM, Giménez Maurel T, Vallejo Bernad C, Aguirre Prat N, Miguelena Bobadilla JM. Ultrasonography and the Alvarado score in the diagnosis of acute appendicitis: impact on the negative appendectomy rate. [Article in Spanish]. Emergencias 2016;28:396–9. 11. Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, et al. US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis. Radiology 2006;241:83−94.

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12. Ma KW, Chia NH, Yeung HW, Cheung MT. If not appendicitis, then what else can it be? A retrospective review of 1492 appendectomies. Hong Kong Med J 2010;16:12–7. 13. Sezer TO, Gulece B, Zalluhoglu N, Gorgun M, Dogan S. Diagnostic value of ultrasonography in appendicitis. Adv Clin Exp Med 2012;21:633–6. 14. Rastović P, Trninić Z, Galić G, Brekalo Z, Lesko J, Pavlović M. Accuracy of Modified Alvarado Score, Eskelinen Score and Ohmann Score in Diagnosing Acute Appendicitis. Psychiatr Danub 2017;29:134–41. 15. Zielke A, Sitter H, Rampp T, Schäfer E, Möbius E, Lorenz W, et al. Can diagnostic scoring systems help decision making in primary care of patients with suspected acute appendicitis?. [Article in German]. Dtsch Med Wochenschr 1999;124:545−50. 16. Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management [published correction appears in Lancet 2017;390:1736. 17. Ahmai Nejad M, Saki M. Study of sonography sensitivity and specificity to the diagnosis of acute appendicitis in suspected patients referred to Khorramabad Ashayer hospital. Sci Mag Yafte 2012;13:23–7. 18. Russo A, Cappabianca S, Iaselli F, Reginelli A, D’Andrea A, Mazzei G, et al. Acute abdominal pain in childhood and adolescence: Assessing the impact of sonography on diagnosis and treatment. J Ultrasound 2013;16:201–7. 19. Hosseini A, Omidian J, Nazarzadeh R. Investigating Diagnostic Value of Ultrasonography in Acute Appendicitis. Adv Biomed Res 2018;7:113 20. Pinto F, Pinto A, Russo A, Coppolino F, Bracale R, Fonio P, et al. Accuracy of ultrasonography in the diagnosis of acute appendicitis in adult patients: review of the literature. Crit Ultrasound J 2013;5 Suppl 1:S2. 21. Althoubaity FK. Suspected acute appendicitis in female patients. Trends in diagnosis in emergency department in a University Hospital in Western region of Saudi Arabia. Saudi Med J 2006;27:1667–73. 22. Ohle R, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med 2011;9:139. 23. Horzić M, Salamon A, Kopljar M, Skupnjak M, Cupurdija K, Vanjak D. Analysis of scores in diagnosis of acute appendicitis in women. Coll Antropol 2005;29:133–8. 24. Kamran H, Naveed D, Asad S, Hameed M, Khan U. Evaluation of modified Alvarado score for frequency of negative appendicectomies. J Ayub Med Coll Abbottabad 2010;22:46–9. 25. Chae MS, Hong CK, Ha YR, Chae MK, Kim YS, Shin TY, et al. Can clinical scoring systems improve the diagnostic accuracy in patients with suspected adult appendicitis and equivocal preoperative computed tomography findings? Clin Exp Emerg Med 2017;4:214−21. 26. Sitter H, Hoffmann S, Hassan I, Zielke A. Diagnostic score in appendicitis. Validation of a diagnostic score (Eskelinen score) in patients in whom acute appendicitis is suspected. Langenbecks Arch Surg 2004;389:213– 8. 27. Yoldas O, Karaca T, Tez M. External validation of Lintula score in Turkish acute appendicitis patients. Int J Surg 2012;10:25–7. 28. Sammalkorpi HE, Mentula P, Savolainen H, Leppäniemi A. The Introduction of Adult Appendicitis Score Reduced Negative Appendectomy Rate. Scand J Surg 2017;106:196–201. 29. Jha P, Espinoza N, Webb E, Kohli M, Poder L, Morgan T. Single institutional experience with initial ultrasound followed by computed tomography or magnetic resonance imaging for acute appendicitis in adults. Abdom Radiol (NY) 2019;44:2357–65.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Skorlama sistemleri ve ultrasonografinin tanısal doğruluğunun negatif apandektomi oranı ve cinsiyet üzerine etkisi Dr. Rahman Şenocak, Dr. Şahin Kaymak Sağlık Bilimleri Üniversitesi, Gülhane Eğitim ve Araştırma Hastanesi, Genel Cerrahi Anabilim Dalı, Ankara

AMAÇ: Klinik, laboratuvar ve görüntüleme yöntemlerinin gelişmesine rağmen akut apandisit tanısı her zaman kolay olmamakta ve negatif apendektomi oranları hala yüksek seyretmektedir. Bu çalışmada amaç skorlama sistemlerinin kendi başına ve ultrasonografi (USG) ile beraber değerlendiğinde, doğru tanı oranlarına (DOR: Diagnostic Odds Ratio) ve negatif apendektomi oranlarına etkilerinin ortaya konulması amaçlandı. GEREÇ VE YÖNTEM: Çalışmamıza akut apandisit tanısıyla ameliyat edilen ardışık 202 hasta ileriye yönelik olarak dahil edildi. Tüm hastaların Ohmann, Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA), Lintula, Eskelinen ve Alvarado skorlama sistemleri kullanılarak ameliyat öncesi skorları hesaplandı. Olguların tümüne abdominal ultrasonografi randomize olarak uygulandı. Skorlama sistemlerinin sensitivitesi ve spesifitesi eşik değerlerine göre hesaplanmıştır. Eğri altındaki alan (AUC), ROC analizi ile hesaplanmıştır. Regresyon modelinde bağımlı değişken olarak apandisit histolojik tanısı kullanılırken, bağımsız değişkenler olarak skorlama sistemleri ve USG tercih edildi. BULGULAR: Negatif apendektomi oranı %15.8’di. Akut apandisit tanısında her iki cinsiyet için de en belirleyici yöntemin Ohmann olduğu görüldü (Diagnostic Odds Ratio (DOR)=24.2, %95 GA 6.98–84.44). Benzer şekilde en düşük negatif apandektomi oranları kadınlarda %6.9, erkeklerde %3.4 ile Ohmann ölçeğiyle elde edildi. Ölçekler, USG ile kombine edildiğinde, akut apandisit belirleyiciliğinde artış olmadığı görüldü. Bununla birlikte kadınlarda Ohmann ile USG kombine edildiğinde negatif apandektomi oranlarının daha da düştüğü görüldü (%6.9 ve %4). TARTIŞMA: Ohmann skorlaması kadın ve erkek hastalarda akut apandisit için iyi bir belirleyici olmasının yanı sıra, en iyi negatif apendektomi oranlarını sağlamaktadır. USG ile skorlama sistemlerinin kombinasyonu akut apandisit tanı değerini arttırmamaktadır, ancak kadınlarda USG ile Ohmann ölçeği birlikte kullanıldığında negatif apandektomi oranları oldukça düşmekteyken, erkeklerde bu fayda minimumdur. Anahtar sözcükler: Alvarado; Eskelinen; Lintula; negatif apendektomi oranı; Ohmann; RIPASA; USG. Ulus Travma Acil Cerrahi Derg 2020;26(2):306-313

doi: 10.14744/tjtes.2019.86717

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ORIGIN A L A R T IC L E

Comparison of tandir burns and other flame burns Hakan Çinal, M.D.,

Ensar Zafer Barın, M.D.

Department of Plastic Reconstructive and Aesthetic Surgery, Atatürk University Faculty of Medicine, Erzurum-Turkey

ABSTRACT BACKGROUND: Because internal temperature of tandir may reach up very high levels, tandir burns, which is one of flame burns, may cause more morbidity and mortality than those of other flame burns. Therefore, we aimed to compare tandir burns with other flame burns in the present study. METHODS: In this study, we compared tandir burns with other flame burns concerning age, gender, total burn surface area, burn depth, hospitalization times, hospitalization duration, surgical procedures performed, wound culture results, burn localization and mortality. RESULTS: Tandir burn patients were treated in the hospital for an average of 27.6±9.5 days, while non-tandir burn patients were treated for a period of 16.5±12.5 days. A significant difference was found between the hospitalization periods of the two groups (p<0.001). Tandir burn, which is a type of flame burn, affects the women and children much more frequently than other flame burns (p=0.0001), causes deeper burns (p=0.0001), which requires more surgical intervention (p=0.0001) and causes more frequent wound site infection. CONCLUSION: We think that it would be beneficial to treat high-temperature burns, such as tandir burns, as a separate group from other flame burns. We believe that further studies to be conducted in this field will bring new approaches to the treatment of tandir burns. Keywords: Amputation; burn; flame burn; high temperature; tandir burn.

INTRODUCTION Burns are one of the main causes of traumatic injuries that cause morbidity[1–4] and mortality[5] in all age groups. The diversity and frequency of etiological factors in burn trauma vary depending on the climate, as well as on industrialization, socio-economic, cultural and educational characteristics of each region. Although electricity and natural gas are commonly used for heating and cooking all over the world, fire is still used in some rural areas as the main source of heat for preparing food. The tandir, also called tandoor in India and Pakistan, is widely used in wide geography, including West and South Asia.[6,7] Dakota hole fire used in North America is a miniature of tandir. This method is used for a variety of purposes, such as to warm up food, to make kebabs, as well as to bake bread in

rural areas of eastern Turkey. The tandir is usually in the form of a well in the room or in the garden of a house, with a depth of about 150 cm and a diameter of 60 cm, and to ventilate the fumes, it will have a ventilator tube (Fig. 1). Wood and coal are burned inside it and food is cooked by either being hung or fixed to the walls of the well. The internal temperature of tandir can reach up to 470 °C (6). Therefore, it can be observed that tandir burns may cause more morbidity (Fig. 2) and mortality[8–11] as compared to other burns. There is a study comparing tandir burns with other types of burns in the literature.[9] However, so far, to our knowledge, there has been no particular study comparing tandir burn, which is a type of a flame burn, with other types of flame burns. Comparing these two groups of burn trauma with similar mechanisms will enable us to better understand tandir burns that are encountered in common geography and

Cite this article as: Çinal H, Barın EZ. Comparison of tandir burns and other flame burns. Ulus Travma Acil Cerrahi Derg 2020;26:314-319. Address for correspondence: Hakan Çinal, M.D. Atatürk Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Erzurum, Turkey Tel: +90 442 - 344 70 21 E-mail: mdcinal@gmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):314-319 DOI: 10.14744/tjtes.2020.25160 Submitted: 20.08.2019 Accepted: 08.03.2020 Online: 11.03.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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Çinal et al. Comparison of tandir burns and other flame burns

Figure 1. Image of a tandir oven.

Figure 2. A tandir victim.

which also have severe medical consequences. To this end, in this study, we compared tandir burns with other flame burns concerning age, gender, total burn surface area, burn depth, hospitalization times, hospitalization duration, surgical procedures performed, wound culture results, burn localization and mortality.

female patients and group 2 consisted of 92 (78.7%) male and 25 (21.3%) female patients. In Group 1, only 2 of 12 patients over the age of 10 were male. A statistically significant difference was found between the two groups in terms of gender distribution (p=0.0001). In Group 1, female cases were significantly higher than male cases (Table 1).

MATERIALS AND METHODS

While all of Group 1 consisted of tandir burns, the causes of burns in Group 2 were recorded as flammable liquids, such as gasoline-thinner (42 patients), flammable gas flare (33 patients), fire flame (32 patients), ignition of clothing (seven patients) and bomb-dynamite explosion (3 patients).

The patients utilized for this study were treated in the Burn Treatment Unit of Atatürk University Faculty of Medicine, between the years of 2011 and 2018. There were a total of 172 patients, including 55 with tandir burns (Group 1), 117 with flame burns (Group 2), who were included in this study. Data were collected retrospectively by scanning patient files, automation records and other files of the burn unit. Total burn surface areas (TBSA) were divided into four categories as 1–10%, 11-20%, 21–30% and more than 30% of TBSA. The groups were compared concerning age, gender, TBSA, burn depth, hospitalization times, hospitalization duration, surgical procedures performed, wound culture results, burn localization and mortality. In the study, all data were expressed as mean±SD. Differences between the two groups (tandir burns and flame burns) were analyzed using the independent Student’s t-test. Chi-square tests were used for the categorical variables where appropriate. All statistical calculations were done using the program SPSS for Windows (version 11.00; SPSS, Inc., Chicago, IL). Differences were considered statistically significant at levels of probability of p<0.05.

RESULTS Mean ages of the groups were found 12.98±22.09 (1–76) and 27.07±18.06 (0–76) in Group 1 and Group 2, respectively (p=0.001). Percentages of the patients’ age 10 years or below were 78.1% (43 cases) in Group 1 and 19.6% (23 cases) in Group 2. Group 1 consisted of 28 (50.1%) male, 27 (49.9%) Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

In group 1, the most commonly, the hands, feet, forearms, legs and gluteal regions of patients burned. Extremity burns were not present in only three of the 55 cases (5.45%). In all of the remaining 52 cases (94.55%), burns were present in at least one extremity (Table 2). A certain localization did not stand out in Group 2. Considering the burn distribution of extremities, in Group 2, it was found that the burn rates of the hands and feet and the right-left extremities were very close to each other. The burn surface width of the majority of patients in both groups was between 1–20%. In group 1 patients, the deepest burns were second-degree burns (40.2%) and in group 2, superficial second-degree burns (48.6 %). Third-degree burns occurred in 34.2% of patients in group 1 and in 12.1% of patients in group 2. Patients in Group 1 had significantly deeper burns (p=0.001), while the mean burn surface was close to each other in both groups and was around 14% (p=0.782) (Table 1). Although most hospitalization in group 1 was observed to be clustered in June-July-August, hospitalization in group 2 distributed homogeneously throughout the year. The mean hospitalization duration was found to be 34.2±24.22 (1–106) days in Group 1 and 23.5±18.28 (1–84) days in Group 315

Çinal et al. Comparison of tandir burns and other flame burns Table 1. Comparison of the group data Variables Mean age (years), mean±SD

0–10 (years), %

Group 1

Group 2

p

12.98±22.09

27.07±18.06

=0.0001

78.1%

19.6

Gender, n (%)

Female

27 (49%)

25 (21.4%)

Male

28 (50%)

92 (78.6%)

Total body surface area

14.8% (mean)

14.4% (mean)

1–10%, n (%)

19 (34.5)

47 (40.2)

11–20%, n (%)

23 (41.8)

46 (39.4)

21–30%, n (%)

9 (16.4)

17 (14.5)

>30%, n (%)

4 (7.3)

7 (5.9)

=0.0001 =0.782

Burn degree, n (%) 1st 2nd (superficial)

3 (3.7)

14 (9.5)

18 (21.9)

72 (48.6)

2nd (deep)

33 (40.2)

44 (29.8)

3rd

28 (34.2)

18 (12.1)

=0.0001

Operations, n (%)

Auto-grafting

36 (65.4)

Reconstruction

11 (20)

6 (5.1)

Fasciotomy

7 (12.7)

1 (0.8)

Amputation, n (%)

31 (Six patients) (10.9)

0 (0)

Mean length of stay (days)

34.2

23.5

1 patient (1.8)

2 patients (1.7)

Mortality, n (%)

2. There was a statistically significant difference between the two groups concerning hospitalization durations (p=0.005). Burn patients underwent debridement/escharotomy under operating room conditions as indicated accompanied by stanTable 2. Localization of tandir burns Tandir burn location

n

Hand

48 20.3

Forearm

25 20.3

Arm

18 20.3

Foot

48 20.3

Leg

49 20.3

Thigh

5 20.3

Hip

21 20.3

Genital

2 0.8

Trunk

7 20.3

Face

7 20.3

Head

4 1.6

Neck

2 0.8

Total

316

40 (34.1)

%

236 100

=0.0001

=0.005

dard dressing-medical treatment. In 65.4% of patients in group 1 and 34.1% of patients in group 2, split or full-thickness skin grafts were applied and burn wounds were closed. In 20% of those in group 1 and 5.1% of those in group 2 patients, flap surgery was performed since tissue defects were too deep to be closed with skin grafts. Seven patients in group 1 and one patient in group 2 were diagnosed with compartment syndrome. Thus, emergency fasciotomy was performed. Six patients (10.9%) underwent 31 finger amputations in group 1 due to burn complications, while none of the patients in group 2 had to undergo finger amputation (Table 1). Patients in Group 1 were observed to undergo more surgical operations in a statistically significant manner (p=0.001). Wound infection developed in 23 cases (41.8%), including multiple microorganisms in 13 cases in group 1 and in 19 cases (16.2%), including nine multiple microorganisms in group 2. Statistically significant wound site infection was seen in group 1 (p=0.002). In both groups, pathogenic microorganisms that reproduce most in culture were found to be Pseudomonas aeruginosa, Methicillin-resistant coagulase-negative Staphylococci (MRCNS) and Escherichia coli (Table 3). One patient (1.8%) was lost in group 1 and two patients (1.7%) in group 2. Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Çinal et al. Comparison of tandir burns and other flame burns

Table 3. The distribution of organisms isolated from burn patients Microorganisms

Group 1

Group 2 %

n

P. aeruginosa

9 22.5 10 30.23 =0.002

Methicillin-resistant coagulase-negative Staphylococci (MRCNS)

10

Escherichia Coli

5 12.5 5 15.05

25

n

p

3

%

9.12

Enterobacter

4 10 1 3.04

Acinetobacter

4 10 2 6.08

Enterococcus

1 2.5 1 3.04

Methicillin-sensitive coagulase-negative Staphylococci (MSCNS) 1 2.5 2 6.08 Others

6 15 9 27.36

Total

40 100 33 100

DISCUSSION Mostly, the use of the tandir may lead to the children being injured due to its location on the ground and the lack of a protective barrier on it (Fig. 3).[8–11] In parallel with the literature, in our study, the mean age in tandir burn group was found to be 12.98±22.09, and the rate of patients under the age of 10 was found to be 78.1%. On the other hand, the mean age in the flame burn group was found to be 27.07±18.06 (0–76). In tandir burns, patients were in a much smaller age group than other flame burns. This was especially since the tandir was located at the homes of the patients. Thus, children and women were more often exposed to burns than adult men who went to work. Although the ratio of men and women in the tandir burn group was very close to each other, only two of the 12 patients over the age of 10 were male. This result again sug-

Figure 3. Schematic view of tandir.

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gests that women who cook the bread and children are more likely to fall into the tandir. The number of female cases in other tandir burn studies also supports this idea.[8–11] On the other hand, in the flame burn group, 78.7% and statistically significantly more male cases were present in line with burn etiology (gasoline, diesel fuel, flammable gas and explosives). Since the tandir is in the form of a hole made in the ground, the lower and upper extremities of the body are most commonly affected as a result of falling into it.[11,12] In our study, at least one extremity burn was present in approximately 95% of the cases. As such, it would not be wrong to treat tandir burns as extremity burns. This also explains why the morbidity rate of tandir burns is high. In other flame burns, it was observed that there was no specific localization for the burn, while the hands, feet, forearms, legs and gluteal regions burned most commonly in the burn group due to tandir burns. In tandir burns and other flame burns, the mean burn surface was close to each other. Although the rate was around 14%, the deepest burns were of the second degree (40.2%) in tandir burn patients and of superficial second-degree burns (48.6%) in other flame burn patients. In addition, third-degree burns were higher in tandir burns than other flame burns (34.2%, 12.1%). We think there are two possible reasons for this. Firstly, while it is possible for the survivor to escape from the burning environment and protect himself/herself in other flame burns since the patient falls into a burning pit in the form of a well, it takes more time for him/her to get out of/be taken out of there and he/she is exposed to heat for a longer duration. It was shown as the second reason that the temperature in the tandir rises up to 470 degrees. This heat level, which is higher than other flame burns, causes deeper burns in the case. In other flame burns, the hospitalization was homogeneous throughout the year, but the hospitalization in tandir burn was most commonly in June-July-August. During these months, children were more exposed to burns due to the 317

Çinal et al. Comparison of tandir burns and other flame burns

summer holidays. The school appeared as a factor protecting children from trauma. According to the literature, tandir burns need longer inpatient treatment compared to non-tandir burns.[9,11] In our study, tandir burns (34.2 days) required inpatient treatment longer than other flame burns (23.5 days). We believe this result arises from tandir burns being more severe burns. Approximately two-fold autograft, four-fold flap and seven-fold fasciotomy were performed in patients with tandir burns. Amputation was not required in any patient with other flame burns, while 31 finger amputations were performed in six (10.9%) patients with tandir burns. In similar studies, the amputation rate was found to be 11.3% and 14.2%, respectively.[10,11] In parallel with other tandir burn studies,[8,9] the most common pathogenic agents were found to be Pseudomonas aeruginosa and MRCNS. Tandir burns developed more wound site infections than other flame burns. Because tandir causes deeper burns than other flame burns, this causes the wound site infection to be seen more frequently. Although the mortality rate was higher in tandir burns concerning non-tandir burns in the literature,[9,11] it was close to each other in our study (1.8%, 1.7%).

Conclusion The frequency and diversity of etiological factors in burn trauma varies depending on the climate, as well as the industrialization, socio-economic, cultural and educational characteristics of each region and it may arise from flame, scalding, electricity, radiation or chemical agents.[7,13] Flame is one of the most common causes of burns.[13] Tandir, a traditional oven, causes flame burns, since it is widely used in rural areas in eastern Turkey. The severity of the damage doubles as the temperature increases every 10 °C since the possibility of chemical reactions causing destruction of tissue structures is doubled.[14] Since the tandir is shaped like a jug, it concentrates on the heat in the pit and may reach a temperature of 470 °C. In addition, the tandir design incorporates all the primary forms of heat transfer, namely radiation, conduction and convection.[6] Therefore, tandir causing flame burns may cause deeper burns than other flame burns since it has much higher temperatures. Depth of burn was important predictors of patient survival.[13] Having a deeper depth of burn leads to a longer treatment period, more reconstructive surgery, and to more limb amputation, which leads to a more costly treatment.[15] It affects children at the beginning of their lives and causes permanent physical and psychological problems. Lifting the tandir off the ground, blocking it with barriers around or completely prohibiting it, will prevent the occurrence of irreversible traumas since tandir has the potential to cause more severe burns, as stated above. 318

As a result, tandir burn, which is a type of flame burn, affects the women and children much more frequently than other flame burns, causes deeper burns, requires more surgical intervention, causes more frequent wound site infection and causes longer hospitalization duration. Therefore, we think that it would be beneficial to treat high-temperature burns, such as tandir burns, as a separate group from other flame burns. We believe that further studies to be conducted in this field will bring new approaches to the treatment of tandir burns. Ethics Committee Approval: Approved by the local ethics committee. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: H.Ç.; E.Z.B.; Design: H.Ç.; E.Z.B.; Supervision: H.Ç.; E.Z.B.; Materials: H.Ç.; Data: H.Ç.; E.Z.B.; Analysis: H.Ç.; Literature search: H.Ç.; E.Z.B.; Writing: H.Ç.; E.Z.B.; Critical revision: H.Ç.; Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Goverman J, Mathews K, Goldstein R, Holavanahalli R, Kowalske K, Esselman P, et al. Adult Contractures in Burn Injury: A Burn Model System National Database Study. J Burn Care Res 2017;38:e328−36. 2. Goverman J, Mathews K, Goldstein R, Holavanahalli R, Kowalske K, Esselman P, et al. Pediatric Contractures in Burn Injury: A Burn Model System National Database Study. J Burn Care Res 2017;38:e192−9. 3. Oosterwijk AM, Mouton LJ, Schouten H, Disseldorp LM, van der Schans CP, Nieuwenhuis MK. Prevalence of scar contractures after burn: A systematic review. Burns 2017;43:41–9. 4. Doğan A, Sungur I, Bilgiç S, Uslu M, Atik B, Tan O, et al. Amputations in eastern Turkey (Van): a multicenter epidemiological study. Acta Orthop Traumatol Turc 2008;42:53−8. 5. Çakır B, Yeğen BÇ. Systemic responses to burn injury. Turk J Med Sci 2004;34:215−26. 6. Saxena DC, Rao PH, Rao R. Analysis of modes of heat transfer in tandoor oven. J Food Engineering 1995;26:209−17. 7. Bekerecioğlu M, Yüksel F, Peker F, Karacaoğlu E, Durak N, Kişlaoğlu E. “Tandir”: an old and well known cause of burn injury in the Middle East. Burns 1998;24:654−7. 8. Akçay MN, Oztürk G, Aydinli B, Ozoğul B. Tandir burns: a severe cause of burns in rural Turkey. Burns 2008;34:268–70. 9. Albayrak Y, Cakır C, Albayrak A, Aylu B. A comparison of the morbidity and mortality of tandir burns and non-tandir burns: experience in two centers. Ulus Travma Acil Cerrahi Derg 2011;17:323–8. 10. Al B, Coban S, Güloğlu C. Tandir burns in and around Diyarbakir, Turkey. Ulus Travma Acil Cerrahi Derg 2010;16:59−62. 11. Kurt Ozkaya N, Aktar S, Algan S, Akkaya H. A retrospective analysis of tandoor burn injuries in Eastern Anatolia. Turkish J Plastic Surg 2019;27:23−9. 12. Emsen IM, Oral A, Özcan Ö, Gencel E. Catastrophic and severity burning type among the middle asia countries “Tandoor” burns and its hard complications in our life: review of 15 years. Eur J Plast Surg 2008;31:299–304.

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Çinal et al. Comparison of tandir burns and other flame burns 13. Anlatici R, Ozerdem OR, Dalay C, Kesiktaş E, Acartürk S, Seydaoğlu G. A retrospective analysis of 1083 Turkish patients with serious burns. Part 2: burn care, survival and m ortality. Burns 2002;28:239–43. 14. Pennes HH. Analysis of tissue and arterial blood temperatures in the

resting human forearm. J Appl Physiol 1948;1:93–122. 15. Açıkel C, Eren F, Çeliköz B. Bir yanık ünitesinde yatarak tedavi edilen akut yanıklı hastaların maliyeti. Türk Plast Rekonstr Est Cer Derg 2002;10:186−9.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Tandır yanıkları ve diğer alev yanıklarının karşılaştırılması Dr. Hakan Çinal, Dr. Ensar Zafer Barın Atatürk Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Erzurum

AMAÇ: Bir tür alev yanığı olan tandır yanığı, tandırın çok yüksek sıcaklığa çıkabilmesi nedeniyle daha fazla mortalite ve morbiditeye neden olmaktadır. Bu nedenle, bu çalışmada tandır yanıkları ve diğer alev yanıklarını karşılaştırmayı amaçladık. GEREÇ VE YÖNTEM: Bu çalışmada tandır yanıkları ile diğer alev yanıklarını yaş, cinsiyet, toplam yanık yüzey alanı, yanık derinliği, yatış zamanları, yatış süreleri, yapılan cerrahi işlemler, yara kültür sonuçları, yanık lokalizasyonu ve mortalite açısından karşılaştırdık. BULGULAR: Tandır yanıklı hastaların ortalama hastanede kalma süresi 27.6±9.5 gün idi. Buna karşın tandır dışı yanıklı hastaların ortalama hastanede kalma süresi ise 16.5±12.5 gün idi. Bu iki grup arasında hastanede kalma süreleri arasında anlamlı derecede farklılık saptandı (p<0.001). Bir alev yanığı türü olan tandır yanıkları, diğer alev yanıklarına göre kadın ve çocukları çok daha sık etkilemekte (p=0.0001), daha derin yanıklara sebep olmakta (p=0.0001), daha fazla cerrahi müdahale gerektirmekte (p=0.0001) ve daha sık yara yeri enfeksiyonuna neden olmaktadır. TARTIŞMA: Tandır gibi yüksek dereceli yanıkların, diğer alev yanıklarından ayrı bir grup olarak ele alınmasının faydalı olacağını düşünüyoruz. Bu konuda yapılacak başka çalışmaların tandır yanıklarının tedavisi konusunda yeni yaklaşımlar getireceğine inanıyoruz. Anahtar sözcükler: Alev yanığı; amputasyon; tandır yanığı; yanık; yüksek sıcaklık. Ulus Travma Acil Cerrahi Derg 2020;26(2):314-319

doi: 10.14744/tjtes.2020.25160

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319

CA S E SERI ES

Endovascular embolisation treatment in a rare acute abdomen spontaneous rectus sheath haematoma Çağlayan Çakır, M.D. Department of Radiology, University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Resarch Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: In this study, we aimed to review spontaneous rectus sheath hematoma (RSH) and the results of endovascular therapy in patients presenting with a rare acute abdomen. METHODS: We evaluated the patients with RSH because of acute abdominal pain and applied endovascular embolization treatment who were admitted to our hospital emergency department retrospectively between December 2016 and December 2018. RESULTS: Rectus muscle sheath bleeding is an extremely rare and urgent emergency intervention. In the etiology, chronic severe cough crises and trauma may be the cause of haemorrhage in the elderly patient group; spontaneous bleedings may be seen with the increase in the use of anticoagulants. In this study, a total of six patients, 53–95 years old (mean 75.5) endovascular embolization treatment was administered on who were admitted to our hospital with the diagnosis of RSH and long-term anticoagulant use. In our series, physical examination findings, laboratory values, computed tomography (CT), CT angiography and digital subtraction angiography (DSA) findings were presented. The findings showed an active extravasation from the superficial circumflex iliac artery in two patients and the inferior epigastric artery in three patients. We had no bleeding focus in only one patient. An ultrasound-guided 5 Fr arterial sheath was placed on the side of the hematoma in the procedure. Then, the inferior epigastric artery and deep circumflex arteries were selectively catheterized using the Vertebral Diagnostic Catheter (5 Fr or 4 Fr). Superselective catheterization, with the help of microcatheter from the existing diagnostic catheter, was used to embolize the arteries and branches with active extravasation using a detachable coil. In the control angiographies performed after embolization, pathological staining disappeared, and complete embolization was achieved. There were no complications associated with the endovascular procedures. No active extravasation was detected in angiography examination, and inpatient follow-up, blood transfusion, antibiotics and analgesic support were performed in only one patient. However, it was ex as a result of reasons related to advance heart failure. CONCLUSION: RSH is a life-threatening condition that may cause acute abdominal pain, and endovascular embolization is a safe and effective treatment option that can be applied quickly in this patient group. Keywords: Embolization treatment; hematoma; rectus abdominis.

INTRODUCTION Spontaneous rectus sheath hematoma (RSH) is an emergency that occurs in elderly patients with the increased use of anticoagulant medications and may result in death if not intervened. Hematoma is frequently located in the lower wall of the rectus muscle in the abdominal wall and is formed by the rupture in the arteries and branches of the muscle.[1,2] In the

unstable patient group, endovascular embolization is an important alternative life-saving alternative treatment method.

MATERIALS AND METHODS In this retrospective study, six patients who were admitted to our emergency department with an acute abdomen and treated with the endovascular embolization between Decem-

Cite this article as: Çakır Ç. Endovascular embolisation treatment in a rare acute abdomen spontaneous rectus sheath haematoma. Ulus Travma Acil Cerrahi Derg 2020;26:320-324. Address for correspondence: Çağlayan Çakır, M.D. Kocaeli Derince Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, Kocaeli, Turkey Tel: +90 262 - 317 80 00 E-mail: drcakir1983@gmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):320-324 DOI: 10.14744/tjtes.2019.44015 Submitted: 19.03.2019 Accepted: 28.05.2019 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

320

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Çakır. Endovascular embolisation treatment in a rare acute abdomen spontaneous RSH

ber 2016-December 2018 were included. Demographic data, application complaints, medical history, computed tomography (CT) (Aquilion, Toshiba Medical, Japon) and CT angiography and digital subtraction angiography (DSA) images were reviewed from the patient file, computer registry system and imaging archives retrospectively.

Fresh frozen plasma (TDP) was administered intravenously until the INR was lower than 1.5 to reduce the tendency of patients with normal International Normalized Ratio (INR) to bleed. Hemogram follow-up at the same time every six hours in a day and hourly vital follow-up were performed to patients. Blood transfusion was performed to the patients before the procedure to reduce the Hb values to the normal limits. Each patient used low molecular weight heparin as the anticoagulant due to the current disease in this study. In addition, two patients had additional use of aspirin and clopidogrel. Clinically, acute abdominal pain, abdominal mass, and hypotension were present in the patients (Table 2). In our series, preoperative arterial, portal venous and late-phase CT and CT angiography showed active extravasation findings with giant rectus hematoma (Fig. 1). Afterwards, endovascular embolization was performed in the interventional treatment unit of our hospital (Table 3). An ultrasound-guided 5 Fr arterial sheath was placed on the side of the hematoma in the procedure. Subsequently, the diagnostic catheter was selectively catheterized using the vertebral catheter (5 Fr or

RESULTS A total of six patients (five female, one male) were admitted to our hospital, who used anticoagulant for a long time and diagnosed with spontaneous rectus hematoma (RSH). The mean age of the patients 75,5. The RSH’s of the patients who presented with acute abdomen to the emergency department were staged according to the computed tomography imaging findings in Table 1, and their treatment was arranged according to this table.[3] The patients were in the stage 3 group, and five of the six patients were treated with endovascular embolization and conservative treatment in our study. Only one patient had only conservative treatment.

Table 1. Classification of the rectus sheath haematoma based on clinical and computed tomographic (CT) findings Type

Clinical findings

CT findings

1

No haemodynamic compromise

Unilateral, intramuscular haematoma

2

Drop in haematocrit level, moderate deterioration

Uni- or bilateral, haematoma extending to between rectus

in clinical condition

muscle and transversalis fascia

3

Haemodynamic instability, requiring transfusion,

Extension of haematoma to the peritoneum and prevesical space of

fluid resuscitation

Retzius

Table 2. Clinical details, treatment, and outcome of patients Sex Age Anticoagulation/ Abnormal Clinical Transfusion Fresh Medication (years) antiplatelet coagulation presentations frozen used profile plasma Female

95

LMWH,

NO

Hypotension,

Yes

Yes

Factor IX

aspirin,

abdominal mass,

complex,

clopidogrel

pain

vitamin K1

Female

68

LMWH

Abdominal

Yes

Yes

mass, pain

Female

Abdominal

79

LMWH

NO

Female

76

LMWH, aspirin,

NO

82

LMWH

NO

Abdominal mass,

53

LMWH

NO

Yes

Vitamin K1

Yes

Yes

vitamin K1

Yes

Yes

Vitamin K1

Yes

Yes

Factor IX

pain

Abdominal mass,

Female

Yes

mass, pain

clopidogrel Female

Vitamin K1

pain

Abdominal mass,

pain complex, vitamin K1 LMWH: Low-molecularweight heparin.

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Çakır. Endovascular embolisation treatment in a rare acute abdomen spontaneous RSH

(a)

(b)

Figure 1. (a) Axial and (b) sagital maximum intensity projection images of contrast-enhanced computed tomography showing leftt rectus sheath haematoma with fluid-fluid levels and active contrast extravasation (black arrows).

(a)

(b)

(c)

Figure 2. Digital subtraction angiography showing (a) extravasation from the right inferior epigastric artery (black arrow) and (b) embolisation with microcoil (white arrow). (c) Follow-up computed tomography showing the microcoil and resolved left rectus sheath haematoma (black arrow).

4 Fr) [Cordis, Miami Lakers [FL], USA]. Active extravasation was observed in angiography imaging. Subsequently, the microcatheter was inserted using microcatheter 1.8 Fr Echelon 10 [Medtronic, Irvine [CL], USA], and it was used to embolize the arteries and branches with active extravasation using detachable coils [Medtronic, Irvine [CL], USA]. In the control angiographies, we performed pathological staining

disappeared, and complete embolization was achieved after embolization (Fig. 2). There were no complications associated with the endovascular procedures. It was not active extravasation detected in angiography examination only one patient, and we follow-up, blood transfusion, antibiotics and analgesic support this patient, but it was ex as a result of reasons related to the advanced heart failure.

Table 3. Endovascular embolization treatment procedure Side of RSH Right Left

Size of RSH (cm)

Pelvic Arteries Embolisation extension cannulated agent

18x9x9 Yes

No

14x9x6 Yes

Length of stay (days)

No

4

Outcome

Death

Yes Microcoil

9 Discharged

Right

10x11x16 Yes

Yes Microcoil

3

Discharged

Right

15x10x10 Yes

Discharged

Yes Microcoil

3

Right

12x8x7 Yes

Yes Microcoil

23 Discharged

Left

10x7x7 Yes

Yes Microcoil

14 Discharged

RSH: Rectus sheath hematoma

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Çakır. Endovascular embolisation treatment in a rare acute abdomen spontaneous RSH

DISCUSSION Spontaneous rectus sheath haematoma (RSH) is frequently seen in female patients with anticoagulant use.[1] In our study, the female to male ratio is similar to the literature with 1/5. It is observed most frequently in the 5th most common and it accounts for approximately 2% of the abdominal pain that is not known.[4,5] RSH is characterized by a rupture of superior and inferior epigastric veins and arteries, especially in the posterior border in the rectus muscle.[6] Spontaneous rectus hematomas have been reported in the epigastric vessels due to decreased arterial wall elasticity secondary to atherosclerosis changes in epigastric vessels.[7] Some hematological diseases that disrupt the blood coagulation mechanisms, surgical interventions, trauma and cough secondary conditions, such as sudden rupture of the rectus muscle, may cause hematoma in the abdominal wall. RSH increases the possibility of the increasing use of anticoagulants. [3] INR values were increased in all of the patients due to the use of low molecular weight heparin with an oral anticoagulant in our study. INR was taken to normal limits with fresh frozen plasma support before the procedure. As in our series, complaints of sudden onset abdominal pain, abdominal distention and accompanying hypotension are common. All patients in our series had complaints of abdominal pain and abdominal distention when they were admitted to the hospital emergency department due to an acute abdomen. Abdominal CT is a commonly used imaging modality for the differential diagnosis of other intraabdominal pathologies in patients with rectus hematoma. The sensitivity and specificity is 100%.[8,9] In our study, a detailed anatomic evaluation was performed with CT and CTA in all patients and the active extravasation in the vascular wall and the localization of the hematoma were recorded in three different planes. They were divided into three groups according to clinical and CT imaging findings, as indicated in Patients with RSH in our series (Table 1). The current opinion is that conservative treatment is sufficient in stage 2 and stage 1 group. If there is an elevation of INR in the laboratory values of these patients, it is recommended that the TDP and erythrocyte suspension replacement is sufficient and if the INR level is normal, it should be followed up with erythrocyte suspension. Patients in this group are hemodynamically stable after 24 hours of follow-up. Our stage 3 RSH patient group is hemodynamically unstable and requires rapid surgical intervention or endovascular intervention. Surgical intervention is used to evacuate the hematoma, to find the ligation of the bleeding vessel and to repair the damage in the rectus sheath.[10] However, as the patients were surgically in the high-risk group, endovascular embolization treatment was applied as the first choice in our series. When we review the literature, selective or superselective catheterization and embolization of the damaged vessel with DSA is a very successful method in patients with RSH.[11,12] Complications in the treatment of endovascular embolization in RSH, especially pseudoaneurysm due to vascular injury at the introducer access site, arterial dissection and arteriovenous Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

fistulas, distal embolization due to improper migration of the coil that is the embolizing agent used during the procedure, ischemia which may occur in the rectus muscle with contrast nephropathy due to the contrast of the loaded substance.[10] In our study, no major or minor complications were observed in the patient group. In our series, successful endovascular embolization was achieved in a small group of patients with RSH due to anticoagulant use, and this should be supported by a higher number of patients in the future.

Conclusion Endovascular embolization is an effective and safe treatment modality for unstable patients who applied to the hospital with acute abdominal pain with RSH. Informed Consent: Written informed consent was obtained from the patient for the publication of the case report and the accompanying images. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: Ç.Ç.; Design: Ç.Ç.; Supervision: Ç.Ç.; Fundings: Ç.Ç.; Materials: Ç.Ç.; Data: Ç.Ç.; Analysis: Ç.Ç.; Literature search: Ç.Ç.; Writing: Ç.Ç.; Critical revision: Ç.Ç. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

REFERENCES 1. Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore) 2006;85:105–10. 2. Siu WT, Tang CN, Law BK, Chau CH, Li MK. Spontaneous rectus sheath hematoma. Can J Surg 2003;46:390. 3. Rosen M, Haskins IN. Rectus sheath hematoma. In: UpToDate, Berman RS, Chen W, eds. Waltham, MA; UpToDate: 2016. 4. Donaldson J, Knowles CH, Clark SK, Renfrew I, Lobo MD. Rectus sheath haematoma associated with low molecular weight heparin: a case series. Ann R Coll Surg Engl 2007;89:309–12. 5. Osinbowale O, Bartholomew JR. Rectus sheath hematoma. Vasc Med 2008;13:275–9. 6. Henzel JH, Pories WJ, Smith JL, Burget DE Jr, Plecha FR. Pathogenesis and management of abdominal wall hematomas. Arch Surg 1966;93:929–35. 7. Verhagen HJ, Tolenaar PL, Sybrandy R. Haematoma of the rectus abdominis muscle. Eur J Surg 1993;159:335–8. 8. Fothergill WE. Haematoma in the Abdominal Wall Simulating Pelvic New Growth. Br Med J 1926;1:941–2. 9. Luhmann A, Williams EV. Rectus sheath hematoma: a series of unfortunate events. World J Surg 2006;30:2050–5. 10. JHM Cheng, FKY Cho, WKW Leung, WK Kan. Endovascular Embolisation for Rectus Sheath Haematoma Hong Kong J Radiol 2017;20:324−9. 11. Rimola J, Perendreu J, Falcó J, Fortuño JR, Massuet A, Branera J. Percutaneous arterial embolization in the management of rectus sheath hematoma. AJR Am J Roentgenol 2007;188:W497–W502. 12. Pieri S, Agresti P, Buquicchio GL, Di Giampietro I, Trinci M, Miele V. Endovascular management of the rectus muscle hematoma. Radiol Med 2015;120:951–8.

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CASE SERIES - ÖZET OLGU SUNUMU

Nadir bir akut karın nedeni olan spontan rektus hematomunda endovasküler embolizasyon tedavisi Dr. Çağlayan Çakır Sağlık Bilimleri Üniversitesi Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, İstanbul

AMAÇ: Bu çalışmada, nadir bir akut karın nedeni olan spontan rektus hematomu (SRH) ile gelen hastalarda endovasküler tedavinin sonuçlarını incelemeyi amaçladık. GEREÇ VE YÖNTEM: Aralık 2016–Aralık 2018 tarihleri arasında, hastanemiz acil servisine akut karın nedeni olan SRH nedeniyle başvurup endovasküler embolizasyon tedavi işlemi uygulanan hastaları geriye dönük olarak inceledik. BULGULAR: Çalışmamızda, uzun süreli antikoagülan kullanımı olan SRH tanısı ile hastanemiz acil servisine başvuran 53–95 yaş arası (ort. 75.5) beş kadın, bir erkek olmak üzere toplam altı hastaya endovasküler embolizasyon tedavi işlemi yapıldı. Çalışmamızda, hastaların fizik muayene bulguları, laboratuvar değerleri, bilgisayarlı tomografi (BT), BT anjiyografi ve dijital subtraksiyon anjiyografi (DSA) bulguları sunulmuştur. Üç hastada inferiyor epigastrik arterden iki hastada superfisiyal sirkumfleks iliak arterden aktif ekstravazasyon izlenmiş sadece bir hastada kanama odağı saptanmamıştır. İşlem tekniğinde hematomun olduğu taraftan ultrason eşliğinde 5 Fr arteryel kılıf yerleştirildi. Daha sonra vertebral diagnostik kateteri (5 Fr veya 4 Fr) kullanılarak inferiyor epigastrik arter ve derin sirkumfleks arterler selektif olarak kataterize edildi. Mevcut diagnostik kataterin içerisinden mikrokateter yardımıyla süperselektif kataterizasyon ile aktif ekstravazyonun olduğu arter ve dalları ayrılabilir koil kullanılarak embolize edildi. Embolizasyon sonrası yapılan kontrol anjiyografilerde patolojik boyanmalar ortadan kalktı ve tam embolizsayon sağlandı. Hastalarda endovasküler işlemle ilişkili herhengi bir komplikasyon gelişmedi. Sadece bir hastada anjiyografi incelemesinde aktif ekstravazasyon saptanmamış olup yatarak takip, kan transfüzyonu, antibiyotik, analjezik desteği uygulandı. Ancak ileri kalp yetersizliğine bağlı nedenlerden dolayı hayatını kaybetti. TARTIŞMA: Spontan rektus hematomu akut karın ağrısına neden olabilen hayatı tehdit edici bir durum olup endovasküler embolizasyon bu hasta grubunda hızlı uygulanabilen, güvenli ve etkili bir tedavi seçeneğidir. Anahtar sözcükler: Embolizasyon; hematom; rektus abdominis. Ulus Travma Acil Cerrahi Derg 2020;26(2):320-324

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CA S E R EP O RT

Posterior reversible encephalopathy syndrome as an underlying cause for encephalopathy in a sepsis patient in the intensive care unit: A case report Günseli Orhun, M.D. Department of Anesthesiology and Intensive Care, İstanbul University İstanbul Faculty of Medicine, İstanbul-Turkey

ABSTRACT Posterior reversible encephalopathy (PRES) is a clinical and radiological syndrome characterized by neurological findings and vasogenic edema in the posterior regions of the cerebral hemispheres. Sepsis and septic shock have recently been recognized as an etiological factor in PRES. In this case report, we are presenting a patient with intraabdominal sepsis and PRES followed in the intensive care unit with an unfavorable neurological outcome. Wider recognition of PRES as a cause of encephalopathy in sepsis patients is necessary. Keywords: Posterior reversible encephalopathy syndrome; prognosis; sepsis.

INTRODUCTION Posterior reversible encephalopathy syndrome (PRES) is a well-recognized syndrome characterized by mental status changes, seizures, focal neurological signs and coma, initially described in acutely hypertensive patients usually with favorable clinical prognosis and reversible radiological findings. [1] The etiology list has been lengthened in many papers to comprise other underlying causes, including sepsis.[2,3] The management of sepsis requires a multidisciplinary approach, and prompt and precise diagnosis is mandatory for treatment and favorable prognosis. With the etiology of sepsis or other causes, PRES is a very important entity for the intensivist to recognize. PRES presents with acute or subacute neurological findings and well established radiological findings. We are reporting a patient with intraabdominal sepsis and PRES with the hope that PRES gains wider recognition as a cause of encephalopathy in sepsis patients in the intensive care unit (ICU), resulting in timely treatment and better prognosis.

CASE REPORT 52-year-old female patient with hypertension, diabetes mel-

litus and congestive heart failure has been admitted to the emergency unit with an acute abdomen two days after an attempt to retrieve stem cells by liposuction from the abdomen for treatment of knee osteoarthritis. Upon detection of fluid and hematoma between the bowel loops on abdominal computed tomography (CT), the patient was taken into emergency laparotomy. Multiple small bowel perforations and intestinal fluid were detected in the abdomen whereupon small bowel resection, diverting ileostomy and abdominal vacuum-assisted closure were performed. In the perioperative period, the patient was taken into the ICU with hemodynamic deterioration and hypotension unresponsive to vasopressor infusion. On admission to the ICU, laboratory workup demonstrated leucocyte count 11200/mm3, C-reactive protein 613.6 mg/L, procalcitonin levels 45.5 ng/L, creatinine 2.9 mg/dL, serum ammonia level 33 mg/dL. Liver enzymes, coagulation tests and serum electrolytes were normal. A wide spectrum of antibiotic treatment was initiated. Hemodynamic problems deteriorated further shortly after admission into the ICU, requiring a second vasopressor and hydrocortisone treatment. Hemofiltration was started upon disturbance of renal functions. Intraabdominal fluid cultures showed Kleb-

Cite this article as: Orhun G. Posterior reversible encephalopathy syndrome as an underlying cause for encephalopathy in a sepsis patient in the intensive care unit: A case report. Ulus Travma Acil Cerrahi Derg 2020;26:325-327. Address for correspondence: Günseli Orhun, M.D. İstanbul Üniversitesi İstanbul Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, 34093 İstanbul, Turkey Tel: +90 212 - 414 20 00 E-mail: gunseli_orhun@hotmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):325-327 DOI: 10.14744/tjtes.2019.82668 Submitted: 06.11.2019 Accepted: 23.12.2019 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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siella pneumonia, and a suitable antibiotic regimen was administered. On the sixth day of ICU admission, vasopressor infusion and hemofiltration were stopped. During the ICU stay, sedation was discontinued daily for neurological examination and delirium assessment with the Confusion Assessment Method for the ICU. The patient was weaned from the respirator and discharged to the ward conscious and neurologically intact state on the eleventh day of ICU admission. The patient deteriorated and developed septic shock on the ward and was re-admitted into the ICU five days after and intubated. The patient went through repeated surgical procedures for intraabdominal infection and abdominal wall defect. Neurological assessment after cessation of sedation revealed that the patient was unresponsive with no movement in four extremities and intact brain stem reflexes. Laboratory investigation during acute neurological dysfunction showed a leukocyte count of 11500/mm3, C-reactive protein 105.4 mg/L, procalcitonin levels 7.6ng/L, creatinine 0.8 mg/dL and lactate dehydrogenase 419 U/L. Liver function tests were slightly elevated, and coagulation tests were abnormal. Endotracheal aspirate culture revealed K. pneumoniae and Grampositive rods. Intraabdominal fluid cultures and blood cultures showed K. pneumoniae growth. A non-enhanced brain CT was unremarkable. The electroencephalogram showed a diffuse slowing of electrical activity. The cerebrospinal fluid analysis was not possible due to acquired coagulopathy. Brain magnetic resonance imaging (MRI) was possible only on the ninth day of acute neurological deterioration due to hemodynamic instability revealing cortical and subcortical vasogenic edema symmetrically in the parietal and occipital lobes extending into the temporal and frontal regions and deep white matter. Hemorrhage was present in the frontal and parietal cortex (Fig. 1). The patient was diagnosed clinically and radiologically with PRES. The neurological status of the patient showed no improvement. She was weaned from the respirator, and a tracheostomy was performed. MRI scan was repeated one month later, showing the same lesion involvement with some cystic transformation in the frontal deep white

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(b)

matter, suggesting no radiological improvement, and on the contrary, ongoing neural tissue loss leading to cystic changes. The patient was discharged home as a care patient.

DISCUSSION PRES is a clinical and radiological syndrome that is usually diagnosed with acute or subacute neurological findings.[1] Neuroimaging has greatly facilitated the diagnosis of PRES, which is usually characterized by vasogenic edema in the cortical and subcortical region of parietal and occipital regions, sometimes extending into temporal and frontal lobes. Although this is the classical radiological tableau, cytotoxic edema, deep gray matter, corpus callosum and posterior fossa involvement have also been described.[4,5] Extensive involvement and hemorrhage have been loosely correlated with a less favorable prognosis, as well as the presence of sepsis as underlying etiology.[6,7] Clinical and radiological findings of PRES in hypertension, immunosuppressive treatment and rheumatological diseases have been shown to resolve over time, following prompt diagnosis and treatment; on the other hand, sepsis and septic shock are usually associated with worse prognosis in PRES.[7,8] On the pathophysiological level, the cellular processes leading to PRES in sepsis are still unclear. The vasogenic theory suggesting loss of autoregulation and leakage of fluid into the interstitial space due to abrupt hypertension may not apply to the septic patient in the majority of cases.[8,9] The endothelial damage theory hypothesizes an increase in blood pressure due to endothelial dysfunction.[10] The immunogenic theory, which is thought to involve activation of T cells and release of cytokines can be considered as the most relevant since cytokine-mediated mechanism inducing sepsis is very similar to those underlying PRES.[11] Sepsis is a grave condition that influences the whole body and the central nervous system may be the first system involved.

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Figure 1. Representative images of posterior reversible encephalopathy syndrome (PRES). PRES findings in 52-year-old septic shock patient who developed acute neurologic deterioration. FLAIR, T2-weighted and T1-weighted axial MR images show cortical and subcortical edema extending into the deep white matter (a, b). The hyperintense region in (c) (arrowhead) depicts hemorrhage.

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Although the radiology of PRES more or less follows the same pattern in most patients, a specific radiological pattern in sepsis has not been described.[2,3] In our case, there was hemorrhage and extensive cortical, subcortical and deep white matter involvement in both hemispheres and cortical hemorrhage. These findings were irreversible with some cystic and encephalomalacic changes on the first control MRI scan. The patient never made a neurological recovery. The specific radiological findings of PRES in sepsis, reversibility and correlation with clinical findings and the reflection on prognosis remain to be determined.

[12]

Sepsis and septic encephalopathy entail the involvement of physicians from many disciplines, including critical care physicians, neurologists, neurosurgeons and general surgeons in the care of the patient. PRES is an entity that needs to be recognized by the treating team. The authors believe that well-documented case series and epidemiological studies will shed better light on PRES in sepsis patients. Informed Consent: Written informed consent was obtained from the patient’s relatives for the publication of the case report and the accompanying images. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: G.O.; Design: v Supervision: G.O.; Fundings: G.O.; Materials: G.O.; Data: G.O.; Analysis: G.O.; Literature search: G.O.; Writing: G.O.; Critical revision: G.O. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

REFERENCES 1. Fugate JE, Rabinstein AA. Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions [published correction appears in Lancet Neurol. 2015 Sep;14(9):874]. Lancet Neurol 2015;14:914–25. 2. Bartynski WS, Boardman JF, Zeigler ZR, Shadduck RK, Lister J. Posterior reversible encephalopathy syndrome in infection, sepsis, and shock. AJNR Am J Neuroradiol 2006;27:2179–90. 3. Fugate JE, Claassen DO, Cloft HJ, Kallmes DF, Kozak OS, Rabinstein AA. Posterior reversible encephalopathy syndrome: associated clinical and radiologic findings. Mayo Clin Proc 2010;85:427–32. 4. Bartynski WS. Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR Am J Neuroradiol 2008;29:1036–42. 5. Bartynski WS, Boardman JF. Distinct imaging patterns and lesion distribution in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol 2007;28:1320–7. 6. Alhilali LM, Reynolds AR, Fakhran S. A multi-disciplinary model of risk factors for fatal outcome in posterior reversible encephalopathy syndrome. J Neurol Sci 2014;347:59–65. 7. Schweitzer AD, Parikh NS, Askin G, Nemade A, Lyo J, Karimi S, et al. Imaging characteristics associated with clinical outcomes in posterior reversible encephalopathy syndrome. Neuroradiology 2017;59:379−86. 8. Gao B, Lyu C, Lerner A, McKinney AM. Controversy of posterior reversible encephalopathy syndrome: what have we learnt in the last 20 years?. J Neurol Neurosurg Psychiatry 2018;89:14–20. 9. Bartynski WS. Posterior reversible encephalopathy syndrome, part 2: controversies surrounding pathophysiology of vasogenic edema. AJNR Am J Neuroradiol 2008;29:1043–9. 10. Marra A, Vargas M, Striano P, Del Guercio L, Buonanno P, Servillo G. Posterior reversible encephalopathy syndrome: the endothelial hypotheses. Med Hypotheses 2014;82:619–22. 11. Chen Z, Shen GQ, Lerner A, Gao B. Immune system activation in the pathogenesis of posterior reversible encephalopathy syndrome. Brain Res Bull 2017;131:93–9. 12. Zampieri FG, Park M, Machado FS, Azevedo LC. Sepsis-associated encephalopathy: not just delirium. Clinics (Sao Paulo) 2011;66:1825–31.

OLGU SUNUMU - ÖZET

Yoğun bakım ünitesinde sepsisli bir hastada ensefalopatinin altında yatan bir neden olarak posterior reversible ensefalopati sendromu: Olgu sunumu Dr. Günseli Orhun İstanbul Üniversitesi İstanbul Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, İstanbul

Posterior reversible ensefalopati sendromu (PRES), nörolojik bulgular ve serebral hemisferlerin posterior bölgelerinde vazojenik ödem ile karakterize klinik ve radyolojik bir sendromdur. Sepsis ve septik şok yakın zamanda PRES’te etiyolojik bir faktör olarak kabul edilmiştir. Yoğun bakım ünitesinde intraabdominal sepsis ve PRES’i takiben olumsuz nörolojik sonlanımı olan bir hastayı sunuyoruz. Sepsis hastalarında ensefalopatinin bir nedeni olarak PRES’in daha geniş tanınması gerekmektedir. Anahtar sözcükler: Posterior reversible ensefalopati sendromu; prognoz; sepsis. Ulus Travma Acil Cerrahi Derg 2020;26(2):325-327

doi: 10.14744/tjtes.2019.82668

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A rare case report: Cervical subcutaneous and mediastinal emphysema due to mastoid fracture Haydar Gök, M.D., Selim Şeker, M.D., Mehmet Alpay Çal, M.D., Tamer Altay,

Halil Olgun Peker, M.D., Suat Çelik, M.D.

Department of Neurosurgery, Okmeydanı Training and Research Hospital, İstanbul-Turkey

ABSTRACT Subcutaneous emphysema occurs when air enters the soft tissue, which usually appears in the soft tissues of the chest wall or neck. It may also arise from pneumothorax or skin lacerations after trauma or other reasons. Mediastinal emphysema may be either associated with subcutaneous emphysema or seen alone.The air in the mastoid cells may spread from the retropharyngeal region or various neck compartments into the mediastinum. Usually, no severe neurological or clinical findings are observed except crepitation on palpation. We present a case report of a mastoid fracture as a rare cause of cervical subcutaneous and mediastinal emphysema. Keywords: Head trauma; mastoid fracture; mediastinal emphysema; subcutaneous emphysema.

INTRODUCTION Subcutaneous emphysema occurs with the penetration of air into the skin. It usually occurs in the soft tissues of the chest wall or neck.[1,2] The air enters the skin from the neck or lung but also rarely from the other anatomical parts of the body. Blunt or penetrating trauma, pneumothorax barotrauma, infection, malignancy and surgical procedures may cause subcutaneous emphysema and even it may occur spontaneously. [2–6] Iatrogenic procedures (tonsillectomy, dental extraction, endoscopy) and trauma (especially maxillofacial traumas) are the usual causes of cervical subcutaneous and mediastinal emphysema.[7,8] Rarely, it may occur due to mastoid fracture. If there is no significant clinical sign, the mastoid fracture can easily be overlooked. We report a case of cervicomediastinal emphysema due to mastoid fracture. At first, nobody could have thought that it could happen due to head trauma because the patient had a blow to the chest mainly and had no cranial symptom.

CASE REPORT A 25-year-old man was brought to the emergency department. He stated that he was beaten and had been hit to his

chest and head. He described pain in the neck and chest region. There was no neurologic deficit or any cranial nerve pathology. There was no any marked bruise on his chest, neck, face or head. However, there was crepitus on palpation of the chest and right neck area. Thorax computerized tomography (CT) revealed subcutan emphysema extending from the cervical region to the upper mediastinal area and neighborhood to arcus aorta (Fig. 1). The patient was wanted to be admitted to the General Surgery service. However, there was no costal, sternal or clavicular fracture, and it was not clear from where the air entered the skin. The patient also had cervical and cranial CT scans. Firstly, no skull pathology was considered because there was no neurologic sign or intracranial pathology related to fracture. However, when we looked carefully, massive air seemed in the soft tissue planes of the right cervical area related to the mastoid air cells (Fig. 2). The air was forced towards the loose layers of connective tissue and subcutaneous cervical emphysema was occurred. Unlike the other two cases, in our patient, the fracture line was in front of the mastoid bone. Thus, the emphysema occurred in the anterior

Cite this article as: Gök H, Şeker S, Peker HO, Çal MA, Altay T, Çelik S. A rare case report: Cervical subcutaneous and mediastinal emphysema due to mastoid fracture. Ulus Travma Acil Cerrahi Derg 2020;26:328-330. Address for correspondence: Haydar Gök, M.D. Okmeydanı Eğitim ve Araştırma Hastanesi, Beyin ve Sinir Cerrahisi Kliniği, İstanbul, Turkey Tel: +90 212 - 314 55 55 E-mail: haydarctf@hotmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):328-330 DOI: 10.14744/tjtes.2019.02828 Submitted: 04.10.2018 Accepted: 22.02.2019 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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Figure 1. (a, b) Thorax CT scan demonstrating subcutan emphysema extending from the cervical region to the upper mediastinal area and neighborhood to arcus aorta.

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DISCUSSION Subcutaneous crepitus, swelling and pain in the neck and chest, dyspnea, and a sore throat are the clinical manifests of subcutaneous and mediastinal emphysema.[9,10]

Figure 2. (a, b) Coronal cervical CT scan demonstrating massive air in the soft tissue planes of the right cervical area related with mastoid air cells.

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Figure 3. (a-d) Axial cranial and cervical CT scans demonstrating emphysema in the anterior area of the chest and neck.

area of the chest (Fig. 3). Patient’s consent was obtained for this study. Ulus Travma Acil Cerrahi Derg, March 2020, Vol. 26, No. 2

Eustachian tube protects the eardrum and otic ossicles by equilibrating the pressure in the middle ear with atmospheric pressure.[11] It links the nose and nasopharynx cavity to the middle ear and mastoid cavity. The gas reservoir of the middle ear is served by the mastoid cavity. If the air is forced into the middle ear, the pressure of the air within the mastoid air cells increases. The mastoid fracture may lead to squeezing out the air from within and dissecting into the surrounding soft tissue planes.[12] Many cases have been reported about subcutaneous and mediastinal emphysema. Lots of subcutaneous cervical emphysema reports are related to maxillofacial and/or cervical traumas and surgery complications. Cervical subcutaneous and mediastinal emphysema due to isolated mastoid fracture has been reported twice. In the first case, a patient was kicked in the mastoid several times, and a linear closed fracture of the mastoid occurred. The authors attributed the source of the air from the patient’s self-induced Valsalva maneuvers that forced air out beyond the fracture.[13] In the second case, a patient was struck with a batted baseball to the right mastoid. Thus, a high velocity, focal impact to the mastoid bone led to a comminuted fracture of the mastoid. According to the authors, the impact displaced the mastoid air into the soft tissues and the air exited with sufficient force to dissect through the fascial planes.[14] Cervicomediastinal emphysema due to mastoid injury is a rare pathology, but it can be difficult to diagnose. Incorrect or incomplete diagnosis may affect the treatment. In addition, possible complications related to the mastoid fracture will be ignored. Thus, when we see the cervical subcutaneous and mediastinal emphysema, if there is a history of head trauma, we should consider the mastoid fracture. 329

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Informed Consent: Written informed consent was obtained from the patient for the publication of the case report and the accompanying images. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: H.G., S.Ç.; Design: H.G., S.Ş.; Supervision: S.Ç.; Fundings: S.Ş., H.O.P.; Materials: S.Ş., M.A.Ç.; Data: H.O.P., M.A.Ç.; Analysis: H.G., T.A.; Literature search: S.Ş., H.O.P., M.A.Ç.; Writing: H.G., S.Ş.; Critical revision: T.A., S.Ç. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

REFERENCES 1. Gajardo RMA, Gajardo RPE, Zúñiga TCG, Sepúlveda PD, López CA, Roa HIJ, et al. Subcutaneous emphysema after ultrasonic treatment: a case report. Int J Odontostomatol 2009;3:67–70. 2. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984;144:1447–53. 3. Beck PL, Heitman SJ, Mody CH. Simple construction of a subcutaneous catheter for treatment of severe subcutaneous emphysema. Chest 2002;121:647–9. 4. Johnson F, Semaan MT, Megerian CA. Temporal bone fracture: evaluation and management in the modern era. Otolaryngol Clin North Am

2008;41:597–618. 5. Jones RM, Rothman MI, Gray WC, Zoarski GH, Mattox DE. Temporal lobe injury in temporal bone fractures. Arch Otolaryngol Head Neck Surg 2000;126:131–5. 6. Kuncz A, Roos A, Lujber L, Haas D, Al Refai M. Traumatic prepontine tension pneumocephalus--case report. Ideggyogy Sz2004;57:313–5. 7. Brasileiro BF, Cortez AL, Asprino L, Passeri LA, De Moraes M, Mazzonetto R, et al. Traumatic subcutaneous emphysema of the face associated with paranasal sinus fractures: a prospective study. J Oral Maxillofac Surg 2005;63:1080−7. 8. McKenzie WS, Rosenberg M. Iatrogenic subcutaneous emphysema of dental and surgical origin: a literature review. J Oral Maxillofac Surg 2009;67:1265–8. 9. Som PM, Curtin HD. Fascia and neck spaces. In: Head and Neck Imaging, 5th ed. St. Louis, MO: Elsevier; 2011. p. 2203–34. 10. Flint P, Haughey B, Lund V, Niparko J, Robbins K, Thomas JR, et al. Cummings Otolaryngology- Head and Neck Surgery: Head and Neck Surgery, 6th ed. Philadelphia, PA: Elsevier; 2015. 11. Seibert JW, Danner CJ. Eustachian tube function and the middle ear. Otolaryngol Clin North Am 2006;39:1221–35. 12. Alper CM, Kitsko DJ, Swarts JD, Martin B, Yuksel S, Cullen Doyle BM, et al. Role of the mastoid in middle ear pressure regulation. Laryngoscope 2011;121:404−8. 13. Lee JY, Zovickian J, Wang KC, Pang D. Subcutaneous cervical emphysema associated with mastoid fracture. Childs Nerv Syst 2012;28:489– 91. 14. Ahmed Y, Ng M. Extensive Cervicomediastinal Emphysema from Mastoid Injury. Craniomaxillofac Trauma Reconstr 2016;9:338−41.

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Nadir bir olgu sunumu: Mastoid kırığı nedeniyle oluşan servikal subkutan ve mediastinal amfizem Dr. Haydar Gök, Dr. Selim Şeker, Dr. Halil Olgun Peker, Dr. Mehmet Alpay Çal, Dr. Tamer Altay, Dr. Suat Çelik Okmeydanı Eğitim ve Araştırma Hastanesi, Beyin ve Sinir Cerrahisi Kliniği, İstanbul

Subkutan amfizem, cilt altı yumuşak dokuya hava girmesiyle oluşur. Genellikle göğüs duvarı veya boyun yumuşak dokularında ortaya çıkar. Travma sonrası pnömotoraks veya cilt laserasyonlarına bağlı gelişebildiği gibi başka nedenlerle de oluşabilmektedir. Mediastinal amfizem tek başına veya subkutan amfizemle birlikte görülebilir. Çok nadir sebeplerinden bir tanesi de mastoid kemik kırığıdır. Mastoid hücrelerinde bulunan hava retrofaringeal bölgeden veya çeşitli boyun kompartmanları arasından mediastene doğru yayılabilir. Genellikle bu hastalarda palpasyonla krepitasyon alınması dışında ciddi nörolojik veya klinik bulgu izlenmemektedir. Bu yazıda servikal subkutan ve mediastinal amfizemin nadir nedenlerinden biri olan mastoid kırığı sunulmaktadır. Anahtar sözcükler: Kafa travması; mastoid kırığı; medistinal amfizem; subkutan amfizem. Ulus Travma Acil Cerrahi Derg 2020;26(2):328-330

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CA S E R EP O RT

Successful treatment of a combined bronchial and aortic trauma Murat Sarıçam, M.D.,1

Berker Özkan, M.D.,2

Alper Toker, M.D.2

1

Department of Thoracic Surgery, Namık Kemal University, Tekirdağ-Turkey

2

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

ABSTRACT Tracheobronchial injury is an uncommon but severe complication of blunt thoracic trauma. In this study, we present a patient who developed complete avulsion of the left main bronchus with a vertical rupture toward the carina accompanying a contained rupture of the descending aorta after being run over by a van. We performed a left upper lobectomy and reimplantation of the lower lobe to the left main bronchus. Subsequently, an endovascular stent was placed to cover the pseudoaneurysm. The patient was discharged on day nine after an uneventful postoperative course. Tracheobronchial trauma complicated with concomitant major injuries apparently requires a rapid and challenging multidisciplinary approach in a well-developed and experienced trauma centre for a successful treatment. Keywords: Blunt chest trauma; endovascular stent; rupture of the aorta; tracheobronchial injury.

INTRODUCTION

CASE REPORT

Tracheobronchial injury (TBI) developing upon blunt chest trauma is rare, counting for only 1–2% of all blunt thoracic trauma cases but notably life-threatening.[1] TBI from blunt trauma more commonly involves distal trachea or main bronchi.[1,2] The right main bronchus is more susceptible to blunt trauma, perhaps as an outcome of relative protection of the left main bronchus warranted by the aorta.[3] Although injuries of intrathoracic major vascular structures frequently develop upon penetrating trauma, thoracic aorta is the vessel that most commonly sustains damage from blunt thoracic injuries.[4] Regarding that, 30–80% of the deaths arising from TBI occur at the scene of the trauma, rapid diagnosis and surgical management of these patients are mandatory.[5]

A 22-year-old male was admitted to a rurally located emergency centre after being run over by a van. The patient was transferred to our unit after two chest drains were placed, one in each hemithoracic cavity. A computed tomography (Fig. 1a) revealed a contused right lung and a chest drain in the left main bronchus (LMB) extending toward the trachea. Fiberoptic bronchoscopy confirmed that the chest drain was in the LMB (Fig. 1b). The intubation tube was introduced into the right main bronchus. Although the computed tomography was not contrast-enhanced, a contained aortic rupture could be recognized (Fig. 2).

Herein, we present a case with a complete transection of the left main bronchus and rupture of the descending aorta who was successfully treated with a left upper sleeve lobectomy and endovascular repair of the aorta.

An exploratory thoracotomy revealed a complete avulsion of the LMB with a vertical rupture toward the carina and complete avulsion of the two segmentary pulmonary arteries to the upper lobe (Fig. 3). An immediate left upper lobectomy and reimplantation of the left lower lobe to the LMB was performed after the repair of the LMB.

Cite this article as: Sarıçam M, Özkan B, Toker A. Successful treatment of a combined bronchial and aortic trauma. Ulus Travma Acil Cerrahi Derg 2020;26:331-333. Address for correspondence: Murat Sarıçam, M.D. Namık Kemal Üniversitesi Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, Tekirdağ, Turkey Tel: +90 282 - 250 55 00 E-mail: drsaricam@gmail.com Ulus Travma Acil Cerrahi Derg 2020;26(2):331-333 DOI: 10.5505/tjtes.2018.23429 Submitted: 20.03.2018 Accepted: 24.12.2018 Online: 24.02.2020 Copyright 2020 Turkish Association of Trauma and Emergency Surgery

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Sarıçam et al. Successful treatment of a combined bronchial and aortic trauma

(a)

(b)

Figure 1. Images of the computed tomography (a) and fiberoptic bronchoscopy (b) revealing a chest drain in the left main bronchus.

Figure 3. Avulsion of left main bronchus with a rupture toward the carina.

Figure 2. Contained rupture of the descending aorta.

Figure 4. Chest X-ray of the patient before the discharge.

The patient was stabilized in the intensive care unit; then, an endovascular stent (Medtronic, Minneapolis, USA) was placed in the descending aorta to cover the pseudoaneurysm. After an uneventful postoperative course, the patient was discharged on day nine (Fig. 4). Consent was obtained from the patient for this case report.

playing pneumomediastinum and pneumothorax, which is present in approximately 60% of the patients with TBI.[7–9] Furthermore, computed tomography can elaborate on the injury and identify associated injuries helping to plan the priority management.[10] Examination of the tracheobronchial tree with a fiberoptic bronchoscope allows assessment of the site and the extent of the injury, making it the only study that can reliably exclude central airway trauma.[11] The purpose of the surgical repair includes patching up the airway defect to maintain ventilation, preventing mediastinal infection and avoiding healing complications, such as airway stenosis and pulmonary infections. Small tears and lacerations should be repaired with direct sutures while complete or partial transections require debridement of the devitalized tissues and end to end anastomosis.[10–12] Moreover, tissue flaps e.g., muscle flaps, mediastinal fat, pericardium covering the sutures, may be applied to provide continuance of the vascular supply. However, serious bronchial damage, accompanying pulmonary vascular damages, and/or irreversible destruction of lung parenchyma may necessitate lung resections.[12] Regarding that most of TBI arising from blunt trauma occurs

DISCUSSION Several mechanisms were introduced for TBI in blunt trauma, including pressure upon the sternum reflecting on the vertebral column crushing the trachea or the main bronchi, widening of the chest transversely causing the traction of the trachea, sudden deceleration of lungs fixed at the hilum or increased airway pressure resulting from the closure of the glottis bringing out a rupture in the wall of trachea and/or main bronchi.[4–6] The initial assessment of a potential airway trauma should proceed rapidly for the diagnosis, particularly paying attention to the airway stability. A chest X-ray is helpful in dis332

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around the carinal level and main bronchus and needs technically challenging surgical reconstruction,[12] it is obvious that appropriate strategy for treatment in an experienced trauma centre is necessary.[13] Traumatic aortic injuries are estimated to be lethal in 80–90% of the cases. Treatment options are open surgical repair, endovascular repair and medical management.[14] Open surgical repair is still the first procedure of choice for the injuries of the aortic root, ascending aorta and aortic arch while endovascular repair shall be preferred as a management option for the injuries affecting aortic isthmus, descending thoracic or abdominal aorta.[14,15] The results of thoracic endovascular aortic repair for blunt traumatic aortic rupture are very successful and allow us to treat multi-trauma patients avoiding high-risk open repair.[15]

Conclusion TBI is an infrequent but serious complication of blunt chest trauma demanding high-level suspicion in diagnosis and effective strategy in treatment. It becomes evident that complex cases as presented in our paper can be safely treated by technically sufficient and experienced surgeons in well-equipped medical centres. Informed Consent: Written informed consent was obtained from the patient for the publication of the case report and the accompanying images. Peer-review: Internally peer-reviewed. Authorship Contributions: Concept: M.S.; Design: M.S.; Supervision: M.S.; Materials: B.Ö.; Data: B.Ö.; Literature search: M.S.; Writing: M.S.; Critical revision: A.T. Conflict of Interest: None declared. Financial Disclosure: The autors declared that this study has received no financial support.

REFERENCES 1. Symbas PN, Justicz AG, Ricketts RR. Rupture of the airways from blunt trauma: treatment of complex injuries. Ann Thorac Surg 1992;54:177–83. 2. Alassal MA, Ibrahim BM, Elsadeck N. Traumatic intrathoracic tracheobronchial injuries: a study of 78 cases. Asian Cardiovasc Thorac Ann 2014;22:816–23. 3. Hwang JJ, Kim YJ, Cho HM, Lee TY. Traumatic tracheobronchial injury: delayed diagnosis and treatment outcome. Korean J Thorac Cardiovasc Surg 2013;46:197–201. 4. Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney PA, et al. Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma. J Trauma 1997;42:374-80; discussion 380−3. 5. Mahmodlou R, Sepehrvand N. Tracheobronchial injury due to blunt chest trauma. Int J Crit Illn Inj Sci 2015;5:116–8. 6. Nishiumi N, Inokuchi S, Oiwa K, Masuda R, Iwazaki M, Inoue H. Diagnosis and treatment of deep pulmonary laceration with intrathoracic hemorrhage from blunt trauma. Ann Thorac Surg 2010;89:232–8. 7. Karmy-Jones R, Jurkovich GJ. Blunt chest trauma. Curr Probl Surg 2004;41:211–380. 8. Koletsis E, Prokakis C, Baltayiannis N, Apostolakis E, Chatzimichalis A, Dougenis D. Surgical decision making in tracheobronchial injuries on the basis of clinical evidences and the injury’s anatomical setting: a retrospective analysis. Injury 2012;43:1437–41. 9. Stark P. Imaging of tracheobronchial injuries. J Thorac Imaging 1995;10:206−19. 10. Madden BP. Evolutional trends in the management of tracheal and bronchial injuries. J Thorac Dis 2017;9:E67–E70. 11. Jennings A, Joe M, Karmy-Jones R. Tracheobronchial trauma. JSM Burns Trauma 2017;2:1011. 12. Prokakis C, Koletsis EN, Dedeilias P, Fligou F, Filos K, Dougenis D. Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment. J Cardiothorac Surg 2014;9:117. 13. Welter S, Hoffmann H. Injuries to the tracheo-bronchial tree. [ Article in German]. Zentralbl Chir 2013;138:111–6. 14. Ziza V, Canaud L, Molinari N, Branchereau P, Marty-Ané C, Alric P. Thoracic endovascular aortic repair: A single center’s 15-year experience. J Thorac Cardiovasc Surg 2016;151:1595–603.e7. 15. Cullen EL, Lantz EJ, Johnson CM, Young PM. Traumatic aortic injury: CT findings, mimics, and therapeutic options. Cardiovasc Diagn Ther 2014;4:238–44.

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Bronş ve aortun müşterek yaralanmasının başarılı tedavisi Dr. Murat Sarıçam,1 Dr. Berker Özkan,2 Dr. Alper Toker2 1 2

Namık Kemal Üniversitesi Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, Tekirdağ İstanbul Üniversitesi İstanbul Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, İstanbul

Trakeobronşiyal yaralanmalar künt göğüs travmalarının nadir ancak ciddi komplikasyonudur. Yazımızda kamyonet tarafından ezilme sonucu karinaya doğru vertikal rüptürle beraber sol ana bronşu tamamen kopan ve inen aortasında kendini sınırlamış rüptür gelişen hastayı sunmaktayız. Hastaya sol üst lobektomi ve alt lobun sol ana bronşa tekrar takılması ameliyatını uyguladık. Bunu takiben aortadaki psödoanevrizmayı kapsayacak şekilde damar içi stent yerleştirildi. Hasta ameliyat sonrası sorun yaşanmadan dokuzuncu günde taburcu edildi. Yandaş büyük yaralanmalarla komplike olmuş trakeobronşiyal travmaların başarılı tedavisi gelişmiş ve tecrübeli travma merkezlerinde hızlı ve mücadeleci multidisipliner yaklaşım gerektirmektedir. Anahtar sözcükler: Aort rüptürü; damar içi stent; künt göğüs travması; trakeobronşial yaralanma. Ulus Travma Acil Cerrahi Derg 2020;26(2):331-333

doi: 10.5505/tjtes.2018.23429

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