travma 2015 / 6

www.tjtes.orgVolume 21 | Number 6 | November 2015

ISSN 1306 - 696X

TURKISH JOURNAL of TRAUMA& EMERGENCY SURGERYUlusal Travma ve Acil Cerrahi Dergisi

TURKISH JOURNAL of TRAUMA& EMERGENCY SURGERYUlusal Travma ve Acil Cerrahi Dergisi

Editor-in-Chief Recep Güloğlu

Editors Kaya Sarıbeyoğlu (Managing Editor) M. Mahir Özmen Hakan Yanar

Former Editors Ömer Türel, Cemalettin Ertekin, Korhan Taviloğlu

Section Editors Anaesthesiology & ICU Güniz Meyancı Köksal, Mert Şentürk Cardiac Surgery Münacettin Ceviz, Murat Güvener Neurosurgery Ahmet Deniz Belen, Mehmet Yaşar Kaynar Ophtalmology Cem Mocan, Halil Ateş Ortopedics and Traumatology Mahmut Nedim Doral, Mehmet Can Ünlü Plastic and Reconstructive Surgery Ufuk Emekli, Figen Özgür Pediatric Surgery Aydın Yagmurlu, Ebru Yeşildağ Thoracic Surgery Alper Toker, Akif Turna Urology Ali Atan, Öner Şanlı Vascular Surgery Cüneyt Köksoy, Mehmet Kurtoğlu

www.tjtes.org

THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERYULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ

President (Başkan) Kaya Sarıbeyoğlu Vice President (2. Başkan) M. Mahir Özmen Secretary General (Genel Sekreter) Hakan Yanar Treasurer (Sayman) Ali Fuat Kaan Gök Members (Yönetim Kurulu Üyeleri) Gürhan Çelik Osman Şimşek Orhan Alimoğlu

CORRESPONDENCEİLETİŞİM

ISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERYULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ YAYIN ORGANI

UlusalTravmaveAcilCerrahiDerneği Tel: +90 212 - 588 62 46ŞehreminiMah.,KöprülüMehmetPaşaSok. Fax (Faks): +90 212 - 586 18 04DadaşoğluApt.,No:25/1, e-mail (e-posta):[email protected]Şehremini,İstanbul,Turkey Web:www.travma.org.tr

Owner (Ulusal Travma ve Acil Cerrahi Derneği adına Sahibi) KayaSarıbeyoğluEditorialDirector (Yazı İşleri Müdürü) KayaSarıbeyoğluManagingEditor (Yayın Koordinatörü) M.MahirÖzmenAmblem MetinErtemCorrespondenceaddress (Yazışma adresi) UlusalTravmaveAcilCerrahiDergisiSekreterliği ŞehreminiMah.,KöprülüMehmetPaşaSok., DadaşoğluApt.,No:25/1,34104Şehremini,İstanbul Tel +90 212 - 531 12 46 - 588 62 46 Fax (Faks) +90 212 - 586 18 04

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

Publisher (Yayımcı): KARE Yayıncılık (KARE Publishing) • www.kareyayincilik.com • Design (Tasarım): Ali Cangül • Graphics (Grafikler): Edibe Çomaktekin • Linguistic Editor (İngilizce Editörü): Merve Şenol • Redaction (Redaksiyon): Erman Aytaç • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): October (Ekim) 2015 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)

www.tjtes.org

KARE

The Turkish Journal of Trauma and Emergency Surgery (TJTES) is an official publication of the Turkish Association of Trauma and Emer-gency Surgery. It is a peer-reviewed periodical that considers for pub-lication clinical and experimental studies, case reports, technical con-tributions, and letters to the editor. Six issues are published annually.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 / Sci-ence Edition, and as from 2008 in Index Copernicus. For the five-year term of 2001-2006, our impact factor in SCI-E indexed journals is 0.5. It is cited as ‘Ulus Travma Acil Cerrahi Derg’ in PUBMED. 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 Asso-ciation 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 lan-guage without the consent of the Association. If the manuscript has been presented at a meeting, this should be stated together with the name of the meeting, date, and the place.Manuscripts may be submitted in Turkish or 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 ad-dition 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, re-jected manuscripts will not be returned to the authors, including ac-companying materials.TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medi-cal Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for re-views and case reports.Open Access Policy: Full text access is free. There is no charge for publication or downloading the full text of printed material.Manuscript submission: TJTES accepts only on-line submission via the official web site (please click, www.travma.org.tr/en) and refuses printed manuscript submissions by mail. All submissions are made by the on-line submission system called Journal Agent, by clicking the icon “Online manuscript submission” at the above mentioned web site homepage. The system includes directions at each step but for fur-ther information you may visit the web site (http://www.travma.org/en/journal/).Manuscript preparation: Manuscripts should have double-line spac-ing, leaving sufficient margin on both sides. The font size (12 points) and style (Times New Roman) of the main text should be uniformly taken into account. All pages of the main text should be numbered consecutively. Cover letter, manuscript title, author names and institu-tions and correspondence address, abstract in Turkish (for Turkish au-thors only), and title and abstract in English are uploaded to the Journal Agent system in the relevant steps. The main text includes Introduc-tion, Materials and Methods, Results, Discussion, Acknowledgments, References, Tables and Figure Legends.The cover letter must contain a brief statement that the manuscript has been read and approved by all authors, that it has not been submit-ted to, or is not under consideration for publication in, another journal. It should contain the names and signatures of all authors. The cover letter is uploaded at the 10th step of the “Submit New Manuscript” sec-

tion, called “Upload Your Files”.Abstract: The abstract should be structured and serve as an informa-tive 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.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 photo-micrographs 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 pre-pared. 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 men-tion in the text. All reference figures in the text should be given in brack-ets without changing the font size. References should only include articles that have been published or accepted for publication. Refer-ence format should conform to the “Uniform requirements for manu-scripts submitted to biomedical journals” (http://www.icmje.org) and its updated versions (February 2006). Journal titles should be abbrevi-ated 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: Mc-Graw-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 ar-ticles 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 is-sue of the journal. The presented case(s) should be educative and of in-terest to the readers, and should reflect an exclusive rarity. Case reports should contain the title, summary, and the case, discussion, and refer-ences sections. These reports may consist of maximum five authors.Letters to the Editor: “Letters to the Editor” are only published elec-tronically 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 ex-ceed 500 words. The letter must clearly list the title, authors, publica-tion date, issue number, and inclusive page numbers of the publication for which opinions are released.Informed consent - Ethics: Manuscripts reporting the results of ex-perimental 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.

INFORMATION FOR THE AUTHORS

Ulusal Travma ve Acil Cerrahi Dergisi, Ulusal Travma ve Acil Cerrahi Derneği’nin yayın organıdır. Travma ve acil cerrahi hastalıklar konuların-da 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, 2001 yılından itibaren Index Me-dicus ve Medline’da, 2005 yılından itibaren Excerpta Medica / EMBASE indekslerinde, 2007 yılından itibaren Science Citation Index-Expanded (SCI-E) ile Journal Citation Reports / Science Edition uluslararası in-dekslerinde ve 2008 yılından itibaren Index Copernicus indeksinde yer almaktadır. 2001-2006 yılları arasındaki 5 yıllık dönemde SCI-E kapsa-mındaki dergilerdeki İmpakt faktörümüz 0,5 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 dışın-da), başka bir yerde yayınlanmasının düşünülmediği ve Ulusal Travma ve Acil Cerrahi Dergisi’nde yayınlanmasının tüm yazarlar tarafından uygun bulunduğu anlamına gelmektedir. Yazar(lar), çalışmanın yayın-lanmasının kabulünden başlayarak, yazıya ait her hakkı Ulusal Travma ve Acil Cerrahi Derneği’ne devretmektedir(ler). Yazar(lar), izin almaksı-zın 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 Türkçe ve İngilizce yazılmış makaleler yayınlanabilir. Tüm yazı-lar önce editör tarafından ön değerlendirmeye alınır; daha sonra incelen-mesi için danışma kurulu üyelerine gönderilir.Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; ge-rektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamam-lanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “ma-nuscript 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 zo-runluluğu yoktur.Açık Erişim İlkesi: Tam metinlere erişim ücretsizdir. Yayınlanan basılı materyali tam metni indirmek için herhangi bir ücret alınmaz.Yazıların hazırlanması: Tüm yazılı metinler 12 punto büyüklükte “Times New Roman” yazı karakterinde iki satır aralıklı olarak yazılmalıdır. Say-fada her iki tarafta uygun miktarda boşluk bırakılmalı ve ana metindeki sayfalar numaralandırılmalıdır. Journal Agent sisteminde, başvuru mek-tubu, başlık, yazarlar ve kurumları, iletişim adresi, Türkçe özet ve yazının İngilizce başlığı ve özeti ilgili aşamalarda yüklenecektir. İngilizce yazı-lan 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 okun-duğu, 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” bölü-münde, 10. aşamada yer alan dosya yükleme aşamasında yollanmalıdır.Başlık sayfası: Yazının başlığı, yazarların adı, soyadı ve ünvanları, ça-lışmanın yapıldığı kurumun adı ve şehri, eğer varsa çalışmayı destekle-yen fon ve kuruluşların açık adları bu sayfada yer almalıdır. Bu sayfaya ayrıca “yazışmadan sorumlu” yazarın isim, açık adres, telefon, faks, mo-bil 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 Söz-cükler başlıklarını; İngilizce özet Background, Methods, Results, Conc-lusion ve Key words başlıklarını içermelidir. İngilizce olarak hazırlanan çalışmalarda da Türkçe özet yer almalıdır. Özetler başlıklar hariç 190-210 sözcük olmalıdır. Tablo, şekil, grafik ve resimler: Şekillere ait numara ve açıklayıcı bil-giler 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 kişiler-

den 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. Ma-kale içinde geçen kaynak numaraları köşeli parantezle ve küçültülmeden belirtilmelidir. Kaynak listesinde yalnızca yayınlanmış ya da yayınlan-ması 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.” ek-lenmelidir. 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.trav-ma.org.tr adresli web sayfamızda eski yayınlara tam metin olarak ulaşa-bileceğiniz bir arama motoru vardır.Derleme yazıları: Bu tür makaleler editörler kurulu tarafından gerek ol-duğunda, konu hakkında birikimi olan ve bu birikimi literatüre de yan-sımış kişilerden talep edilecek ve dergi yazım kurallarına uygunluğu saptandıktan sonra değerlendirmeye alınacaktır. Derleme makaleleri; başlık, Türkçe özet, İngilizce başlık ve özet, alt başlıklarla bölümlendiril-miş metin ile kaynakları içermelidir. Tablo, şekil, grafik veya resim varsa yukarıda belirtildiği şekilde gönderilmelidir.Olgu sunumları: Derginin her sayısında sınırlı sayıda olgu sunumu-na yer verilmektedir. Olgu bildirilerinin kabulünde, az görülürlük, eğitici olma, ilginç olma önemli ölçüt değerlerdir. Ayrıca bu tür yazıların olabil-diğince kısa hazırlanması gerekir. Olgu sunumları başlık, Türkçe özet, İngilizce başlık ve özet, olgu sunumu, tartışma ve kaynaklar bölümlerin-den 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 mektup-lar 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 ola-rak 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 bil-diren 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 hüküm-lere uyulduğunu belirtmeli ve kurumdan aldıkları Etik Komitesi onayını göndermelidir. Hayvanlar üzerinde yapılan çalışmalarda ağrı, acı ve ra-hatsızlık verilmemesi için neler yapıldığı açık bir şekilde belirtilmelidir.Yazı gönderme - Yazıların gönderilmesi: Ulusal Travma ve Acil Cer-rahi 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 “Onli-ne Makale Gönderme” ikonuna tıklandığında ulaşılan Journal Agent sis-teminden yollanmaktadır. Sistem her aşamada kullanıcıyı bilgilendiren özelliktedir.

YAZARLARA BİLGİ

ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİVol. - Cilt 21 Number - Sayı 6 November - Kasım 2015

Deneysel Çalışma - Experimental Study

419-424 Saving the zone of stasis in burns with melatonin: an experimental study in rats Yanık staz zonunun melatonin kullanımıyla kurtarılması: Sıçanlarda deneysel çalışma Kayapınar M, Seyhan N, Avunduk MC, Savacı N

425-431 Effects of decompressive craniectomy, hypertonic saline solution and mannitol on an experimental model of cerebral ischemia Dekompresif kraniektomi, hipertonik salin ve mannitol’ün deneysel serebral iskemi üzerine etkilerinin karşılaştırılması Çalıkoğlu Ç, Akgül MH, Akgül O, Karataş A

432-439 Diversity of the definition of stable vital sign in trauma patients: results of a nationwide survey Travma hastalarında stabil yaşamsal bulgunun tanımındaki farklılık: Ulusal çaplı bir taramanın sonuçları Mun S

440-445 A prospective clinical study of the effects of the physical features of the appendix on perforation Apendiksin fiziksel özellklerinin perforasyon üzerine etkileri: İleriye yönelik klinik çalışma Tanrıkulu Y, Yılmaz G, Şen Tanrıkulu C, Temi V, Köktürk F, Çağsar M, Yalçın B

446-449 Comparison of intracorporeal knotting and endoloop for stump closure in laparoscopic appendectomy Laparoskopik appendektomide intrakorporal düğüm ve endoloop ile güdük kapama yöntemlerinin karşılaştırılması Bali İ, Karateke F, Özyazıcı S, Adnan Kuvvetli A, Oruç C, Menekşe E, Emir S, Özdoğan M

450-456 Surgical management of traumatic cerebrospinal fluid fistulas with associated lesions İlişkili lezyonlarla birlikte olan travmatik beyin omurilik sıvısı kaçaklarının cerrahi tedavisi Alagöz F, Dağlıoğlu E, Korkmaz M, Yıldırım AE, Uçkun ÖM, Divanlıoğlu D, Polat Ö, Dalgıç A, Ösün A, Yılmaz F, Sönmez M, Belen AD

457-462 Staged repair of severe open abdomens due to high-energy gunshot injuries with early vacuum pack and delayed tissue expansion and dual-sided meshes Yüksek enerjili ateşli silah yaralanmalarına bağlı açık karın olgularının tedavisinde erken dönem vakum uygulaması ile geç dönem doku genişletme ve çift taraflı yama Alhan D, Şahin İ, Güzey S, Aykan A, Zor F, Öztürk S, Nışancı M, Özerhan İH

463-468 Resuscitation complications encountered in forensic autopsy cases performed in Muğla province Muğla ilinde yapılan otopsi olgu sonuçlarında karşılaşılan resüsitasyon komplikasyonları Beydilli H, Balcı Y, Işık Ş, Erbaş M, Acar E, Savran B

469-476 Comparison of clinical outcomes with three different intramedullary nailing devices in the treatment of unstable trochanteric fractures İnstabil trokanterik kırık tedavisinde kullanılan üç farklı intramedüller çivinin klinik sonuçlarının karşılaştırılması Zehir S, Şahin E, Zehir R

477-483 Multivariate analysis of patients with blunt trauma and possible factors affecting mortality Künt travma sonucu yaralanan hastaların çok yönlü analizi ve mortaliteye etkili faktörler Özpek A, Yücel M, Atak İ, Baş G, Alimoğlu O

Ulus Travma Acil Cerrahi Derg, November 2015, Vol. 21, No. 6 vii

TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

Original Articles - Orijinal Çalışma

Experimental Studies - Deneysel Çalışma

Contents - İçindekiler

484-490 The diagnostic efficacy of computed tomography in detecting diaphragmatic injury secondary to thoracoabdominal penetrating traumas: a comparison with diagnostic laparoscopy Torakoabdominal delici-kesici alet yaralanmalarında bilgisayarlı tomografinin diyafragma yaralanmasını göstermedeki etkinliği, tanısal laparoskopi ile karşılaştırma İlhan M, Bulakçı M, Bademler S, Gök AFK, Azamat İF, Ertekin C

491-495 Comparison of antemortem clinical diagnosis and postmortem findings in burn-related deaths Yanığa bağlı ölümlerde antemortem klinik tanılar ve postmortem bulguların karşılaştırması Tuğcu H, Zor F, Toygar M, Balandız H

496-502 Posterior segment intraocular foreign bodies: the effect of weight and size, early versus late vitrectomy and outcomes Arka segment göz içi yabancı cisimleri: Ağırlık ve boyut etkisi, erken veya geç vitrektomi ve sonuçlar Öztaş Z, Nalçacı S, Afrashi F, Erakgün T, Menteş J, Değirmenci C, Akkın C

503-508 Comparison of femur intertrochanteric fracture fixation with hemiarthroplasty and proximal femoral nail systems Femur intertrokanterik kırıklarının tedavisinde proksimal femur çivisi ve hemiartroplasti sistemlerinin karşılaştırılması Görmeli G, Korkmaz MF, Görmeli CA, Adanaş C, Karataş T, Şimşek SA

509-513 Dilemma in pediatric mandible fractures: resorbable or metallic plates? Pediatrik mandibula kırıklarındaki ikilem: Eriyen plaklar mı yoksa metal plaklar mı? Taylan Filinte G, Akan İM, Ayçiçek Çardak GN, Özkaya Mutlu Ö, Tayfu T

514-519 Toraks travması takibinde dikkat edilmesi gereken durum: Diyafragma yaralanmaları Diaphragmatic injury: condition be noticed in the management of thoracic trauma Meteroğlu F, Şahin A, Başyiğit İ, Oruç M, Monıs S, Sızlanan A, Onat S, Ülkü R

520-523 Solitary caecum diverticulitis mimicking acute appendicitis Akut apendisite benzeyen soliter çekum divertiküliti Hot S, Eğin S, Gökçek B, Yeşiltaş M, Alemdar A, Akan A, Karahan SR

524-526 Penetrating brain injury with a bike key: a case report Bisiklet anahtarıyla penetran beyin yaralanması: Bir olgu sunumu Das JM, Chandra S, Prabhakar RB

527-530 Blunt cardiac injury: case report of salvaged traumatic right atrial rupture Künt kardiyak yaralanma: Tamir edilebilir travmatik sağ atrial yaralanma olgusu Ayyan MA, Aziz T, Sherif AE, Bekdache O

531-533 Twistin’ the night away: gallbladder torsion accompanying large bowel malignancy Geceyi zehir etmek, kalın bağırsak malinitesinin eşlik ettiği safra kesesi torsiyonu Shikhare S, Clarke M, Shimpi T, Lee CY

534-536 Chilaiditi’s syndrome complicated by colon perforation: a case report Kolon perforasyonu yapan Chilaiditi Sendromu: Bir olgu sunumu Acar T, Kamer E, Acar N, Er A, Peşkersoy M

537-540 Ulusal Travma ve Acil Cerrahi Dergisi 21. Cilt Dizin Turkish Journal of Trauma and Emergency Surgery Index of Vol. 21

Ulus Travma Acil Cerrahi Derg, November 2015, Vol. 21, No. 6viii

Contents - İçindekiler

Case Reports - Olgu Sunumu

ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİVol. - Cilt 21 Number - Sayı 6 November - Kasım 2015

TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

Saving the zone of stasis in burns with melatonin:an experimental study in ratsMuhammed Kayapınar, M.D.,1 Nevra Seyhan, M.D.,1

Mustafa Cihad Avunduk, M.D.,2 Nedim Savacı, M.D.1

1DepartmentofPlasticSurgery,NecmettinErbakanUniversityFacultyofMedicine,Konya2DepartmentofPathology,NecmettinErbakanUniversityFacultyofMedicine,Konya

ABSTRACT

BACKGROUND: Studies aimed at recovering the zone of stasis are one of the major issues of experimental burn studies. Many drugs including antithrombotics, anticoagulants, anti-inflammatories have been investigated experimentally for saving the zone of stasis. In this study, the effect of the systemic melatonin on the zone of stasis was evaluated.

METHODS: Twenty Wistar Albino rats were used in the study. Rats were assigned to two groups (n=10). The metal comb 1x2 cm in size was immersed in boiling water and held for 20 seconds on the back of the rats to create burn wounds.No treatment was given to the control group. Melatonin was given at a dose of 10 mg/kg/d by intraperitoneal injection in the treatment group for 7 days. Daily digital photographs of both groups were obtained. Total necrotic burn areas and the zone of stasis were assessed with Auto CAD and Visual Analyzing computer programs. At the end of one week, rats were sacrificed and skin biopsies were taken for histological examination. Edema, congestion, inflammatory infiltration, vascular proliferation and fibrosis were the parameters evaluated. Data were evaluated statistically by Chi-square test and Student-t test.

RESULTS: When histopatologic data and the measured values for total necrotic areas and zone of stasis of the experimental group werecompared to control group, the results were statistically significant (p<0.05).

CONCLUSION: According to the results of this study, melatonin is efficient in saving the zone of stasis in burns.

Key words: Burn model; melatonin; zone of stasis.

The area encircling the zone of coagulation is the zone of stasis, which is affected indirectly by the trauma.[4]

The outermost layer is the zone of hyperemia with increased blood flow, representing an inflammatory response to the tissue injury. It always stays viable. Investigations on the pathobiology of the zone of stasis revealed that irrevers-ible tissue necrosis ensues with progression of hypoxia and ischemia in 1–48 hours, resulting in total loss of this inter-mediate zone.[4] In this zone, petechial hemorrhage, vascular thrombosis, increased vascular permeability and local edema are seen. Local edema increases the severity of hypoxia. Diminished circulation in this region results in progressive ischemia. Maintaining adequate blood flow and vessel paten-cy can save viable tissues and dermis of this zone of stasis.[5] Both hypercoagulability and systemic activation of white blood cells are reported as underlying reasons of progressive tissue injury in this zone. Relying on experimental studies, treatment modalities, such as increasing tissue tolerance to ischemia, enhancement of perfusion and inhibition of inflam-matory response, have been proposed to enable salvage of this zone. The use of antithrombotic, anticoagulant, anti-in-

EXPERIMENTAL STUDY

Ulus Travma Acil Cerrahi Derg, November 2015, Vol. 21, No. 6 419

Address for correspondence: Muhammed Kayapınar, M.D.

Necmettin Erbakan Üniversitesi Tıp Fakültesi, Plastik Cerrahi

Anabilim Dalı, Konya, Turkey

Tel: +90 332 - 223 60 00 E-mail: [email protected]

Qucik Response Code Ulus Travma Acil Cerrahi Derg2015;21(6):419–424doi: 10.5505/tjtes.2015.53059

Copyright 2015TJTES

INTRODUCTION

Salvaging the zone of stasis is of clinical importance for burn specialists because saving this zone prevents the potential in-crease in the depth and width of the burned area, thereby de-creasing mortality and morbidity.[1] Based on the severity of destruction and blood flow alterations, three distinct zones of tissue injury can be distinguished. Jackson described these three zones in 1947.[2] The zone of coagulation is the central zone, which is directly and irreversibly affected by the burn. Coagulation necrosis is the characteristic sign of this area.

Kayapınar et al. Saving the zone of stasis in burns with melatonin

flammatory and antioxidant medication has all been studied.[4] The hormone melatonin (N-acetyl-5methoxy-tryptamine) is produced by the pineal gland. Melatonin is known to ex-hibit free radical scavenging ability and reduces neutrophil accumulation.[6] The scavenging ability of melatonin is more effective than other intracellular antioxidants.[7] The aim of this study was to test the effects of melatonin, the chief se-cretory product of pineal gland and a highly effective antioxi-dant, on saving the zone of stasis in rats.

MATERIALS AND METHODS

Animals and the Burn ModelIn this experiment, twenty Wistar albino rats weighing 250 to 275 g were used. The animals were caged individually at room temperature with a 12 h light /dark cycle and had free access to water and standard laboratory food for rats. General an-esthesia was induced with intramuscular ketamine (10%) 80 mg/kg and xylazine (2%) 10 mg/kg. The dorsal skins of the rats were shaved. A metal comb 1x2 cm in size was immersed in boiling water for 5 min, until thermal equilibrium was achieved between the comb and the water. The heated comb was placed on the back of the rat 0.5 cm lateral and paral-lel to midline and held for 20 sec without pressure (Fig. 1). Four burn areas (1x2 cm) and three interspaces were created on one side. The same burn model was made on the other side of the rat’s back again 15 min later (Fig. 2). Twenty rats were randomly separated to control (Group 1) and experi-

mental (Group 2) groups. Each group was consisted of ten rats. Thirty minutes after burn injury, the treatment group was treated with melatonin. The control group received no treatment. Daily intraperitoneal melatonin injection 10 mg/kg continued for 7 days.

PhotoanalysisDaily photographs of the burned areas in both groups were taken under diethylether anesthesia. The initial surface of the burned area was assigned as 200 mm2. Auto CAD computer programme was used to calculate the burned areas in the photographs. By placing milimetric ruler in each photograph, calibration was done for the calculation of the burned area in square millimeter (Fig. 3). Necrotic areas were calculated and the obtained values recorded (Table 1). The total necrotic areas between the two groups were compared.

Histological AnalysisThe rats were sacrificed 7 days after burn injury. Skin biopsies were taken from full thickness burn areas. Samples were fixed in neutral buffered formalin and embedded in paraffin me-

Ulus Travma Acil Cerrahi Derg, November 2015, Vol. 21, No. 6420

Figure 1. Applicationofmetalcombonthebackoftheratforcre-atingburnwound.

Figure 2. Fullthicknessskinburnswerecreated0.5cmlateralandparaleltomidline.

Figure 3. CalculationofthenecroticareasinburnwoundsbyAuto-CADcomputerprogram.

Table 1. The values of total necrotic burn area in mm2

measured by photoanalysis method

Group 1 Group 2

1 132.78 52.42

2 124.34 75.14

3 141.08 92.10

4 112.36 67.2

5 107.80 70.10

6 125.47 62.12

7 130.18 76.10

8 99.8 63.21

9 102.7 64.37

10 107.89 42.22


dia. Micron sections were deparafinnized and processed for hemotoksilin eosin staining. Histological preparations were investigated under Nikon Eclipse E400 light microscope. Digi-tal images of the zone of stasis were taken by Nikon Coolpix 5000 digital camera connected to Nikon SMZ 1500 stero-scopic light microscope. All digital images were analyzed by Visual Analyzing programme (Clemex Vision Lite 3.5, Cana-da). The zone of stasis was marked as two points, and Visual Analyzing programme automatically measured the distance between these two points (Figs. 4a, b) and the obtained val-ues were recorded (Table 2) Histological parameters evaluat-

ed included edema, congestion, inflammatory infiltration, vas-cular proliferation and fibrosis. Each parameter was graded based on a scale from 0 to 3 as 0: none, 1: mild, 2: moderate and 3: significant (Figs. 5a-d). Evaluations of histology were made by a pathologist blinded to the groups.

Statistical AnalysisIn order to evaluate the differences in datas of edema, con-gestion, inflammatory infiltration, vascular proliferation and fibrosis, Chi square test was used. Student-T test was used to assess the numeric data for necrotic burn and zone of stasis areas. Significance was assigned at p<0.05.

RESULTS

No deaths occurred during this study. At the end of 7 days gross observation revealed that in the experimental group, most of the interspace areas appeared to be alive while in the control group; the interspace areas were necrotic in appear-ance. The mean percentage of the calculated necrotic area


(a)

(b)

Figure 4. (a)MeasurementofthezoneofstasisbyVisualAnalyz-ing computer program in the control group. (b) Measurement ofthe zoneof stasis byVisualAnalyzing computer program in theexperimentalgroup.

Figure 5. Schematic presentation of the grading scale of eachhistologicparameterforbothcontrolandexperimentalgroupsareshown.(a)Fibrosis,(b)vascularproliferation,(c)congestion,(d) inflammatoryinfiltration.

4

3

2

1

M1K1

M2K2

M3K3

M4K4

M5K5

M6K6

M7K7

M8K8

M9K9

M10K10

0

(a)4

3

2

1

M1K1

M2K2

M3K3

M4K4

M5K5

M6K6

M7K7

M8K8

M9K9

M10K10

0

(b)4

3

2

1

M1K1

M2K2

M3K3

M4K4

M5K5

M6K6

M7K7

M8K8

M9K9

M10K10

0

(c)

4

3

2

1

M1K1

M2K2

M3K3

M4K4

M5K5

M6K6

M7K7

M8K8

M9K9

M10K10

0

(d)

Table 2. The values of total necrotic burn area in mm2

measured by Visual Analyzing programme

Group 1 Group 2

1 11.2 6.8

2 13.7 8.2

3 9.6 5.4

4 8.4 4.9

5 10.7 6.8

6 8.8 5.5

7 6.5 4.3

8 12.6 4.2

9 14.4 4.6

10 8.9 4.1

by Auto CAD programme and measurement of the distance of the stasis zone by Visual Analyzing programme in the con-trol group was higher than that of the experimental group. Comparison of the data obtained by AUTO CAD program showed statistical significance (p<0.05). All the data obtained from the investigation of histopathological parameters in-cluding edema, congestion, inflammatory infiltration, vascu-lar proliferation and fibrosis was found to be higher in the control group when compared with the experimental group (Figs. 6a, b). The difference between the groups were all sta-tistically significant (p<0.05).

DISCUSSIONAs long as proper interventions are undertaken during the first 72 hours following thermal injury, tissue damage in the zone of stasis may be reversible. The comb burn model first described by Regas and Erlich has been found to be ideal for research on the zone of stasis[8] and has been used in many experimental models until today. Inflammation, ischemia and oxygen free radical formation affect the viability of the zone of stasis. Relying on experimental studies, treatment modalities, such as increasing tissue tolerance to ischemia, enhancement of perfusion and inhibition of inflammatory re-sponse, have been proposed to enable salvage of the zone of stasis.

Ischemia reperfusion stimulates inflammatory cells to gener-ate reactive oxygen species (ROS) in many tissues especially after burns. Free oxygen radicals and peroxidases increase following cutaneous burn. Production of oxygen derived free radicals result in the disruption of plasma membranes. The major targets of ROS are long chain-polyunsaturated fatty acids of cellular phospholipids. Antioxidants prevent poten-tial cellular damage resulting from ROS. Melatonin is a safe and non-toxic molecule, penetratingcells to scavenge free radicals.[9] It is highly lipophilic, and it passes easily through biological membranes.[10] This is an advantage for melatonin over some other antioxidants, which penetrate cells more slowly. It also acts synergistically with antioxidant agents such as vitamins C, E and glutathione.[11]

Melatonin activates glutathione peroxidase (GSH-Px) and reduces lipid peroxidation.[12,13] It also stimulates superoxide dismutase and inhibits human platelet aggregation and throm-boxane production.[14] Urata et al. have found that the rate limiting enzyme in GSH synthesis, gama-glutamylcysteine syn-thetase, is increased after the administration of melatonin to rats.[15]

Burn injury causes systemic activation of leucocytes and ac-cumulation of white cells in microcirculation.[16] Neutrophil recruitment and adherence to the endothelium following burn injury decreases the lumen diameter[17] and results in microvascular compromise. Bertuglia et al. have reported that treatment with melatonin completely inhibits micro-vascular edema formation, reduces the number of leuko-cytes sticking to venules, and preserves microvascular per-fusion.[18] It has been shown that antibodies which block adhesion of neutrophil to endothelial cell following 30 min following burn improve blood flow in the zone of stasis.[19–21] Melatonin blocks the synthesis of adhesion molecules, which increase leukocyte infiltration into the damaged tis-sue. Melatonin increases, but gluthatione decreases NO levels. Although NO is an essential molecule, it is also a free radical and its production is not always beneficial. Ex-cessive NO production has harmful effects in microcircula-tion. When the production of NO increases, its production must be controlled. The reaction of NO and superoxide anion generates peroxynitrite (ONOO-). ONOO-, which is a highly reactive molecule, reacts with cellular compo-nent (e.g. membrane lipids and proteins), disturbing their function and consequently cellular hemostasis.[22] Melatonin has an inhibitory effect on NOS activity. Tissue NO level was reduced after melatonin treatment in a rat skin flap ischemia-reperfusion model.[23] In this experiment, melato-nin significantly decreased malondialdehyde (MDA) levels, which is an end product of lipid peroxidation and elevated the GSH content. MAD is generated as a result of toxic ef-fects of active oxygen radicals. It destroys unsaturated fatty acids in the cell membranes. In addition, melatonin inhibits the production of tumor necrosis factor.[24] TNF-α is known to induce neutrophil and endothelial cell activation.[25] Ce-



(a)

(b)

Figure 6. (a)Inthecontrolgroup;undertheepitheliumvascularpro-liferation,fibrosisandinflammatoryinfiltrationaremoreprominent.(b) In theexperimentalgroup; lessvascularproliferation, fibrosisandinflammatoryinfiltrationareobservedundertheepithelium.

rium nitrate[26] and N-acetylcysteine[27] was found to be ef-fective in saving the zone of stasis by decreasing the level of TNF production.

An ideal pharmacological agent for saving the zone of stasis should have the following features: safety, clinical availability, and easy administration. Melatonin fulfills all of these criteria. Anti-thrombotic agents have serious side effects that restrict their clinical use; whereas, melatonin has a very little side ef-fect potential.

Melatonin induced microvascular protection is the result of its scavenging effect on free radicals. In the present study, use of melatonin due to its antioxidant effect showed favorable results in saving the zone of stasis. In conclusion, systemic usage of melatonin may be considered as an effective method to prevent the cells in the zone of stasis to go under necrosis and possible extension of burn area.

Conflict of interest: None declared.

REFERENCES

1. Uygur F, Evinc R, Urhan M, Celikoz B, Haholu A. Salvaging the zone of stasis by simvastatin: an experimental study in rats. J Burn Care Res 2009;30:872–9.

2. Jackson Dm. The diagnosis of the depth of burning. [Article in Undeter-mined Language] Br J Surg 1953;40:588–96.

3. Zor F, Ozturk S, Deveci M, Karacalioglu O, Sengezer M. Saving the zone of stasis: is glutathione effective? Burns 2005;31:972–6.

4. 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.

5. Işik S, Sahin U, Ilgan S, Güler M, Günalp B, Selmanpakoğlu N. Saving the zone of stasis in burns with recombinant tissue-type plasminogen ac-tivator (r-tPA): an experimental study in rats. Burns 1998;24:217–23.

6. Reiter RJ, Melchiorri D, Sewerynek E, Poeggeler B, Barlow-Walden L, Chuang J, et al. A review of the evidence supporting melatonin’s role as an antioxidant. J Pineal Res 1995;18:1–11.

7. Tan DX Chen LD, Poeggeler B. Melatonin: A potent, endogenous hy-droxyl radical scavenge. Endocr J 1993; 1:57–60.

8. Regas FC, Ehrlich HP. Elucidating the vascular response to burns with a new rat model. J Trauma 1992;32:557–63.

9. Wang WZ, Fang XH, Stephenson LL, Baynosa RC, Khiabani KT, Zam-boni WA. Microcirculatory effects of melatonin in rat skeletal muscle after prolonged ischemia. J Pineal Res 2005;39:57–65.

10. Vaughan GM, Reiter RJ. Pineal dependence of the Syrian hamster’s noc-turnal serum melatonin surge. J Pineal Res 1986;3:9–14.

11. Gitto E, Tan DX, Reiter RJ, Karbownik M, Manchester LC, Cuzzocrea S, et al. Individual and synergistic antioxidative actions of melatonin: studies

with vitamin E, vitamin C, glutathione and desferrioxamine (desferox-amine) in rat liver homogenates. J Pharm Pharmacol 2001;53:1393–401.

12. Reiter RJ, Guerrero JM, Garcia JJ, Acuña-Castroviejo D. Reactive oxygen intermediates, molecular damage, and aging. Relation to melatonin. Ann N Y Acad Sci 1998;854:410–24.

13. Reiter RJ, Tan DX, Osuna C, Gitto E. Actions of melatonin in the reduc-tion of oxidative stress. A review. J Biomed Sci 2000;7:444–58.

14. Del Zar MM, Martinuzzo M, Falcón C, Cardinali DP, Carreras LO, Va-cas MI. Inhibition of human platelet aggregation and thromboxane-B2 production by melatonin: evidence for a diurnal variation. J Clin Endo-crinol Metab 1990;70:246–51.

15. Urata Y, Honma S, Goto S, Todoroki S, Iida T, Cho S, et al. Melato-nin induces gamma-glutamylcysteine synthetase mediated by activa-tor protein-1 in human vascular endothelial cells. Free Radic Biol Med 1999;27:838–47.

16. Eski M, Deveci M, Celiköz B, Nisanci M, Türegün M. Treatment with cerium nitrate bathing modulate systemic leukocyte activation following burn injury: an experimental study in rat cremaster muscle flap. Burns 2001;27:739–46.

17. Boykin JV, Eriksson E, Pittman RN. In vivo microcirculation of a scald burn and the progression of postburn dermal ischemia. Plast Reconstr Surg 1980;66:191–8.

18. Bertuglia S, Marchiafava PL, Colantuoni A. Melatonin prevents ischemia reperfusion injury in hamster cheek pouch microcirculation. Cardiovasc Res 1996;31:947–52.

19. Baskaran H, Toner M, Yarmush ML, Berthiaume F. Poloxamer-188 improves capillary blood flow and tissue viability in a cutaneous burn wound. J Surg Res 2001;101:56–61.

20. Choi M, Rabb H, Arnaout MA, Ehrlich HP. Preventing the infiltration of leukocytes by monoclonal antibody blocks the development of pro-gressive ischemia in rat burns. Plast Reconstr Surg 1995;96:1177–87.

21. Bucky LP, Vedder NB, Hong HZ, Ehrlich HP, Winn RK, Harlan JM, et al. Reduction of burn injury by inhibiting CD18-mediated leukocyte adherence in rabbits. Plast Reconstr Surg 1994;93:1473–80.

22. Radi R, Peluffo G, Alvarez MN, Naviliat M, Cayota A. Unraveling peroxynitrite formation in biological systems. Free Radic Biol Med 2001;30:463–88.

23. Gurlek A, Aydogan H, Parlakpinar H, Bay-Karabulut A, Celik M, Sezgin N, et al. Protective effect of melatonin on random pattern skin flap necro-sis in pinealectomized rat. J Pineal Res 2004;36:58–63.

24. Sacco S, Aquilini L, Ghezzi P, Pinza M, Guglielmotti A. Mechanism of the inhibitory effect of melatonin on tumor necrosis factor production in vivo and in vitro. Eur J Pharmacol 1998;343:249–55.

25. Deveci M, Eski M, Sengezer M, Kisa U. Effects of cerium nitrate bath-ing and prompt burn wound excision on IL-6 and TNF-alpha levels in burned rats. Burns 2000;26:41–5.

26. 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.

27. 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.





OLGU SUNUMU

Yanık staz zonunun melatonin kullanımıyla kurtarılması: Sıçanlarda deneysel çalışmaDr. Muhammed Kayapınar,1 Dr. Nevra Seyhan,1 Dr. Mustafa Cihad Avunduk,2 Dr. Nedim Savacı1

1NecmettinErbakanÜniversitesiTıpFakültesi,PlastikCerrahiAnabilimDalı,Konya2NecmettinErbakanÜniversitesiTıpFakültesi,PatolojiAnabilimDalı,Konya

AMAÇ: Staz zonunun kurtarılmasını amaçlayan çalışmalar deneysel yanık çalışmalarının önemli bir bölümünü oluşturmaktadır. Staz zonunun kurta-rılmasında deneysel olarak antitrombotik, antienflamatuvar, antikoagülan gibi birçok ilaç araştırılmıştır. Bu çalışmanın amacı sistemik melatoninin staz zonuna etkisini değerlendirmektir.GEREÇ VE YÖNTEM: Çalışmada 20 adet erişkin Wistar Albino sıçan kullanıldı. Randomize seçilen sıçanlar iki gruba ayrıldı (n=10). Sıçanların sırtları tıraşlandıktan sonra 1x2 cm ebadında kaynar suda ısıtılmış metal plak 20 sn bekletilerek yanık oluşturuldu. Kontrol grubuna tedavi verilmedi. Tedavi grubuna yedi gün süreyle 10 mg/kg/gün dozunda intraperitoneal melatonin enjeksiyonu yapıldı. Her iki grubun günlük dijital fotoğrafları çekildi. Total nekrotik yanık alanları ve staz zonu Auto CAD ve görüntü analizi programlarıyla değerlendirildi. Bir hafta sonunda sıçanlar sakrifiye edilerek histolojik inceleme için cilt biyopsisi alındı. Ödem, konjesyon, enflamatuvar infiltrasyon, vasküler proliferasyon ve fibrozis değerlendirilen paramet-relerdi. Elde edilen veriler ki-kare ve student t-testleri ile değerlendirildi.BULGULAR: Experimental gruba ait histopatolojik veriler ile total nekrotik yanık alanları ve staz zonu ölçümlerine ait sayısal veriler kontrol grubu ile karşılaştırıldığında melatoninin staz zonuna etkinliğini kanıtlayacak şekilde istatistiksel olarak anlamlıydı (p<0.05).TARTIŞMA: Bu çalışmanın sonucuna göre yanıkta staz zonunun kurtarılmasında melatonin etkilidir.Anahtar sözcükler: Melatonin; staz zonu; yanık.

Ulus Travma Acil Cerrahi Derg 2015;21(6):419–424 doi: 10.5505/tjtes.2015.53059

DENEYSEL ÇALIŞMA - ÖZET

Effects of decompressive craniectomy, hypertonic salinesolution and mannitol on an experimental modelof cerebral ischemiaÇağatay Çalıkoğlu, M.D.,1 Mehmet Hüseyin Akgül, M.D.,2 Osman Akgül, M.D.,3 Ayşe Karataş, M.D.4

1DepartmentofNeurosurgery,AtatürkUniversityFacultyofMedicine,Erzurum2DepartmentofNeurosurgery,SeydişehirStateHospital,Konya3DepartmentofNeuorosurgery,DüzceStateHospital,Düzce4DepartmentofNeuorosurgery,KatipÇelebiUniversityFacultyofMedicine,İzmir

ABSTRACT

BACKGROUND: Cerebral ischemia is a cause of serious morbidity and mortality. Strategies that would protect cerebral tissue against ischemic injury are important. The present study aimed to evaluate effects of surgical and medical treatments, either alone or in combination, on infarction area in an experimental rat model of cerebral ischemia.

METHODS: Adult male Sprague-Dawley rats (n=30) were divided into 6 groups, each including 5 experimental animals. Cerebral ischemia was created by right common carotid artery occlusion (CCAO) under anesthesia. Decompressive craniectomy (DC) was performed in the relevant groups at the 12th hour following CCAO, whereas medical treatments were performed in the relevant groups at the 1st, 12th, and 24th hours following CCAO. After CCAO, the control group received 1 mL/kg physiological saline, hyper-tonic saline (HS) group received 3% hypertonic saline (1 mL/kg), and mannitol (MAN) group received 20% mannitol (1 g/kg). While only DC was performed following CCAO in the DC group, DC+HS group underwent DC together with hypertonic saline treatment and DC+MAN group underwent DC together with mannitol treatment. The rats were decapitated at the end of the 24th hour following ischemia. Cerebral sections were stained with 2% 2,3,5-triphenyltetrazolium chloride (TTC). The ratio of infarction area to the total area of section was calculated as percentage.

RESULTS: Mean infarction areas were 27.9% in the control group, 13.7% in the HS group, 15.1% in the MAN group, 10.6% in the DC group, 8.1% in the DC+HS group, and 9.7% in the DC+MAN group. Mean infarction areas were significantly lower in all groups than in the control group. While the mean infarction area did not differ between the HS and MAN groups, it was lower in the groups undergoing DC as compared to these two groups. The best outcome was observed in the DC+HS group.

CONCLUSION: Both medical and surgical treatments were effective in decreasing cerebral ischemic infarction. There was no differ-ence between medical treatments groups in terms of efficacy, whereas DC led to a substantial decrease in ischemic infarction volume as compared with the medical treatment groups. Combined treatment approaches performed to decrease infarction volume also resulted in favorable outcomes.

Key words: Cerebral ischemia; experimental study; decompressive craniectomy; hypertonic saline; mannitol; rat.

INTRODUCTION

Stroke, the leading cause of disability, is the most devastat-ing disease among all neurological conditions.Globally, stroke causes approximately 5.5 million deaths yearly and accounts for 44 million disability-adjusted life year lost.[1] In addition to the economic burden of treatment during disease, eco-nomic burden due to post-treatment rehabilitation and loss of workforce also reaches to a substantial extent.[2] Well de-termination of the risk factors of stroke and prevention from stroke would reduce morbidity and mortality.

EXPERIMENTAL STUDY


Address for correspondence: Çağatay Çalıkoğlu, M.D.

Atatürk Üniversitesi Tıp Fakültesi, Beyin Cerrahi Kliniği,

25040 Erzurum, Turkey



Copyright 2015TJTES

Çalıkoğlu et al. Effects of decompressive craniectomy, hypertonic saline solution and mannitol on an experimental model of cerebral ischemia

The World Health Organization defines stroke as “rapidly developing clinical signs of focal (or global) disturbance of ce-rebral function, with symptoms lasting for 24 hours or longer or leading to death, with no apparent cause other than of vas-cular origin”. Eighty percent of strokes is of ischemic origin, whereas 20% is of hemorrhagic origin.[3] The term cerebral ischemia defines inadequate blood circulation for the mainte-nance of normal metabolic functions of brain and results from decreased or ceased blood flow or extravasation of blood due to laceration of arteries because of various pathologies in arteries that supply brain.[4] Energy sources (oxygen and glucose) of the neurons are depleted owing to decreased or ceased cerebral blood flow. Cerebral ischemia may be en-countered as either global ischemia resulting from cardiac ar-rest or as focal cerebral ischemia resulting from obstruction of a single cerebral artery, and may either be temporary or permanent.[5]

The main goal in the treatment of ischemic stroke is the cor-rection of the cause of ischemic area in an early phase. The brain area, in which blood flow decreases but permanent in-jury has not occurred yet, is the basic target of therapeutic approaches. If ischemic condition does not improve, these areas have the potential to develop necrosis and irreversible neuronal injury in time.[6] The treatment of stroke is usually medical including thrombolytic therapy performed to prevent secondary injury and drugs that prevent oxidative stress and brain edema caused by stroke. Mannitol and furosemide are among osmotherapeutic agents that are most frequently used in clinical practice. However, hypertonic saline (HS) treat-ment has also been used in numerous experimental and clini-cal trials in recent years.[7] In addition, decompressive crani-ectomy (DC) is a surgical treatment method used for years in experimental and clinical trials as an alternative to effective medical treatment.[8] The goal of DC is to decrease elevated intracranial pressure and minimize the edema resulting from secondary injury that occurs in infarction area after stroke.

The present study aimed to expose the effects of medical and surgical treatments, either alone or in combination, on infarction area in an experimental model of cerebral ischemia. For this purpose, medical and surgical treatments were per-formed alone or in combination on rats, on which cerebral ischemia was induced by right common carotid artery occlu-sion (CCAO), and the results were compared.


Experimental AnimalsThe present study included 30 adult male Sprague-Dawley rats, weighing between 250 g and 350 g. Before the study, the rats were given ad libitum access to water and food. Ap-proval of Düzce University, Animal Research Local Ethics Committee was obtained for the study (dated 15.02.2011 and numbered B.30.2.ABU.0.05.05-050.01.04-12). The rats

were divided into six groups, each including five rats. The control group included rats on which CCAO was performed and physiological saline (1 mL/kg) was administered. The hy-pertonic saline (HS) group included rats on which CCAO was performed and hypertonic saline was administered. The mannitol (MAN) group included rats on which CCAO was performed and mannitol was administered. The DC group included rats on which CCAO and DC were performed. The DC+HS group included rats on which CCAO and DC were performed and hypertonic saline was administered. The DC+MAN group included rats on which CCAO and DC were performed and mannitol was administered.

Common Carotid Artery Occlusion (CCAO)In order to create a diffuse hemispheric ischemia, the CCAO model described by Rice et al.[9] was preferred as an experi-mental model of ischemic stroke. Anesthesia was performed using 75 mg/kg ketamine hydrochloride (Ketalar, Parke-Davis, UK) via intraperitoneal route. The rats were immobilized in supine position using adhesive bandage. After cleaning the surgical area using polivinilpirolidon iodine (polividon iodine 10%), a paramedian 2 cm skin incision was made using No. 18 scalpel in the way that the right sternocleidomastoid muscle would be on the lateral aspect. Thereafter, CCA was exposed via microdissection. Under a surgical microscope, 8/0 Ethilon nylon filament (Ethicon, Inc., Johnson & Johnson, New Jersey, USA) was attached to the proximal and distal aspects of the CCA and tied. The CCA was cauterized and cut between the tied points. It was sutured with 2/0 silk (Ethicon, Inc.) in ac-cordance with the dermal-subdermal anatomy.

Medical and Surgical TreatmentMedical treatments were performed in relevant groups on the 1st, 12th and 24th hours following CCAO. Surgical treat-ment (DC) was performed in relevant groups at the 12th hour following CCAO. Following CCAO, 1 mL/kg physiological sa-line was administered in the control group, 3% hypertonic saline (1 mL/kg) was administered in the HS group, and 20% mannitol (1 g/kg) was administered in the MAN group via intraperitoneal route. The DC group underwent only DC fol-lowing CCAO, whereas the DC+HS group underwent DC together with hypertonic saline treatment and the DC+MAN group underwent DC together with mannitol treatment.

For DC, the rats were fixed in prone position and subdermal temporal muscle was exposed following large skin incision in the right temporoparietal region. The temporal muscle was peeled off from the bone together with periosteal layer. Dur-ing DC, which was performed using a dental drill, irrigation was performed with 0.9% physiological saline for the under-lying cortex not to be harmed. Following a craniectomy of 5x5 mm, the dura mater was opened by a curvilinear inci-sion using a 30-gauge needle and the parenchymal tissue was exposed. Thereafter, the temporal muscle and the skin were properly closed. In all groups, it was observed that the right



eyelids of the rats were closed as compared to their left eye-lids after CCAO.

Neurological ExaminationThe scoring system, defined by Bederson et al.[10] and modi-fied by Kawamura et al.,[11] was used for neurological exam-ination. Accordingly, the scoring was as follows: 0, normal neurological examination; 1, weakness in the left forepaw; 2, circling by twisting towards to the left side while walking; 3, falling to the left side when pushed slightly; 4, inability to walk spontaneously.

Healthy rats normally extend their both forepaws down to-ward the floor when they are hung by the tail. However, the rats undergoing CCAO could not extend their contralateral front and hind extremities down toward the floor. Decreased resistance in the contralateral front extremity was assessed by observing the rats while they were gripping the bars of the cage after being hung by the tail. Resistance loss was noted in the paretic extremity in all six groups. However, no remark-able deficit was observed in any of the four extremities of the rats at the 24th hour before they were sacrificed. The animals were sacrificed after 24 hours following CCA infarction. No significant difference was found between the groups in terms of neurological examination before decapitation.

Decapitation and StainingThe rats were decapitated 24 hours after CCAO; their brains were removed rapidly and sectioned into 7 coronal sections. A 2,3,5-triphenyltetrazolium chloride (TTC) solution was prepared at a concentration of 2% before staining. After im-mersing each section with 2% TTC in 0.9% physiological sa-line, they were incubated at 37°C in a dark medium for 30 minutes. After incubation, the tissues were kept in 10% form-aldehyde for the stain to penetrate into the tissues. As the consequence of these procedures, cerebral infarction areas were observed as unstained white areas, whereas intact cere-bral areas were stained pink or red. Moreover, one rat with-out CCAO was exposed to the same procedures to obtain a normal tissue sample; it was decapitated with no medical or surgical treatment.

After the sections were kept in formaldehyde for 10 minutes following staining, they were photographed by a digital cam-era (Kodak 8.2 MP digital camera, USA). Since body weights and total brain areas of the rats were different, relative infarc-tion area was calculated. For this purpose, an image analysis system (Digimizer Medical Imaging Software Version 3.7.0.0; MedCalc Software, Ostend, Belgium) was used. After calcu-lating total brain area and infarction area, if any, in each of the 7 sections obtained from the brain of each rat, the ratio of the infarction area to the total brain area was calculated as percentage (%).

The ratios of infarction areas (%) were summed separately

for each brain and divided by the number of sections ob-tained from that brain. Thereby, the percentage of the infarc-tion area was determined for each brain. The percentages of infarction areas for each brain in each group were summed and divided by the number of rats examined; the mean infarc-tion area was then determined for each group.

Statistical AnalysisThe Predictive Analysis Software (PASW) Statistics 18.0 (SPSS Inc., Chicago, IL, USA) for Windows was used for statistical analysis. Multiple independent group comparisons were performed using the Kruskal-Wallis test, whereas sub-group analyses were performed using the Mann Whitney U-test with Bonferroni correction. A p value of <0.05 was considered statistically significant.

RESULTS

None of the rats died during perioperative period. There was no rat without infarction despite CCAO. Mean cerebral infarction rates of the rats in the study groups are demon-strated in Table 1.

A significant difference was determined between the groups in terms of cerebral infarction rate (p<0.001). Paired com-parisons were performed in subgroup analyses. Although the level of statistical significance was p<0.001 according to the Bonferroni correction, p=0.009 was considered clinically sig-nificant because of limited number of experimental animals in the sample. Accordingly, paired comparisons revealed that the infarction rate of each experimental group was significant-ly lower than that in the control group (p<0.009 for each). There was no significant difference between the infarction rates of HS and MAN groups (p=0.175). The infarction rates of HS and MAN groups were significantly higher than those of the DC, DC+HS, and DC+MAN groups (p<0.009 for each). The infarction rate of DC+HS group was significantly lower than those of DC and DC+MAN groups (p<0.009 for each).


Table 1. Mean cerebral infarction area of the rats in the study groups

Groups Cerebral infarction area (%)

Mean±SD

Control 27.9±1.9

HS 13.7±1.5

MAN 15.1±1.6

DC 10.6±0.6

DC+HS 8.1±1.0

DC+MAN 9.7±0.4

SD: Standard deviation; HS: Hypertonic saline; MAN: Mannitol; DC: Decomp-ressive craniectomy.

Moreover, there was no significant difference between the DC and DC+MAN groups (p=0.047; Fig. 1).

DISCUSSIONSeveral medical or surgical methods that have different mech-anism of action were tried in the past to prevent ischemic injury and are still being tried today. Currently, there is no method or drug that would completely solve this problem. Many of the attempted drugs are effective over one or more mechanisms, cannot radically solve this chain of events, which are quite complex and multifactorial, and provide limited benefit. Under the light of current knowledge, agents that are anti-excitotoxic, anti-inflammatory, antioxidant and/or anti-apoptotic could easily pass into the central nervous sys-tem, have tolerable side effects, could be effective when used even 4-6 hours after development of ischemia, and have no unfavorable interaction with other neuron protective agents are the ideal neuron protectors. No ideal agent or method meeting these conditions has been discovered yet. Neverthe-less, various neuron protective effects have been reported in the studies performed with glutamate receptor antago-nists,[12,13] calcium channel blockers,[14] free oxygen radical scavengers,[15–17] citicoline,[18] hypothermia,[19] and sometimes combination of these.

In their review, Kollmar and Schwab[20] have expressed that experimental trials should continue and that combination therapies might be convenient in the treatment of stroke. In the present study, we also evaluated the effects of mannitol, hypertonic saline, and DC alone or in combination, neuron protective effects of which have been individually demon-strated in experimental trials, on infarction volume in isch-emic injury that was created irreversibly without reperfusion following CCAO.

Many studies have demonstrated that surgical and medical treatments should be performed at early phase to reduce ischemic infarction and edema because the first 72 hours in cellular ischemic injury following occlusion is of great impor-tance and that irreversible ischemic process following delayed treatment could not be stopped. Thus, in the present study, volume-reducing efficacy in early treatment was tried to be

determined. In previous studies, either the outcomes of very early period (first 6 hours) or at the 36th and 72nd hours have been discussed and sacrificing performed.[21–24]

Bederson et al.[10] have stated that TTC is a rapid, reliable, cheap, easily detectable, and convenient substance in dem-onstrating infarction area in the screening and recognition of cerebral infarction in rats. In the present study, we used TTC, as well.

In a clinical study by Delashaw et al.,[25] DC was performed in nine patients and neurological improvement was report-ed in six patients on postoperative firstday. They reported that 6 of these patients were functionally dependent and the remaining three patients were functioning with minimal assistance during a follow-up period ranging from 5 to 25 months and that hemispheric craniectomy had life-saving and life-prolonging effect in the treatment of extensive cerebral infarction and malignant cerebral edema. Rengachary et al.[26] have reported that waiting is necessary for whole benefits of medical treatment and that DC, therefore, should not be performed before the development of irreversible brain stem injury. Young et al.[27] have defended that it would be nec-essary to control medical treatment closely via intracranial pressure (ICP) monitoring and to decide craniectomy later, when needed. DC varies according to the localization and the cause of increase in ICP. Decompression in diffuse brain injury shows variations as bilateral hemicraniectomy, bifron-tal craniectomy, and circumferential craniectomy. Hatashita and Hoff[28] have recommended craniectomy in case of oc-currence of brain edema due to the changes in hydrostatic pressure gradient resulting in increased cerebral tissue ten-sion and compliance. Ivamoto et al.[29] have expressed that the survival of eighteen patients undergoing craniectomy for cerebral infarction was prolonged by 60%; however, survival was further decreased and substantial disability developed in the patients who did not undergo craniectomy. Forsting et al.[30] have demonstrated that DC did not only reduce mor-tality but also infarction size in cerebral ischemia. Kondziolka and Fazl[31] have carried out a study in five cases and stated that survival was prolonged with DC and long-term func-tional outcomes were encouraging. Engelhorn et al.[22] have suggested that early reperfusion was the primary goal of the treatment of diffuse hemispheric ischemia and that early DC reduced infarction volume. However, they determined that DC together with reperfusion resulted in no difference in infraction and edema volume as compared to the single treat-ment regimen. Studies have revealed that early DC provides substantial improvement. In the present study, we also ob-tained similar results in the DC group. Only DC was per-formed in the above-mentioned studies, in the present study; however, medical treatment was also performed alone or in combination with DC. It was demonstrated that infarction volume was substantially decreased by DC combined with medical treatment. In their later study, Engelhorn et al.[23] have compared the effectiveness of reperfusion, craniectomy



Figure 1. Cerebralinfarctionareainthestudygroups.HS:Hyper-tonicsaline;MAN:Mannitol.

Cerebralinfarctionarea(%

)

Control

HSGroup

DCGroup

MAN

Group

DC+HS

Group

DC+MAN

Group

05

1015202530

Groups

or combination of these in malignant middle cerebral artery infarction. They have demonstrated that early reperfusion and craniectomy at 1 hour have similar efficacy but reperfu-sion after one hour is not beneficial; however, late craniec-tomy provides reduction in infarction volume even when it is performed at the 4th or 12th hour. They have also reported that combined treatment is also dependent on time and pro-vides no additional efficacy unless performed within the first hour. In their previous study, Engelhorn et al.[22] have found the infarction area to be 43.6% in the control group, 19.4% in the craniectomy group, 8.8% in the reperfusion group, and 18.7% in the reperfusion in combination with craniectomy group. In the present study, the mean infarction area was 27.9% in the control group and 10.5% in the craniectomy group. Although Engelhorn et al.[22] reported the outcomes for the first 6 hours, 24-hour period of the present study demonstrated how effective the combination treatment was and that significance could be enhanced with further studies that would be carried out in longer periods.

In an experimental model of focal cerebral ischemia created by Doerfler et al.[24] to study the combination of DC and hy-pothermia therapy, treatment at the 6th and 24th hours were discussed. A definite decrease in the infarction size was not determined only in the 6-hour hypothermia group; howev-er, it was found that hypothermia performed together with DC was more beneficial in decreasing the ischemic infarc-tion size. When the result of the study by Doerfler et al.[24] was compared with that of the present study, it was 11.8% and 10.6%, respectively, in the craniectomy groups. More-over, as compared with the infarction ratio of 9.10% in the craniectomy+hypothermia group in the study by Doerfler et al.,[24] the present study determined a similar infarction ratio of 9.7% in the DC+MAN group. Hypertonic saline and manni-tol infusions were administered in an experimental model of diffuse ischemic infarction by Toung et al.[32] and it was dem-onstrated that continuous infusion of hypertonic saline at the doses of 5% and 7.5% decreased infarction volume by increas-ing the amount of water in the brain and lungs. Reichenthal et al.[33] have expressed that mannitol administered in the early period within the first 90 minutes provided a notable decrease in the amount of edema as compared to the late administration (based on density on computed tomography). In an experimental model of cerebral edema created by Al-bright et al.[34] to evaluate systemic and intracranial effects of osmotic and oncotic therapies, five groups were constituted including crystalloid, mannitol, albumin, furosemide, and albu-min/furosemide treatment groups. They observed decreased ICP in the treatment groups except for the albumin group. After the administration of high- or low-dose mannitol in an experimental model of ischemic stroke, Paczynski et al.[35] observed that low-dose mannitol had more beneficial effects and led to decreased infarction volume. In the present study, we also preferred mannitol, intended to provide volume-re-ducing efficacy by decreasing ICP, and performed low-dose administration similar with the previous study. Sutherland et

al.[36] investigated the effects of indomethacin, nimodipine, and mannitol either alone or in combination in a rat model of cerebral ischemia and determined that combined use of many drugs provided the most beneficial effect in discontinuing ischemic process. Bhardwaj et al.[7] have demonstrated that hypertonic saline treatment reduces brain edema that devel-op after stroke in rats undergoing reperfusion but worsenes infarction area due to an elevation in blood sodium concen-tration following 7.5% hypertonic saline infusion. Schwarz et al.[37] have demonstrated that infarction volume-reducing ef-ficacy of 7.5% and 6.5% saline infusion was higher than that of mannitol treatment. Ziai et al.[38] have emphasized that clinical practice is available with hypertonic saline in infarction associ-ated with ischemic stroke, tumor-related edema, intracranial hemorrhage, postoperative retraction edema, and traumatic brain injury; however, attention should be paid during treat-ment for likely hypernatremia. In the present study, better ef-ficacy in terms of decrease in ischemic volume was observed with low-dose hypertonic saline as compared with mannitol; however, the difference was not statistically significant.

In conclusion, the present experimental study determined that both medical and surgical treatments significantly re-duced infarction volume in irreversible ischemic injury (with-out reperfusion). When medical treatment groups were compared in terms of infarction volume-reducing efficacy, it was higher in the hypertonic saline group as compared with the mannitol group; however, the difference was not statisti-cally significant. It was demonstrated that DC combined with medical treatment led to a higher reduction in the ischemic infarction volume. It was observed that DC together with hypertonic saline treatment significantly decreased the infarc-tion volume at the highest. In the present experimental study, demonstration of substantial reduction in infarction volume with the use of DC combined with medical treatment in ce-rebral ischemia would shed light on clinical practices. It is necessary for neurologists and neurosurgeons dealing with ischemic events to discuss clinical therapeutic regimens, to conduct studies concerning whether reduction in edema and infarction volume after ischemia would make positive con-tribution or not to the clinical picture, and in addition, to consider surgical approach that might have favorable effect on ischemia-related complaints, which are likely to be over-looked.


REFERENCES

1. Mukherjee D, Patil CG. Epidemiology and the global burden of stroke. World Neurosurg 2011;76(6 Suppl):85–90.

2. Norrving B, Kissela B. The global burden of stroke and need for a con-tinuum of care. Neurology 2013;80(3 Suppl 2):5–12.

3. Truelsen T, Begg, S, Mathers C. Global burden of cerebrovascular dis-ease. 2000. Retrieved from: http://www.who.int/healthinfo/statistics/bod_cerebrovasculardiseasestroke.pdf. Last Access: 22 October 2014.

4. Raichle ME. The pathophysiology of brain ischemia. Ann Neurol



1983;13:2–10.5. Ginsberg MD. Adventures in the pathophysiology of brain ischemia:

penumbra, gene expression, neuroprotection: the 2002 Thomas Willis Lecture. Stroke 2003;34:214–23.

6. Jivan K, Ranchod K, Modi G. Management of ischaemic stroke in the acute setting: review of the current status. Cardiovasc J Afr 2013;24:86–92.

7. Bhardwaj A, Ulatowski JA. Hypertonic saline solutions in brain injury. Curr Opin Crit Care 2004;10:126–31.

8. Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013;27:979–91.

9. Rice JE 3rd, Vannucci RC, Brierley JB. The influence of immaturity on hypoxic-ischemic brain damage in the rat. Ann Neurol 1981;9:131–41.

10. Bederson JB, Pitts LH, Germano SM, Nishimura MC, Davis RL, Bart-kowski HM. Evaluation of 2,3,5-triphenyltetrazolium chloride as a stain for detection and quantification of experimental cerebral infarction in rats. Stroke 1986;17:1304–8.

11. Kawamura S, Li Y, Shirasawa M, Yasui N, Fukasawa H. Reversible mid-dle cerebral artery occlusion in rats using an intraluminal thread tech-nique. Surg Neurol 1994;41:368–73.

12. LeBlanc MH, Li XQ, Huang M, Patel DM, Smith EE. AMPA antagonist LY293558 does not affect the severity of hypoxic-ischemic injury in new-born pigs. Stroke 1995;26:1908–15.

13. Childs AM, Evans RH, Watkins JC. The pharmacological selectivity of three NMDA antagonists. Eur J Pharmacol 1988;145:81–6.

14. Franke CL, Palm R, Dalby M, Schoonderwaldt HC, Hantson L, Er-iksson B, et al. Flunarizine in stroke treatment (FIST): a double-blind, placebo-controlled trial in Scandinavia and the Netherlands. Acta Neurol Scand 1996;93:56–60.

15. Cho S, Park EM, Febbraio M, Anrather J, Park L, Racchumi G, et al. The class B scavenger receptor CD36 mediates free radical production and tissue injury in cerebral ischemia. J Neurosci 2005;25:2504–12.

16. Adibhatla RM, Hatcher JF, Dempsey RJ. Cytidine-5’-diphosphocholine affects CTP-phosphocholine cytidylyltransferase and lyso-phosphatidyl-choline after transient brain ischemia. J Neurosci Res 2004;76:390–6.

17. Adibhatla RM, Hatcher JF, Dempsey RJ. Phospholipase A2, hydroxyl radicals, and lipid peroxidation in transient cerebral ischemia. Antioxid Redox Signal 2003;5:647–54.

18. Adibhatla RM, Hatcher JF, Dempsey RJ. Citicoline: neuroprotective mechanisms in cerebral ischemia. J Neurochem 2002;80:12–23.

19. Coimbra C, Drake M, Boris-Möller F, Wieloch T. Long-lasting neuro-protective effect of postischemic hypothermia and treatment with an an-ti-inflammatory/antipyretic drug. Evidence for chronic encephalopathic processes following ischemia. Stroke 1996;27:1578–85.

20. Kollmar R, Schwab S. Ischaemic stroke: acute management, intensive care, and future perspectives. Br J Anaesth 2007;99:95–101.

21. Tamura A, Graham DI, McCulloch J, Teasdale GM. Focal cerebral isch-aemia in the rat: 1. Description of technique and early neuropathological consequences following middle cerebral artery occlusion. J Cereb Blood Flow Metab 1981;1:53–60.

22. Engelhorn T, Doerfler A, Kastrup A, Beaulieu C, de Crespigny A, Forst-ing M, et al. Decompressive craniectomy, reperfusion, or a combination for early treatment of acute “malignant” cerebral hemispheric stroke in rats? Potential mechanisms studied by MRI. Stroke 1999;30:1456–63.

23. Engelhorn T, von Kummer R, Reith W, Forsting M, Doerfler A. What is effective in malignant middle cerebral artery infarction: reperfusion, cra-niectomy, or both? An experimental study in rats. Stroke 2002;33:617–22.

24. Doerfler A, Schwab S, Hoffmann TT, Engelhorn T, Forsting M. Com-bination of decompressive craniectomy and mild hypothermia amelio-rates infarction volume after permanent focal ischemia in rats. Stroke 2001;32:2675–81.

25. Delashaw JB, Broaddus WC, Kassell NF, Haley EC, Pendleton GA, Vollmer DG, et al. Treatment of right hemispheric cerebral infarction by hemicraniectomy. Stroke 1990;21:874–81.

26. Rengachary SS, Batnitzky S, Morantz RA, Arjunan K, Jeffries B. Hemicraniectomy for acute massive cerebral infarction. Neurosurgery 1981;8:321–8.

27. Young PH, Smith KR Jr, Dunn RC. Surgical decompression after cere-bral hemispheric stroke: indications and patient selection. South Med J 1982;75:473–5.

28. Hatashita S, Hoff JT. The effect of craniectomy on the biomechanics of normal brain. J Neurosurg 1987;67:573–8.

29. Ivamoto HS, Numoto M, Donaghy RM. Surgical decompression for ce-rebral and cerebellar infarcts. Stroke 1974;5:365–70.

30. Forsting M, Reith W, Schäbitz WR, Heiland S, von Kummer R, Hacke W, et al. Decompressive craniectomy for cerebral infarction. An experi-mental study in rats. Stroke 1995;26:259–64.

31. Kondziolka D, Fazl M. Functional recovery after decompressive craniec-tomy for cerebral infarction. Neurosurgery 1988;23:143–7.

32. Toung TJ, Chang Y, Lin J, Bhardwaj A. Increases in lung and brain water following experimental stroke: effect of mannitol and hypertonic saline. Crit Care Med 2005;33:203–60.

33. Reichenthal E, Kaspi T, Cohen ML, Shevach I, Shalmon E, Bar-Ziv Y, et al. The ambivalent effects of early and late administration of man-nitol in cold-induced brain oedema. Acta Neurochir Suppl (Wien) 1990;51:110–2.

34. Albright AL, Latchaw RE, Robinson AG. Intracranial and systemic ef-fects of osmotic and oncotic therapy in experimental cerebral edema. J Neurosurg 1984;60:481–9.

35. Paczynski RP, Venkatesan R, Diringer MN, He YY, Hsu CY, Lin W. Ef-fects of fluid management on edema volume and midline shift in a rat model of ischemic stroke. Stroke 2000;31:1702–8.

36. Sutherland G, Lesiuk H, Bose R, Sima AA. Effect of mannitol, nimodip-ine, and indomethacin singly or in combination on cerebral ischemia in rats. Stroke 1988;19:571–8.

37. Schwarz S, Schwab S, Bertram M, Aschoff A, Hacke W. Effects of hyper-tonic saline hydroxyethyl starch solution and mannitol in patients with increased intracranial pressure after stroke. Stroke 1998;29:1550–5.

38. Ziai WC, Toung TJ, Bhardwaj A. Hypertonic saline: first-line therapy for cerebral edema? J Neurol Sci 2007;261:157–66.





OLGU SUNUMU

Dekompresif kraniektomi, hipertonik salin ve mannitol’ün deneyselserebral iskemi üzerine etkilerinin karşılaştırılmasıDr. Çağatay Çalıkoğlu,1 Dr. Mehmet Hüseyin Akgül,2 Dr. Osman Akgül,3 Dr. Ayşe Karataş4

1AtatürkÜniversitesiTıpFakültesi,BeyinveSinirCerrahisiAnabilimDalı,Erzurum2SeydişehirDevletHastanesi,BeyinveSinirCerrahisiKliniği,Konya3DüzceDevletHastanesi,BeyinveSinirCerrahisiKliniği,Düzce4KatipÇelebiÜniversitesiTıpFakültesi,BeyinveSinirCerrahisiKliniği,İzmir

AMAÇ: Serebral iskemi son derece önemli ve ciddi bir mortalite ve morbidite sebebidir. Serebral dokuyu iskemik zedelenmenin oluşturacağı hasar-dan korumak için seçilecek yöntem son derece önemlidir. Bu çalışmada kullanılan medikal ve cerrahi tedavi yöntemleri deneysel fare serebral iskemi modeli ile karşılaştırıldı, tek başına veya kombine uygulamalarında etki düzeyleri araştırıldı.GEREÇ VE YÖNTEM: Erişkin erkek Sprague-Dawley sıçanlar (n=30) altı gruba ayrıldı, sağ kommon karotis arter oklüzyonu ile serebral enfarkt oluşturuldu. Bir gruba iskemiden 12 saat sonra Dekompressif kraniectomi (DC) uygulandı. Diğer bir gruba ise iskemi sonrası 1, 12 va 24. saatlerde medikal tedavi verildi. Kontrol grubuna serum fizyolojik verilirken, bir gruba %3 hipertonik saline, diğer bir gruba %20 mannitol tedavisi. Sadece kraniyektom yapılanlar dekompressif kraniektomi grubu (DC), DC+HS grubu ise DC ve hipertonik salin verilenlerden oluştu. DC+MAN ise DC ve mannitol beraber verilen grubu olurturdu. Sıçanlar 24. saatin sonunda dekapite edildi, beyinleri alınarak patolojik olarak incelendi ve iskemi sahaları hesaplanarak tedaviye yanıtları değerlendirildi.BULGULAR: Kontrol grubunda ortalama enfarkt alanı %27.9, HS grubunda %13.7, MAN grubunda %15.1, DC grubunda %10.6, DC+HS grubunda %8.1, ve DC%+MAN %9.7. Ortalama enfarkt alanları hemen tüm gruplarda kontrol grubuna gore düşük görüldü, HS ve MAN grupları arasında fark bulunamadı, DC grubunda bu iki gruba göre daha iyi sonuç elde edildi fakat en iyi sonuçlar DC+MAN grubunda tespit edildi.TARTIŞMA: Serebral iskemik enfarkt tedavisinde hem medikal hem cerrahi etkili yöntemlerdir. Medikal tedavi yöntemleri arasında fark bulunamadı, halbuki cerrahi tedavi grubunda, medikal tedavi grubuna göre daha iyi sonuç elde edildi. Kombine tedavide diğerlerine göre en iyi sonuç alındı. Bu sonuçlar iskemik beyin zedelenmesinde en iy sonucun cerrahi ve medikal tedavi kombinasyonu olduğunu göstermektedir.Anahtar sözcükler: Dekompresif kraniektomi; deneysel çalışma; hipertonik salin; mannitol; serebral iskemi.


DENEYSEL ÇALIŞMA - ÖZET

Diversity of the definition of stable vital sign in traumapatients: results of a nationwide surveySeongpyo Mun, M.D.

DepartmentofSurgery,ChosunUniversity,Gwangju,SouthKorea

ABSTRACT

BACKGROUND: Hemodynamic stability (HS) based on vital sign (VS) is thought to be the most useful criteria for successful non-operative management (NOM) of blunt spleen injury (BSI). However, a consistent definition of HS has not been established. We wanted to evaluate the definition of HS through conducting a nationwide survey and find the factors affectting diversity.

METHODS: The questionnaire regarding the definition of HS was sent to the department of trauma surgery and emergency medi-cine of level I trauma center between October 2012 and November 2012. Data was compared using analysis of variance, t-test, χ2 test and logistic regression.

RESULTS: Among five hundred and sixty-three doctors, 507 responded (90%). Forty-eight responses were incomplete, and hence, 459 (81.5%) responses were analyzed. There was a significant diversity in the definition of HS on the subject of type of blood pres-sure (BP), cut off value of hypotension, measuring technique of BP, duration of hypotension, whether or not using heart rate (HR) as a determinant of HS, cut off value of hypotension when the patient has comorbidity or when the patient is a pediatric patient. 91.5% replied that they were confused defining HS and felt the need to have more objective determinants. Nevertheless, 90% of the respond-ers were not using laboratory test to define HS.

CONCLUSION: Many trauma doctors are using only VS to define HS. This is why there is a confusion regarding how to define which patient is hemodynamically stable. More objective determinants such as base deficit or lactate can be useful adjuncts.

Key words: Blunt spleen injury; definition; diversity; hemodynamic instability; survey.

that cautious selection of the patient is fundamental for the success of NOM in BSI. Many selection criteria have been suggested and evaluated for this purpose and examples are vital sign, FAST, CT scan, injury scale or laboratory tests.[5–7]

Hemodynamic stability (HS) based on vital sign is being used most frequently. However, a consistent definition of “hemo-dynamic stability” is lacking. There is a possibility that trauma doctors are using a different definition, numerical value, and an obtaining method to define HS. We wanted to evaluate the diversity of the definition of HS through conducting a nationwide survey and provide the suggestion to unify the diversity of the definition of HS.


Questionnaire and SurveyA nationwide survey was performed between October 2012 and November 2012. The questionnaire was composed of 3 sections; 6 questions about biography, career, and circum-stances of working environment, 11 questions about the definition of HS based on the simulated trauma case, and 7 questions about personal opinions regarding the definition of HS (Table 1). The questionnaire was sent to the attending

O R I G I N A L A R T I C L E

Address for correspondence: Seongpyo Mun, M.D.

365 Pilmundaero, Donggu, Gwangju - South Korea

Tel: +82 62-220-3062 E-mail: [email protected]


Copyright 2015TJTES

INTRODUCTION

Trauma is still a major cause of death in young people under the age of 50. Blunt abdominal injury is common in trauma patients. Spleen is the most frequently injured organ in blunt abdominal trauma and hemorrhagic shock is the main cause of death. When hemoperitoneum caused by spleen injury is detected, exploratory laparotomy is usually performed.[1] However, with the increased use of computerized tomogra-phy (CT) scanning and focused assessment with sonography for trauma (FAST), nonoperative management (NOM) of blunt spleen injury (BSI) has been introduced, and is being ac-tively used in many countries.[2–4] Most trauma doctors agree

432 Ulus Travma Acil Cerrahi Derg, November 2015, Vol. 21, No. 6

433Ulus Travma Acil Cerrahi Derg, November 2015, Vol. 21, No. 6

Mun. Diversity of the definition of stable vital sign in trauma patients: results of a nationwide survey

Table 1. Details of the questionnaires

Section 1. Biography, career and circumstances of working

environment

1. How OLD are you?

2. What is your SEX?

① Male ② Female

3. How LONG have you been working for the management of

trauma patients?

4. How many DAYS are you on duty for trauma patient in a

MONTH?

5. How do you DEFINE yourself?

① attending, general surgery ② attending, emergency medicine

③ fellow, general surgery ④ fellow, emergency medicine

⑤ resident, general surgery ⑥ resident, emergency medicine

6. On average, how many TRAUMA PATIENTS do you treat a

month?

Section 2. Definition of HS based on the simulated trauma case

50-year-old male patient (170 cm/70 kg) fell down from 2 meter

high ladder on his left frank area. VSs at ED admission were BP

90/60 mmHg, HR 120/minute, RR 20/minute, BT 37.5 oC. GCS

was 15 and the mental status was drowsy. There was no specific

abnormality. 2 L of normal saline was infused rapidly while FAST

revealed isolated spleen laceration and large amount of fluid around

perirenal and perisplenic area. Secondary VS is being checked.

1. Which parameter(s) of VS(s) do you use as a determinant of

your definition of hemodynamic instability? (BP: blood pressure,

HR: heart rate, RR: respiration rate, BT: body temperature; check

all that apply)

① BP ② HR ③ RR ④ BT

2. What KINDS of blood pressure do you use to determine the HS?

① SBS ② DBP ③ MAP ④ pulse pressure ⑤ others

3. What is your highest cut off value of HYPOTENSION to make you

carry out emergent exploratory laparotomy? (Systolic BP, mmHg)

4. What kind of measuring TECHNIQUE do you use to decide if

the patient is hypotensive?

① manual ② automated cuff ③ arterial line

④ at least two of them ⑤ all three of them ⑥ does not matter

5. How LONG do you feel the patient should be hypotensive be-

fore you to decide to carry out emergent exploratory laparotomy?

(Minutes)

6. Do you use HEART RATE as an independent determinant of

exploratory laparotomy regardless of hypotension?

① Yes ② No

7. What is your cut off value of TACHYCARDIA to make you carry out

emergent exploratory laparotomy regardless of hypotension? (/minute)

8. Do you have a different cut-off value of hypotension in case the patient has been taking medication which affects vascular system

such as antihypertensives or anticoagulation?

① Yes ② No

9. Do you have different cut-off value of hypotension in case the pa-

tient has medical condition such as hypertension, diabetes, asthma etc?

① Yes ② No

10. If the patient is 5 to 15 year old children, do you feel like to use

the different cut off value contrary to the adult’s for the emergent z?

① Yes ② No

11. If the patient is a 5 to 15 year old child, what is your cut off value of blood pressure that makes you carry out emergent laparotomy?

(mmHg)

Section 3. Personal opinions about the definition of HS

1. Do you use BASE DEFICIT as an independent determinant to

carry out emergent exploratory laparotomy regardless of hemody-

namic instability?

① Yes ② No

2. Do you use serum lactate level as an independent determinant to carry out emergent exploratory laparotomy regardless of hemody-

namic instability?

① Yes ② No

3. Do you feel like carrying out emergent laparotomy when the pa-

tient has high grade spleen injury (grade IV or V) although the patient

is hemodynamically stable?

① Yes ② No

4. Do you agree using classic concept of hemodynamic instability (BP

≤90 mmHg AND HR ≥100/min) in order to decide the necessity of

exploratory laparotomy

① strongly agree ② mildly agree ③ neutral

④ mildly disagree ⑤ strongly disagree

5. What is the reason for you to agree using the classic definition of

hemodynamic instability? Because,

① I believe it is evidence based medicine

② I have learned like that from my senior, medical conference, text-

book etc

③ the range seems to be optimal

④ Others ( ) ⑤ do not agree

6. Do you feel the need to have a more clear and objective parameter

in determining to carry out exploratory laparotomy in spleen injury?

① strongly agree ② mildly agree ③ neutral ④ mildly disagree

⑤ strongly disagree

7. Do you have any comments? ( )

doctors, fellows and residents of the department of trauma surgery and emergency medicine of the level I trauma center. The survey was performed through email and an online sur-vey program. It was analyzed under complete confidentiality. This study was approved by Chosun University Hospital IRB.

Statistical AnalysisData were compared using analysis of variance (ANOVA) or t-test for continuous variables and χ2 test for categorical variables. Logistic regression was carried out to evaluate the variables which influence trauma doctors to make a diversity of HS.

RESULTS

Section 1 of the Questionnaire Among five hundred and sixty-three doctors, 507 responded (90%). Forty eight responses were incomplete, and hence, 459 responses were analyzed (81.5%). The average age of the respondents was 46. Of the respondents, four hundred and fourteen (90.2%) were male. They had been working for eighteen years on average. They were on duty for four days and treated three trauma patients per month. Seventy one (15.5%) were attending doctors of TS and eighty three (18.1%) were attending doctors of ED. Forty three (9.4%) were the fellows of TS and forty eight (10.5%) were the fel-lows of ED. One hundred and six (23.1) were the residents of TS and 108 (23.5) were the residents of ED (Table 2).

Section 2 of the QuestionnaireWhen defining HS, one hundred and ninety-eight (43.1%) used only blood pressure (BP), 186 (40.5%) used both BP and heart rate (HR), and 54 (11.8%) used only HR. Eighteen of them used respiratory rate or body temperature as an adjunct of determinant. Two hundred and eighty-five (62.1%) consid-ered systolic blood pressure (SBS) to define HS, 135 (29.4%) considered mean arterial pressure (MAP) and 39 (8.5%) con-sidered diastolic blood pressure (DBP). One hundred and eighty-nine (41.2%) used manual technique to check BP, 111 (24.2%) preferred automated cuff, 150 (32.7%) had no pref-erence. Two hundred and eighty-five respondents who took account of SBP thought emergent laparotomy should be car-ried out when SBP was ≤94 mmHg on average. 73% of the respondents located between 80 to 99 mmHg and the cut off value of hypotension ranged widely from 59 and 104 mmHg (Table 3). The duration of hypotension to make them carry out EL was 1.5 minutes (0–30 minutes). One hundred and eleven respondents (24.2%) used HR as an independent deter-minant of hemodynamic stability. On average, they thought EL should be carried out when HR was ≥109/min. One hundred and ninety-eight (43.1%) used a different cut off value of BP when the patient was on vasoactive medicine. Two hundred and thirty-one (50.3%) of the respondents used a different value of BP when the patients had medical comorbidity. Three hundred and seventy-eight[8] (82%) used a lower cut-off value

of hypotension to define HS in pediatric patients and the value of BP was distributed from 60 to 99 mmHg. On average, they thought EL should be carried out when BP was equal or below 85 mmHg or HR was equal or above 119/minute (Table 3). Section 3 of the QuestionnaireFour hundred and seventeen respondents (90.8%) did not use base deficit as determinants of HS. Four hundred and twenty-three of them (92.2%) did not use lactic acid as a determinant of HS. Two hundred and ninety-one respondents (63.4%) replied that they would not perform emergency laparotomy even when the injury grade was high as long as the patient was hemodynamically stable. One hundred and eighty-three (39.9%) agreed to use the classic definition of hypotension; BP <90 mmHg and HR ≥120/minute. One hundred and sev-enteen respondents (25.5%) agreed to use the classic defini-tion because they thought it was evidence based medicine. One hundred and twenty-three agreed because they believed they were supposed to follow classic definition. Seventy-two respondents replied that the range of classic definition seemed to be optimal. Four hundred and twenty respondents (91.5%) replied that they were confused defining HS and felt the need for more objective determinants (Table 4).

Univariate and Multivariate AnalysisIn univariate analysis, factors that were significantly associated with the respondents defining HS differently with the classic definition were younger (<40), female trauma doctors with a short career (<5 years). The diversity of HS seems to be

Table 2. The results of Section 1 questionnaire (No=459)

Characteristics No (range or %)

Age (year) 46.7 (28–62)

Sex

Male 414 (90.2)

Female 45 (9.8)

Career (year) 18 (3–31)

NO of New trauma patients per week 3.1 (0–15)

Definition of self

Attending

Trauma surgery 71 (15.5)

Emergency medicine 83 (18.1)

Fellow



Resident



No: Numbers.




more prevalent among young doctors. Not agreeing to use the classic definition of HS was only significant in multivariate analysis (Table 5).

DISCUSSIONWhen there is intraperitoneal hemorrhage due to BSI, trauma

doctors have to decide whether the patient needs emergent operation or not. Before the 1980s, operative treatment was prevalent regardless of the severity of the spleen injury. How-ever, some doctors observed that patients could be cured by NOM and tried to find the criteria for successful outcomes.[1,8,9] The first suggested determinant was radiologic findings.

Table 3. The results of Section 2 questionnaire

Characteristics Mean (range) or No (%) p

Determinants to define heart rate

Blood pressure 198 (43.1)

Heart rate 54 (11.8)

Respiratory rate 0 (0)

Body temperature 0 (0)

Blood pressure and heart rate 186 (40.5)

Blood pressure and respiratory rate 6 (1.3)

Blood pressure and body temperature 12 (2.6)

Others 3 (0.7)

Favorite blood pressure to define hemodynamic stability

Systolic blood pressure 285 (62.1) <0.05

Diastolic blood pressure 39 (8.5)

Mean arterial pressure 135 (29.4)

Pulse pressure 0 (0)

Others 0 (0)

Cut off value of blood pressure to carry out emergent laparotomy 94 (59–104)

Technique to check blood pressure to define hemodynamic stability

Manual 189 (41.2)

Automated cuff 111 (24.2)

Arterial line 9 (2.0)

Do not care 150 (32.7)

Duration of hypotension (minutes) to define as hemodynamic instability 1.5 (0–30)

Using heart rate as independent determinants

Yes 111 (24.2)

No 348 (75.8)

Cut off value of heart rate to carry out emergent laparotomy 109 (100–130)

Using different value in case taking vasoactive agents

Yes 198 (43.1)

No 261 (56.9)

Using different value in case having medical comorbidity

Yes 231 (50.3)

No 228 (49.7)

Using different value to define HS in pediatrics

Yes 378 (82.4) <0.01

No 81 (17.6)

Cut off value of blood pressure to carry out emergent laparotomy in pediatrics 85 (60–99)


McKenney et al. suggested a unique hemoperitoneum score system calculated by FAST. They calculated the depth in cen-timeters of the largest collection from the abdominal wall plus the total additional areas positive for fluid. Forty of 46 patients (87%) with a score ≥3 required therapeutic laparot-omy. Forty-six of 54 patients (85%) with a score <3 did not need operative intervention. The sensitivity of the score in determining the need for therapeutic operation was higher than systolic blood pressure (83% vs 28%).[10] Starnes et al. re-viewed the role of computed tomography (CT) grade in NOM of BSI. The only significant difference between the success and failure of NOM was CT grade (1.47 vs 3.5; p=0.0001). Although the amount of hemoperitoneum and the grade of injury are useful to evaluate the severity of the patients, NOM is regarded reasonable as long as the patient is hemodynami-cally stable. Radiologic findings cannot be an absolute contra-indication for NOM nowadays. In our survey, 63.4% did not

consider the amount of hemoperitoneum as a determinant of NOM. It is a well accepted concept for the trauma doctor to perform NOM regardless of radiologic findings.

Hemodynamic stability (HS) has been suggested and evaluat-ed vigorously in many studies attempting to find the selection criteria for NOM. Longo et al. have reviewed sixty patients managed successfully with NOM. They have concluded that hemodynamic stability after initial fluid challenge is a useful predicting factor. Despite prioritizing HS in initial decision-making, they have not made a description of the definition of HS.[11] Lynch, Wasvary and Siplovich also have not described the definition of HS.[12,13] Some studies have described the definition of HS using only VS. However, the numeric value and the determinants are frequently different. They have de-fined HS as BP ≥90 mmHg,[14–18] ≥100 mmHg,[19,20] and ≥110 mmHg (Table 6).[21] Besides the numeric value, the type of BP

Table 4. Results of Section 3 questionnaire

Categories Number % p

Using base deficit

Yes 42 9.2

No 417 90.8 <0.01

Using lactic acid

Yes 36 7.8

No 423 92.2 < 0.01

Carrying out emergent laparotomy based on radiologic finding

Yes 168 36.6

No 291 63.4 < 0.05

Agreeing to the classic definition* of hemodynamic stability

Strongly agree 84 18.3

Mildly agree 99 21.6

Neutral 141 30.7

Mildly disagree 81 17.6

Strongly disagree 54 11.8

Reason to agree to classic definition of hemodynamic stability

I believe it is evidence based medicine 117 25.5

I have learned like that from my senior, medical conference, textbook etc 123 26.8

The range seems to be optimal 72 15.7

Others 12 2.6

Do not agree 135 29.4

Feeling the necessity to use other objective parameters

strongly agree 225 49.0 <0.01**

Mildly agree 195 42.5

Neutral 24 5.2

Mildly disagree 15 3.3

Strongly disagree 0 0

*: SBP <90 mmHg and HR ≥120/minute; **: Comparison between agreeing group and disagreeing group.



and the measuring technique of BP are amongother diversi-ties. There are basically three methods of measuring blood pressure; manual auscultatory method, automated cuff and arterial line. It is well known that there is a discrepancy be-tween these methods.[22–24] In spite of the variability of the method of obtaining BP, most studies do not elucidate the method they use to determine HS. In our study, 62.1% used SBP to define HS. However, the others used MAP and DBP. There is no study evaluating the sensitivity of the type of BP to define HS. Therefore, it is hard to determine which type of BP should be used. Another well-known determinant of HS is heart rate (HR). Some authors have included HR as a

determinant while others have not. Tachycardia appears ear-lier than hypotension in hypovolemic status. When a patient losesbetween 750 to 1500 ml of blood, BP is normal but HR increases to 100–120/min. Physiologically, HR is more sensi-tive. However, tachycardia can result from pain, emotional status or heart problem regardless of volume status. It makes us hesitate to use HR as an independent determinant of HS. Only 24.2% used HR as an independent determinant of HS in our study, meaning thatHR is regarded as an unreasonable determinant of HS for the trauma doctor. Considering the duration of hypotension or tachycardia, the problem of di-versity gets more complicated. Some responders decided to

Table 6. Studies that insist the usefulness of HS for successful NOM in BSI

Author Year Study type No of patients/ Criteria for NOM Definition of Age (year)

Longo 1989 Retrospective 60/≥16 HS, transfusion <4U age <50 None

William 1990 Retrospective 16/all age Hemodynamic stability SBP ≥90 mmHg

Lynch 1993 Retrospective 48/unknown Hemodynamic stability, Class I, II and III None

Archer 1996 Retrospective 87/≥16 Hemodynamic stability SBP ≥90 mmHg

Clancy 1996 Retrospective 31/all age HS, low injury severity score, CT scan SBP ≥90 mmHg

Wasvary 1997 Retrospective 40/all age HS, no evidence of decreased sensorium None

Siplovich 1997 Retrospective 55/≤14 clinical response to injury CT grade None

Cathey 1998 Retrospective 38/all age Hemodynamic stability, SBP ≥100 mmHg

no multiple injuries, and HR ≤100/min

normal laboratory finding

no transfusion

Konstantakos 1999 Retrospective 147/all age Hemodynamic stability SBP ≥120 mmHg

and HR ≤95/min

Krause 2000 Retrospective 18/≥55 HS, Transfusion <2 Unit SBP ≥100 mmHg

No associated abdominal

injury

Brasel 2003 Retrospective 20/all age Hemodynamic stability SBP ≥90 mmHg

and HR ≤100/min

Watson 2006 Retrospective 1392/all age Hemodynamic stability, Low grade SBP ≥90 mmHg

BSI: Blunt spleen injury; HS: Hemodynamic stability; NOM: Nonoperative management; SBP: Systolic blood pressure; HR: Heart rate.

Table 5. Variables associated with the respondent who has cut off value different from classic defini-tion of hemodynamic stability

Variable Odds Ratio (95% CI)

Univariate analysis Multivariate analysis

Age <40 1.23 (1.03–2.14) 0.48 (0.14–1.76)

Female Sex 1.12 (1.02–1.98) 0.13 (0.12–1.75)

Short career less than 5 year 1.54 (1.17–2.56) 0.33 (0.14–1.36)

Do not agree to classic definition 8.65 (5.67–9.45) 4.67 (3.17–6.38)

Only variables that were significant in the univariate analysis are listed. CI: Confidence interval.



carry out EL as long as the patient was hypotensive at least once. Some observed for 30 minutes (Table 3). However, there is no constant definition of the duration of hypotension or tachycardia to define HS. When the patient has medical problems, defining HS is harder.[25] Confusion in defining HS also happens when the patient has spinal cord injury or when the patient was previosly on vasoactive medication.[26] Most trauma doctors agree to use lower cut off value of hypoten-sion to define HS for pediatric patients, but there is no study defining the numeric value of VS of HS according to the age of the patients. Many retrospective studies, concluding that NOM in BSI of pediatric patients is more reasonable than that of the adults, have actually failed to explain the clear defi-nition of HS.[27,28] Much of the confusion and variability of the definition of HS is caused by using VS to define HS. Contrary to laboratory test or radiologic findings, VS is too diverse in terms of obtaining method, normal physiologic value, type, and duration. The only way to unify the diversity is a random-ized prospective study. Unfortunately, prospective studies to define HS are unlikely to be performed due to concerns over patient’s safety. We tried to find out the factors influencing the responders to make the diversity of HS. Although young age, female sex and short career seemed to be significant in the univariate analysis, there was no significant factor in the multivariate analysis, meaning thatthe problem of the diverse definition of HS is universal (Table 5).

Contrary to VS, laboratory test of anaerobic metabolism like arterial base deficit or venous lactate are more objective and can be used in conjunction with VS to define HS. Bannon et al. have evaluated the efficacy of arterial base deficit and lactate concentration in trauma patients. They prospectively studied forty patients with truncal injuries to examine the usefulness of central venous oxygen saturation (ScvO2), arte-rial lactate concentration, and arterial base deficit. Both base deficit and lactate concentration correlated with transfusion requirements; in addition, base deficit (BD) correlated with trauma score, and lactate correlated with the amount of he-moperitoneum.[29] Rixen et al. have also performed a pro-spective, multi-center, observational study of 2,069 multiple trauma patients to evaluate the significance of BD. BD was associated with a significant decrease in systolic blood pres-sure, prothrombin time, amount of transfusion, and mortal-ity. Their data showed that BD was an early available impor-tant indicator of hemodynamic instability in trauma patients and predicted higher probability of death.[30–32] BD and lactate are laboratory tests that can be available in the emergency room. There is only one method to get the results, that is, blood sampling regardless of sampling site. The results are revealed by numeric value. Normal physiologic range is not diverse at all. Thus, they can be useful adjuncts in assess-ing HS in trauma patients. Based on these studies, some au-thors insist to use lactic acid and BD as a determinant of HS. Some national guidelines suggest using BD or lactate. One of them is as following; regardless of causes, the patient is defined hemodynamically unstable if four of the following cri-

teria meet.[33] (1) acutely ill-looked appearance or deteriora-tion of mental status; (2) HR ≥100/minute; (3) RR ≥22/min or PaCO2 ≤21 mmHg; (4) arterial BD ≤-5 mEq/L or lactic acid ≥4 mM/L; (5) urine out <0.5 ml/kg/hour; (6) hypoten-sion (systolic blood pressure <90 mmHg) lasts longer than 20 minutes. Most trauma doctors agree that HS should be defined systematically using patient’s symptoms and signs, VS, laboratory test. It is quite surprising that many trauma doc-tors are still using only VS to define HS even though there are several studies suggesting objective determinants. In order to standardize NOM for trauma patients, the diversity of the definition of HS should be unified and a more objective de-terminant should be used.

ConclusionTrauma doctors are using VS as major determinants to define HS, resulting indiverse definitions of HS for patients with BSI. There is confusion regarding how to define which patient is HS. Most surveyed respondents felt the need for the clarifi-cation of HS and how it should be used to determine NOM versus operation. Using patients’ symptoms and signs, base deficit and lactic acid can minimize diversity and aid in the decision making process.

AcknowledgementThe present study was supported by grants from Chosun University 2015.


REFERENCES

1. Hebeler RF, Ward RE, Miller PW, Ben-Menachem Y. The management of splenic injury. J Trauma 1982;22:492–5.

2. Cooney DR, Michalak WA, Michalak DM, Fisher JE. Comparative methods of splenic preservation. J Pediatr Surg 1981;16:327–38.

3. Popovsky J, Wiener SN, Felder PA, Biramje A, Reydman M. Liver trauma: conservative management and the liver scan. Arch Surg 1974;108:184–6.

4. Yoo SY, Lim KS, Kang SJ, Kim CS. Pitfalls of nonoperative manage-ment of blunt abdominal trauma in children in Korea. J Pediatr Surg 1996;31:263–6.

5. Fifer T, Obeid FN, Sorensen VJ, Horst HM, Bivins BA. Comparative accuracy of diagnostic peritoneal lavage, liver-spleen scintigraphy, and vis-ceral angiography in blunt abdominal trauma. Am Surg 1989;55:612–5.

6. Starnes S, Klein P, Magagna L, Pomerantz R. Computed tomographic grading is useful in the selection of patients for nonoperative management of blunt injury to the spleen. Am Surg 1998;64:743–9.

7. Köksal N, Uzun MA, Müftüoğlu T. Hemodynamic stability is the most important factor in nonoperative management of blunt splenic trauma. Ulus Travma Derg 2000;6:275–80.

8. Morgenstern L, Uyeda RY. Nonoperative management of injuries of the spleen in adults. Surg Gynecol Obstet 1983;157:513–8.

9. Zucker K, Browns K, Rossman D, Hemingway D, Saik R. Nonoperative management of splenic trauma. Conservative or radical treatment? Arch Surg 1984;119:400–4.

10. McKenney KL, McKenney MG, Cohn SM, Compton R, Nunez DB,



Dolich M, et al. Hemoperitoneum score helps determine need for thera-peutic laparotomy. J Trauma 2001;50:650–6.

11. Longo WE, Baker CC, McMillen MA, Modlin IM, Degutis LC, Zucker KA. Nonoperative management of adult blunt splenic trauma. Criteria for successful outcome. Ann Surg 1989;210:626–9.

12. Lynch JM, Ford H, Gardner MJ, Weiner ES. Is early discharge follow-ing isolated splenic injury in the hemodynamically stable child possible? J Pediatr Surg 1993;28:1403–7.

13. Wasvary H, Howells G, Villalba M, Madrazo B, Bendick P, DeAngelis M, et al. Nonoperative management of adult blunt splenic trauma: a 15-year experience. Am Surg 1997;63:694–9.

14. Siplovich L, Kawar B. Changes in the management of pediatric blunt splenic and hepatic injuries. J Pediatr Surg 1997;32:1464–5.

15. Williams MD, Young DH, Schiller WR. Trend toward nonoperative management of splenic injuries. Am J Surg 1990;160:588–93.

16. Archer LP, Rogers FB, Shackford SR. Selective nonoperative manage-ment of liver and spleen injuries in neurologically impaired adult patients. Arch Surg 1996;131:309–15.

17. Clancy TV, Weintritt DC, Ramshaw DG, Churchill MP, Covington DL, Maxwell JG. Splenic salvage in adults at a level II community hospital trauma center. Am Surg 1996;62:1045–9.

18. Brasel KJ, Weigelt JA, Christians KK, Somberg LB. The value of pro-cess measures in evaluating an evidence-based guideline. Surgery 2003;134:605–12.

19. Watson GA, Rosengart MR, Zenati MS, Tsung A, Forsythe RM, Peitzman AB, et al. Nonoperative management of severe blunt splenic injury: are we getting better? J Trauma 2006;61:1113–9.

20. Cathey KL, Brady WJ Jr, Butler K, Blow O, Cephas GA, Young JS. Blunt splenic trauma: characteristics of patients requiring urgent laparotomy. Am Surg 1998;64:450–4.

21. Krause KR, Howells GA, Bair HA, Glover JL, Madrazo BL, Wasvary HJ, et al. Nonoperative management of blunt splenic injury in adults 55 years and older: a twenty-year experience. Am Surg 2000;66:636–40.

22. Eastridge BJ, Salinas J, McManus JG, Blackburn L, Bugler EM, Cooke WH, et al. Hypotension begins at 110 mm Hg: redefining “hypotension”

with data. J Trauma 2007;63:291–9.

23. Jones D, Engelke MK, Brown ST, Swanson M. A comparison of two noninvasive methods of blood pressure measurement in the triage area. J Emerg Nurs 1996;22:111–5.

24. Cienki JJ, DeLuca LA, Daniel N. The validity of emergency department triage blood pressure measurements. Acad Emerg Med 2004;11:237–43.

25. Skirton H, Chamberlain W, Lawson C, Ryan H, Young E. A systematic review of variability and reliability of manual and automated blood pres-sure readings. J Clin Nurs 2011;20:602–14.

26. McCann UG 2nd, Schiller HJ, Carney DE, Kilpatrick J, Gatto LA, Pas-kanik AM, et al. Invasive arterial BP monitoring in trauma and critical care: effect of variable transducer level, catheter access, and patient posi-tion. Chest 2001;120:1322–6.

27. Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL, Chen MF. Liver cirrhosis: an unfavorable factor for nonoperative management of blunt splenic injury. J Trauma 2003;54:1131–6.

28. Levi L, Wolf A, Belzberg H. Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome. Neurosurgery 1993;33:1007–17.

29. McVay MR, Kokoska ER, Jackson RJ, Smith SD. Throwing out the “grade” book: management of isolated spleen and liver injury based on hemodynamic status. J Pediatr Surg 2008;43:1072–6.

30. Tataria M, Nance ML, Holmes JH 4th, Miller CC 3rd, Mattix KD, Brown RL, et al. Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental. J Trauma 2007;63:608–14.

31. Bannon MP, O’Neill CM, Martin M, Ilstrup DM, Fish NM, Barrett J. Central venous oxygen saturation, arterial base deficit, and lactate concen-tration in trauma patients. Am Surg 1995;61:738–45.

32. Rixen D, Raum M, Bouillon B, Lefering R, Neugebauer E; Arbeitsge-meinschaft “Polytrauma” of the Deutsche Gesellschaft fur Unfallchirur-gie. Base deficit development and its prognostic significance in post-trauma critical illness: an analysis by the trauma registry of the Deutsche Gesellschaft für unfallchirurgie. Shock 2001;15:83–9.

33. Hongcheol L, Namsoo J. Korean Trauma Assessment and Treatment course 1st ed, Koonja 2010. p. 73.

OLGU SUNUMU

Travma hastalarında stabil yaşamsal bulgunun tanımındaki farklılık:Ulusal çaplı bir taramanın sonuçlarıDr. Seongpyo MunChosunÜniversitesi,CerrahiAnabilimDalı,Gwangju,GüneyKore

AMAÇ: Yaşamsal bulgulara (YB) dayalı hemodinamik stabilitenin (HS) künt dalak travmasının (KDT) başarılı cerrahi dışı tedavisinde (CDT) en yararlı kriter olduğu düşünülürdü. Ancak HS’nin tutarlı bir tanımı tespit edilememiştir. Ulusal çapta bir taramayla HS tanımını değerlendirmeyi ve bu farklılığı yaratan faktörleri saptamayı istedik.GEREÇ VE YÖNTEM: Ekim 2012 ile Kasım 2012 arasında birinci seviyede bir travma merkezinin travma ve acil cerrahi bölümüne HS tanımını içeren bir anket gönderildi. Variyans analizi, t-testi, χ2 testi ve lojistik regresyon analiziyle veriler karşılaştırıldı.BULGULAR: 563 doktorun 507’si (%90) yanıt vermişti. Kırk sekizinin yanıtları eksikti ve 459 (%81.5) yanıt incelendi. Kan basıncı (KB), hipotansiyo-nun kestirim değeri, KB’yi ölçüm tekniği, hipotansiyonun süresi, HS’nin belirleyicisi olarak kalp hızının (KH) kullanılıp kullanılmadığı, hastada komor-bidite varlığına veya çocuk hasta olduğuna göre HS tanımlarında anlamlı farklılık mevcuttu. Doktorların %91.5’i HS’yi tanımlamada kafalarının karışık olduğu ve daha somut belirleyicilere gerek duydukları yanıtını verdi. Her halde yanıt verenlerin %90’ı HS’yi tanımlamak için laboratuvar testlerinden yararlanmamaktaydı.TARTIŞMA: Birçok travmatoloji uzmanı HS’yi tanımlamak için yalnızca YB’yi kullanmaktadır. İşte bu nedenle hangi hastanın hemodinamik açıdan stabil olduğunu tanımlamada karmaşa yaşanmaktadır. Baz eksikliği veya laktat tayini gibi daha somut belirleyiciler daha yararlı ek bilgiler sağlayabilir.Anahtar sözcükler: Farklılık; hemodinamik instabilite; künt dalak travması; tanım; tarama.


ORİJİNAL ÇALIŞMA - ÖZET



A prospective clinical study of the effects of the physical features of the appendix on perforationYusuf Tanrıkulu, M.D.,1 Gökhan Yılmaz, M.D.,1 Ceren Şen Tanrıkulu, M.D.,2 Volkan Temi, M.D.,1

Fürüzan Köktürk, M.D.,3 Mithat Çağsar, M.D.,1 Boran Yalçın, M.D.1

1DepartmentofGeneralSurgery,ZonguldakAtatürkStateHospital,Zonguldak2DepartmentofEmergencyMedicine,BülentEcevitUniversityFacultyofMedicine,Zonguldak3DepartmentofBiostatistics,BülentEcevitUniversityFacultyofMedicine,Zonguldak

ABSTRACT

BACKGROUND: Acute appendicitis (AA) is one of the most common surgical emergencies, whosepostoperative morbidity and mortality increase significantly when the appendix perforates. The identification of factors that lead to perforation in these patients might effectively reduce morbidity. In this study, factors associated with perforation in AA were examined.

METHODS: The study included sixty patients divided into equal non-perforated and perforated groups. Preoperative body mass in-dex (BMI) and prehospital delay of the patients, the appendix location, presence of fluid or abscesses during surgery, and the appendix wall thickness, root and end diameters, and length in the surgery specimen were compared.

RESULTS: The patients were comprised of forty males and 20 females, with a median age of 27 (range 16–84) years. BMI was signifi-cantly higher in the perforated group than the non-perforated group (p=0.039). There was no difference between the groups in terms of the presence of fluid (p=0.792); the presence of abscess was higher in the perforated group (p=0.017). The most common location of the appendix was retrocecal in the perforated group (p=0.007). While there was no difference in the appendix end diameter, root diameter was significantly higher in the perforated group (p=0.041), as were wall thickness (p<0.001) and appendix length (p=0.037).

CONCLUSION: BMI, prehospital delay, a retrocecally positioned appendix, presence of an abscess, and appendix wall thickness, root diameter, and length are risk factors for perforation in AA.

Key words: Appendectomy; perforated appendicitis; risk factors.

because it is generally assumed that untreated appendicitis will eventually perforate after the appendix has become in-flamed.[6] If AA is diagnosed and treated early, recovery time and process remain normal. However, a delay in diagnosis and surgical intervention leads to an increased rate of perfora-tion, longer hospital stay, and increased costs, mortality, and morbidity.[7]

The diagnosis of complicated appendicitis depends on subjec-tive criteria, such as the symptom onset, type of pain, and physical examination. There is a need for objective tests for a definite diagnosis. Despite the use of a variety of objective diagnostic methods, such as radiological imaging, laboratory tests, and scoring systems, in the diagnosis of complicated appendicitis and studies[8–11] of factors affecting the risk of perforation in AA, such as body mass index (BMI), gender, age, season, and time to appendectomy, no comprehensive study has examined the risk factors directly related to perfo-ration. Therefore, we investigated the factors associated with perforation in AA, such as BMI, the physical parameters and location of the appendix and time to operation.


Address for correspondence: Yusuf Tanrıkulu, M.D.

Zonguldak Atatürk Devlet Hastanesi, Genel Cerrahi Kliniği,

Zonguldak, Turkey



Copyright 2015TJTES

INTRODUCTION

Acute appendicitis (AA) is one of the most common reasons for emergency surgery, with approximately 280,000 appen-dectomies performed each year in the United States.[1–3] The incidence of perforated or gangrenous appendicitis remains high (28–29%).[4,5]

Although the appropriateness of non-surgical treatment for AA is debated, appendectomy is the gold-standard treatment



Tanrıkulu et al. A prospective clinical study of the effects of the physical features of the appendix on perforation


Study Groups and DesignThis prospective study was conducted from 1 February 2014 to 30 November 2014 in the general surgery and emergency medicine departments of an urban hospital, after being ap-proved by the Regional Ethics Review Committee (Abant İzzet Baysal University Clinical Research Ethics Committee Approval on 10/02/2014 approval no. 2013/46-32). Informed consent was obtained from all patients.

The study enrolled sixty patients operated on for AA and di-agnosed with AA histopathologically. The number of patients in the groups was calculated using power analysis and was dis-tributed evenly. The sample size was determined to be thirty patients per group with a power of 0.9 and 95% confidence interval. Patients were divided into non-perforated (n=30) and perforated (n=30) groups. When thirty patients were enrolled in the non-perforated group, patient enrollment in that group was stopped. Subsequently, patients were accepted only for the perforated group until thirty patients were also enrolled.

Patients were excluded if one of the following criteria were present: younger than 16 years (no upper age limit), pregnan-cy, patients with gastrointestinal malignancies, and perforated appendix induced by trauma.

Patients with a diagnosis of AA based on history, physical examination, laboratory tests, and imaging methods were operated on. Antibiotics were administered at the beginning

of surgery. The choice of surgical procedure was left to the surgeon. Laparoscopic appendectomies were performed us-ing the standard three-port technique and conventional ap-pendectomies were performed using the McBurney incision.

The time to the diagnosis of AA from the onset of complaints and the BMI of patients were calculated preoperatively. Ap-pendix location (retrocecal, laterocecal, antececal, or medio-cecal) and the presence of fluid or abscesses were assessed intraoperatively. Appendix wall thickness, root and end di-ameters, and length were measured on the surgical speci-men. In addition, appendix diameter at the perforation was measured in the perforated group. Finally, all appendectomy specimens were evaluated histopathologically. The criterion for histological AA was infiltration of the muscularis propria with polymorphonuclear cells. Patients with histopathological non-acute appendicitis were excluded from the study.

Laboratory AnalysisA complete blood count analysis was done and C-reactive protein (CRP) levels were measured using venous blood samples with automated analyzers. Normal values were de-termined based on reference values accepted by hematology laboratories.

Statistical AnalysisData were analyzed using SPSS (Statistical Package for Social Science) for Windows 15.0 package program. Data normality was tested by one-sample Kolmogorov-Smirnov test. Contin-uous variables were given as mean± standard deviation, and

Table 2. Comparison of laboratory parameters of groups

Nonperforated group Perforated group Overall p (n=30) (n=30) (n=60)

White blood count (x109/L) 13.27±3.66 14.03±3.63 13.78±3.65 0.279

Neutrophilia (%) 79.28±7.54 80.94±7.75 80.11±7.62 0.406

C-reactive protein (mg/dL) 0.40 (0.10–13.60) 4.20 (0.10–44.10) 1.25 (0.10–44.10) <0.001

Table 1. The analysis of demographic features of groups


Age (years) 23.5 (16–84) 31 (16–69) 27 (16–84) 0.366

Gender

Male 20 (50%) 20 (50%) 40

Female 10 (50%) 10 (50%) 20

Body mass index (kg/cm2) 22.87±4.07 25.09±4.06 23.98±4.18 0.039

Prehospital delay (hr)* 25.60±10.26 34.70±14.53 30.15±13.28 0.015

*Duration from the onset of symptoms to operation time.


were compared with One-Way ANOVA or Kruskal Wallis variance analysis. When p value was significant, Mann-Whit-ney U multi variance analysis was used to detect the group creating the difference. Non-continuous variables were given as median (min-max), and were compared using Chi-Square test. A p value <0.05 was considered statistically significant.

RESULTS

Thirty patients with AA and thirty with perforated AA were evaluated. The demographic characteristics of the groups are shown in Table 1. The patients included forty (66.6%) males and twenty (33.3%) females with a median age of 27 (range 16–84) years. There was no difference in gender and mean age between the groups. BMI was significantly (p=0.039) high-

er in the perforated group than the non-perforated group. Prehospital delay was significantly (p=0.015) longer in the perforated group (Fig. 1).

Laboratory values of the groups are summarized in Table 2. While there was no difference in white blood count (WBC) and percent neutrophils, CRP level was significantly (p<0.001) higher in the perforated group (Fig. 2).

According to the data obtained during surgery, abscesses were more frequent in the perforated group (p=0.017) while there was no difference between the groups in terms of the presence of fluid (p=0.792). The most common location of the appendix was retrocecal in the perforated group and an-tececal in the non-perforated group (p=0.007) (Table 3).

Table 3. The distribution of the features identified in the operation


n % n % n

Presence of abscess 0.017

Yes 3 20 12 80 15

No 27 60 18 40 45

Presence of fluid 0.792

Yes 11 45.8 13 54.2 24

No 19 52.8 17 47.2 36

Localization of appendix 0.007

Retrocecal 8 27.6 21 72.4 29

Laterocecal 3 75 1 25 4

Antececal 12 66.7 6 33.3 18

Mediocecal 7 77.8 2 22.2 9

Figure 1. Therelationbetweengroups(withandwithoutperfora-tion)andBMI.

25

20

15

10

30

35

Nonperforatedgroup Perforatedgroup

Bodymassindex(kg/cm

2 )

Figure 2. Therelationbetweengroups(withandwithoutperforati-on)andCRPlevels.

30

20

20

29

24

6

****

410

0

40

50


C-reactiveprotein(mg/dL)


Table 4 and Figure 3 summarize the physical parameters of the appendix in the two groups. Wall thickness (p<0.001) and appendix length (p=0.037) were significantly higher in the perforated group. While there was no difference in the appendix end diameter, the root diameter was significantly higher in the perforated group (p=0.041).

The correlations between the location of the perforation and the physical parameters of the appendix in the perforated

group are shown in Table 5. No correlation was found be-tween the distance from the cecum/end to the perforation with root diameter, perforated diameter, or end diameter (r=0.350, p=0.058; r=0.079, p=0.680; and r=0.242, p=0.198, respectively). However, there was a weak positive correla-tion between the appendix length and the location of the perforation; as the appendix length increased the perforation approached the end of appendix (r=0.369, p=0.045).

DISCUSSIONThis study investigated physical factors associated with perfo-ration in AA. A few studies have examined the factors affect-ing the risk of perforation in complicated AA. These studies mostly evaluated the time to appendectomy, gender, and age. No comprehensive study has examined the risk factors re-lated to perforation directly.

The lifetime rate of appendectomy is 7%. Despite various advanced laboratory and imaging techniques, the rate of mis-diagnosis remains the same (15%), and equals the rate of ap-pendiceal rupture. If diagnosis and surgical intervention are delayed, the perforation, morbidity, and mortality rates all increase considerably in AA.[12,13] The appendiceal perforation rate is higher in the elderly population due to the atypical presentation, presence of comorbid disease, and age-specific physiological changes, such as changes in the colon wall me-chanical strength (32–72%).[14–16] Barreto et al.[8] have found that male sex and being older than 60 are significantly as-sociated with a risk of perforation. Augustin et al.[17] have obtained the same results in patients older than 50. Similarly, Sulu et al.[18] have found that the perforation rate is higher in elderly patients. In the present study, sex distributions and


Table 5. The relationship between the location of perforation and the physical properties of appendix in perforated group

Measures (mm) Cecum close perforation End close perforation Overall p (n=14) (n=16) (n=30)

Appendix root diameter (Mean±SD) 10.28±3.09 8.87±3.32 9.53±3.25 0.286

Appendix end diameter (Mean±SD) 11.50±8.70 10.31±3.48 10.87±6.41 0.571

Appendix length 70 (35–120) 87.50 (48–130) 85 (35–130) 0.351

Appendix perforated diameter 12.50 (6–80) 13.00 (6–22) 13 (6–80) 0.436

Table 4. Distributions of the physical quantities of appendix in groups

Measures (mm) Nonperforated group Perforated group Overall p (n=30) (n=30) (n=60)

Wall thickness 3.00 (1.90–8.00) 4.00 (2.00–10.00) 3.00 (1.90–10.00) <0.001

Appendix root diameter 7.00 (4.00–15.00) 9.50 (4.00–16.00) 8.00 (4.00–16.00) 0.041

Appendix end diameter 9.00 (5.00–18.00) 10.00 (3.00–40.00) 9.50 (3.00–40.00) 0.225

Appendix length (Mean±SD) 66.53±25.70 80.30±24.14 73.41±25.68 0.037

Figure 3. Therelationbetweengroups(withandwithoutperfora-tion)andsizes(wall thickness,rootandenddiameter, length)ofappendicitis.

75

50

25

0

100

125


Size(mm)

*

*

WellthicknessApp.rooldiameterApp.enddiameterAppendixlength


mean age of the patients in the two groups were similar and these were not risk factors for perforation (p=0.366 for age, p=1.000 for sex).

Another parameter that is believed to be associated with appendix perforation is BMI. The diagnosis of AA in obese patients is difficult and the misdiagnosis rate is high due to clinical challenges related to increased BMI, such as decreased mobility, increased fat in the abdominal wall, and an altered response to stress.[19,20] In this study, BMI was higher in the perforated group than in the non-perforated group (p=0.039).The timing of appendectomy is one of the most-studied top-ics. It is believed that a delay in the surgical removal of the inflamed appendix will result in perforation. Bickell et al.[21] have reported that the risk for developing a perforated ap-pendix is high when the period from the onset of symptoms to surgery exceeds 36 h. In a study of an elderly population, Omari et al.[14] have reported that pre-hospital delay is higher in the perforated group (p<0.0001). In contrast, Drake et al.[9] have found no relationship between the time to treatment and perforation. In our study,pre-hospital delay was higher in the perforated group (p=0.015).

Leukocytosis, neutrophilia, and CRP are important diagnostic markers in AA. Interestingly, the combined use of the three markers improves the sensitivity to 97–100% for the diagno-sis of AA. CRP is most likely to be elevated in appendicitis if symptoms are present for more than 12 h.[22] Panagiotopou-lou et al.[23] have found that CRP has the highest diagnostic accuracy for perforated appendicitis. Similarly, Moon et al.[11] have reported a significantly elevated CRP in complicated ap-pendicitis. In the present study, CRP levels were markedly higher in the perforated group (p<0.001). In contrast, no re-lationships between WBC count or neutrophilia and perfora-tion were seen although the levels of both were higher than the reported cut-off values.

Abdominal ultrasonography (US) and computed tomography (CT) are the most common methods used in the diagnosis of AA. Although operator skill is an important factor in all US examinations, its accuracy rates vary. In experienced hands, US has sensitivities of 75–90%, specificities of 86–95%, ac-curacies of 87–96%, positive predictive values of 91–94%, and negative predictive values of 89–97% for the diagnosis of AA. Abdominal CT complements US and is recommended when-ever US results are suboptimal. Its accuracy rates vary ac-cording to the appendix diameter. Helical CT has sensitivities of 90–98%, specificities of 91–98%, accuracies of 94–98%, positive predictive values of 92–98%, and negative predic-tive values of 95–98% for the diagnosis of AA.[22] In a study evaluating the usefulness of CT findings for differentiating perforated from non-perforated appendicitis, Suthikeeree et al.[24] have found that an abscess, extra-luminal appendicolith, and extra-luminal air have the highest specificities for perfo-rated appendicitis, at 95.24%, 100%, and 95.24%, respectively.

Tsuboi et al.[25] have found that multi-detector row CT al-lows an accurate (96.1%) diagnosis of appendiceal perforation when a defect is seen in the contrast-enhanced appendiceal wall. As noted in previous studies, the appendiceal transverse diameter and wall thickness have been evaluated in all imag-ing methods, while very few studies have examined the re-lationship between appendix perforation and position. Sheu et al.[16] have found that a retrocecally positioned appendix is a risk factor for perforation of the appendix (OR 1.93, CI 1.15–3.24). In the present study, we were unable to evaluate the imaging methods because of inadequate and inappropri-ate radiological techniques. We detected significant differ-ences between groups in terms of the presence of an abscess (p=0.017) and retrocecally positioned appendix (p=0.007). We found that the rate of perforation of the appendix in-creased with appendix length. While we found no difference between groups according to the appendix end diameter, the appendix root diameter was greater in the perforated group (p=0.041). In addition, comparing the location of the perfora-tion and the physical properties of the appendix in the perfo-rated group, we found no correlation between the distance from the cecum or to the perforation with root diameter, perforated diameter, or end diameter; however, there was a weak correlation between the appendix length and the loca-tion of perforation (p=0.045, r=0.369).

In summary, BMI, prehospital delay, elevated CRP, a retrocecal-ly positioned appendix, the presence of an abscess, and appen-dix wall thickness, root diameter, and length are risk factors for perforation in AA. The first four parameters are evalu-ated preoperatively, and the others intraoperatively. Further research should verify our findings and seek preoperatively diagnostic methods for evaluating intraoperative parameters.

Notes: The English in this document has been checked by at least two professional editors, both native speakers of Eng-lish. For a certificate, please see: http://www.textcheck.com/certificate/5lYGST


REFERENCES

1. Bergeron E, Richer B, Gharib R, Giard A. Appendicitis is a place for clini-cal judgement. Am J Surg 1999;177:460–2.

2. Adesunkanmi AR, Ogunrombi O. Unusual causes of acute abdomen in a Nigerian hospital. West Afr J Med 2003;22:264–6.

3. National Center for Health Statistics. Ambulatory and Inpatient Proce-dures in the United States, 1996. National Center for Health Statistics Series 13, No. 139. 2004.

4. Cueto J, D’Allemagne B, Vázquez-Frias JA, Gomez S, Delgado F, Trul-lenque L, et al. Morbidity of laparoscopic surgery for complicated appen-dicitis: an international study. Surg Endosc 2006;20:717–20.

5. Yaghoubian A, de Virgilio C, Lee SL. Appendicitis outcomes are better at resident teaching institutions: a multi-institutional analysis. Am J Surg 2010;200:810–3.



OLGU SUNUMU

Apendiksin fiziksel özellklerinin perforasyon üzerine etkileri:İleriye yönelik klinik çalışmaDr. Yusuf Tanrıkulu,1 Dr. Gökhan Yılmaz,1 Dr. Ceren Şen Tanrıkulu,2 Dr. Volkan Temi,1

Dr. Fürüzan Köktürk,3 Dr. Mithat Çağsar,1 Dr. Boran Yalçın1

1ZonguldakAtatürkDevletHastanesi,GenelCerrahiKliniği,Zonguldak2BülentEcevitÜniversitesiTıpFakültesi,AcilTıpAnabilimDalı,Zonguldak3BülentEcevitÜniversitesiTıpFakültesi,BiyoistatistikAnabilimDalı,Zonguldak

AMAÇ: Akut apandisit (AA) en yaygın görülen cerrahi acillerden birisidir ve apendiks perfore olduğunda ameliyat sonrası morbidite ve mortalite artar. Apendiks perforasyonuna yol açan faktörlerin belirlenmesi morbiditeyi azaltmada etkili olabilir. Biz akut apandisitte perforasyonla ilişkili fak-törleri inceledik.GEREÇ VE YÖNTEM: Bu çalışmada 60 hasta ele alındı ve hastalar eşit sayıda iki gruba ayrıldı: Non-perfore ve perfore grup. Biz, ameliyat öncesi dönemde hastaların vücut kitle indeksini (VKİ) ve başvuru öncesi gecikme zamanını, ameliyat esnasında apendiks pozisyonunu, apse veya sıvı varlığı ile cerrahi spesmende apendiksin duvar kalınlığını, kök ve uç çapı ile uzunluğunu karşılaştırdık.BULGULAR: Hastaların 40’ı erkek, 20’si kadın olup ortanca yaş 27 idi (min-maks: 16–84). Vücut kitle indeksi perfore grupta non-perfore gruptan belirgin şekilde yüksekti (p=0.039). Sıvı varlığı açısından gruplar arasında fark yok iken, apse varlığı perfore grupta daha yüksekti (p=0.017). Perfore grupta, apendiksin en yaygın görüldüğü pozisyon retroçekaldi (p=0.007). Apendiks uç çapına göre gruplar arasında fark yokken, kök çapı, duvar kalınlığı ve apendiks uzunluğu perfore grupta belirgin olarak daha yüksekti (sırasıyla p=0.041, p<0.001 ve p=0.037).TARTIŞMA: Vücut kitle indeksi, başvuru öncesi gecikme zamanı, retroçekal yerleşimli apendiks, apse varlığı ile duvar kalınlığı, kök çapı ve apendiks uzunluğu akut apandisitte perforasyonu etkileyen risk faktörleridir.Anahtar sözcükler: Apendektomi; perfore apandisit; risk faktörleri.




6. Fitz RH. Perforating inflammation of the vermiform appendix with spe-cial reference to its early diagnosis and treatment. Trans Assoc Am Physi-cians 1886;1:107–44.

7. Kim JI, Seong MK, Lee KY. Preoperative prediction of acute perforative and gangrenous appendicitis by clinical features of pa¬tients. J Korean Surg Soc 1993;44:1048–60.

8. Barreto SG, Travers E, Thomas T, Mackillop C, Tiong L, Lorimer M, et al. Acute perforated appendicitis: an analysis of risk factors to guide surgi-cal decision making. Indian J Med Sci 2010;64:58–65.

9. Drake FT, Mottey NE, Farrokhi ET, Florence MG, Johnson MG, Mock C, et al. Time to appendectomy and risk of perforation in acute appendi-citis. JAMA Surg 2014;149:837–44.

10. Ramos CT, Nieves-Plaza M. The association of body mass index and perforation of the appendix in Puerto Rican children. J Health Care Poor Underserved 2012;23:376–85.

11. Moon HM, Park BS, Moon DJ. Diagnostic Value of C-reactive Protein in Complicated Appendicitis. J Korean Soc Coloproctol 2011;27:122–6.

12. Körner H, Söndenaa K, Söreide JA, Andersen E, Nysted A, Lende TH, et al. Incidence of acute nonperforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg 1997;21:313–7.

13. Graff L, Russell J, Seashore J, Tate J, Elwell A, Prete M, et al. False-neg-ative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery. Acad Emerg Med 2000;7:1244–55.

14. Omari AH, Khammash MR, Qasaimeh GR, Shammari AK, Yaseen MK, Hammori SK. Acute appendicitis in the elderly: risk factors for per-foration. World J Emerg Surg 2014;9:6.

15. Lee JF, Leow CK, Lau WY. Appendicitis in the elderly. Aust N Z J Surg 2000;70:593–6.

16. Sheu BF, Chiu TF, Chen JC, Tung MS, Chang MW, Young YR. Risk factors associated with perforated appendicitis in elderly patients pre-senting with signs and symptoms of acute appendicitis. ANZ J Surg 2007;77:662–6.

17. Augustin T, Cagir B, Vandermeer TJ. Characteristics of perforated ap-pendicitis: effect of delay is confounded by age and gender. J Gastrointest Surg 2011;15:1223–31.

18. Sulu B, Günerhan Y, Palanci Y, Işler B, Cağlayan K. Epidemiological and demographic features of appendicitis and influences of several environ-mental factors. Ulus Travma Acil Cerrahi Derg 2010;16:38–42.

19. Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne D. Assessment of child and adolescent overweight and obesity. Pediatrics 2007;120 Suppl 4:193–228.

20. Grimble RF. The true cost of in-patient obesity: impact of obesity on in-flammatory stress and morbidity. Proc Nutr Soc 2010;69:511–7.

21. Bickell NA, Aufses AH Jr, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am Coll Surg 2006;202:401–6.

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

23. Panagiotopoulou IG, Parashar D, Lin R, Antonowicz S, Wells AD, Bajwa FM, et al. The diagnostic value of white cell count, C-reactive protein and bilirubin in acute appendicitis and its complications. Ann R Coll Surg Engl 2013;95:215–21.

24. Suthikeeree W, Lertdomrongdej L, Charoensak A. Diagnostic perfor-mance of CT findings in differentiation of perforated from nonperforated appendicitis. J Med Assoc Thai 2010;93:1422–9.

25. Tsuboi M, Takase K, Kaneda I, Ishibashi T, Yamada T, Kitami M, et al. Perforated and nonperforated appendicitis: defect in enhancing appendiceal wall-depiction with multi-detector row CT. Radiology 2008;246:142–7.


Comparison of intracorporeal knotting and endoloop for stump closure in laparoscopic appendectomyİlhan Bali, M.D.,1 Faruk Karateke, M.D.,2 Sefa Özyazıcı, M.D.,2 Adnan Kuvvetli, M.D.,2

Cem Oruç, M.D.,3 Ebru Menekşe, M.D.,2 Seyfi Emir, M.D.,1 Mehmet Özdoğan, M.D.4

1DepartmentofGeneralSurgery,NamıkKemalUniversityFacultyofMedicine,Tekirdağ2DepartmentofGeneralSurgery,AdanaNumuneTrainingandResearchHospital,Adana3DepartmentofGeneralSurgery,MustafaKemalUniversityFacultyofMedicine,Hatay4DepartmentofGeneralSurgery,MedlineHospital,Adana

ABSTRACT

BACKGROUND: Several appendiceal stump closure tecniques such as intracorporoeal-knotting, endoloop, stapler and clips are used during laparoscopic appendectomy. This study aimed to compare intracorporoeal-knotting and endoloop tecniques used to close appendiceal stump in laparoscopic appendectomy.

METHODS: This study included patients who underwent laparoscopic appendectomy with preliminary diagnosis of acute appendicitis in General Surgery Department of Adana Numune Training and Research Hospital between June 2009 and July 2013. The demograph-ics, appendiceal stump closure tecniques, operation time, complications, and length of hospital stays of the patients were compared.

RESULTS: A total of one hundred and twenty-six patients underwent laparoscopic appendectomy (Female: 81, Male: 45). Intracor-poreal-knotting (Group 1) was performed in sixty-five patients; whereas, endoloop (Group 2) was performed in sixty-one patients in order to close appendiceal stump. The operation time was longer in Group 1 compared to Group 2 (62.0±10.67 min., 56.80±11.94 min., p=0.01). The length of hospital stays were nonsignificant between the groups. Four patients were complicated by superficial surgical site infection in both groups.

CONCLUSION: In the present study, the operation time was found to be longer for intracorporeal knotting tecnique compared to endoloop tecnique; however, there was no significant difference regarding the length of hospital stay and complications. Performing intracorporeal-knotting technique is suggested since it is cheaper than endoloops and it may also improve hand manipulations of the surgeons who intend to advanced laparoscopy.

Key words: Acute appendicitis; appendiceal stump; endoloop; intracorporeal knotting; laparoscopic appendectomy.

years in western countries. However, although LA is shown once again in several western studies as the first surgical op-tion that shortens hospital stay compared to OA, decreases the pain after surgery, and accelerates the early recovery es-pecially in women and overweight patients, debates are still ongoing in this era.[1,2]

In laparoscopic appendectomy, there are several methods to close the appendix stump. Closing the stump with an intracor-poreal knotting (IK), endoloop (EL), endostapler or polymer clips etc. are the most frequently used surgical techniques.[3–5] Usage of these different techniques on different clinical stages of acute appendicitis, advantages and disadvantages have been reported in terms of both execution and expenditure.[6–10] In this study, we aimed to compare the clinical results of the EL and IK techniques which we used to close the appendix stump, in patients with acute appendicitis. To our knowledge, this is the first study comparing intracorporoeal-knotting and


Address for correspondence: Faruk Karateke, M.D.

Adana Numune Eğitim ve Araştırma Hastanesi,

Genel Cerrahi Kliniği, Adana, Turkey



Copyright 2015TJTES

INTRODUCTION

Although open appendectomy (OA) is one of the first learned procedures in general surgery assistant training period, lapa-roscopic appendectomy (LA) is not routinely performed as it is not a gold standard like laparoscopic cholecystectomy. LA has been performed in general surgical practice for over 30



Bali et al. Comparison of intracorporeal knotting and endoloop for stump closure in laparoscopic appendectomy

endoloop tecniques used to close appendiceal stump in lapa-roscopic appendectomy.


Patients, who underwent laparoscopic appendectomy with the prediagnosis of acute appendicitis in Adana Numune Train-ing and Research Hospital, General Surgery Department be-tween June 2009 and July 2013, were taken into this study. In-stituonal ethical committee approved the study. Patients who were under eighteen years of age, patients with a perforated appendicitis and generalized peritonitis, cases those required conversion to open appendectomy during laparoscopy and patients not diagnosed with acute appendicitis after surgery in histopathologic evaluation were excluded from the study. Also, patients with pregnancy, American Society of Anesthe-siologists III and IV patients were excluded from the study population. All operations were performed by a single sur-geon (IB). Written consent was taken from all patients before surgery. All patients received 1 g cefazoline preoperatively.

Patients were divided into two groups as IK knotting group (Group 1) and EL group (Group 2). A 10 mm telescope was inserted to all patients above the umblicus with a 10 mm trocar with open procedure and two more trocars were in-serted left lateral area under the umblicus. Mesentery of the appendix was cut with either Ligasure (Covidien, Boulder, CO) or with an ultrasonic dissector (31 ACE 36 E harmonic scalpel, Ethicon Endo-Surgery, Inc.). Vicryl™-0 Ethicon was used in Group 1 patients for the closure of the stump. After the closure of the stumps in this group with a double manual knotting, appendectomy was completed and specimen was taken out from the abdomen. Vicryl-Endoloop 0 (Ethicon Endo-surgery) was used in Group 2 patients. After appendix stump was closed with EL, proximal end was cut by clipping and specimen was taken out from the abdomen. Operation

time, length of hospital stay (LOS) after surgery and compli-cations were obtained from patient records.

Statistical AnalysisIn data analysis, IBM Statistical Packaged Software for Social Sciences (IBM SPSS; SPSS, Inc., Chicago, IL, USA) version 20.0 was used. For continuous data, mean (standard deviation, SD) was used and for non-relevant to normal distribution, median (min-max) was used, and categorical data were showed with percentages (%). Demographics of patients, whose appendix stump was closed with IK and EL techniques depending on Gaussian distribution, were evaluated with Student’s t-test or Mann–Whitney U test in in continuous data, whereas cat-egorical data were tested with Chi-square. P<0.05 was con-sidered statistical significant.

RESULTS

During the study period, laparoscopic appendectomy was performed to a total of one hundred and twenty-sixpatients consisting of 81 females (64.3%) and 45 males (35.7%). De-mographics of the patients, surgery findings and follow-up data after surgery are shown in Table 1. Patients’ mean age was 32.33±10.97 years. For closure of the the appendix stump, IK knotting (Group 1) was used in sixty-five patients and EL was used in 61 patients (Group 2). Operation time of patients in Group 1 was statistically longer than of Group 2 (p<0.05). No significant difference was found between the groups in terms of LOS (p>0.05). Superficial infections - not requiring drainage or intervention - on the trocar sites were seen in four patients from each group.

DISCUSSIONIn several studies, in comparison with open appendectomy, LA has been found to fasten early recovery after surgery,

Table 1. The demoghrapics of the patients underwent laparoscopic appendectomy

Parameters Group 1 (Intracorporeal knotting) Grup 2 (Endoloop) Univariate (n=65) (n=61) p

Age 33.24±11.16 31.36±10.76 0.33

(18.0–66.0) (19.0–62.0)

Gender (Male/Female) 23/42 22/39 0,54

(35.4/64.6) (36.1/63.9)

Operation time (min.) 62.0±10.67 56.80±11.94 0.01

(30.0–95.0) (15.0–105.0)

Length of hospital stay (day) 1.00 1.00 0.89

(1.0–6.0) (1.0–4.0)

Total cost (TL) 675 768 0.04

Data were given mean±SD/median (min.-max.). SD: Standard deviation.İK: Intracorporeal knotting; EL: Endoloop.Total cost was calculated after adding EL and Vicryl prices for groups.


shorten early return to daily life and work.[1,2,6] However, al-though 30 years have passed over the first LA surgery de-scription,[11] discussions on the recommended technique on appendix stump closure are still ongoing today. According to the current literature, most frequent methods of stump closure are with endostaplers (ES), EL and clips.[3–6,12] In the first years of LA, EL was frequently used in stump closure; whereas, it is known that ES is safer and commonly used in recent years.[13] However, in numerous prospective studies and meta-analysis, it is stated that these three methods don’t show any significant superiorities to each other in terms of operation time, preoperative and postoperative complication rates and hospital stay durations.[10,12]

In this study, when we compared the IK knotting technique in terms of operation time, complication and hospital stay, we only found that mean operation time was 6–7 min. longer in Group 1 than in Group 2. Our findings in both groups are co mpatible with theliterature.[4,12,14] Bowel injury, bleeding, stump leakage and intra-abdominal abscess after LA are the most frequent complications.[2] However, in our study no ma-jor complications were seen in any of the patients.

Laparoscopic appendectomy cost changes according to the surgical materials used, such as ES, EL, endoclip and trocar.[2] However, it is suggested that the optimal technique to use in LA appendix stump closure should be reliable and cost effec-tive as it was stated in previous studies15. In our study, cost of a single EL (Vicryl-Endoloop 0; Ethicon Endo-surgery) was 28€, suture (Vicryl™-0 Ethicon) cost was 1.85€.

In a study by Gönenç et al.,[14] it was suggested to surgeons who would perform the IK knotting technique to close the appendix stump in LA to do it with an experienced surgeon on the first[10–15] cases. Also, it is stated that IK knotting tech-nique will contribute to the training of surgeons in the begin-ning of advanced laparoscopic surgery. On the contrary to western countries, considering that laboratories don’t exist in our country for surgeons to improve the advanced laparo-scopic surgery training, we suggest applying this technique in institutions where surgery training is being given.

This retrospective study has several limitations. First of all, our study was not a prospective randomized trial. However, patients in the groups were divided homogeneously to be compared with each other. Secondly, the study population was small due to the patients with complicated appendicitis, and LAs done by other surgeons weren’t included with the purpose of standardization.

ConclusionIn our study, we found that operation time in IK knotting technique used to close the appendix stump was longer than the EL technique; however, no significant difference was found in terms of hospital stay and complications. We suggest

using IK knotting technique for closing the appendix stump since it is cost-effective and it improves hand manipulation of surgeons who will begin advanced laparoscopy.

Financial SupportAuthors declared they didn’t have a financial support for this study.


REFERENCES

1. Li X, Zhang J, Sang L, Zhang W, Chu Z, Li X, et al. Laparoscopic versus conventional appendectomy-a meta-analysis of randomized controlled trials. BMC Gastroenterol 2010;10:129.

2. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010;10:CD001546.

3. Hanssen A, Plotnikov S, Dubois R. Laparoscopic appendectomy using a polymeric clip to close the appendicular stump. JSLS 2007;11:59–62.

4. Delibegović S. The use of a single Hem-o-lok clip in securing the base of the appendix during laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A 2012;22(1):85–7.

5. Sohn M, Hoffmann M, Pohlen U, Lauscher JC, Zurbuchen U, Holmer C, et al. Stump closure in laparoscopic appendectomy. Influence of en-doloop or linear stapler on patient outcome. [Article in German] Chirurg 2014;85:46–50. [Abstract]

6. Beldi G, Muggli K, Helbling C, Schlumpf R. Laparoscopic appendecto-my using endoloops: a prospective, randomized clinical trial. Surg Endosc 2004;18:749–50.

7. Sahm M, Kube R, Schmidt S, Ritter C, Pross M, Lippert H. Cur-rent analysis of endoloops in appendiceal stump closure. Surg Endosc 2011;25:124–9.

8. Beldi G, Vorburger SA, Bruegger LE, Kocher T, Inderbitzin D, Candinas D. Analysis of stapling versus endoloops in appendiceal stump closure. Br J Surg 2006;93:1390–3.

9. Rakić M, Jukić M, Pogorelić Z, Mrklić I, Kliček R, Družijanić N, et al. Analysis of endoloops and endostaples for closing the appendiceal stump during laparoscopic appendectomy. Surg Today 2014;44:1716–22.

10. Sajid MS, Rimple J, Cheek E, Baig MK. Use of endo-GIA versus en-do-loop for securing the appendicular stump in laparoscopic appen-dicectomy: a systematic review. Surg Laparosc Endosc Percutan Tech 2009;19:11–5.

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

12. Ates M, Dirican A, Ince V, Ara C, Isik B, Yilmaz S. Comparison of in-tracorporeal knot-tying suture (polyglactin) and titanium endoclips in laparoscopic appendiceal stump closure: a prospective randomized study. Surg Laparosc Endosc Percutan Tech 2012;22:226–31.

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

14. Gonenc M, Gemici E, Kalayci MU, Karabulut M, Turhan AN, Alis H. Intracorporeal knotting versus metal endoclip application for the closure of the appendiceal stump during laparoscopic appendectomy in uncom-plicated appendicitis. J Laparoendosc Adv Surg Tech A 2012;22:231–5.

15. Gomes CA, Nunes TA, Soares C Jr, Gomes CC. The appendiceal stump closure during laparoscopy: historical, surgical, and future perspectives. Surg Laparosc Endosc Percutan Tech 2012;22:1–4.



OLGU SUNUMU

Laparoskopik appendektomide intrakorporal düğüm ve endoloop ilegüdük kapama yöntemlerinin karşılaştırılmasıDr. İlhan Bali,1 Dr. Faruk Karateke,2 Dr. Sefa Özyazıcı,2 Dr. Adnan Kuvvetli,2 Dr. Cem Oruç,3

Dr. Ebru Menekşe,2 Dr. Seyfi Emir,1 Dr. Mehmet Özdoğan4

1NamıkKemalÜniversitesiTıpFakültesi,GenelCerrahiAnabilimDalı,Tekirdağ2AdanaNumuneEğitimveAraştırmaHastanesi,GenelCerrahiKliniği,Adana3MustafaKemalÜniversitesiTıpFakültesi,GenelCerrahiAnabilimDalı,Hatay4MedlineHastanesi,GenelCerrahiKliniği,Adana

AMAÇ: Laparoskopik apendektomi sırasında apendiks güdüğünü kapatmak için intrakorporal düğüm, endoloop, stapler ve klips gibi çeşitli yön-temler kullanılmaktadır. Bu çalışmada laparoskopik apendektomide apendiks güdüğünü kapatmak için kullanılan intrakorporal düğüm ve endoloop yöntemlerinin karşılaştırılması amaçlandı.GEREÇ VE YÖNTEM: Bu çalışmaya Adana Numune Eğitim ve Araştırma Hastanesi Genel Cerrahi Kliniği’nde Haziran 2009 ile Temmuz 2013 tarih-leri arasında akut apandisit ön tanısı ile laparoskopik apendektomi yapılan hastalar dahil edildi. Hastaların demografik özellikleri, apendiks güdüğünü kapatma tekniği, ameliyat süresi, komplikasyon ve yatış süreleri olarak karşılaştırıldı.BULGULAR: Seksen biri kadın, 45’i erkek olmak üzere toplam 126 hastaya laparoskopik apendektomi yapıldı. Altmış beş hastada apendiks güdüğü-nü kapamak amacıyla intrakorporal düğüm (Grup 1), 61 hastada ise endoloop (Grup 2) kullanıldı. Grup 1’deki hastaların ameliyat süresi Grup 2’ye göre daha uzun idi (62.0±10.67 dk, 56.80±11.94 dk, p=0.01). Gruplar arası hastanede kalış süreleri arasında fark saptanmadı. Her iki grupta dörder hastada yüzeyel cerrahi alan enfeksiyonu görüldü.TARTIŞMA: Bu çalışmada intrakorporal düğüm tekniğinde ameliyat süresinin endoloop tekniğine göre daha uzun olduğu, ancak hastanede yatış süresi ve komplikasyon açısından birbirinden anlamlı bir fark bulunmadığı tespit edilmiştir. İntrakorporal düğüm tekniğinin endolooptan daha ucuz olduğu ve ileri laparoskopik cerrahiye başlayacak olan cerrahlar için el manüpülasyonunu geliştirdiğinden dolayı tercih edilmesini önermekteyiz.Anahtar sözcükler: Akut apandisit; apendiks güdüğü; endoloop; intrakorporal düğüm; laparoskopik apendektomi.




Surgical management of traumatic cerebrospinalfluid fistulas with associated lesionsFatih Alagöz, M.D.,1 Ergün Dağlıoğlu, M.D.,1 Murat Korkmaz, M.D.,2 Ali Erdem Yıldırım, M.D.,1

Özhan Merzuk Uçkun, M.D.,3 Denizhan Divanlıoğlu, M.D.,1 Ömer Polat, M.D.,4 Ali Dalgıç, M.D.,1

Arif Ösün, M.D.,2 Fevzi Yılmaz, M.D.,5 Müge Sönmez, M.D.,5 Ahmet Deniz Belen, M.D.1

1DepartmentofNeurosurgery,AnkaraNumuneTrainingandResearchHospital,Ankara2DepartmentofNeurosurgery,KutahyaEvliyaCelebiTrainingandResearchHospital,Kutahya3DepartmentofNeurosurgery,YunusEmreStateHospital,Eskisehir4DepartmentofNeurosurgery,FatmaHatunPrivateHostpital,Bolu5DepartmentofEmergency,AnkaraNumuneTrainingandResearchHospital,Ankara

ABSTRACT

BACKGROUND: Head trauma is associated with a significant risk of cerebrospinal fluid (CSF) fistula.

METHODS: In this study, it was aimed to report twenty-two cases subjected to operative intervention for otorrhea, rhinorrhea and oculorrhea with associated traumatic lesions. Majority of the cases had moderate to severe head trauma with a Glascow Coma Scale (GCS) score under 14. The study group included eleven cases with depression fractures, 6 with epidural hematomas and 4 with tension pneumocephalus.

RESULTS: Rhinorrhea was the most common presenting symptom encountered in fifteen cases; whereas, otorrhea was prominent in 7 and oculorrhea in 2 cases. Two patients having rhinorrhea also had oculorrhea and otorrhea. The patients were operated with unilateral approaches in twelve and bifrontal approaches in ten of the cases.

CONCLUSION: Early surgical intervention should be performed in cases presenting with CSF fistula and associated traumatic le-sions without considering conservative management to provide an effective control of associated complications due to CSF fistulas.

Key words: CSF fistula; oculorrhea; otorrhea; rhinorrhea; surgery; trauma.

tion and verification of the exact site of leakage since in-fectious complications are the major causes of morbidity at acute and subacute stages.[1,3–5] Although CSF leaks, par-ticularly mild ones, do resolve spontaneously, some tend to persist and necessitate other treatment modalities including daily lumbar punctures or external lumbar drainage. Despite conservative measures, a portion of CSF leaks do not cease and surgical treatment should be performed. Some CSF fis-tula patients require urgent surgical repair due to associ-ated pathologies.[6–8] This group is unique in that the cases are usually subjected to moderate or severe head trauma requiring surgery due to associated lesion together with rhinorrhea, oculorrhea or otorrhea which tends to persist. Although there are conservative measures advocated for definitive treatment, appropriate timing of surgery is also crucial to prevent complications particularly in fractures in-volving sinuses.

In the present study, we reported our indications for urgent surgical repair of traumatic CSF fistulas via the anterior and middle cranial fossa with a specific interest on associated


Address for correspondence: Ergün Dağlıoğlu, M.D.

Ankara Numune Eğitim ve Araştırma Hastanesi, Beyin ve Sinir

Cerrahisi Kliniği (B-Blok 3. Kat), Altındağ, 01600 Ankara, Turkey



Copyright 2015TJTES

INTRODUCTION

Trauma is the most commonly encountered reason for ce-rebrospinal fluid (CSF) fistula. Two percent of head traumas and %20 of skull base fractures carry the risk of traumatic CSF fistula.[1,2] About one fifth of CSF fistulas are seen as otorrhea due to middle cranial fossa fractures and the re-maining 80% is seen as rhinorrhea secondary to anterior cranial fossa fractures.[3,4] Treatment starts at early recogni-


Alagöz et al. Surgical management of traumatic cerebrospinal fluid fistulas with associated lesions

traumatic lesions like depression fractures, epidural hemato-mas or tension pneumocephalus.


Patient SelectionThe study included twenty-two patients admitted to Ankara Numune Education and Research Hospital in a period of five years. The patients presented with acute head trauma and as-sociated CSF fistulas (rhinorrhea, oculorrhea and otorrhea). The study group was selected among sixty-five patients pre-sented with traumatic CSF fistulas. All of the patients were managed conservatively (closed lumbar drainage or observa-tion alone) before CSF fistula repair except associated le-sions, which should be operated urgently, such as depression fractures, epidural hematoma, etc.[9] Sixteen patients were male and 6 were female. Seven patients were in the pediatric (<16 years) and 15 cases were in the adult group with a mean age of 27 years at presentation. The patients were further classified into three groups as mild (5 cases with GCS score between 14 and 15), moderate (13 cases with GCS score between 8 and 13) and severe head trauma (4 cases with GCS score 7 or less). Patient characteristics on presentation and details of clinical management were summarized in Table 1.

Site of the CSF fistula might not be determined accurately without CT cisternography and we relied on axial and coronal milimetric high-resolution CT scans since some of the cases were operated in an urgent manner. However, metrizamide CT cisternography was performed on a few cases operated in a delayed fashion. Surgical success was assessed clinically, and provocative tests like CT cisternography was not performed unless overt CSF fistula was detected clinically. The therapy was found to be successful at the early period if there was no recurrent CSF fistula for successive 7 days. Glasgow Out-come Scale (GOS) was also used as an adjunct measure to assess clinical success.

Surgical TechniqueWide exposure through intracranial approaches provides enough space for the removal of associated traumatic pa-thologies and adequate closure of the defect. If frontal and ethmoidal sinuses are involved, craniotomy should extend to frontal sinuses and cranialization with proper positioning at the operation and CSF drainage may aid in the minimiza-tion of frontal lobe retraction. Among the twenty-two cases studied in the present report, unilateral approach was per-formed in 12 and bilateral approach in the remaining 10 cases. A unilateral frontal or temporal craniotomy was preferred in patients with unilateral injury with otorrhea or rhinorrhea; whereas, a conventional bifrontal craniotomy was the most common procedure in bilateral approaches. Dural repair was performed in all cases either with fascia lata or galeal graft. Surgical techniques regarding the interventions were summa-rized in Table 1.

Closure with viable or nonviable grafts can be performed. However, we suggest that nonviable fascia lata or galeal grafts are practical to use when compared to pericranium flaps es-pecially in wide defects. Depending on our previous experi-ence about non viable grafts, we usually notice that most of them revascularize a few months after surgery. We prefer to preserve pericranium for the viability of bone flap. Thus, we preferred surgical repair of the fistulous point with viable graft in all cases of the present study. Fibrin glue was used as an adjunctive measure almost for every case to increase the success of surgical repair. Antibiotics were given intravenously at full regimen when CSF fistula was detected and continued for 7 days (oral or intravenous) after surgical intervention.

RESULTS

On admission, seven patients had otorrhea, 15 patients had rhinorrhea and 2 patients had oculorrhea (some patients had multiple findings, a patient with oculorrhea also had rhinorrhea and a patient with otorrhea also had rhinorrhea). Seventeen patients were operated after conservative treatment while the remaining 5 cases were urgently operated for associated intra-cranial lesions and complications. Besides otorrhea, rhinorrhea or oculorrhea, associated pathologies were classified as linear fractures (8 cases), depression fracture (11 cases), Le Fort frac-tures (3 cases), epidural hematoma (6 cases), cerebral contu-sion (9 cases), intracerebral and subarachnoid hemorrhage (4 cases) and wound CSF fistula (1 case) (some patients had mul-tiple findings). One patient was operated in an emergent basis due to the presence of wound CSF fistula. Unilateral approach was performed in twelve patients and the remaining 10 cases were operated by bifrontal approaches with ligation of the su-perior sagittal sinus. All of the patients were subjected to dural repair with either fascia lata or galeal graft, however, no syn-thetic material was used for duraplasty. In urgently operated patients with associated lesions such as epidural hematoma, in-tracerebral hematoma and pneumocephalus, CSF fistula repair was done at the same operation. Depression fractures were surgically reconstructed. Among the patients with depression fractures, seven patients were also subjected to orbital recon-struction for severe orbital roof fractures. Distribution of le-sion localizations was demonstrated in Table 1.

At the postoperative period, meningitis (5 cases), urinary tract infection (1 case), pulmonary infection (1 case), deep venous thrombosis (1 case), and transient diabetes insipidus (3 cases) were seen as complications. There was no mortality rate. Complications were managed successfully by conserva-tive measures. All of the patients were followed up for a mean of 32 months and their last neurological examination revealed that the GOS (Glasgow Outcome Scale) score was 4 in six cases and 5 in sixteen cases.

Illustrative CasesCase 2: A 15-year-old female patient with head trauma ad-



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mitted with a GCS score of 10 and otorrhea was seen at the initial examination (Table 1). Axial CT (Computerized to-mography) scan showed a left-sided fronto-temporal epidural hematoma, fracture lines at the orbita, temporal and occipital bones (Figs. 1a and b). She was operated for the evacuation of hematoma and surgical repair of otorrhea. At the operation, the defect at the tegmental portion of the temporal bone was repaired with fascia lata graft and fibrin glue. At the postop-erative period, her neurological status improved significantly and she was discharged on the seventh postoperative day. There was no otorrhea on follow-up examinations and post-operative changes were noted on CT scan (Fig. 1c).

Case 4: A 40-year-old male presented with rhinorrhea, sud-den loss of consciousness, tension pneumocephalus and an-

terior cranial fossa fracture involving fronto-ethmoid bone (Table 1). Priorly, he had been operated at another center for an unknown traumatic lesion. Axial CT image showed severe tension pneumocephalus extending from anterior cranial fos-sa to lateral ventricles and compressing cerebral cisterns (Fig. 2a). Right sided frontal craniotomy was performed and fron-tal sinus fracture was repaired with galeal graft and fibrin glue. Clinical condition improved dramatically at the early postop-erative period. CSF leakage also ceased, and there was no rhi-norrhea on follow-up. Postoperative axial CT image showed successful decompression of pneumocephalus (Fig. 2b).

Case 11: A 17-year-old male presented with clouding of consciousness, rhinorrhea, hemiparesis and tension pneu-mocephalus (Table 1). He had a history of head trauma 25


(a) (b) (c)

Figure 1. 15-year-oldfemalepresentswithotorrheaandepiduralhematomawithaGCSscoreof10onadmission.(a)AxialbonewindowCTimageshowsthefracturelineatthetegmental(arrow)andmastoidportionofthetemporalboneaswellasorbita.(b) Axial CT scan showsagrowingepiduralhematomaonthesameside.(c)PostoperativeaxialCTimagerevealsdecompressionofthehematomaandbettervisualizationsofmesencephaliccisterns.

Figure 2. 40-year-oldmalepresentswithrhinorrheaandsuddenlossofconsciousness.Patienthis-toryrevealedthathehadbeenoperatedatanothercenterforatraumaticlesionseveralyearsago.(a)AxialCTimageshowsseveretensionpneumocephalusextendingfromanteriorcranialfossatocerebralcisternsandlateralventricles.(b)PostoperativeaxialCTimagedemonstratesalmostcom-pleteresorptionofpneumocephalus.

(a) (b)

days ago. Axial CT image showed left frontal tension pneu-mocephalus (Figs. 3a and b). Metrizamide CT scan could not be performed due to patient’s general condition and urgency of the operation. He was operated with a bifrontal approach for the evacuation of pneumocephalus and repairing the du-ral defect over the anterior cranial fossa. At the operation, the dural defect extending from frontal to the posterior por-tion of the ethmoid bone was repaired. On the postopera-tive course, polyuria and severe hypernatremia were seen and desmopressin was used for diabetes insipidus treatment. Se-rum ADH (Antidiuretic hormone) level was normal; however, GH (Growth hormone) and cortisol levels were moderately low. CT scan showed successful resorption of pneumocepha-lus (Fig. 3c). Magnetic Resonance Imaging (MRI) of the sellar region didn’t show any abnormalities except hypointense sig-nals on T1-weighted MR images (Fig. 3d). Findings of diabetes insipidus resolved completely 5 months after trauma.

DISCUSSIONCSF fistula presenting with associated traumatic lesions is a challenging situation for neurosurgeons particularly due to the timing of the surgical repair. Management may be quite difficult because of a dilemma due to patient’s general condi-tion and the risk of the planned surgical approach. Tension pneumocehalus, persistent otorrhea and rhinorrhea are main indications for surgical treatment. In this study, we reported our experience regarding anterior and middle cranial fossa

fractures particularly presenting with otorrhea, rhinorrhea and oculorrhea. CSF leakage is a serious condition which could be complicated with severe meningitis and pneumo-cephalus. It occurs when the barriers retaining CSF around the brain are breached. There are various methods advocated for the treatment of CSF fistulas. But, there is still a debate about the timing of surgical intervention. Associated lesions necessitating immediate surgical intervention is the most im-portant factor to decide for timing of surgery.[10,11]

Conservative management strategies include elevation of head about 30–45 degrees, fluid restriction and diuretic treatment, daily lumbar punctures and intermittent or con-tinuous lumbar drainage. If the patient is not to be operated in an emergent manner due to lack of an associated lesion, conservative treatment methods are performed under com-bined antibiotic prophylaxis. CSF leakage has been reported to stop 4.1 days (mean value) after trauma and 5.3 days af-ter lumbar drainage, and ratio of spontaneous cessation has been reported to be 61%.[5,8] Surgical treatment should be considered in cases with leak that persists for more than one week.[12,13] However, there are some exceptions to this prin-cipal management strategy such as high risk elderly patients, patients with diabetes mellitus and immunosuppressed con-dition, associated intracranial pathologies or profuse leaks. CSF leakage should be managed in these patients without any delay.[8,12,14] Similarly, patients with severe head trauma or


Figure 3. 17-year-old male presents withapathy, hemiparesis, rhinorrheaand tensionpneumocephalus.He had a history of headtraumaonemonthago.Atthepostoperativeperiod, the patient experienced findings ofdiabetesinsipidus.(a)AxialCTimageshowsleftfrontaltensionpneumocephalus.(b)Cor-onal CT scan reveals the bony defect overtheethmoidbone (arrow). (c)Postoperativeaxial CT image reveals disappearance ofpneumocephaluswithminimalhemorrhageattheoperationlodge.(d)SagittalT1-weightedMR imageat the early postoperative perioddemonstrates hypointense changes on hy-pothalamopituitaryaxisandhardlyvisualizedpituitarystalk.

(a)

(c)

(b)

(d)


low GCS should be managed with radical surgical measures since the risk of infectious complications or neurological de-terioration is quite high.[5,8] Surgical intervention should also be considered for cases with subdural or epidural hemato-mas, tension pneumocephalus, depression fractures includ-ing comminuted skull base fractures or patients with severe contusion and edema. These lesions require decompressive measures, all of which limit the use of lumbar drainage or temporary lumbar punctures for CSF fistulae.

Wide exposure provides enough space for the removal of associated traumatic pathologies and adequate closure of the defect. If frontal and ethmoidal sinuses are involved, crani-otomy should be extended to frontal sinuses and cranializa-tion with proper positioning at the operation, and CSF drain-age could aid in the minimization of frontal lobe retraction. Closure with viable or nonviable grafts was reported in the previous studies and there was no difference in success.[15]

However, it is our suggestion that fascia lata graft is proper to use especially in wide defects to preserve pericranium for the viability of the operative area and bone flap. Any artificial material for surgical repair was not preferred because of our prior surgical experience.

Anterior cranial fossa fractures involving cribriform plate and ethmoid or frontal sinus frequently give rise to rhinorrea and forms the second leading cause of tension pneumocephalus and surgical treatment may be required.[16,17] Dural tear and entrapped air could be sequelae of fractures involving ante-rior cranial fossa via siphon effect or a Valsalva maneuver. Entrapped air is usually seen as intracerebral, subdural and intraventricular in decreasing order of frequency and could be associated with rhinorrhea or sometimes oculorrhea. Fur-thermore, traumatic oculorrhea is very rare, and conserva-tive management of oculorrhea is controversial.[18] Although there are asymptomatic and conservatively managed cases, surgical intervention is usually necessary to close the associ-ated dural defect particularly behind the orbit and decom-pression of tension pneumocephalus.[17,19–21] In evidence of acute clinical deterioration and signs of increased intracra-nial pressure (ICP), or pressure on adjacent cerebral tissue or ventricular wall, or presence of the Mount Fuji sign, ur-gent surgical intervention is indicated.[22] Many cases present within a few weeks, several months or even years after head trauma. However, cases presenting with sudden neurological deterioration and low GCS should be immediately operated before performing a contrast enhanced CT study for the ex-act localization of fistula. In the present report, four cases were operated for delayed pneumocephalus, rhinorrhea-otorrhea and clinical deterioration.

Anterior or middle fossa fractures are associated with a sig-nificant morbidity rate due to related complications. Trauma to the anterior and middle cranial fossa could give rise to CSF leak, and there is an increased risk for infectious com-plications after one week.[1,5,9,23] However, in another report,

antibiotic prophylaxis is usually ineffective for minimizing therisk of meningitis.[24] In the present study, infection ratio was detected to be 23%, which does not seem to justify our main idea of urgent surgical intervention for the prevention of early posttraumatic morbidity. The ratio seemed to be high although nearly all cases were lacking the awaiting period for conservative management. Nevertheless, the study group in-cluded eight patients with severe and six patients with mod-erate head trauma, which does not appear to be high.

Apart from infectious complications like meningitis, trauma itself could also cause hypopituitarism. Hypopituitarism is a well known complication of moderate to severe cerebral trauma.[25,26] However, the condition is not associated with radiological abnormalities on regular CT or MR studies. Hy-pointense signals on T1-weighted MR images of Case 11 were accepted as non-specific findings. GH and gonadal sex ste-roid secretion levels are very sensitive to cerebral trauma; however, deficiency of steroid and thyroid hormones would certainly have an impact on the clinical condition.[25] Defi-ciency of posterior pituitary hormones could result in dia-betes insipidus giving rise to metabolic problems after head trauma.[27,28] Although the condition is transient in most of the cases, disorders of water imbalance could increase the severity of traumatic cerebral edema or neurological condi-tion, and hence, result in increased morbidity and mortality. Awareness of the levels of pituitary hormones could assist in good clinical outcomes.

Postoperative use of lumbar drainage catheters or lumbar punctures should be reserved for cases having persistent postoperative CSF fistulas. Although lumbar drainage cath-eters provide minimal invasive treatment of CSF fistulae in uncomplicated cases, it may cause severe complications such as subdural hematoma, herniation, meningitis and other infec-tious problems.

ConclusionThe present report emphasizes the importance of early surgi-cal intervention for head trauma with CSF fistula particularly presenting with associated lesions like depression fractures, subdural hematomas, wound CSF fistulas and pneumocepha-lus. Repair for CSF fistulae should not be delayed, and com-bined approaches both for associated lesion and fistula should not be avoided even though it bears high risk of morbidity and mortality.


REFERENCES

1. Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol 1997;18:188–97.

2. Mendizabal GR, Moreno BC, Flores CC. Cerebrospinal fluid fis-tula: frequency in head injuries. Rev Laryngol Otol Rhinol (Bord) 1992;113:423–5.



3. Stenzel M, Preuss S, Orloff L, Jecker P, Mann W. Cerebrospinal fluid leaks of temporal bone origin: etiology and management. ORL J Otorhi-nolaryngol Relat Spec 2005;67:51–5.

4. McCormack B, Cooper PR, Persky M, Rothstein S. Extracranial repair of cerebrospinal fluid fistulas: technique and results in 37 patients. Neu-rosurgery 1990;27:412–7.

5. Friedman JA, Ebersold MJ, Quast LM. Post-traumatic cerebrospinal fluid leakage. World J Surg 2001;25:1062–6.

6. Savva A, Taylor MJ, Beatty CW. Management of cerebrospinal fluid leaks involving the temporal bone: report on 92 patients. Laryngoscope 2003;113:50–6.

7. Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transna-sal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope 2000;110:1166–72.

8. Yilmazlar S, Arslan E, Kocaeli H, Dogan S, Aksoy K, Korfali E, et al. Cerebrospinal fluid leakage complicating skull base fractures: analysis of 81 cases. Neurosurg Rev 2006;29:64–71.

9. Dalgic A, Okay HO, Gezici AR, Daglioglu E, Akdag R, Ergungor MF. An effective and less invasive treatment of post-traumatic cerebrospinal fluid fistula: closed lumbar drainage system. Minim Invasive Neurosurg 2008;51:154–7.

10. Choi D, Spann R. Traumatic cerebrospinal fluid leakage: risk factors and the use of prophylactic antibiotics. Br J Neurosurg 1996;10:571–5.

11. McGuirt WF Jr, Stool SE. Cerebrospinal fluid fistula: the identification and management in pediatric temporal bone fractures. Laryngoscope 1995;105:359–64.

12. Bell RB, Dierks EJ, Homer L, Potter BE. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma. J Oral Maxillofac Surg 2004;62:676–84.

13. Abuabara A. Cerebrospinal fluid rhinorrhoea: diagnosis and manage-ment. Med Oral Patol Oral Cir Bucal 2007;12:397–400.

14. Piek J. Surgical treatment of complex traumatic frontobasal lesions: per-sonal experience in 74 patients. Neurosurg Focus 2000;9:2.

15. Bhatoe HS. Missile injuries of the anterior skull base. Skull Base 2004;14:1–8.

16. Keskil S, Baykaner K, Ceviker N, Işik S, Cengel M, Orbay T. Clinical

significance of acute traumatic intracranial pneumocephalus. Neurosurg Rev 1998;21:10–3.

17. Hotta T, Kodama Y, Yuki K, Taniguchi E, Kuroki K, Hashizume A, et al. Two cases of traumatic intracerebral pneumocephalus. [Article in Japa-nese] No Shinkei Geka 1994;22:259–63. [Abstract]

18. Salame K, Segev Y, Fliss DM, Ouaknine GE. Diagnosis and management of posttraumatic oculorrhea. Neurosurg Focus 2000;9:3.

19. Oge K, Akpinar G, Bertan V. Traumatic subdural pneumocephalus caus-ing rise in intracranial pressure in the early phase of head trauma: report of two cases. Acta Neurochir (Wien) 1998;140:655–8.

20. Skuna S, Chaiyabud P, Pakdirat B. Subdural tension pneumocephalus fol-lowing head injury: report of five cases. J Med Assoc Thai 1993;76:345–52.

21. Kilincoğlu BF, Mukaddem AM, Lakadamyali H, Altinörs N. Posttrau-matic tension pneumocephalus causing herniation. [Article in Turkish] Ulus Travma Acil Cerrahi Derg 2003;9:79–81.

22. Michel SJ. The Mount Fuji sign. Radiology 2004;232:449–50.

23. Gliklich RE, Lazor JB. The subcranial approach to trauma of the anterior cranial base: preliminary report. J Craniomaxillofac Trauma 1995;1:56–62.

24. Eftekhar B, Ghodsi M, Nejat F, Ketabchi E, Esmaeeli B. Prophylac-tic administration of ceftriaxone for the prevention of meningitis af-ter traumatic pneumocephalus: results of a clinical trial. J Neurosurg 2004;101:757–61.

25. Powner DJ, Boccalandro C, Alp MS, Vollmer DG. Endocrine failure af-ter traumatic brain injury in adults. Neurocrit Care 2006;5:61–70.

26. Schneider HJ, Kreitschmann-Andermahr I, Ghigo E, Stalla GK, Agha A. Hypothalamopituitary dysfunction following traumatic brain injury and aneurysmal subarachnoid hemorrhage: a systematic review. JAMA 2007;298:1429–38.

27. Agha A, Thornton E, O’Kelly P, Tormey W, Phillips J, Thompson CJ. Posterior pituitary dysfunction after traumatic brain injury. J Clin Endo-crinol Metab 2004;89:5987–92.

28. Tsagarakis S, Tzanela M, Dimopoulou I. Diabetes insipidus, secondary hypoadrenalism and hypothyroidism after traumatic brain injury: clinical implications. Pituitary 2005;8:251–4.


OLGU SUNUMU

İlişkili lezyonlarla birlikte olan travmatik beyin omurilik sıvısı kaçaklarının cerrahi tedavisiDr. Fatih Alagöz,1 Dr. Ergün Dağlıoğlu,1 Dr. Murat Korkmaz,2 Dr. Ali Erdem Yıldırım,1 Dr. Özhan Merzuk Uçkun,3

Dr. Denizhan Divanlıoğlu,1 Dr. Ömer Polat,4 Dr. Ali Dalgıç,1 Dr. Arif Ösün,2 Dr. Fevzi Yılmaz,5

Dr. Müge Sönmez,5 Dr. Ahmet Deniz Belen1

1AnkaraNumuneEğitimveAraştırmaHastanesi,BeyinCerrahisiKliniği,Ankara2KütahyaEvliyaÇelebiEğitimveAraştırmaHastanesi,BeyinCerrahisiKliniği,Kütahya3YunusEmreDevletHastanesi,BeyinCerrahisiKliniği,Eskişehir4ÖzelFatmaHatunHastanesi,BeyinCerrahisiKliniği,Bolu5AnkaraNumuneEğitimveAraştırmaHastanesi,AcilKliniği,Ankara

AMAÇ: Kafa travması beyin omurilik sıvısı (BOS) fistülü ile önemli bir ilişki gösterir.GEREÇ VE YÖNTEM: Bu çalışmada travmaya bağlı gelişen otore, rinore ve oküloresi bulunan 22 hastanının cerrahi yaklaşımı sunuldu. Hastaların büyük çoğunluğu Glaskow Koma Skalası (GKS) 14 puanın altında olan şiddetli kafa travmalı hastalardır. Bu hastaların 11’inde depresyon fraktürü, altısında epidural hematom ve dördünde ise basınçlı pnemosefalus eşlik etmekteydi.BULGULAR: Rinore, en sık görülen semptom olup 15 hastada, otore yedi hastada ve okülore iki hastada saptandı. Rinoresi olan iki hastada ayrıca otore ve okülore de mevcuttu. On iki hasta tek taraflı yaklaşımla, 10 hasta ise bifrontal yaklaşımla opere edildi.TARTIŞMA: Beyin omurilik sıvısı kaçağı ile prezente olan travma olgularında, konservatif tedavinin aksine yapılan erken cerrahi girişimler BOS kaça-ğına bağlı gelişebilecek komplikasyonların engellenmesinde son derece etkili bir yöntemdir.Anahtar sözcükler: BOS kaçağı; cerrahi; okülore; otore; rinore; travma.




Staged repair of severe open abdomens due to high-energy gunshot injuries with early vacuum pack and delayed tissue expansion and dual-sided meshes

series of intra-abdominal interventions. At the end of this long treatment period, persistent intestinal edema and retraction of the abdominal wall are the main factors why fascias cannot be connected at an early time. Moreover, in severe abdomi-nal traumas like the ones caused by high-energy gunshots, trauma may not only affect the intra-abdominal components but may also cause loss of domain of the abdominal wall.

A staged reconstruction protocol is required for this type of patients. Firstly, a temporary closing of the viscera is pro-vided, and subsequently, permanent repair of the abdominal wall should be done. Many procedures have been advocated to close the viscera at the first stage.[1–6] The fundamental principle in all of these procedures is forming the granula-tion tissue on the open abdominal wall and closing it with partial-thickness skin graft (PTSG). With these procedures, a



Doğan Alhan, M.D.,1 İsmail Şahin, M.D.,2 Serbülent Güzey, M.D.,3 Andaç Aykan, M.D.,2 Fatih Zor, M.D.,2 Serdar Öztürk, M.D.,2 Mustafa Nışancı, M.D.,4 İsmail Hakkı Özerhan, M.D.5

1DepartmentofPlastic,ReconstructiveandAestheticSurgery,EskisehirMilitaryHospital,Eskisehir2DepartmentofPlastic,ReconstructiveandAestheticSurgery,GulhaneMilitaryMedicalAcademy,Ankara3DepartmentofPlastic,ReconstructiveandAestheticSurgery,KasimpasaMilitaryHospital,Istanbul4AestheticSurgeryCentre,Ankara5 DepartmentofGeneralSurgery,GulhaneMilitaryMedicalAcademy,Ankara

ABSTRACT

BACKGROUND: Open abdomen is a salvage procedure that prevents catastrophes after severe intraabdominal traumas. However, following this life saving attempt, it is mostly not feasible to close the abdomen immediately after the recovery of intraabdominal inju-ries. Consequently, a staged reconstruction is required, and the first stage is usually a temporary closing approach. At the end of this stage, resulting giant “ventral hernia” is a burden for both the patient and the surgeon. Therefore a permanent repair is subsequently needed. Although there are many treatment modalities described for this goal, etiologies like high-energy gunshots may cause an ex-actly nuisance scene which can limit treatment options and reduce final success. Herein, it was the objective of this study to present our staged protocol to restore the abdominal wall defect and strategy for optimizing the results in such conundrum cases.

METHODS: Treatment was performed on nine male patients suffering from severe open abdomen due to high-energy gunshot injury. In all patients, temporary closure was provided by negative pressure wound treatment applied directly to the viscera and followed by skin grafting. Late permanent closure was performed with the lamination of expanded abdominal skin and dual-sided meshes.

RESULTS: The follow-up period ranged between 24 months to 4.5 years (mean, 3 years). During this period, no recurrence of ventral hernia, enteric fistula formation, abdominal infection and seroma formation was observed in any patient.

CONCLUSION: In this study, NPWT, tissue expansion and dual-sided mesh were used together as a staged procedure for optimiz-ing the results in the clinical scenario of an open abdomen due to high-energy gunshot wound. Results were highly satisfactory for patients and acceptable aesthetically.

Key words: Dual meshes; gunshot injury; open abdomen; tissue expansion; vacuum assisted closure.

Address for correspondence: Serbülent Güzey, M.D.

Kasımpaşa Asker Hastanesi, Plastik Rekonstrüktif ve

Estetik Cerrahi Kliniği, İstanbul, Turkey



Copyright 2015TJTES

INTRODUCTION

Immediate closure of the abdominal wall after severe abdomi-nal traumas is not always preferable because of the need for a

Alhan et al. Stage repair of severe open abdomens due to high-energy gunshot injuries

defect called “planned ventral hernia” is formed in the front abdominal wall.

This abdominal hernia brings with itself numerous problems for the patient and the surgeon, and it is a necessity to repair the abdominal wall permanently in the future. Many methods including myofascial rotation flaps, distant flaps and tissue ex-pansion have been advocated to repair this ventral hernia.[7–14] However, it cannot be expected to successfully close all kinds of defects byusing only one technique. The state of the components of the abdominal wall and the overall medical status of the patient are vitally important as well as the size of the defect for selecting the reconstructive technique. These situations obstruct the usage of local and distant flaps in high-energy gunshot injuries, which can lead to loss of domain and damage vascular pedicles of local reconstructive options. In this paper, a staged repair protocol of severe open abdomens in such scenario was presented. Temporary closing of the de-fect was provided with negative pressure wound treatment (NPWT), and late definitive surgery was performed with ex-panded abdominal skin due to dual-sided meshes.


This study included nine male patients suffering from high-energy gunshot injures with open abdomen. Approved pa-tient informed consent was taken from all patients. Mean age of the patients was 25 years (range, 21–30). After completing intra-abdominal interventions, a temporary closing was pro-vided at the beginning, and subsequently, a two-staged defini-tive reconstruction of the abdomen wall was performed.

Surgical Protocol and Technique

Temporary Closing In order to obtain temporary closing on open visceral struc-tures, negative-pressure wound treatment (NPWT) was di-rectly performed on the visceral structures and no patch was used. After obtaining the granulation tissue, viscera were cov-ered with a PTSG taken from the anterior thigh in accordance with the size of the defect.

Definitive ReconstructionFirst stage (placement of tissue expander and tissue expansion): This stage was performed after the edema of the bowel was resolved. First, the areas tissue expanders would be placed were planned as the lateral of the skin graft preferably in the unscarred areas as much as possible. Follow-ing the small zigzag incision to the lateral of the skin graft, a pocket was prepared on the fascial plane using a lighted retractor. Proper tunnels were formed on the thoracic wall for a port. At the lateral abdominal area which is rich in per-forator vessels, an attentive bleeding control was performed, and a drain was placed. After placing the tissue expander, 10% inflation was applied in intraoperative scene.

On the 7th postoperative day, tissue expanders were started to inflate. The inflation process was carried out by the same physician daily or every other day according to the examina-tion of the expanding tissues.

Second stage (permanent repair of the abdominal wall): This stage was performed after the completion of the inflation process. Following the skin incision made from the lat-eral border of the graft tissue, the graft tissue was dissected out of the viscera. Since the skin grafts were very close to the in-testinal serosa, dissection was performed meticulously in order to avoid micro perforation in the intestines. Later, the tissue expanders were removed, and capsulotomies were made paral-lel to the vertical axes in order to increase tissue advancement.

The composite (dual-sided) meshes (HI-TEX®, textile Hi-Tec, France) were placed on the viscera in the manner of extend-ing over the fascia 10 cm from the lateral sides and 5 cm from the top and bottom and fixed by 3 lines of single sutures (Fig. 1). The sutures in the inner line were performed on the edges of the fascia against the possibility of intestinal herniation. By hastening the abdominal wall from both sides, the fascial edges were drawn nearer and the patch was sutured is such tense form. “Jackson Pratt” drains were placed on both sides of the abdominal wall, and then, the skin edges were brought together. Once making sure that the expanded skin was suf-ficient for full closing of the defect, the graft was completely excised and skin edges were sutured (Fig. 2).


Figure 1. Case1,(a) abdominalwalldefectcoveredwithmaturedskingraftandexpanderswereplacedbothsides.(b) Intra-opera-tiveview;compositemesheswereplacedonthevisceraandfixedbysinglesutures.

(a) (b)

Figure 2. Same patient (case 1), after definitive restoration ofabdominalwall.(a)Earlyappearancepostoperatively.(b, c)Lateviewsatpostoperative13thmonth.

(a) (b) (c)


RESULTS

NPWT was performed on average of five sessions; each session lasting for four days. It was observed in all patients that the skin grafts were entirely viable. An average of seven months (range, 6–11 months) passed for the second phase after the forming of the maturation of the grafts, and during this time, the patients wore an abdominal corset. Mean hori-zontal width of the ventral hernia was 23 cm (range, 17–25 cm) and mean vertical width was 25 cm (range, 22–30 cm). Two patients underwent a unilateral procedure with an 850 cc of rectangular tissue expander, and bilateral 700 cc and 750 cc of rectangular tissue expanders were used on others and an average of 20% over-inflation was performed.

Infection developed in one of the patients with unilateral tis-sue expander, and this device was salvaged by antibiotherapy and rigorous irrigation that was performed twice a day. Dur-ing the first and second phases of the treatment, no abdomi-nal complications such as infection, formation of fistula, and intestinal obstruction were observed. Skin flaps were sutured without any tonicity, and no skin necrosis was observed on the flaps after the third stage. Only a superficial skin dehis-cence in size of 2×1 cm occurred in one patient. Conserva-tive dressing and a stamp skin graft treated it seamlessly.

The follow-up of the patients ranged from 24 months to 4.5 years (mean, 3 years). During this period, no recurrence of ventral hernia, enteric fistula formation, abdominal infection and seroma formation occurred in any patient.

The patients were forced to use an abdominal corset for an average of 18 months (12–24 months) and were recommend-ed to use it a lifetime while engaged in strenuous activities.

CasesCase 1– A 22-year-old male patient suffered high-energy gunshot injury. Intestine and colon resections and end-to-end anastomoses were performed in the acute period. Upon theoccurrence of a necrotizing fasciitis, the abdomen was left open and the patient underwent a series of exploratory laparotomies and debridements. During this period, one third inferior part of the left rectus abdominis muscle with a wide overlying skin block were debrided and a horizontally skin defect was formed. The patient was consulted by our clinic on the 20th day after trauma. After five sessions of negative-pressure wound treatment, the defect was covered by PTSG. Six months later, a ventral hernia covered with ma-tured skin graft in size of 25×25 cm was observed, and the patient underwent the first stage of definitive reconstruc-tion which 850 cc tissue expanders placed on both sides of anterior abdominal wall (Fig. 1). Tissue expansion was com-pleted in forty days, and the abdominal wall was restored. No complication was seen for a period of 30- months fol-low-up (Fig. 2).

Case 2– The patient was a 30 year-old malewho had suffered high-powered gunshot injury. Colon resection and colostomy (Hartmann procedure) were performed and the abdomen was left open. The patient was consulted on the 15th day of injury. After performing eight sessions of negative-pressure wound treatment, the abdomen was closed by PTSG. Co-lostomy was restored nine months later, and 750 cc tissue expanders were placed on both sides four months after co-lostomy restoration. During this period, the defect at the frontal abdominal wall was covered with PTSG in the size of 30×25 cm (Fig. 3). Tissue expansion was completed in three months and abdominal wall restoration was performed. No problem was encountered with the patient at 2 years follow-up (Fig. 4).

DISCUSSIONThough leaving the abdomen open after traumas was put for-ward as a life saving procedure, it brings many other problems such as fluid and electrolyte imbalance, loss of protein, he-mostasis and deterioration in temperature balance, dryness, damaging of the abdominal viscera and evisceration, forma-tion of fistula, hemorrhage and infection. Therefore, after eliminating intra-abdominal damage and improving the overall status of the patient, the abdomen must be closed immedi-


Figure 3. (Patientincase2),Abdominalwalldefectbeforedefini-tivereconstruction;(a)coveredwithmaturedskingraft insizeof25×25cm.(b)750cctissueexpanderswereplacedbothsides.

(a) (b)

Figure 4. (a, b) Samepatient(case2),Lateviewsatpostoperative12thmonth.

(a) (b)

ately. However, it is not mostly possible to close the abdomi-nal wall in anatomical layers. The main reasons are expanding abdominal content, lateral retraction of the abdominal mus-cles and loss of domain of abdominal wall mostly resulting after serious traumas like high-energy gunshot injuries. In ad-dition, a major reconstructive surgery may not be applicable for multiple trauma patients as they have residual systemic diseases. Consequently, a staged reconstruction is required for this type of patients: first a temporary closing is provided, and subsequently, permanent repair should be done.[15,16]

The techniques for temporary closing of the abdomen aim to protect the viscera somehow. In this sense, absorbable or non-absorbable meshes, the Bogota Bag and negative-pressure wound therapy are used. The main objective in all of these procedures is forming the granulation tissue on the open abdominal wall and closing it with partial-thickness skin graft.

NPWT, while acting by increasing the granulation tissue and the blood stream, reducing the edema and the bacterial count, has gained popularity due to these qualities in treating the complex and chronic wounds in the last 15 years. Us-ing this method in open abdomens was inevitable and Barker and his colleagues used the technique called Vacuum Pack or

“Sandwich” in open abdomens in 2000.[17] Negative pressure therapy advances over other methods with the advantages it provides.[18]

In this study, NPWT was directly applied on the viscera for temporary closure and no mesh was used, and then, PTSG was placed on the formed granulation tissue. As mentioned in many previous studies, granulation layer is formed after the usage of the prosthesis mesh, and mesh extrusion and fistula formation are widely encountered complications.[19,20] On the contrary, no fistula and infection formation was found in the temporary closure stage of our patients, which is a positive fact of our using NPWT directly on the viscera and not a mesh.

It is not a preferable method to close a full thickness ab-dominal wall defect permanently with a partial thickness skin. Partial skin grafting is prone to sinus and fistula formation and may not be sufficient to protect the internal organs against traumas. All these reasons make it a necessity to repair the abdominal wall with a permanent way in the future. For the late definitive restoration of the abdominal wall, many flaps that provide contractile muscle and fascial support have been advocated including rectus femoris, latissimus dorsi, tensor fascia latae and vastus lateralis myofascial flaps.[7–11] However, due to the limited rotation arcs and/or small size of the flaps, these defects generally require more than one flap, which lim-its the usage of these flaps. On the other hand, both the scar and functional loss in donor site are other limiting factors. In 1990, Ramirez and his colleagues defined the technique they called as “components separation”, which is based on relax-ation incisions to the lateral of the rectus muscle allowing medial movement of the rectus muscle.[21] Although it was declared that wide defects of 20 cm could be closed with this technique, a high ratio of recurrent hernia, which was also noted, should not be overlooked.[22–24] On the other hand, in traumas that damage the abdominal domain and the epigas-tric vessels, it’s hard to use this reconstructive choice.

The usage of tissue expanders in abdominal wall reconstruc-tion is not novel, butit does not also deserve to be archaic. We believe that it still has its validity, and in this study we used tissue expanders for late definitive reconstruction of se-rious abdominal wall defects caused by high-energy gunshot injuries. Byrd and Hobar pioneered thetissue expansion pro-tocol in abdominal wall reconstruction in 1989. They placed expanders under anterior rectus sheet in two cases.[25] In 2000, they placed an expander between the internal oblique and transversus abdominis muscles in a traumatic abdominal wall defect.[11] We placed expanders in subcutaneous plane as used previously in the reconstruction of abdominal wall defects.[12–14] As distinct from previous studies in our proto-col, an enduring abdominal wall was acquired by lamination of the expanded abdominal skin and subcutaneous tissue and composite mesh together.

The usage of meshes in the treatment of abdominal hernia



Figure 5. 22years-oldmalepatient.A30x15cmdefectwasclosed;(a, b)appearancesbeforedefinitivesurgery, (c, d)appearancesninemonthsafterpermanentclosure.

(a) (c)

(b) (d)

is a very common method. Approximately a decade ago, the usage of non-absorbable (polypropylene) meshes in maintain-ing the entirety of the abdominal wall was the most popular method. Although the ability of holding the visceral content inside the peritoneum is fairly good for this kind of meshes, serious fistula ratio has been reported due to the adhesive and erosive effects of the material on the intestines. How-ever, it has been advocated in several studies that the usage of absorbable meshes reduce the likelihood of this problem. We used dual meshes for our patients in the last stage of our protocol. The side of the mesh that touches the viscera is in a polytetrafluoroethylene structure with unbraided smooth surface, and the outer side is in polypropylene structure. The adhesive and erosive effect on the visceral organs is minimal-ized thanks to its special structure and it aims to have a long-lasting endurance. We believe that the mesh we used had its contribution to our success.

After the process of tissue expansion, a capsula formation was formed. While the capsula is an unwanted structure in many other parts of the body since it forms thickness and reduces the elasticity of the flap, this feature creates a se-rious advantage in our treatment of abdominal defects. An excellently vascularized autogenetic tissue advancing onto the prosthetic mesh used in permanent repair was beneficial in reducing complications that would occur due to the mesh. In addition, no seroma formation was seen in our series. We believe the main reasons of this result were the capsuloto-mies and long-term use of drains. Drains were removed at an average of two weeks after the reconstruction.

The method was simple and the results were satisfactory. Do-nor site morbidities were not seen when other flap techniques were considered. The contracted skin was restored in its na-tive location by expanding, and in this sense, a treatment with color and tissue match was realized. Another and most impor-tant advantage of this technique is that it can be used in any kind of etiologic-reasoned abdominal wall defect. All patients treated in this study were patients injured by high-energy gun-shots. An extremely successful result was achieved even from a patient with rectus abdominis muscle defect and a skin defect in the horizontal plan (Fig. 5). It is nearly impossible to close these kinds of defects with the usage of local myofascial flap. Moreover, it would be a great luck if the entirety of the vas-cular structures that were exposed to the “blast effect” were preserved. The disadvantages of the procedure are that the process is slow and that it requires a long-term hospitalization period. It was in our favor that our patients were young.

In conclusion, we aimed to present a modern and safe alter-native treatment approach for staged repair of severe open abdomens. In previous studies, each of these treatment mo-dalities was used individually for different clinical scenarios. In this study, NPWT, tissue expansion and dual-sided mesh were used together as a staged procedure for optimizing the

results in the clinical scenario of an open abdomen due to high-energy gunshot wound. We also optimized the usage of each technique according to review of the literature. AcknowledgementThe Authors have no conflict of interest any financial and per-sonal relationships with other people or organizations that could inappropriately influence (bias) their work. Examples of potential conflicts of interest include employment, consul-tancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding.


REFERENCES

1. Howdieshell TR, Yeh KA, Hawkins ML, Cué JI. Temporary abdominal wall closure in trauma patients: indications, technique, and results. World J Surg 1995;19:154–8.

2. Stonerock CE, Bynoe RP, Yost MJ, Nottingham JM. Use of a vacuum-assisted device to facilitate abdominal closure. Am Surg 2003;69:1030–5.

3. Wechselberger G, Schoeller T, Rainer C, Papp C. Temporary closure of full-thickness abdominal-wall defects with mesh grafts. Langenbecks Arch Surg 1999;384:88–9.

4. Greene MA, Mullins RJ, Malangoni MA, Feliciano PD, Richardson JD, Polk HC Jr. Laparotomy wound closure with absorbable polyglycolic acid mesh. Surg Gynecol Obstet 1993;176:213–8.

5. Voyles CR, Richardson JD, Bland KI, Tobin GR, Flint LM, Polk HC Jr. Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications. Ann Surg 1981;194:219–23.

6. Gervin AS, Fischer RP. The reconstruction of defects of the abdominal wall with split thickness skin grafts. Surg Gynecol Obstet 1982;155:412–4.

7. Houston GC, Drew GS, Vazquez B, Given KS. The extended latissimus dorsi flap in repair of anterior abdominal wall defects. Plast Reconstr Surg 1988;81:917–24.

8. Ramasastry SS, Tucker JB, Swartz WM, Hurwitz DJ. The internal oblique muscle flap: an anatomic and clinical study. Plast Reconstr Surg 1984;73:721–33.

9. Ger R, Duboys E. The prevention and repair of large abdominal-wall defects by muscle transposition: a preliminary communication. Plast Re-constr Surg 1983;72:170–8.

10. Williams JK, Carlson GW, deChalain T, Howell R, Coleman JJ. Role of tensor fasciae latae in abdominal wall reconstruction. Plast Reconstr Surg 1998;101:713–8.

11. Rohrich RJ, Lowe JB, Hackney FL, Bowman JL, Hobar PC. An algorithm for abdominal wall reconstruction. Plast Reconstr Surg 2000;105:202–17.

12. Paletta CE, Huang DB, Dehghan K, Kelly C. The use of tissue expanders in staged abdominal wall reconstruction. Ann Plast Surg 1999;42:259–65.

13. Carlson GW, Elwood E, Losken A, Galloway JR. The role of tissue ex-pansion in abdominal wall reconstruction. Ann Plast Surg 2000;44:147–53.

14. Livingston DH, Sharma PK, Glantz AI. Tissue expanders for abdominal wall reconstruction following severe trauma: technical note and case re-ports. J Trauma 1992;32:82–6.



15. Jernigan TW, Fabian TC, Croce MA, Moore N, Pritchard FE, Minard G, et al. Staged management of giant abdominal wall defects: acute and long-term results. Ann Surg 2003;238:349–57.

16. Baker S, Millard DR Jr. Two-stage abdominal-wall reconstruction of sepsis-induced dehiscence. Plast Reconstr Surg 1995;96:898–904.

17. Barker DE, Kaufman HJ, Smith LA, Ciraulo DL, Richart CL, Burns RP. Vacuum pack technique of temporary abdominal closure: a 7-year experi-ence with 112 patients. J Trauma 2000;48:201-7.

18. Miller PR, Meredith JW, Johnson JC, Chang MC. Prospective evaluation of vacuum-assisted fascial closure after open abdomen: planned ventral hernia rate is substantially reduced. Ann Surg 2004;239:608-16.

19. Fansler RF, Taheri P, Cullinane C, Sabates B, Flint LM. Polypropyl-ene mesh closure of the complicated abdominal wound. Am J Surg 1995;170:15–8.

20. Karakousis CP, Volpe C, Tanski J, Colby ED, Winston J, Driscoll DL. Use of a mesh for musculoaponeurotic defects of the abdominal wall in cancer

surgery and the risk of bowel fistulas. J Am Coll Surg 1995;181:11–6.

21. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519–26.

22. de Vries Reilingh TS, van Goor H, Charbon JA, Rosman C, Hesselink EJ, van der Wilt GJ, et al. Repair of giant midline abdominal wall her-nias: “components separation technique” versus prosthetic repair : interim analysis of a randomized controlled trial. World J Surg 2007;31:756–63.

23. Lowe JB 3rd, Lowe JB, Baty JD, Garza JR. Risks associated with “com-ponents separation” for closure of complex abdominal wall defects. Plast Reconstr Surg 2003;111:1276–88.

24. Fabian TC, Croce MA, Pritchard FE, Minard G, Hickerson WL, Howell RL, et al. Planned ventral hernia. Staged management for acute abdomi-nal wall defects. Ann Surg 1994;219:643–53.

25. Byrd HS, Hobar PC. Abdominal wall expansion in congenital defects. Plast Reconstr Surg 1989;84:347–52.



OLGU SUNUMU

Yüksek enerjili ateşli silah yaralanmalarına bağlı açık karın olgularının tedavisindeerken dönem vakum uygulaması ile geç dönem doku genişletme ve çift taraflı yamaDr. Doğan Alhan,1 Dr. İsmail Şahin,2 Dr. Serbülent Güzey,3 Dr. Andaç Aykan,2 Dr. Fatih Zor,2

Dr. Serdar Öztürk,2 Dr. Mustafa Nışancı,4 Dr. İsmail Hakkı Özerhan5

1EskişehirAskerHastanesi,PlastikRekonstrüktifveEstetikCerrahiKliniği,Eskişehir2GülhaneAskeriTıpAkademisi,PlastikRekonstrüktifveEstetikCerrahiAnabilimDalı,Ankara3KasımpaşaAskerHastanesi,PlastikRekonstrüktifveEstetikCerrahiKliniği,İstanbul4EstetikCerrahiMerkezi,Ankara5GülhaneAskeriTıpAkademisi,GenelCerrahiAnabilimDalı,Ankara

AMAÇ: Açık karın; ciddi abdominal travmalar sonrası ortaya çıkabilecek katastrofilerden kaçınılması amacıyla uygulanan bir koruyucu prosedürdür. Fakat, açık karın olgularında yaralanma sonrası abdominal iyileşme sağlansa bile erken dönemde defekt alanının kapatılması çok kolay olmamaktadır. Bu nedenle açık karın olgularının tedavisinde aşamalı onarım ihtiyacı bulunurken, birinci aşama geçici kapamadır. Bu aşamanın sonrasında ortaya çıkan dev boyutlu ventral herni ise hem cerrah hem de hasta açısından büyük sıkıntı oluşturmaktadır. Oluşan bu tablo nedeniyle kalıcı bir onarım kaçınılmazdır. Her ne kadar bu amaçla birçok farklı tedavi yaklaşımları tanımlanmış olsa da ateşli silah yaralanması gibi yüksek enerjili travmalar nihai sonucu etkileyebilen, tedavi seçeneklerini kısıtlayan karmaşık tabloların oluşumuna neden olabilir. Bu çalışmada abdominal duvar defekti bulunan komplike olguların onarımında uyguladığımız aşamalı tedavi yaklaşımı sunuldu.GEREÇ VE YÖNTEM: Ateşli silah yaralanmasına bağlı açık karın bulunan dokuz erkek hastada aşamalı tedavi uygulandı. Bütün hastalarda geçici kapatma direkt visera üzerine yerleştirilen negatif basınçlı yara bakım uygulaması ve sonrasında gerçekleştirilen cilt grefti yardımıyla sağlandı. Geç dönemdeki kalıcı onarım ise ekspanse edilen abdominal duvarın laminasyonu ve iki taraflı yama sayesinde gerçekleştirildi.BULGULAR: Hastaların takip süreleri 24 ay ile 4.5 yıl arasında (ortalama üç yıl) değişmekteydi. Bu periyot dahilinde hiçbir hastada ventral hernide nüks, enterik fistül, abdominal enfeksiyon ve seroma oluşumu gözlenmedi.TARTIŞMA: Bu çalışmada yüksek enerjili ateşli silah yaralanmalarına bağlı açık karın olgularının tedavisinde negatif basınçlı yara terapisi, doku geniş-letici ve çift taraflı yama uygulamaları aşamalı olarak kullanılmıştır. Sonuçlar hastalar açısından son derece memnuniyet verici olup estetik sonuçlar ise kabul edilebilir düzeydedir.Anahtar sözcükler: Açık karın; ateşli silah yaralanması; çift taraflı mesh; doku genişletici; vakum yardımlı kapatma.



Resuscitation complications encountered in forensicautopsy cases performed in Muğla provinceHalil Beydilli, M.D.,1 Yasemin Balcı, M.D.,2 Şahin Işık, M.D.,2 Melike Erbaş, M.D.,3

Ethem Acar, M.D.,1 Bülent Savran, M.D.3

1DepartmentofEmergencyMedicine,MuğlaSıtkıKoçmanUniversityFacultyofMedicine,Muğla2DepartmentofForensicMedicine,MuğlaSıtkıKoçmanUniversityFacultyofMedicine,Muğla3MinistryofJustice,TheForensicBranchManagerofForensicMedicineInstituteofMuğla,Muğla

ABSTRACT

BACKGROUND: The purpose of this study was to determine complications of resuscitation seen during autopsies and evaluate the effectiveness of basic life support training.

METHODS: Autopsy case reports conducted in The Forensic Branch Manager of Muğla were retrospectively examined. Demo-graphic data of the patients with resuscitation complications such as age, gender, manner of death, and kinds and features of the complications were recorded.

RESULTS: In total, seventy-fourof the 100 cases with resuscitation complications were males. The autopsies in most of these cases were performed during the summer season. Among the patients, 68% died for non-traumatic reasons. Rib fractures were detected in seventy-one patients and sternum fractures in thirty-two patients. Moreover, damage to the pericardium (2%) and lung parenchymal (4%), heart lesions (4%), and liver lacerations (2%) were detected. Regarding rib fractures, fractures were found between the first and eighth ribs on both sides, with the highest numbers occurring in the fourth rib.

CONCLUSION: Resuscitation complications are important since they can be presumed to have carried out for traumatic reasons.Resuscitation complications seen in autopsy cases with non-traumatic causes can be perceived as traumatic events. They can be as-sumed incorrectly as trauma symptoms. These complications can be reduced with a good resuscitation training of the health personnel.

Key words: Autopsy; basic life support; closed-chest compression; resuscitation; resuscitation complications.

the last 10 years. The training mentioned above, in-service training, and certification courses have been provided espe-cially to personnel working in emergency services, intensive care, and 112 units. In order to maintain the required quality standards in hospitals, in-service training is provided every 6 months in the form of BLS or cardiopulmonary resuscitation courses. These training sessions are also monitored by the education and quality units of the hospitals.[2,3]

Airway patency establishment and closed-chest compression techniques are taught in first aid and BLS training courses. Training is provided according to the current guidelines pub-lished by the American Heart Association (AHA) and the European Resuscitation Council (ERC). Much of the infor-mation about closed-chest compression, chest compression physiology, the effects of various compression rates, ventila-tion/compression ratios, compression and relaxation times have been obtained from animal studies. This information has also been updated and strengthened by human studies. Finally, clear information about chest compressions was provided in the 2010 AHA and ERC guidelines.[4,5]



Address for correspondence: Halil Beydilli, M.D.

Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim

Dalı, Muğla, Turkey



Copyright 2015TJTES

INTRODUCTION

Today, many people worldwide have taken courses in first aid and basic life support (BLS) or have undergone diverse train-ing in this area. In Turkey, BLS training is provided as part of first aid courses. Such first aid and BLS training is widely avail-able to anyone and provided by expert associations within regulations from the Ministry of Health or at certain cen-tres approved by the ministry.[1] In this regard, the Ministry of Health has accelerated the training of medical personnel over

Beydilli et al. Resuscitation complications encountered in forensic autopsy cases performed in Muğla province

Effective chest compression is an early procedure during BLS used to provide blood flow. Chest compressions should be strong and effective. At least 100 compressions should be performed per minute, and their depth should be at least 5 cm for adults. After each compression, the chest should be allowed to pull back, and compression and decompression times should be approximately equal. There should not be any interruption between chest compressions.[4,5] Application of closed-chest compression itself is traumatic. Unwanted com-plications caused by chest compressions, particularly rib and sternum fractures, can be encountered. Additionally, injuries to internal organs, such as the heart, lungs, liver, or stomach, may occur.[6–10] Complication rate can vary depending on the individual performing the chest compression (medical per-sonnel vs. lay people), the surface on which it is performed (soft vs. hard surface), the location where it is performed (in or outside a hospital), and the quality of the education and ability of the individual applying it.[6–10]

After Kouwenhoven and Baringer provided two separate de-scriptions of closed-chest massage, which was the basis of cardiopulmonary resuscitation in hospitals in the 1960s, stud-ies aimed at reducing complications, morbidity, and mortal-ity gained more attention. In 1976, Enarson and colleagues published the first studies on resuscitation complications.[9,10] The recognition of various complications caused by resuscita-tion attempts in a series of autopsies gained great importance from a forensic viewpoint as well. Additionally, the develop-ment of cardiopulmonary resuscitation created a need for multidisciplinary post-mortem studies to help prevent com-

plications. Little research has been done in this field in our country. In our study, we analysed post-mortem autopsy findings in patients to whom BLS was provided by medical personnel in or outside the hospital.

The aim of this study was to analyse in detail the findings of autopsy reports from patients who received BLS from medi-cal personnel to determine the frequency of complications, evaluate the effectiveness of the training provided, and inves-tigate the subjects in the relevant literature.


In this study, autopsy reports from cases who received BLS performed between 2011 and 2013 in the Forensic Branch Manager of Muğla were analysed retrospectively. Complica-tions related to closed-chest compressions were recorded in the cases who underwent BLS. Moreover, they were analysed in terms of socio-demographic characteristics, cause of death and the location where BLS was performed. Patients with thorax trauma were excluded from the study.

Complications related to closed-chest compressions per-formed during resuscitation attempts, rib fractures, sternum fractures, chest wall ecchymosis, haemothorax, cardiac con-tusion, pulmonary contusion, liver laceration, pericardial inju-ries, and soft tissue damage, such as marks left on the skin by defibrillator pads were included in the evaluation.

For statistical analyses, the SPSS software was used. Percent-


Table 1. Complications related to chest compressions

Complication All patients Male Female p

Skin Defibrillator pads skin marks or burn marks 16 13 3 0.471

Ecchymosis and bleeding in skin/subcutaneous tissue 9 5 4 0.034

Upper airway Endotracheal ecchymosis 1 1 – –

Thorax Rib fracture 71 52 19 0.786

Haematoma around rib fractures 8 7 1 0.364

Ecchymosis around rib fractures 17 14 3 0.799

Sternal fracture 32 24 8 0.876

Ecchymosis around sternal fractures 4 2 2 0.264

Haematoma around sternal fractures 4 3 1 0.963

Anterior mediastinal hemorrhage 1 1 – –

Pneumothorax 1 1 – –

Lung Lung contusion 4 3 1 0.963

Pleural rupture 2 1 1 0.464

Heart Pericardial injury/haematoma 2 1 1 0.464

Endomyocardial hemorrhage 1 1 – –

Atrioventricular hemorrhage 1 1 – –

Abdomen Liver laceration 2 1 1 0.769


ages for the classified variables and averages for the con-tinuous variables were calculated routinely. We used χ2 and Fisher’s exact test for comparisons. P values <0.05 were con-sidered to indicate statistical significance.

RESULTS

Among the cases who underwent BLS and whose autopsy was performed in the Forensic Branch Manager of Muğla be-tween 2011 and 2013, resuscitation complications were de-tected in one hundred (Table 1) patients. Of these one hun-dred patients, there were 74 males and 26 females. In Table 2, the distribution of rib fractures according to gender is shown. The average age of the patients was 54.57 (range, 0–93) years. Autopsies were performed in sixty-eight cases for non-trau-matic reasons. The resuscitation process was performed on seventy-four patients in the hospital and twenty-six patients at the scene of an accident by 112 service ambulance person-nel. There was no statistically significant difference in terms of resuscitation complications according to the scene of the event or practitioner (p>0.05).

The autopsy results identified rib fractures in seventy-one patients; 61 of these fractures were located in the ribs of the right thorax area and another 66 in the ribs of the left thorax. In fifty-nine cases, there were rib fractures on both sides. On each side, rib fractures were detected between the first and eighth ribs. The highest number of fractures on each side occurred in the third (right: 52%, n=52, left: 56%, n=56), fourth (right: 54%, n=54, left: 64%, n=64), and fifth ribs (right:

44%, n=44, left: 57% n=57). The distribution of rib fractures according to their location is shown in Table 2.

In total, ten rib fractures were parasternal (10 males [M]). There were two axillary rib fractures (1 M/1 Famles [F]). Moreover, twenty-three rib fractures (15 M/8 F) were local-ized at the midclavicular line. There were haematomas around eight rib fractures (6 M/2 F). Ecchymosis was found around twelve rib fractures (7 M/5 F). Superficial skin ecchymosis/haematomas were detected in nine cases (5 M/4 F).

In thirty-two (32%) cases, sternum fractures were detected at the levels of the second, third, and fourth ribs, with the highest number at the level of the third rib (n=14) (Table 3). There were both rib fractures as well as sternum fractures in thirty-one (31%) cases (8 females and 23 males).

Apart from rib fractures, pericardium and heart injuries were detected in four cases, lung parenchymal damage in four, and rupture of the pleura in two. From the external examinations, defibrillator pad marks were found in sixteen patients, and skin and/or subcutaneous soft tissue ecchymosis and bleeding were detected in nine patients (Fig. 1).

Regarding chest injuries related to CPR, there was no statis-tically significant difference between the traumatic and non-traumatic groups in terms of rib or sternum fractures, age, or gender (p>0.05). Although more cases occurred during summer, no statistically significant difference by season was found (Fig. 2; p>0.05).


Table 2. Distribution of rib fractures according to location and gender

Fracture location Men Women Total

Parasternal 10 10 –

Midclavicular 23 15 8

Axillar 2 1 1

Not specified 36 26 10

Table 3. Distribution of sternum fractures according to location and gender

Fracture location Men Women Total

1 Level of 2nd rib 6 6 0

2 Level of 2nd–3rd intercostal space 6 5 1

3 Level of 3rd rib 14 9 5

4 Level of 3rd–4th intercostal space 2 1 1

5 Level of 4th rib 5 4 1

Total 33* 25 8

*Had broken in two locations in a patient’s sternum.

Figure 1. Ratesofcomplicationsotherthanribfractures.

37.5

22.5

7.5

15

30

Percentage

Sternum

fracture Sk

in

ecchymosis

Defibrillator

marks

Cardiac

injury Ot

hers

Lung

parenchymal

damage

0

Figure 2. Seasonaldistributionofthecases.

7.8

15.5

23.3

31.

38.8

Percentage

Winter

22.4 21.5

30.125.8

Spring Summer Autumn0.

DISCUSSIONIf closed-chest compressions are not performed properly during BLS, they can be traumatic. After examination of the patients, complications related to thorax compression such as rib and sternum fractures, were observed. Additionally, injuries to internal organs such as the heart, lung, liver, and stomach, occur frequently.[6–10] Complication rate can vary depending on the individual performing the chest compres-sion (e.g., medical personnel vs. lay people at the scene), the surface on and location at which it is performed (in the hos-pital vs. outside), and the education level and capability of the individual applying it.[6–10] Thus, we believe that continuous development of BLS training strategies and high-quality train-ing in cardiopulmonary resuscitation can reduce resuscita-tion-related complications.

When analysing complications caused by closed-chest com-pressions, methodological issues must be resolved first. Besides autopsies, computed tomography (CT) and X-ray equipment were used in this research. In this study, 86% of rib fractures detected by autopsy were not detected by AP chest X-rays.[11] CT is much more sensitive than X-ray radiography, especially for rib fracture detection. Regardless, in general, an autopsy is the best method for detecting resuscitation com-plications.[6,11,12] According to the above mentioned studies, detailed autopsy is still the most sensitive method.

The incidences of rib and sternum fractures, the most of-ten encountered complications of chest compressions, were 4–97% according to autopsy and 8-32% according to X-ray. For sternum fractures, the incidences were 1–43% by autopsy and 0–26% by X-ray.[6–13] However, in a prospective CT study performed in patients who were resuscitated as a result of successful BLS, the incidence of rib fractures amounted to 31% and that of sternum fractures to 4%.[6] The third, fourth, and fifth ribs, especially on the left side of the sternum, were fractured most often. In our autopsy study, the rates of rib and sternum fractures were similar and amounted to 71% for rib fractures and 32% for sternum fractures. Fractures resulting from complications related to resuscitation were observed mostly on the left side (66%) in the third, fourth, and fifth ribs. Although the studies were heterogeneous, it is clear that complications appearing during cardiopulmonary resuscitation are still very common.

Having analysed the distribution of rib fractures according to location (Table 2), most fractures occurred at the midcla-vicular line. Kricher and colleagues have stated that most ribs fracture at the sterno-condral junction.[10] However, Baubin and colleagues have claimed in their study using cadavers that most ribs fractures result from chest compressions occur-ring at the axillary line.[14] However, according to the study of Buschmann and Tsokos and many researches performed, frac-tures usually occur at the midclavicular line.[6–9,11–13] In three studies conducted in Turkey in 2003, 2008, and 2010, most

rib fractures were reported to occur at the midclavicular line.[7,8,15] The results of our study were consistent with the lit-erature reports, in that most rib fractures occurred at the midclavicular line.

The localization of sternal fractures has been reported to be between the second and fourth ribs. Most fractures occur at the sternum at the level of the third intercostal space. Similar results have been reported in domestic and foreign research studies.[7,8,10–12,15,16]

Having analysed the results in terms of skin complications and internal organ damage, in the cases of distant organs (e.g., retinal haemorrhage and subarachnoid haemorrhage) and internal organ damage, their occurrence is not common. When compressing the thorax, stress created by increased thoracic pressure affects many organs. Lacerations of diverse organs related to this issue have been described.[11] In our research, injury to internal organs (lung, heart, and liver) was seen at a low rate (10%). The rates of internal organ injury have not changed much since the reports of Krischer and col-leagues and Paaske and colleagues on such injuries and other life-threatening complications related to closed-chest com-pressions. Krischer and colleagues have reported in detail on ten complications, mentioned above, among 705 cases, while Paaske and colleagues have noticed three complications among 268 cases.[10–18] Life-threatening complications were rare in these studies.

Due to closed-chest compressions, damage to intrathoracic organs is often encountered. They usually occur in relation to rib and sternum fractures. However, this is not always the case. Organ injuries can also occur without fracture. The most important factors leading to this situation include misapplication and external chest compressions that are too strong, fast, deep, and long. Multiple injuries such as lung con-tusions, pleural rupture, anterior mediastinal bleeding, peri-cardial injury, cardiac injury, pneumothorax, haemothorax, and mediastinal emphysema have been observed. When the heart is tightened between the anterior chest wall and spine during chest compressions, epicardial petechiae and myocar-dial haemorrhage can occur.[6–18] In addition, in our autopsy reports, cases with pulmonary contusion, pleural rupture, pericardial injury/bleeding, and endomyocardial bleeding were observed. These findings were similar to those of the litera-ture reports.

Intra-abdominal injuries are rare resuscitation complications. However, many organs may be affected. Liver and spleen lac-eration, gastric dilatation and gastric perforation are encoun-tered. Moreover, intestinal trauma, intraperitoneal bleeding, and retroperitoneal haematomas have been recorded as complications. In the literature, liver damage is seen at an incidence of ~0.6 3% and is the most frequent intra-abdom-inal complication related to CPR.[10,19–26] Liver laceration was recorded in two of our cases and is observed more often on



the left lobe. The most important factor in this is the close anatomical relationship between the left lobe of the liver and the sword-shaped lower end of the sternum. A similar lacera-tion was seen in our cases. Two other important factors that can increase the risk of liver laceration are hepatic ischaemia and liver distension due to venous obstruction.[10,19–26] The reason for liver laceration in our case was thought to be simi-lar. Moreover, treatments with antiplatelet, antithrombotic, and thrombolytic agents in patients with myocardial infarc-tion may cause such lacerations.[21,22,26]

No significant gender influence on rib fractures has been detected by the majority of studies. However, rib fractures generally occur more frequently in elderly women with high osteoporosis rates and in both genders of more advanced age.[9–13] However, according to research conducted in our country by Şam and colleagues in 2003, more complications were detected in men and younger patients (average age of 35 years).[15] In the studies of Boz and colleagues from 2008, the rate of resuscitation complications was found to be high in men and the elderly.[7] Similarly, in a study conducted in 2010 by Özer and colleagues, the rate of resuscitation com-plications was high (71.9%) in men and the elderly.[8] In our study, similar to others conducted in Turkey, more than half of the cases (55%) were 55 years and over, and most (75%) were male.

Hoke et al. and Black et al. have reported an incidence of rib cage fractures of less than 50% and of sternum fracture of less than 30%. In our study, we detected 71% rib cage frac-tures and 32% sternum fractures, higher than the average in-cidences reported in the literature. These results emphasise the importance of the education provided on resuscitation, and significant effort should be given to revise this to lower the complication rates.

A limitation of our study is the lack of data regarding sur-face type on which the chest compressions were performed, the depth of application, and the duration of application. Moreover, to obtain more detailed results on resuscitation complications, more in-depth reports on chest compressions cases should be prepared based on the following: a sufficient number of cases, homogenized study populations, exclusion of associated conditions, and stratification by age, gender, du-ration of application, depth of application, and soft or hard surfaces.

Our research was conducted with approval from our local ethics committee. There are no conflicts of interest to re-port.

ConclusionIn BLS, resuscitation is a procedure performed to bring pa-tients back to life and to increase their chance of survival. However, at the same time, it can also cause complications

that may even lead to the patient’s death. Resuscitation per-formed in the correct manner will cause less organ injury and prevent potentially fatal complications. It should be noted that chest compressions applied with enough strength to break the ribs or sternum can harm the thorax and many organs and may decrease the patient’s chance of survival.

Awareness of the complications occurring with BLS is vital in autopsy investigations. In patients in whom the major cause of death is trauma, these complications may be interpreted as additional trauma symptoms. However, in patients who died due to non-traumatic reasons, autopsy may be misinterpret-ed by these complication findings, suggesting that the cause of death involved trauma. Thus, detailed information about the application of BLS and its possible complications are cru-cial for forensic medical specialists to distinguish them from actual trauma symptoms. Moreover, it is also important for doctors, who usually perform resuscitation, and other medi-cal personnel to be aware of these complications in terms of comprehension and a reduction in medical errors. Thus, BLS training should be repeated at appropriate intervals based on current approaches.

Note: The English in this document has been checked by at least two professional editors, both native speakers of Eng-lish. For a certificate, please see: http://www.textcheck.com/certificate/zzLYdk


REFERENCES

1. http://www.saglik.gov.tr/TR/belge/1-552/ilkyardim-yonetmeligi.html. Access date:15.01.2014.

2. http://www.kalite.saglik.gov.tr/content/files/mevzuat/saglikta_perfor-mans_ve_kalite_yonergesi_yeni/hkskitap.pdf. Access date:15.01.2014.

3. http://www.kalite.saglik.gov.tr/content/files/mevzuat/saglikta_per-formans_ve_kalite_yonergesi_yeni/3_2ek4112son.pdf. Access date:15.01.2014.

4. Berg RA, Hemphill R, Abella BS, Aufderheide TP, Cave DM, Hazinski MF, et al. Part 5: adult basic life support: 2010 American Heart Asso-ciation Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122(18 Suppl 3):685–705.

5. Koster RW, Baubin MA, Bossaert LL, Caballero A, Cassan P, Castrén M, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibril-lators. Resuscitation 2010;81:1277–92.

6. Kim MJ, Park YS, Kim SW, Yoon YS, Lee KR, Lim TH, et al. Chest injury following cardiopulmonary resuscitation: a prospective computed tomography evaluation. Resuscitation 2013;84:361–4.

7. Boz B, Erdur B, Acar K, Ergin A, Türkçüer I, Ergin N. Frequency of skeletal chest injuries associated with cardiopulmonary resuscitation: forensic autopsy. [Article in Turkish] Ulus Travma Acil Cerrahi Derg 2008;14:216–20.

8. Özer E, Şam B, Tokdemir MB, Çetin G. Complications of cardiopul-monary resuscitation. Cumhuriyet Tıp Dergisi Cumhuriyet Tıp Dergisi 2010;32:315–22.




OLGU SUNUMU

Muğla ilinde yapılan otopsi olgu sonuçlarında karşılaşılan resüsitasyon komplikasyonlarıDr. Halil Beydilli,1 Dr. Yasemin Balcı,2 Dr. Şahin Işık,2 Dr. Melike Erbaş,3 Dr. Ethem Acar,1 Dr. Bülent Savran3

1MuğlaSıtkıKoçmanÜniversitesiTıpFakültesi,AcilTıpAnabilimDalı,Muğla2MuğlaSıtkıKoçmanÜniversitesiTıpFakültesi,AdliTıpAnabilimDalı,Muğla3AdaletBakanlığı,MuğlaAdliTıpŞubeMüdürlüğü,Muğla

AMAÇ: Bu çalışmanın amacı, otopsiler sırasında görülen resüsitasyon komplikasyonların belirlenmesi ve temel yaşam desteği eğitimi etkinliğini değerlendirmektir.GEREÇ VE YÖNTEM: Muğla Adli Tıp Şube Müdürlüğü’nde gerçekleştirilen otopsi olgu raporları geriye dönük olarak incelendi. Resüsitasyon komp-likasyonları olan hastaların yaş, cinsiyet, ölüm şekli ve çeşitleri gibi demografik verileri ve komplikasyonların özellikleri kaydedildi.BULGULAR: Toplam, resüsitasyon komplikasyonlara 100 olgunun 74’ü erkektir. Bu olguların çoğunda otopsileri yaz sezonunda yapıldı. Hastalar arasında %68 travmatik olmayan nedenlerle öldü. Kaburga kırıkları 71 hastada, sternum kırıkları 32 hastada tespit edilmiştir. Ayrıca, perikart (%2) ve akciğer parankim (%4), kalp lezyonları (%4) ve karaciğer laserasyon (%2) hasarı tespit edildi. Kaburga kırıkları ile ilgili olarak, meydana gelen kırıklar en yüksek sayılarda dördüncü kaburga, her iki tarafta ilk ve sekizinci kaburga arasında bulundu.TARTIŞMA: Resüsitasyon komplikasyonları önemli, çünkü bu komplikasyonlar otopside travmatik nedenlerle yapılmış sanılabilir. Travmatik olmayan nedenlerle yapılan otopsi durumlarında görülen resüsitasyon komplikasyonları travmatik olaylar olarak algılanabilir. Onlar, yanlış olarak travma be-lirtileri sanılabilir. Bu komplikasyonlar sağlık personelinin iyi resüsitasyon eğitimi ile azaltılabilir.Anahtar sözcükler: Kapalı-göğüs sıkıştırma; otopsi; resüsitasyon; resüsitasyon komplikasyonlar; temel yaşam desteği.




9. Black CJ, Busuttil A, Robertson C. Chest wall injuries following cardio-pulmonary resuscitation. Resuscitation 2004;63:339–43.

10. Krischer JP, Fine EG, Davis JH, Nagel EL. Complications of cardiac re-suscitation. Chest 1987;92:287–91.

11. Lederer W, Mair D, Rabl W, Baubin M. Frequency of rib and sternum frac-tures associated with out-of-hospital cardiopulmonary resuscitation is un-derestimated by conventional chest X-ray. Resuscitation 2004;60:157–62.

12. Kim EY, Yang HJ, Sung YM, Cho SH, Kim JH, Kim HS, et al. Multi-detector CT findings of skeletal chest injuries secondary to cardiopulmo-nary resuscitation. Resuscitation 2011;82:1285–8.

13. Buschmann CT, Tsokos M. Frequent and rare complications of resuscita-tion attempts. Intensive Care Med 2009;35:397–404.

14. Baubin M, Sumann G, Rabl W, Eibl G, Wenzel V, Mair P. Increased fre-quency of thorax injuries with ACD-CPR. Resuscitation 1999;41:33–8.

15. Şam B, Saka E, Süner Ç. Adli otopsilerde resusitasyon komplikasyonları. Adli Tıp Bülteni 2003;8:5–8.

16. Hoke RS, Chamberlain D. Skeletal chest injuries secondary to cardiopul-monary resuscitation. Resuscitation 2004;63:327–38.

17. Paaske F, Hansen JP, Koudahl G, Olsen J. Complications of closed-chest cardiac massage in a forensic autopsy material. Dan Med Bull 1968;15:225–30.

18. Hellevuo H, Sainio M, Nevalainen R, Huhtala H, Olkkola KT, Ten-hunen J, et al. Deeper chest compression - more complications for cardiac arrest patients? Resuscitation 2013;84:760–5.

19. Kapłon-Cieślicka A, Kosior DA, Grabowski M, Rdzanek A, Huczek Z,

Opolski G. Coronary artery dissection, traumatic liver and spleen injury after cardiopulmonary resuscitation - a case report and review of the lit-erature. Arch Med Sci 2013;9:1158–61.

20. Rosen J, Tuchek JM, Hartmann JR. Liver laceration in the hemodynami-cally unstable post-cardiac massage patient: early recognition and man-agement-case report. J Trauma 1999;47:408–9.

21. Adams HA, Schmitz CS, Block G, Schlichting C. Intra-abdominal bleeding after myocardial infarction with cardiopulmonary resusci-tation and thrombolytic therapy. [Article in German] Anaesthesist 1995;44(8):585–9. [Abstract]

22. Pezzi A, Pasetti G, Lombardi F, Fiorentini C, Iapichino G. Liver rupture after cardiopulmonary resuscitation (CPR) and thrombolysis. Intensive Care Med 1999;25:1032.

23. Druwé PM, Cools FJ, De Raedt HJ, Bossaert LL. Liver rupture after car-diopulmonary resuscitation in a patient receiving thrombolytic therapy. Resuscitation 1996;32:213–6.

24. Meron G, Kurkciyan I, Sterz F, Susani M, Domanovits H, Tobler K, et al. Cardiopulmonary resuscitation-associated major liver injury. Resuscita-tion 2007;75:445–53.

25. Camden JR, Carucci LR. Liver injury diagnosed on computed tomog-raphy after use of an automated cardiopulmonary resuscitation device. Emerg Radiol 2011;18:429–31.

26. Ziegenfuss MD, Mullany DV. Traumatic liver injury complicating car-dio-pulmonary resuscitation. The value of a major intensive care facility: a report of two cases. Crit Care Resusc 2004;6:102–4.

Comparison of clinical outcomes with three differentintramedullary nailing devices in the treatmentof unstable trochanteric fracturesSinan Zehir, M.D.,1 Ercan Şahin, M.D.,2 Regayip Zehir, M.D.3

1DepartmentofOrthopedicsandTraumatology,HititUniversityFacultyofMedicine,Çorum2DepartmentofOrthopedicsandTraumatology,BülentEcevitUniversityFacultyofMedicine,Zonguldak3DepartmentofCardiology,CarsambaStateHospital,Samsun

ABSTRACT

BACKGROUND: The aim of this study was toreport our experience regarding the use of three different methods for intramedullary nailing in the treatment of intertrochanteric fractures.

METHODS: Patients with A2 and A3 type fractures operated on for unstable trochanteric fractures were included into this retro-spective cohort study. Patients were divided into three groups based on the technique used; Talon distal fix nail/lag screw (n=78; mean age, 78.5±6.6), PFNA nail (n=96; mean age, 77.2±6.8) or InterTan nails (n=102; mean age, 76.8±6.7). Harris hip scores were recorded at the last outpatient visit and survival information was obtained by phone interview and civil registry database.

RESULTS: Baseline characteristics were similar among groups. Operation time, fluoroscopy time and blood loss were significantly higher in InterTan group. Screw cut-out occurred in eight patients in PFNA group. In-hospital mortality occurred in nine (3.2%) pa-tients. Length of hospital stay and postoperative tip-apex distance was not different among groups. At follow-up, healing time and Harris hip scores were also similar among groups. One-year survival rate was 83.1±4.5% in Talon distal fix nail/lag screw, 84.0±3.8% in PFNA group and 84.4±3.7% in InterTan group (p=0.33).

CONCLUSION: New Talon distal fix nail/lag screw was associated with lower cut-out rates than PFNA and shorter operative times than InterTan. Further study is warranted to clearly establish the potential advantages of Talon distal fix over any other technique described herein.

Key words: Complications; intramedullary nailing; survival; trochanteric fractures.

[2] Patients with trochanteric fractures tend to have a thinner cortical bone of the femur and have more severe osteopo-rosis than those having femoral neck fractures.[3] Moreover, presence of a trochanteric fracture was further shown to be associated with higher mortality after hip fracture.[5]

Surgery is the mainstay of treatment in fractures of the tro-chanteric region, and operation should be undertaken as early as possible to allow early mobilization of the patient.[6] However, although there have been many options to achieve satisfactory functional outcomes in the reconstruction of proximal femoral fractures, each technique has its own spe-cific disadvantages in terms of postoperative complications. Extramedullary implants and intramedullary nails have been used for the internal fixation of trochanteric fractures. Slid-ing hip screws had been the most commonly used devices as they allowed for extramedullary fixation of the fracture while assuring fracture collapse. However, for the last two decades, intramedullary nailing has increasingly gained interest owing



Address for correspondence: Sinan Zehir, M.D.

Hitit Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji

Anabilim Dalı, 19100 Çorum, Turkey

Tel: +90 364 - 222 11 00/01 E-mail: [email protected]


Copyright 2015TJTES

INTRODUCTION

Hip fractures constitute a major health problem in the elderly, and their incidence is increasing as the population worldwide continues to age.[1] Fractures of the intertrochanteric region and femoral neck account for a great majority of hip fractures and, particularly in females, the proportion of intertrochan-teric fractures have been reported to rise with advancing age.

Zehir et al. Comparison of clinical outcomes with three different intramedullary nailing devices in the treatment of unstable trochanteric fractures

to its biomechanical advantages such as allowing more central placement of the implant to assure smaller bending moment and being several times stronger than sliding hip screws which is of importance in enabling better mobilization and resis-tance after surgery.[7]

Talon distal fix nail/lag screw (ODI, Florida, USA) system pro-vided an innovative method for distal femoral fixation. Dis-tal talons on the nail deploy from within the femoral canal and this feature eliminates the need for using cortical screws. Talon Lag screws used in conjunction with the nails feature the same method to improve rotational stability within the femoral head/neck junction. It is still controversial whether intramedullary nailing devices will replace extramedullary fix-ation because biomechanical tests still awaits confirmation by clinical studies. We herein report our instutional experience regarding the use of Talon distal fix nail/lag screw device in comparison with results we obtained using two other com-mon techniques for intramedullary nailing; proximal femur anti-rotation (PFNA, Synthes, Oberdorf, Switzerland) and InterTan nail (Smith & Nephew, Memphis, Tennessee).


The study was approved by local ethics committee. All pa-tients consented to the use of their records for research purposes. The study was undertaken in a tertiary university

hospital. This was a retrospective cohort study and was made up of patients operated on for unstable trochanteric fractures between January 2010 and September 2013. Baseline data were collected by reviewing patients’ charts and medical re-cords. Patients with A2 and A3 type fractures were included and those with pathological fractures, intracapsular fractures, and high-velocity fractures were excluded. Patients who were bedridden or wheel-chair bound before the injury and those having history of previous hip surgery were also excluded. All of the operations were performed by surgeons who had in-dependently performed several operations with either tech-nique. Patients were divided into three groups based on the technique used; Talon distal fix nail/lag screw (since Septem-ber 2012), PFNA nail (since January 2010) or InterTan nails (since January 2010). Baseline characteristics of patients were given in Table 1.

Operations were performed under spinal or general anesthe-sia. Prophylactic antibiotics were given 30 minutes before the skin incision was made. Operations were performed accord-ing to the standard protocols of each device as instructed by the manufacturer.

Surgical TechniqueTalon Distal Fix Nail/Lag ScrewThe patient was placed in supine position on a fracture table


Table 1. Baseline characteristics

Variable Talon Lag screw PFNA InterTan p*

n % Mean±SD n % Mean±SD n % Mean±SD

Number of patients 78 28.3 96 34.8 102 37.0

Age (Years) 78.49±6.64 77.22±6.82 76.86±6.74 0.25

Gender (Males) 32 41 37 38.5 39 38.2 0.92

Fracture side (Right) 33 42.3 53 55.2 57 55.9 0.13

Diabetes 25 32.1 33 34.4 24 23.5 0.21

Hypertension 25 32.1 35 36.5 37 36.3 0.79

Chronic pulmonary disease 14 17.9 22 22.9 18 17.6 0.59

Heart failure 12 15.4 18 18.8 7 6.9 0.04

Coronary artery disease 1 1.3 3 3.1 12 11.8 0.04

Multiple disease 17 21.8 22 22.9 22 21.6 0.97

Fracture type

A2.1 15 19.2 24 25.0 21 20.6 0.61

A2.2 34 43.6 40 41.7 44 43.1 0.96

A2.3 22 28.2 28 29.2 28 27.5 0.96

A3.1 4 5.1 2 2.1 4 3.9 0.55

A3.2 1 1.3 1 1.0 3 2.9 0.55

A3.3 2 2.6 1 1.0 2 2.0 0.74

Time until operation (weeks) 3.49±1.71 3.29±1.89 3.35±2.01 0.43

*According to the Bonferroni correction, p value of <0.05/3=0.017 was considered as limit of statistical significance when comparing ratios among three groups.


with the affected leg fixed in slight adduction. Prior to draping the patient, a closed reduction was made under fluoroscopy. A longitudinal incision was made proximal to the greater trochanter. Proximal femur was reamed over a guidewire to an appropriate length for the given patient. Nail length was measured using a template. A guide assembly composed of an arm and a handle was loaded with a nail of desired length and secured. Lag guide sleeve was inserted through the guide arm and proper alignment of the nail was verified. Lag guide sleeve was removed prior to nail insertion. The nail was passed over the guidewire and advanced down the femur. A lag guide pin obturator was inserted into the lag guide pin sleeve and in-troduced through the hole in the guide arm. A small skin incision was made and the obturator and the sleeve were ad-vanced until the tip contacts the lateral cortex of the femur. The position was radiographically verified and guide arm was tightly secured. An appropriate sized lag guide pin was ad-vanced until it reached the ultimate position of the lag screw within the femoral head. Guide pin depth was measured and the canal for lag screw was drilled to the desired depth based on this measurement. A lag alignment plug was passed over the guidepin passing through the hole in the nail to maintain the nail’s position during deployment of the nail Talons. Using a talon deployment driver and turning it clockwise for several times, nail talons were deployed. Then, lag screw attached to a driver assembly was passed over the guidepin and through the sleeve. The lag screw was fully inserted by turning the driver clockwise and applying pressure. Final screw position-ing was verified radiographically. Using the lag talon driver the talons on the screw were deployed. The lag sleeve and guide arm were removed and the final positioning was verified ra-diographically (Fig. 1a, b).

PFNA (Proximal Femoral Nail Antirotation)Patient positioning and closed reduction were made, as de-scribed above. Nail length was determined. A 5 cm incision was made over the greater trochanter. A guidewire was drilled and the medullary canal was reamed 0.5 to 1.5 mm greater than the nail diameter. Using an insertion handle as-sembly, PFNA was manually inserted into the femoral canal until it reached to the appropriate depth. Sleeve assembly for PFNA was advanced through an appropriate angled aiming arm to the skin. A small incision was made and the sleeve as-sembly was inserted as far as the lateral cortex. A new guide-wire was inserted into the bone with its tip positioned at the exact center of the femoral head. Using a measuring device, PFNA blade length was determined. A cannulated drill bit was drilled over the guidewire and the lateral cortex was opened. Fixing the fixation sleeve, hole for PFNA was reamed. PFNA blade was attached to the impactor and inserted over the guidewire. The PFNA blade was inserted advancing as far as possible in to the femoral head. The blade was locked by turning the impactor clockwise. Distal locking was performed using static or dynamic screws. Final positioning was verified radiographically (Fig. 1c, d).

InterTan Intertrochanteric Antegrade NailPatient positioning and closed reduction was made, as de-scribed above. A longitudinal incision was made proximal to the greater trochanter. A guidepin was inserted 2–3 cm into the trochanteric region by the aid of an entry portal assem-bly. An entry reamer was inserted into a channel reamer and reamed to the level of lesser trochanter. A reducer was introduced into the intramedullary canal while maintaining fracture reduction. The reducer was removed and intramed-ullary canal was reamed 1–1.5 mm larger than the selected nail size. By the aid of a drill guide handle, the nail was ad-vanced into the proximal femur. An incision was made at the site of lag screw entry. The lateral cortex of the femur was drilled through a drill sleeve and a trocar. A threaded guide pin was inserted through the guide pin sleeve until it reached the appropriate position in the femoral neck and head. Guide pin position was verified radiographically. Tri-gen InterTan nail was inserted with single subtrochanteric lag screw. Guidepin sleeve was replaced with lag screw sleeve. Lag screw drill was drilled to the depth measured for the lag screw. By the aid of a T-handle, the lag screw driver was


Figure 1. (a)AnteroposteriorviewofTalondistalfixnailapplica-tion.(b) LateralviewofTalondistalfixnailapplication.(c) Antero-posteriorviewofproximalfemoralnailantirotationapplication.(d) Lateralviewofproximalfemoralnailantirotationapplication.

(a)

(c)

(b)

(d)

manually advanced without compression through the hole within the nail. Distal locking was performed using appropri-ate sized locking screws. Final positioning was verified radio-graphically (Fig. 2a, b).

Postoperative Care and Follow-UpAfter surgery, patients were mobilized out of bed on the first postoperative day and allowed weight bearing, as tolerated. Low molecular weight heparin was given for three days and intravenous antibiotics were used during the time until dis-charge. Patients were discharged home when they began to walk with little assistance. Patients were invited to follow-up at 4 weeks and at every three months thereafter. Harris hip scores were measured at the most recent follow-up and were put into evaluation. Survival information was obtained either by making phone interviews or searching patient data from social security registry network.

Statistical AnalysisStatistical analyses were performed using SPSS 19.0 pack-aged software. Distribution of variables was tested using vi-sual histograms and Kolmogorov-Smirnov test to determine normality. Descriptive statistics for continuous variables were reported as mean±SD and descriptive statistics for categorical variables were reported as frequency and per-centage. One-way ANOVA was used to compare continu-ous variables among three groups. Levene test was used to assess the homogeneity of variances. Post-hoc tests were performed using Tukey’s test. Categorical variables were compared using chi-square test or Fisher’s exact test, where appropriate. Kaplan-Meier survival estimates were calculat-ed. Log rank test was used to identify the independent effect of type of device used on survival. Since time to follow-up variables did not show homogeneity, Welch ANOVA test was used for comparison. A Bonferroni correction was made and p value of less than 0.05/3=0.017 was considered to be statistically significant.

RESULTS

Three groups were similar in terms of baseline characteristics except that heart failure was slightly more common and coro-nary artery disease was slightly less common in InterTan group (non-significant). Baseline patient characteristics and distribu-tion of fracture types among groups were given in Table 1.

Operations were performed under general anesthesia in fifty patients (18.1%) and under spinal/epidural anesthesia in one hundred and eighty-eight patients (68.1%). Thirteen patients (4.8%) received a combination of general and spinal/epidural anesthesia and twenty-five patients (9.0%) received nerve blockade (Table 2). Operation took significantly longer in In-terTan group than in PFNA and Talon distal fix nail/lag screw groups. Patients receiving InterTan nails had significantly more blood loss and significantly longer fluoroscopy times than those receiving other two techniques (Table 2).



Table 2. Surgical data

Variable Talon Lag Screw PFNA InterTan p*

n % Mean±SD n % Mean±SD n % Mean±SD

General 15 19.2 16 16.7 19 18.6 0.89

Spinal 43 55.1 56 58.3 61 59.8 0.81

Epidural 5 6.4 12 12.5 11 10.8 0.40

Combined 1 1.3 5 5.2 7 6.9 0.20

Nerve Block 14 17.9 7 7.3 4 3.9 0.004

Time of operation (min) 42.05±6.24 44.41±5.17 55.35±5.8 <0.001

Blood loss (ml) 126.47±40.93 139.69±39.69 211.42±31.56 <0.001

Time of flouroscopy 1.40±0.11 1.50±0.18 2.0±0.22 <0.001

*According to the Bonferroni correction, p value of <0.05/3=0.017 was considered as limit of statistical significance when comparing ratios among three groups.

Figure 2. (a)AnteroposteriorviewofInterTanintertrochanterican-tegradenailapplication.(b)LateralviewofInterTanintertrochan-tericantegradenailapplication.

(a) (b)

Mean length of postoperative stay was similar among groups (7.01±1.61 days, 7.14±2.13 days and 7.45±1.94 days in Talon distal fix nail/lag screw, PFNA and InterTan groups, respec-tively, p=0.28). Mean tip apex distance (TAD) was also similar among groups (21.25±4.5 mm, 22.70±3.01 mm, 24.02±18.87 mm in Talon distal fix nail/lag screw, PFNA and InterTan groups, respectively, p=0.30).

Postoperative complications and morbidities were given in Table 3. A total of thirteen patients (4.7%) had superficial wound infections and were totally cured with wound care and antibiotics without requiring tissue debridement. Deep wound infection occurred in three patients; one patient in Talon distal fix nail/lag screw group and one of two patients in InterTan group received a single-step tissue debridement for deep wound infection whereas the other patient was cured with conservative treatment alone. None required hardware removal. Staphylococcus aureus was the causative agent in all three patients. Hematomas occurred in seven patients. Three out of these underwent surgical drainage while hematomas resolved spontaneously in the remaining.

Screw cut-out occurred in eight patients in PFNA group with five of these having crew migration. There were no instances of screw cut-out in the other two groups. Three out of these patients had A2.1 type fracture, 4 had A2.2 type fracture and 1 had A2.3 type fracture. In five patients, femoral neck screws were too short and replaced with longer screws. The other three patients underwent revision for hip arthroplasty. Over-all, reoperation rates were similar among the groups. Several morbidities occurred in the minority of patients and were listed in Table 3. A total of nine patients (3.2%) aging from 72 to 91 years died within 30 days after the operation; eight died of decompensated heart failure and one died of pneumonia. Follow-up information was complete in all patients who were discharged home (n=265, 96.8%). Time to healing and Har-ris scores were similar among the groups (Table 4). Median time to follow-up was 12.17 months (1–19 months) in Talon distal fix nail/lag screw group, 16.06 months (1-46 months) in PFNA group, and 16.00 months (1-40 months) in InterTan group. Follow-up was significantly shorter in patients receiv-ing Talon distal fix nail/lag screw (p<0.01) indicating that the



Table 3. Early postoperative complications and morbidites

Variable Talon Lag Screw PFNA InterTan p*

n % n % n %

Superficial wound infection 2 2.6 4 4.2 7 6.9 0.38

Deep wound infection 1 1.3 0 0.0 2 2.0 0.40

Hematoma 1 1.3 2 2.1 4 3.9 0.50

Cut-out 0 0.0 8 8.3 0 0.0 <0.001

Screw migration 0 0.0 5 5.2 0 0.0 0.008

Pain at hip 3 3.8 3 3.1 3 2.9 0.94

Pain at thigh 4 5.1 7 7.3 2 2.0 0.20

Reoperation 3 3.8 9 9.4 5 4.9 0.25

Deep venous thrombosis 5 6.4 7 7.3 6 5.9 0.92

Pulmonary embolism 0 0.0 1 1.0 1 1.0 0.67

Decompensated heart failure 2 2.6 3 3.1 3 2.9 0.97

Urinary tract infection 6 7.7 9 9.4 9 8.8 0.92

Pneumonia 2 2.6 4 4.2 4 3.9 0.83

Pressure ulcer 7 9.0 9 9.4 10 9.8 0.98

In-hospital mortality 2 2.6 2 2.1 5 4.9 0.49

Table 4. Comparison of time to fracture healing and Harris scores among patients surviving at least 6 months after the operation

Variable Talon Lag Screw (n=70) PFNA (n=85) InterTan (n=88) p*

Mean±SD Mean±SD Mean±SD

Time to healing* (weeks) 22.11±2.32 22.86±2.22 22.93±2.39 0.06

Harris scores 75.84±17.79 75.87±22.23 71.26±26.55 0.32

device has been in use for a relatively shorter time (since September 2012) than other two devices. During follow-up, twelve patients (16.0%) in Talon distal fix nail/lag screw, 24 patients (25.5%) in PFNA group and 32 patients (33.0%) in InterTan group died of various causes. Mean time of survival was not significanly different among three groups; 17.06±0.53 months in Talon distal fix nail/lag screw, 34.24±2.10 months in PFNA group, 27.69±1.58 months in InterTan gruoup (over-all Log Rank p value=0.33), (Figure 3). One-year survival rate was 83.1±4.5% in Talon distal fix nail/lag screw, 84.0±3.8% in PFNA group and 84.4±3.7% in InterTan group. Three-year survival rate was 61.0±.9.3% in PFNA group and 49.0±8.1% in InterTan group (p=0.14). More than one-year survival could not be given in Talon distal fix nail/lag screw group since there were less than five patients remained at 18th month of fol-low-up.

DISCUSSIONIn the present study, results with the Talon distal fix nail/lag screw system was comparable to PFNA and InterTan screws in treatment of unstable proximal femoral fractures in pa-tients older than 65 years of age. Operation and flouroscopy times were shorter in Talon distal fix nail/lag screw group and PFNA group than those in InterTan group. We achieved satisfactory results even though during our earlier attempts in implanting the Talon distal fix nail/lag screw, indicating that the system offers a steep learning curve as long as the sur-geon perfoming the procedure has adequate experience in intramedullary device implantation.

A recent Cochrane review demonstrated no superiority of intramedullary nailing over sliding hip screws in terms of

preventing complications and reoperations[8] and concluded that further studies are required to establish the assumed advantages of recenty developed designs. In Sweden, it was reported that, within the last decade, surgeons have become more commonly using intramedullary nailing than sliding hip screws in treatment of pertrochanteric fractures.[9] Moreover, a large Finnish database study showed that patients operated on using intramedullary nails had significantly higher reopera-tion rates (11.1% vs. 8.9%; p<0.0001) and also, higher one-year mortality (26.6% vs. 24.9%; p=0.011) than those receiv-ing conventional techniques.[10]

However, these data seem to exacerbate rather than re-strict the use of intramedullary nailing, especially during the few years. Surgeons are likely to be convinced getting rid of known dysadvantages of hip screws including excessive col-lapse, femoral shortening[11] and late recovery of normal mo-bility,[12] at the expense of incresing cost.[13] Type of the frac-ture should be regarded as an important factor in designing future studies since more unstable fractures of the femoral head (i.e having an extending component through the femoral shaft, AO-A3) may require a distinct approach in the given patient.[14] Data from this perspective may change the view on intramedullary nailing in particular instances. Complication rates were similar among Talon distal fix nail/lag screw, PFNA and InterTan groups except for cut-out which occured only in patients receiving PFNA device. The earlier PFN system which was designed to overcome the shortcom-ings of well-known Gamma nail was further modified in 2003 by adding a lateral locking head to the blade to prevent ro-tation and micro-motion. Supporting this was a large multi-center study suggesting that PFNA was an optimal implant for unstable trochanteric fractures in osteoporotic patients due its capability of limiting early rotation of head/neck fragment.[15] In another comparative study, Gardenbroek et al.[16] have reported that patients receiving PFNA or PFN device have similar positioning of the device whereas late reoperations less frequently occured in PFNA group than in PFN group. A recent model based study has demonstrated that helical blade of the PFNA nail provides better compaction within bone in case of lower femoral head bone density, indicating the device has potential of decreasing cut out in osteoporotic patients.[17]

Nevertheless, risk of cut-out has not totally be eliminated in patients receiving PFNA device and benefits of the modifica-tion have not always been reflected in recent studies. Takiga-mi et al.[18] reported that cut out occured in one patient and lateral sliding of the blade occured in four patients in their series of fifty patients receving Asian modification of PFNA device. In a more recent study, cut out occurred in three pa-tients from PFNA group; whereas, in none receiving Gamma3 nail.[19] Gavaskar et al.[20] have made a stratification based on the AO classification and reported that complication rates are significanly higher in patients with unstable fractures than



Figure 3. Survival graph of study patients (Log rank p=0.33,amonggroups).

0.4

0.2

0.0

.00 10.00 20.00 30.00 40.00 50.00

0.6

0.8

1.0

Cum

Survival

Time

SurvivalFunctions

IMPLANTTalonLagScrewPFNAInterTanTalonLagScrew-censoredPFNA-censoredInterTan-censored

those having A1 type fractures. Eight patients in our study underwent a second operation to fix cut-out problem; three out of them had A2.1 type fracture, four had A2.2 type frac-ture and one had A2.3 type fracture. Six of these patients were over 80 with one being 96 years of age. We are of the opinion that design of the screw - PFNA or not - is not the only concern regarding the risk of failure, but the risk may also be related with patient related factors.

InterTan nail is similar to PFNA both by means of design and technique. Featuring one or two cephalocervical screws inte-grated within a distal nail, the system allows for further ro-tational stability of the fragmented segments at femoral head or neck. Biomechanical tests have shown that InterTan nail is superior to dynamic hip screws, demonstrating a longer sur-vival under cycling loading and less head displacement.[21] In a clinical comparative study, Zhang et al.[22] have reported that patients receiving InterTan experience less pain than those receiving PFNA asia system with postoperative complications occured in similar rates between groups. In InterTan group, we achieved slightly shorter operative and flouroscopy times than reported in this series while it took significanly longer than implanting PFNA or Talon distal fix nail/lag screw. These authors, similar to us, reported that there were no cut-out lesions in patients receiving InterTan nails at follow-up. We think that low rate of complications is due the advantage of implanting two screws in InterTan technique which eliminates the risk of rotational instability produced by a single screw which may fail to resist the excess amount of load during weight bearing.

Talon distal fix nail/lag screw had four deployable talons both in the femoral shaft part and femoral head part which allow it to gain advanced purchase within bone. Biomechanical testing showed improved intrafragmenter compression about one decade ago.[23] To our knowledge, there has been no clinical study reporting outcomes using the device. Our experiences regarding the device’s benefits are as follows; it engaged into the femoral head and the talons deployed and it anchored into the cortex of the bone and provided good pullout force. The talons are likely to provided resistance against rotation about the axis of the screw although these feature was not tested during the operation. Overall, the technique allowed an easy implantation provided that medullary canal was reamed down to the level that is measured before beginning with the nail insertion. Deployment of the Talons was not distressing and did not require additional effort during the operation. Given that it provided shorter operative times, possibly by eliminat-ing the need for a second screw, this tecnique may be pref-fered over InterTan technique since it caused similar rates in terms of postoperative outcomes.

Risk factors for higher mortality after hip fracture have been reported to be related with various factors including, trochan-teric fracture, low body mass index, poor health status and poor pulmonary function.[5] However, data is limited about

mortality rates after receiving different tretment strategies in the literature. In our study, one and three-year survival rates were similar than those previously reported, and survival was not different among patients operated on using different techniques, indicating that this study had a near-equal patient distribution among groups not only in baseline characteristics but also in terms of life expactancy.

Main limitations of our study was its retrospective design and non-randomization of the patients into treatment arms. Since the number of patients were not equally distributed by type of fracture, we could not draw a conclusion based on which technique fits better to a more complicated fracture.

ConclusionOur experiences showed that Talon distal fix nail/lag screw, PFNA and InterTan systems provided similar satifactory out-comes and acceptable complication rates in treatment of in-tertrochanteric fractures. New Talon distal fix nail/lag screw was associated with lower cut-out when compared to PFNA and shorter operative times when compared with InterTan. Retrospective and non-randomized design of the study pre-cluded drawing a definitive conclusion to postulate the supe-riority of any device over another. Thus, further study is war-ranted to clearly establish these potential advantages distal Talon fix in treatment of severely fragmented pertrochanteric fractures.


REFERENCES

1. Cooper C, Cole ZA, Holroyd CR, Earl SC, Harvey NC, Dennison EM, et al. Secular trends in the incidence of hip and other osteoporotic frac-tures. Osteoporos Int 2011;22:1277–88.

2. Tanner DA, Kloseck M, Crilly RG, Chesworth B, Gilliland J. Hip frac-ture types in men and women change differently with age. BMC Geriatr 2010;10:12.

3. Maeda Y, Sugano N, Saito M, Yonenobu K. Comparison of femoral mor-phology and bone mineral density between femoral neck fractures and trochanteric fractures. Clin Orthop Relat Res 2011;469:884–9.

4. Frost SA, Nguyen ND, Center JR, Eisman JA, Nguyen TV. Excess mortality attributable to hip-fracture: a relative survival analysis. Bone 2013;56:23–9.

5. Lin WP, Wen CJ, Jiang CC, Hou SM, Chen CY, Lin J. Risk factors for hip fracture sites and mortality in older adults. J Trauma 2011;71:191–7.

6. Daugaard CL, Jørgensen HL, Riis T, Lauritzen JB, Duus BR, van der Mark S. Is mortality after hip fracture associated with surgical delay or admission during weekends and public holidays? A retrospective study of 38,020 patients. Acta Orthop 2012;83:609–13.

7. Schipper IB, Marti RK, van der Werken C. Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation. Review of literature. Injury 2004;35:142–51.

8. Parker MJ1, Handoll HH. Gamma and other cephalocondylic intramed-ullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2010;9:CD000093.

9. Rogmark C, Spetz CL, Garellick G. More intramedullary nails and



arthroplasties for treatment of hip fractures in Sweden. Acta Orthop 2010;81:588–92.

10. Yli-Kyyny TT, Sund R, Juntunen M, Salo JJ, Kröger HP. Extra- and in-tramedullary implants for the treatment of pertrochanteric fractures -- re-sults from a Finnish National Database Study of 14,915 patients. Injury 2012;43:2156–60.

11. Platzer P, Thalhammer G, Wozasek GE, Vécsei V. Femoral shortening after surgical treatment of trochanteric fractures in nongeriatric patients. J Trauma 2008;64:982–9.

12. Parker MJ, Bowers TR, Pryor GA. Sliding hip screw versus the Targon PF nail in the treatment of trochanteric fractures of the hip: a randomised trial of 600 fractures. J Bone Joint Surg Br 2012;94:391–7.

13. Lüthje P, Helkamaa T, Nurmi-Lüthje I, Kaukonen JP, Kataja M. An 8-year follow-up study of 221 consecutive hip fracture patients in Fin-land: analysis of reoperations and their direct medical costs. Scand J Surg 2014;103:46–53.

14. Kregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF; Evidence-Based Orthopaedic Trauma Working Group. Unstable pertrochanteric femoral fractures. J Orthop Trauma 2005;19:63–6.

15. Simmermacher RK, Ljungqvist J, Bail H, Hockertz T, Vochteloo AJ, Ochs U, et al. The new proximal femoral nail antirotation (PFNA) in daily prac-tice: results of a multicentre clinical study. Injury 2008;39:932-9.

16. Gardenbroek TJ, Segers MJ, Simmermacher RK, Hammacher ER. The proximal femur nail antirotation: an identifiable improvement in the treat-ment of unstable pertrochanteric fractures? J Trauma 2011;71:169–74.

17. Goffin JM, Pankaj P, Simpson AH, Seil R, Gerich TG. Does bone com-paction around the helical blade of a proximal femoral nail anti-rotation (PFNA) decrease the risk of cut-out?: A subject-specific computational study. Bone Joint Res 2013;2:79–83.

18. Takigami I, Matsumoto K, Ohara A, Yamanaka K, Naganawa T, Ohashi M, et al. Treatment of trochanteric fractures with the PFNA (proximal femoral nail antirotation) nail system - report of early results. Bull NYU Hosp Jt Dis 2008;66:276–9.

19. Vaquero J, Munoz J, Prat S, Ramirez C, Aguado HJ, Moreno E, et al. Proximal Femoral Nail Antirotation versus Gamma3 nail for intramedul-lary nailing of unstable trochanteric fractures. A randomised comparative study. Injury 2012;43 Suppl 2:S47–54.

20. Gavaskar AS, Subramanian M, Tummala NC. Results of proximal femur nail antirotation for low velocity trochanteric fractures in elderly. Indian J Orthop 2012;46:556–60.

21. Rupprecht M, Grossterlinden L, Ruecker AH, de Oliveira AN, Sell-enschloh K, Nüchtern J, et al. A comparative biomechanical analysis of fixation devices for unstable femoral neck fractures: the Intertan versus cannulated screws or a dynamic hip screw. J Trauma 2011;71:625–34.

22. Zhang S, Zhang K, Jia Y, Yu B, Feng W. InterTan nail versus Proximal Femoral Nail Antirotation-Asia in the treatment of unstable trochanteric fractures. Orthopedics 2013;36:288–94.

23. Bramlet DG, Wheeler D. Biomechanical evaluation of a new type of hip compression screw with retractable talons. J Orthop Trauma 2003;17:618–24.



OLGU SUNUMU

İnstabil trokanterik kırık tedavisinde kullanılan üç farklıintramedüller çivinin klinik sonuçlarının karşılaştırılmasıDr. Sinan Zehir,1 Dr. Ercan Şahin,2 Dr. Regayip Zehir3

1HititÜniversitesiTıpFakültesi,OrtopediveTravmatolojiAnabilimDalı,Çorum2BülentEcevitÜniversitesiTıpFakültesi,OrtopediveTravmatolojiAnabilimDalı,Zonguldak3ÇarşambaDevletHastanesi,KardiyolojiKliniği,Samsun

AMAÇ: İntertrokanterik kırıkların tedavisinde kullanılan üç farklı intramedüller çivileme yöntemiyle ilişkili sonuçların değerlendirilmesi amaçlandı.GEREÇ VE YÖNTEM: Bu geriye dönük kohort calismasina A2 ve A3 tip stabil olmayan trokanterik kırık nedeniyle opere edilen hastalar dahil edildi. Kullanılan tekniğe göre hastalar üç gruba ayrıldı: Talon distal sabit çivi/lag screw (n=78, ortalama yaş: 78.5±6.6), PFNA çivi (n=96, ortalama yaş: 77.2±6.8) ve İnterTan çivisi (n=102, ortalama yas: 76.8±6.7). Son kontrolde Harris kalça skoru kaydedildi, sağkalım telefon görüşmesi ve vatandaş-lık bilgi bankası kayıtlarından elde edildi.BULGULAR: Grupların temel özellikleri benzerdi. İnterTan grubunda ameliyat süresi, floroskopi zamanı ve kan kaybı anlamlı olarak fazlaydı. PFNA grubunda sekiz hastada cut-out oluştu. Hastane içi mortalite %3.2 idi (dokuz hasta). Hastanede yatış süresi ve ameliyat sonrası tip-apex mesafesi gruplar arasında farklı değildi. İyileşme süresi ve Harris kalça skoru gruplar arasında benzerdi. Bir yıllık sağ kalım Talon distal sabit çivi/lag screw grubunda %83.1±4.5, PFNA grubunda %84.0±3.8 ve İnterTan grubunda 84.4±3.7 bulundu (p=0.33).TARTIŞMA: Talon distal sabit çivi/lag screw yöntemi daha az cut-out oranıyla PFNA tekniğinden ve daha kısa ameliyat süresiyle InterTan yöntemin-den daha iyi olarak bulunmuştur.Anahtar sözcükler: İntramedüller çivi; komplikasyon; sağkalım; trokanterik kırık.



Multivariate analysis of patients with blunt trauma and possible factors affecting mortalityAdnan Özpek, M.D.,1 Metin Yücel, M.D.,1 İbrahim Atak, M.D.,1

Gürhan Baş, M.D.,1 Orhan Alimoğlu, M.D.2

1DepartmentofGeneralSurgery,UmraniyeTrainingandResearchHospital,Istanbul2DepartmentofGeneralSurgery,MedeniyetUniversityFacultyofMedicine,Istanbul

ABSTRACT

BACKGROUND: This study aimed to investigate the signs and prognosis of the patients hospitalized due to blunt trauma injuries and identify possible factors that affect mortality.

METHODS: Between January 2009 and January 2013, a total of 237 patients admitted with blunt trauma injury were retrospectively analyzed. The age and gender of the patients, type of the trauma, injury site, Injury Severity Scores (ISS), Revised Trauma Scores (RTS), Focused Assessment with Sonography in Trauma (FAST) results, hemodynamic status, need for transfusion, treatment modalities, treatment outcomes, and mortality rates were recorded.

RESULTS: Of the patients, 187 (78.9%) were male, 50 (21.1%) were female and mean age was 36.9±16.9 years (3–81 years). Of the patients, 131 (55.3%) suffered thoracic injuries, 110 (46.6%) abdominal injuries, 96 (40.5%) pelvic and limb injuries, 34 (14.3%) head and neck injuries, 26 (11%) maxillofacial injuries, and 24 (10.1%) skin and subcutaneous tissue injuries. Forty-five patients (19%), in-cluding 33 patients with hemodynamic instability and 12 patients with peritonitis-related signs, were operated on. Mortality was seen in 26 patients (11%), including 10 (38.5%) with unstable pelvic fractures. Mortality rates; in patients with packing performed was 75%, in patients without any need for packing was 33.3%, in patients with hemodynamic instablity was 60.6%, in hemodynamically stable patients was 8.3% and in FAST (+) patients was 20.5%, in FAST(–) patients was 3.4% (p<0.05).

CONCLUSION: Blunt trauma often presents with multi-trauma involving more than one anatomical structure of the body. Tho-racic, abdominal, and pelvic injuries usually accompany blunt trauma. The majority of abdominal solid organ injuries are followed non-operatively. Our study results show that ISS, RTS, FAST result, hemodynamic unstability, packing requirment, and need for transfusion are statistically invaluable in identifying the mortality risk.

Key words: Blunt trauma; Injury Severity Score; mortality; multi-trauma; Revised Trauma Score; transfusion.

years.[1] Most trauma-related injuries are blunt injuries.[1] Such injuries can be caused primarily by traffic accidents, falls from height, or assaults.[1] Blunt trauma injuries, which often pres-ent with multi-trauma involving more than one anatomical structure of the body, are the main causes of emergency ad-missions.[2,3] Therefore, management and follow-up of these injuries require a multidisciplinary approach. The mortality and morbidity rate of blunt trauma injuries are higher than penetrating trauma injuries.[4] Based on the trimodal distribu-tion of trauma deaths proposed by Trunkey in 1983, 50% of deaths occur immediately or within seconds of injury, 30% occur within a few hours, and 20% occur within a few weeks.[5] As a result, pre-hospital services that prevent trauma inju-ries are of utmost importance. In addition, emergency physi-cians and the equipment of the facility play a critical role in re-ducing the mortality rate that occurs within a few hours. The mortality rate can be reduced in fully equipped emergency trauma centers where a multidisciplinary team including phy-



Presented at the 9th Congress of National Trauma and Emergency Surgery held on April 19–23, 2013 in Antalya and was awarded with a third place ranking.

Address for correspondence: Adnan Özpek, M.D.

Ümraniye Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği,

Ümraniye, İstanbul, Turkey



Copyright 2015TJTES

INTRODUCTION

Trauma-related mortality is one of the leading causes of glob-al death, accounting for 9% of all deaths in all age groups. It is also the major cause of death in individuals aged 5 to 49

Özpek et al. Multivariate analysis of patients with blunt trauma and possible factors affecting mortality

sicians and other healthcare staff trained on the management of trauma injuries is available.[6,7] In Turkey, general surgeons are still mostly faced with patients with multi-trauma injuries in State Hospitals, University Hospitals, and Training and Re-search Hospitals, followed by the request for consultation. These patients may be referred to the related department for additional therapies when their clinical status is stable.

The current study aimed to investigate the signs and progno-sis of the patients hospitalized due to blunt trauma injuries and identify possible factors that affect mortality.


This retrospective study included a prospective database of a total of 237 patients who were admitted to the Emergency Department with blunt trauma injury and hospitalized in the General Surgery Inpatient Unit between January 2009 and January 2013. All patients were resuscitated on admission in accordance with the Advanced Trauma Life Support (ATLS) protocol. According to this protocol, the patients were moni-torised in the Emergency Room (ER) as yellow or red area and were resuscitated with ABCDEF approach. Patients were accepted as hemodynamically unstable with an arterial sys-tolic blood pressure of less than 90 mmHg, after they were ressucitated with cristalloids and blood products, via at least 2 intravenous lines with 2000cc (for children 20 cc/kg) in 15 minutes. Similarly, if systolic blood pressure improved after ressucitation, but could not be stabilised, then, they were accepted as unsustainable hemodynamic stability. The pa-tients with hemodynamic instability or unsustainable stability based on the ATLS criteria underwent Focused Assessment with Sonography in Trauma (FAST). In patients with free ab-dominal fluid in FAST, emergency laparotomy was performed. Hemodynamically stable patients were admitted to the clinic after FAST, and computerized tomography (CT) and/or other imaging modalities and consultations were carried out. Some of these patients were operated on after developing peritoni-tis findings or hemodynamic instability.

When a thoracotomy was indicated, a thoracic surgeon was consultated for the operation. Most of the tube thoracosto-mies were performed by general surgeons, some by thoracic surgeons. In unstable pelvic fractures, external fixations were done by orthopedic surgeons, and pelvic packing, if required, was performed by general surgeons. All management and fol-low-up of the patients were conducted by general surgeons in the Intensive Care Unit (ICU) and/or general surgery in-patient unit.

Abbreviated Injury Scale (AIS) was used to identify the in-jury site and grade injuries. Injury Severity Scores (ISS) and Revised Trauma Scores (RTS) were estimated. According to vital signs, the patients were followed in the ICU or general surgery inpatient unit. The age and gender of the patients, type of the trauma, injury site, ISS (0–75) and RTS (0–7,84)

levels, FAST results, hemodynamic status, need for transfu-sion, treatment modalities, treatment outcomes, and mortal-ity rates were analyzed.

Statistical analysis was performed using the Number Crunch-er Statistical System (NCSS; NCSS LLC, Utah, USA) 2007 update and Power Analysis and Sample Sizes (PASS; NCSS LLC, Utah, USA) software. Chi-square and Fisher’s exact test (NCSS 2007 Kaysville, Utah, USA) were performed to analyze categorical variables. p value of <0.05 was considered statistically significant.

RESULTS

Of the two hundred and thirty-seven patients, 187 (78.9%) were male and 50 (21.1%) were female. Mean age was 36.9±16.9 years (range, 3-81 years). The main cause of blunt-trauma injury was in-vehicle traffic accident in sixty-six pa-tients (27.8%), fall from a height in sixty-four patients (27%), traffic accident involving a pedestrian in fifty-five patients (23.2%), motorbike accident in twenty-six patients (11%), crush injury in thirteen patients (5.5%), and assault in thir-teen patients (5.5%).

According to AIS, the frequency of the injury sites were; tho-racic, abdominal, pelvic and extremity, head and neck, maxil-


Table 1. Distribution of injury sites based on AIS

Injury site n %

Thoracic 131 55.3

Abdominal 110 46.4

Pelvic and limb 96 40.5

Head and neck 34 14.3

Maxillofacial 26 11.0

External 24 10.1

AIS: Abbreviated injury scale.

Table 2. Distribution of trunk injuries

Injury site n %

Isolated

Thoracic 55 23.2

Abdominal 42 17.7

Pelvic 15 6.3

Multiple

Thoracoabdominal 48 20.3

Thoracoabdominopelvic 16 6.8

Thoracopelvic 12 5.1

Abdominopelvic 4 1.7


lofacial and external body injuries, respectively. A total of 421 injury sites (mean 1.8 per patient) were identified (Table 1).

When the patients were considered according to trunk inju-ries, thoracic, thoracoabdominal and abdominal injuries were found to be the most common. Thoracoabdominopelvic, pel-vic and abdominopelvic injuries followed them (Table 2).

FAST was performed in one hundred and two of the patients, of whom seventy-threewere FAST (+) and nineteen were FAST (–). When they were compared according to their FAST results, there was no significance between their mean RTS and ISS values. However, the need for transfusion and mortality rates were significantly higher in the FAST (+) group (Table 3).

FAST (+) and hemodynamically instable twenty-five patients underwent laparotomy. In hemodynamically stable patients, FAST, CT and/or other imaging modalities were performed.

All patients were evaluated with a multidisciplinary approach. Eight of these were operated on due to unsustainable he-modynamic stability in their follow up. A total of forty-five patients (19%) including 33 patients with hemodynamic insta-bility and 12 patients with peritonitis-related signs were oper-ated on. In patients operated due to hemodynamic instability, mean ISS, need for transfusion and mortality rate were signifi-cantly higher, mean RTS level was significantly lower (Table 4).

Splenectomy was performed in sixteen patients, and nephrec-tomy in three. Furthermore, treatments for intestinal injury in eight patients, pancreatic injury in three, and diaphragmatic injury in two were carried out. Negative laparotomy results were established in two patients with peritonitis-related signs. Two patients underwent thoracotomy due to major thoracic injury.

Hepatic packing was performed in seven patients with high-


Table 3. A statistical comparison of ISS, RTS, need for transfusion and mortality rates among FAST positive and FAST negative patients

Variables FAST (+) FAST (–) Significance (n=73) (n=29) (p<0.05)

Injury Severity Scores (Mean±SD) 19.8±15.7 17.0±12.3 p=0.881

Revised Trauma Scores (Mean±SD) 6.99±1.95 7.55±1.06 p=0.160

Transfusion (Mean±SD) 2.4 U.±3.2 1.2 U.±3.8 p=0.004

Mortality, n (%) 15 (20.5) 1 (3.4) p=0.036

FAST: Focused Assessment with Sonography in Trauma.

Table 4. A statistical comparison of ISS, RTS, need for transfusion and mortality rates among patients oper-ated with hemodynamic unstability and stability

Variables Hemodynamic Hemodynamic Significance unstable (n=33) stable (n=12) (p<0.05)




Mortality, n (%) 20 (60.6%) 1 (8.3%) p=0.006

Table 5. A statistical comparison of ISS, RTS, need for transfusion and mortality rates among patients treated with packing versus no packing performed

Variables Packing No packing Significance (n=12) (n=33) (p<0.05)




Mortality (n, %) 9 (75%) 11 (33.3%) p=0.032

grade liver injury. Five patients underwent pelvic packing with unstable pelvic fracture. When patients were compared ac-cording to need for packing; in the packing group, mean ISS, need for transfusion and mortality rate were significantly higher and mean RTS level was significantly lower (Table 5).

When the patients were classified according to abdominal or-gan injuries; splenic injuries were in the first place, followed by liver, kidney, intestine, pancreas, intraabdominal major ves-sels and the diaphragm, respectively. A total of 71.4% of the patients with spleen injuries, 79.4% with liver injuries, 88% with renal injuries, and 57% with pancreatic injuries were managed non-operatively. These patients were discharged without mortality (Table 6).

When the patients were classified according to thoracic in-juries, rib fracture and pneumothorax were the most com-

mon, followed by pulmonary contusion, haemothorax, hemo-pneumothorax, thoracic vertebra fracture, clavicula fracture, scapula fracture, flail chest, and sternum fracture. Fifty-two patients (21.9%) underwent tube thoracostomy and two pa-tients (0.8%) underwent thoracotomy (Table 7).

Twenty-three of 47 patients with pelvic injuries had unstable pelvic fractures and 10 of them (43.5%) died. Additionally, mortality was seen in twenty-six(11%) of all patients. Nine (34.9%) of these patients had an AIS score >4 along with head injury.

Mean ISS and RTS levels, and need for transfusion were 18.4, 7.30, and 1.6 U in all patients, respectively. These values were 33.6, 5.66, and 5.4 U in patients that were operated on, re-spectively; whereas, these values were 44.6, 4.22, and 7.8 U in exitus patients, respectively. Mean ISS and need for transfu-



Table 6. Distribution of abdominal injuries and rate of non-operative management

Organ injury n % NOM rate (%)

Spleen 56 23.6 71.4

Liver 34 14.3 79.4

Kidney 25 10.5 88

Intestine 8 3.4 –

Pancreas 7 3.0 57

Great vessel 6 2.5 –

Diaphragm 2 0.8 –

NOM: Non-operative management.

Table 7. Distribution of thoracic injuries

Thoracic injury n %

Rib fracture 67 28.3

Pneumothorax 46 19.4

Pulmonary contusion 32 13.5

Hemothorax 23 9.7

Hemopneumothorax 22 9.3

Thoracic vertebral fracture 21 8.9

Clavicle fracture 17 7.2

Scapula fracture 7 3.0

Flail chest 3 1.3

Sternal fracture 1 0.4

Table 9. A statistical comparison of ISS, RTS, and need for transfusion among survivors and exitus patients

Variables Survivors (211) Exitus patients (26) Significance (p<0.05)

Mean±SD Mean±SD

Injury Severity Scores 15.2±10.0 44.6±11.6 p<0.001

Revised Trauma Scores 7.68±0.75 4.22±2.26 p<0.001

Transfusion (mean+SD) 0.8 U.±2.0 7.8 U.±4.4 p<0.001

Table 8. A statistical comparison of ISS, RTS, and need for transfusion among patients operated on and managed non-operatively

Variables Total (237) Operated patients (45) Non-operated patients (192) Significance (p<0.05)

Mean±SD Mean±SD Mean±SD

Injury Severity Scores 18.4±13.8 33.6±15.8 14.9±10.5 p<0.001

Revised Trauma Scores 7.30±1.49 5.66±2.48 7.69±0.73 p<0.001

Transfusion 1.6 U.±3.2 5.4 U.±4.5 0.7 U.±2.0 p<0.001

sion were statistically significantly higher in patients that were operated on compared to those who were not operated on and exitus patients compared to survivors. Mean RTS was significantly lower in these patients. P value was found to be <0.001 in all three variables among the patients (Tables 8 and 9). However, there was no significant difference in age and gender among the patients (p=0.60 and 0.22 for age; p=0.44 and 0.42 for gender).

DISCUSSIONBlunt trauma injuries mainly affect young adult males. Several studies have reported that such injuries mostly occur at the age of 30 to 40 years with 60 to 80% in the male gender.[2,3,8] In our study, median age was 36.9 and male gender was 78.9%. The main causes of blunt trauma injuries are road traf-fic accidents, followed by falls from height. Similarly, 62% of the patients in our study were exposed to traffic accidents, followed by 27% who fell from height.

Blunt trauma often presents with multi-trauma involving more than one anatomical structure of the body. In most of our patients, abdominal injuries were concominant with thoracic and/or pelvic injuries. In our study, mean injury site was a 2 based on AIS classification. It is interesting that only 17.7% of the patients had an isolated abdominal injury. How-ever, majority of the patients with abdominal trauma pres-ent with thoracic and/or pelvic injuries,[6–8] indicating that the management of patients with blunt trauma injuries requires a multidisciplinary approach, including physicians trained in the management of trauma, as well as well-equipped trauma centers. The mortality rate has been reported to be lower in healthcare centers where trauma management is satisfac-tory.[3,6,7]

FAST was first described by Rozycki and friends in 1996 and has an important role in the diagnoses of trauma patients in the ER.[9,10] FAST, which is rapid, easy to perform, cheap, and repeatable, can be performed in hemodynamically stable and unstable patients.[10] However, CT is recommended only for hemodynamically stable patients. FAST positivity in unstable patients is a precise indication of laparotomy.[11] In different studies, sensitivity of FAST ranges between 80% and 100%.[9,11,12] In our study, all of the hemodynamically unstable and FAST (+) twenty-five patients had several injuries in laparot-omy; twenty-three (92%) had intraabdominal organ injuries and two (8%) had retroperitoneal and pelvic hematoma.

With respect to abdominal trauma, the most affected organs are the spleen, liver, kidney, intestines, and pancreas.[13] The majority of solid organ injuries are followed non-operatively.[13–15] In several studies, 70-80% non-operative management rates have beenreported for intraabdominal solid organ in-juries.[14–16] Similarly, 71.4% of spleen injuries, 79.4% of liver injuries, and 88% of renal injuries were managed non-opera-tively in the present study.

Surgery is usually indicated in the presence of hemodynamic instability due to high-grade solid organ injuries and con-comitant additional injuries.[15] In our study, in patients oper-ated with hemodynamic instability mortality rate, ISS level and need for transfusion were significantly higher. In partic-ular, grade IV-V liver injury and intraabdominal great vessel injury increase the mortality rate. In different studies with high grade liver injuries and unstable pelvis fractures, 40-70% mortality rates have been reported after packing and angio-embolisation.[7,16–18] In our study, a total of nine patients (75%) died including five out of 7 patients with hepatic packing and four out of 5 patients with pelvic packing.

Most hollow organ injuries can be diagnosed with clinical signs of peritonitis during follow-up and can be surgically treated.[15] In patients with a suspicion of hollow viscus injury, CT and diagnostic laparoscopy can be used for diagnosis.[19,20] In our study, we operated on five of eight patients with in-testinal injury due to peritonitis-related signs, as revealed by repeated physical examination sessions. Diagnostic laparos-copy was performed to one of these patients. Three of the remaining patients were operated on due to haemodynamic instability caused by accompained organ injury.

Blunt trauma-induced isolated or concomitant thoracic in-jury is common.[21,22] Hemo/pneumothorax presenting with rib fractures is the most frequently seen injury.[22] The major-ity of these patients are treated with tube thoracostomy.[21,22] Unlike penetrating trauma injuries, fewer patients with blunt trauma injury require thoracotomy.[22] In the present study, tube thoracostomy was essential and adequate in 21.9% of the patients, while 0.8% of the patients required thoracoto-my. Patients with AIS >4 along with severe thoracic injuries had a higher mortality risk.

Unstable pelvic fracture is a type of injury that compromises hemodynamic stability and increases the mortality rate.[23–25] Early and adequate blood product transfusion, pelvic stabi-lization techniques, early diagnosis and management of ad-ditional injuries, angio-embolization, avoidance of unneces-sary laparotomy, and thorough monitoring in the ICU can decrease mortality.[26,27] Extra-peritoneal pelvic packing or internal iliac artery ligation can be an alternative to angio-embolization in healthcare centers where the latter is not available.[28] Furthermore, we performed pelvic packing in five patients in our study.

In addition, the presence of concomitant head injury increas-es the mortality to a large extent. However, first-line therapy should include an intervention to maintain hemodynamic sta-bility in a patient with hemodynamic instability despite the presence of a head injury. After stabilizing the patient hemo-dynamically, further investigations, including cranial CT, can be performed.

Many studies have shown that ISS and RTS are major factors



affecting mortality.[29–33] To the best of the knowledge of the researchers, ISS >40 and RTS <4.5 dramatically increase mor-tality risk.[31–33] In the present study, mean ISS was statistically significantly higher in patients who were urgently operated on, compared to those who were not operated on, and exi-tus patients were compared to survivors (p<0.001). Likewise, mean RTS was significantly lower in these patients (p<0.001).

Moreover, various studies have demonstrated that an in-creased need for transfusion is a risk factor for mortality.[34] In our study, mean need for transfusion was 7.8 U in exitus patients, indicating a significantly higher value compared to survivors (p<0.001).

However, there are some limitations to this study. Firstly, the study was designed as retrospective with a prospective data-base since prospective studies including patients with trauma injuries are unlikely to be conducted. Secondly, classification of the patients was problematic as the study included vari-ous types of injury. Therefore, further studies are required to confirm our findings.

In conclusion, blunt trauma often presents with multi-trauma involving more than one anatomical structure of the body. Thoracic, abdominal, and pelvic injuries are usually accompa-nied. The majority of abdominal solid organ injuries are man-aged non-operatively. Most thoracic injuries are treated with tube thoracostomy while thoracotomy is required in a very limited number of patients. In addition, unstable pelvic frac-ture is a type of injury requiring an ICU stay, which increases the mortality rate. ISS, RTS, positive FAST result, packing re-quirement, hemodynamic unstability and need for transfusion are statistically invaluable in identifying the mortality risk.


REFERENCES

1. World Health Organization, Global Health Observatory Data Reposi-tory, Death Rates: WORLD By cause 2011.

2. Ball SK, Croley GG 2nd. Blunt abdominal trauma. A review of 637 pa-tients. J Miss State Med Assoc 1996;37:465–8.

3. Di Saverio S, Gambale G, Coccolini F, Catena F, Giorgini E, Ansaloni L, et al. Changes in the outcomes of severe trauma patients from 15-year ex-perience in a Western European trauma ICU of Emilia Romagna region (1996-2010). A population cross-sectional survey study. Langenbecks Arch Surg 2014;399:109–26.

4. Yang J, Gao JM, Hu P, Li CH, Zhao SH, Lin X. Management of multiple trauma with mainly thoracic and abdominal injuries: a report of 1166 cases. Chin J Traumatol 2009;12:118–21.

5. Trunkey DD. Trauma. Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research. Sci Am 1983;249:28–35.

6. Demetriades D, Martin M, Salim A, Rhee P, Brown C, Doucet J, et al. Re-lationship between American College of Surgeons trauma center designa-tion and mortality in patients with severe trauma (injury severity score >

15). J Am Coll Surg 2006;202:212-5; quiz A45.

7. Demetriades D, Martin M, Salim A, Rhee P, Brown C, Chan L. The effect of trauma center designation and trauma volume on outcome in specific severe injuries. Ann Surg 2005;242:512–9.

8. Farrath S, Parreira JG, Perlingeiro JA, Solda SC, Assef JC. Predictors of abdominal injuries in blunt trauma. Rev Col Bras Cir 2012;39:295–301.

9. Coşkun F, Akıncı E, Ceyhan MA, Sahin Kavaklı H. Our new stethoscope in the emergency department: handheld ultrasound. Ulus Travma Acil Cerrahi Derg 2011;17:488–92.

10. Sgourakis G, Lanitis S, Korontzi M, Kontovounisios C, Zacharioudakis C, Armoutidis V, et al. Incidental findings in focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients: speaking about cost to benefit. J Trauma 2011;71:123–7.

11. Gaarder C, Kroepelien CF, Loekke R, Hestnes M, Dormage JB, Naess PA. Ultrasound performed by radiologists-confirming the truth about FAST in trauma. J Trauma 2009 ;67:323–9.

12. Kumar S, Kumar A, Joshi MK, Rathi V. Comparison of diagnostic peri-toneal lavage and focused assessment by sonography in trauma as an ad-junct to primary survey in torso trauma: a prospective randomized clini-cal trial. Ulus Travma Acil Cerrahi Derg 2014;20:101–6.

13. Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Non-operative treatment of blunt injury to solid abdominal organs: a prospec-tive study. Arch Surg 2003;138:844–51.

14. Yanar H, Ertekin C, Taviloglu K, Kabay B, Bakkaloglu H, Guloglu R. Nonoperative treatment of multiple intra-abdominal solid organ injury after blunt abdominal trauma. J Trauma 2008;64:943–8.

15. D’Errico E, Goffre B, Mazza D. Blunt abdominal trauma: current man-agement. Chir Ital 2009;61:601–6.

16. Asensio JA, Roldán G, Petrone P, Rojo E, Tillou A, Kuncir E, et al. Op-erative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angio-embolization helps. J Trauma 2003;54:647–54.

17. Hagiwara A, Murata A, Matsuda T, Matsuda H, Shimazaki S. The ef-ficacy and limitations of transarterial embolization for severe hepatic in-jury. J Trauma 2002;52:1091–6.

18. Tai DK, Li WH, Lee KY, Cheng M, Lee KB, Tang LF, et al. Retroperitone-al pelvic packing in the management of hemodynamically unstable pelvic fractures: a level I trauma center experience. J Trauma 2011;71:79–86.

19. Mitsuhide K, Junichi S, Atsushi N, Masakazu D, Shinobu H, Tomo-hisa E, et al. Computed tomographic scanning and selective laparoscopy in the diagnosis of blunt bowel injury: a prospective study. J Trauma 2005;58:696–703.

20. Livingston DH, Tortella BJ, Blackwood J, Machiedo GW, Rush BF Jr. The role of laparoscopy in abdominal trauma. J Trauma 1992;33:471–5.

21. Dongel I, Coskun A, Ozbay S, Bayram M, Atli B. Management of tho-racic trauma in emergency service: Analysis of 1139 cases. Pak J Med Sci 2013;29:58–63.

22. Alihodzic-Pasalic A, Grbic K, Pilav A, Hadzismailovic A, Grbic E. Initial treatment of isolated thoracic injuries. Med Arch 2013;67:107–10.

23. Demetriades D, Karaiskakis M, Toutouzas K, Alo K, Velmahos G, Chan L. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 2002;195:1–10.

24. Verbeek DO, Sugrue M, Balogh Z, Cass D, Civil I, Harris I, et al. Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice. World J Surg 2008;32:1874–82.

25. Cordts Filho Rde M, Parreira JG, Perlingeiro JA, Soldá SC, Campos Td, Assef JC. Pelvic fractures as a marker of injury severity in trauma patients. Rev Col Bras Cir 2011;38:310–6.



26. Biffl WL, Smith WR, Moore EE, Gonzalez RJ, Morgan SJ, Hennessey T, et al. Evolution of a multidisciplinary clinical pathway for the manage-ment of unstable patients with pelvic fractures. Ann Surg 2001;233:843–50.

27. Osborn PM, Smith WR, Moore EE, Cothren CC, Morgan SJ, Williams AE, et al. Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically un-stable pelvic fractures. Injury 2009;40:54–60.

28. Tötterman A, Madsen JE, Skaga NO, Røise O. Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvic hemor-rhage. J Trauma 2007;62:843–52.

29. Bruijns SR, Guly HR, Bouamra O, Lecky F, Lee WA. The value of tra-ditional vital signs, shock index, and age-based markers in predicting trauma mortality. J Trauma Acute Care Surg 2013;74:1432–7.

30. Içer M, Güloğlu C, Orak M, Ustündağ M. Factors affecting mor-tality caused by falls from height. Ulus Travma Acil Cerrahi Derg

2013;19:529–35.

31. Sousa AN, Paiva JA, Fonseca SA, Raposo FJ, Loureiro AM, Valente LF, et al. Trauma scores in the management of politrauma patients: which one and what for?. [Article in Portuguese] Acta Med Port 2011;24:943–50. [Abstract]

32. Akhavan Akbari G, Mohammadian A. Comparison of the RTS and ISS scores on prediction of survival chances in multiple trauma patients. Acta Chir Orthop Traumatol Cech 2012;79:535–9.

33. Emircan S, Ozgüç H, Akköse Aydın S, Ozdemir F, Köksal O, Bulut M. Factors affecting mortality in patients with thorax trauma. Ulus Travma Acil Cerrahi Derg 2011;17:329–33.

34. Hussmann B, Taeger G, Lefering R, Waydhas C, Nast-Kolb D, Ruch-holtz S, et al. Lethality and outcome in multiple injured patients after severe abdominal and pelvic trauma. Influence of preclinical volume re-placement - an analysis of 604 patients from the trauma registry of the DGU. [Article in German] Unfallchirurg 2011;114:705–12. [Abstract]



OLGU SUNUMU

Künt travma sonucu yaralanan hastaların çok yönlü analizi ve mortaliteye etkili faktörlerDr. Adnan Özpek,1 Dr. Metin Yücel,1 Dr. İbrahim Atak,1 Dr. Gürhan Baş,1 Dr. Orhan Alimoğlu2

1ÜmraniyeEğitimveAraştırmaHastanesi,GenelCerrahiKliniği,İstanbul2MedeniyetÜniversitesiTıpFakültesi,GenelCerrahiAnabilimDalı,İstanbul

AMAÇ: Bu çalışmada künt travmaya bağlı yaralanma nedeniyle kliniğimize yatırarak tedavi ettiğimiz hastaların çok yönlü analizini ve mortaliteye etkili faktörleri belirlemeyi amaçladık.GEREÇ VE YÖNTEM: Ocak 2009 ile Ocak 2013 tarihleri arasında, künt travmaya bağlı yaralanma nedeniyle kliniğimize yatırarak tedavi ettiğimiz 237 hasta geriye dönük olarak incelendi. Hastalar yaş, cinsiyet, travmanın şekli, yaralanma bölgeleri, Yaralanma Şiddet Skoru (ISS), Revize Edilmiş Travma Skoru (RTS), FAST sonuçları, hemodinamik durum, transfüzyon gereksinimi, uygulanan tedavi yöntemi, tedavi sonuçları ve mortalite yö-nünden analiz edildi.BULGULAR: Hastaların 187’si (%78.9) erkek, 50’si (%21.1) kadın, yaş ortalaması 36.9±16.9 (3–81 yıl) idi. Hastaların 131’inde (%55.3) torakal, 110’unda (%46.4) abdominal, 96’sında (%40.5) pelvis ve ekstremite, 34’ünde (%14.3) baş ve boyun, 26’sında (%11) maksillofasyal, 24’ünde (%10.1) ise cilt ve cilt altı yumuşak doku yaralanması mevcuttu. Hemodinamik instabilite nedeniyle 33, peritonit bulguları nedeniyle 12 hasta olmak üzere toplam 45 (%19) hasta ameliyat edildi. Hastaların 26’sında (%11) mortalite görüldü ve bunların 10’unda (%38.5) instabil pelvis kırığı bulunmaktaydı. Packing gereken hastalarda %75, packing gerekmeyenlerde %33.3; hemodinamisi instabil hastalarda %60.6, hemodinamisi stabil olanlarda %8.3 ve FAST (+) hastalarda %20.5, FAST (–) hastalarda %3.4 mortalite belirlendi (p<0.05). Hastaların tümünde ortalama ISS değeri 18.4, RTS değeri 7.30, transfüzyon gereksinimi 1.6 Ü. olarak hesaplanırken; ölen hastalarda ise aynı sırayla 44.6, 4.22 ve 7.8 Ü. olarak hesaplandı (p<0.05).TARTIŞMA: Künt travmalar genellikle birden fazla anatomik bölgede yaralanmaya neden olmakta; torakal, abdominal ve pelvik bölge yaralanmaları sıklıkla birbirine eşlik etmektedir. Abdominal solid organ yaralanmalarının büyük kısmı nonoperatif olarak takip ve tedavi edilebilmektedir. Çalışma sonuçlarımız ISS, RTS, FAST sonucu, hemodinamik instabilite, packing ve transfüzyon gereksiniminin mortalite riskini belirlemede istatistiksel olarak değerli olduğunu göstermektedir.Anahtar sözcükler: Künt travma; mortalite; multitravma; Revize Edilmiş Travma Skoru; transfüzyon; Yaralanma Şiddet Skoru.



The diagnostic efficacy of computed tomographyin detecting diaphragmatic injury secondaryto thoracoabdominal penetrating traumas:a comparison with diagnostic laparoscopyMehmet İlhan, M.D.,1 Mesut Bulakçı, M.D.,2 Süleyman Bademler, M.D.,1 Ali Fuat Kaan Gök, M.D.,1

İbrahim Fethi Azamat, M.D.,1 Cemalettin Ertekin, M.D.1

1DepartmentofGeneralSurgery,TraumaandEmergencySurgeryService,İstanbulUniversityİstanbulFacultyofMedicine,İstanbul2DepartmentofRadiology,İstanbulUniversityİstanbulFacultyofMedicine,İstanbul

ABSTRACT

BACKGROUND: This study was designed to investigate the diagnostic efficacy of computed tomography (CT) for the detection diaphragmatic injury in cases undergoing diagnostic and therapeutic laparoscopy in left thoracoabdominal penetrating injuries.

METHODS: Demographic properties, stabbed body region, additional injuries, hemodynamic parameters, time to admission, di-agnostic examinations, and type of treatment were retrospectively reviewed in one hundred and eight patients presenting with left thoracoabdominal injury after penetrating sharp object injury between April 2010 and December 2014. Preoperative CT scans of all patients were reviewed blind to the results of surgical evaluation. The relationship between diaphragmatic injury and hemothorax, pneumothorax, abdominal free fluid, and solid organ injuries were analyzed. All patients underwent physical examination, complete blood count monitoring, and hemodynamic assessment prior to surgery.

RESULTS: The most common finding on physical examination was anterior left thoracoabdominal injury. The injury was detected surgically in 36% of twenty-five cases with lateral injury. Diaphragmatic injury was present in twenty-five (23.1%) of all cases, all of whom were treated with laparoscopic repair. An analysis of all CT findings in relation to surgical results revealed that CT had a sensitiv-ity of 80%, a specificity of 95%, a PPV of 83%, and a NPV of 94% for the detection of diaphragmatic injuries. Mean duration of hospital stay was 5.4 days (range, 1–16 days) in the entire study population.

CONCLUSION: CT is still associated with diagnostic challenges in penetrating diaphragmatic injuries. Nevertheless, CT showed a high specificity and a negative predictive value in our study. Detection of a diaphragmatic defect and fatty tissue herniation makes the definitive diagnosis of diaphragmatic injury in penetrating thoracoabdominal injuries. Prospective studies with a larger sample size are necessary to further clarify the role of CT in detection of diaphragmatic injuries in thoracoabdominal sharp penetrating object injuries.

Key words: Diaphragmatic injury; laparoscopy; MDCT; penetrating trauma; thoracoabdominal.

or sharp penetrating object or stabbing injuries, which can be easily overlooked. It is difficult to make the diagnosis when specific symptoms and radiological signs are absent. Some-times, laparotomy operations performed years after sharp penetrating object injuries may incidentally detect diaphrag-matic hernias.[1]

Isolated penetrating diaphragmatic injuries rarely causes clini-cally overt symptoms and prominent radiological signs be-cause they usually give rise to small diaphragmatic tears with a size of only 1 to 4 cm. In cases managed conservatively, missed diaphragmatic injuries may lead to serious diaphrag-matic hernias and associated life-threatening complications over time. Mortality rates of visceral herniation and stran-gulation reportedly range between 30% and 60%. Various


Address for correspondence: Mehmet İlhan, M.D.

İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim

Dalı, Travma ve Acil Cerrahi Servisi 34390 İstanbul, Turkey



Copyright 2015TJTES

INTRODUCTION

Diaphragmatic injuries may occur via blunt or penetrating trauma. Penetrating traumas are caused by firearm injuries



İlhan et al. Role of computed tomography in detecting penetrating diaphragmatic injury

imaging studies including chest X-Ray, ultrasonography, CT, and MRI are used to diagnose diaphragmatic injuries. In emer-gency departments; however, CT is regarded as the imaging test of choice owing to its ability to rapidly detect even small defects with the help of multiplanar reconstruction images.[2,3]

There are only a few studies that have specifically focused on diaphragmatic injuries caused by sharp penetrating ob-jects. This study, by retrospectively reviewing MDCT scans, aimed to determine the diagnostic efficacy of multidetector computed tomography (MDCT) for diaphragmatic injuries in patients presenting with left thoracoabdominal penetrating sharp object injury in which diaphragmatic injury was evalu-ated by laparoscopy. The presence of a diaphragmatic defect, other organ injuries accompanying diaphragmatic injury, and some CT signs specific to diaphragmatic injuries previously described in the literature were sought for.


The ethics committee of our hospital approved this retro-spective case-control study and waived the requirement for informed patient consent.

PatientsThis study retrospectively reviewed the medical records of one undred and eight patients who had a left thoracoab-dominal sharp penetrating object injury and underwent a CT among patients presenting to the Trauma and Emergency Surgery Unit with penetrating trauma between April 2010 and December 2014. Right thoracoabdominal injuries (not surgically intervened), hemodynamic instability, urgent sur-gery for accompanying injuries, and patient refusal of surgery, who have left thoracoabdominal injuries were the exclusion criteria. Patients presenting to our hospital were examined according to the advanced trauma life support protocol.[4] All patients were applied tetanus prophylaxis. The patients were grouped into three groups based on the injured body region:

1. Anterior left thoracoabdominal injury: Injuries located anterior to the axillary line (below the nipple in front, left superior quadrant of the abdomen).

2. Lateral left thoracoabdominal injury: Left thoracoabdomi-nal injuries between the anterior axillary line and the pos-terior axillary line (below the sixth intercostal space, left superior quadrant of the abdomen).

3. Posterior left thoracoabdominal injury: Injuries located posterior to the posterior axillary line (the eighth inter-costal space at the back, left superior quadrant of the abdomen).

All skin incisions were primarily sutured after the first ex-amination. Patients without symptoms, hemodynamical insta-bility, or a need for urgent surgery for accompanying inju-ries were admitted to hospital. After a mean of 48 hours of

monitoring, patients were evaluated for diaphragmatic injury. Patients with intraabdominal solid organ injury were oper-ated on between fourth and fifth days, and six of them were applied thoracoscopy.

Evaluation Methods and Diagnostic Techniques• Physicalexamination-leucocytecounting: Patients

with a high likelihood of simultaneous intraabdominal or-gan injury were followed with close monitoring and serial physical examinations. After hospital admission, leuko-cyte counting and serial physical examinations were per-formed at every four hours.

• Diagnostic laparoscopy: It was applied in lower tho-racic injuries to exclude the possibility of diaphragmatic injury when laparotomy was not indicated.

• Diagnosticthoracoscopy: It was applied in lower tho-racic and splenic injuries to exclude the possibility of dia-phragmatic injury when laparotomy was not indicated.

• Diagnosticsingle-portlaparoscopy: It was applied in left thoracoabdominal injuries as an alternative to diag-nostic laparoscopy to exclude the possibility of diaphrag-matic injury

• Imagingstudies: Chest X-Ray, Abdominal Ultrasound (FAST), MDCT

• MDCTprotocol: Admission thoracoabdominal MDCT was performed on a 16 (Brilliance 16; Philips Medical Sys-tems, Eindhoven, Netherlands) or 64 (Aquilion 64; Toshi-ba Medical Systems, Otawara-shi, Japan) slice CT system. As the CT device used for imaging of the study subjects was replaced by a new one during the study period, the imaging studies were done with two different devices. Body regions from the level of thoracic inlet to symphy-sis pubis were scanned. Oral and IV contrast materials were routinely administered unless there were contrain-dications. A uniphasic injection of 100–120 ml of contrast agent at a rate of 2–3 ml/s was given to the patients, and images were obtained 60–70 s after the start of intrave-nous contrast medium administration.

• Image interpretation: The images of the patients were stored in our hospital’s picture archiving and com-munication system (PACS), and they were retrospective-ly reviewed in thin sections on axial, coronal, and sagit-tal planes (ExtremePACS,Ankara,Turkey). All CT images were reviewed blind to the surgical results. CT scans of the patients were reviewed and classified into two cat-egories; positive ([+]; injury was detected), negative ([-]; no injury was detected). The study was considered posi-tive when the defect was directly visualized, when her-niation of an intraabdominal organ or fatty tissue was observed, or when contiguous injuries extending to both sides of diaphragm along the injury tract were present. Additionally, each patient was also evaluated for the signs accompanying diaphragmatic injury including pericardial effusion, hemothorax, pneumothorax, lung parenchymal injury, rib fracture, hepatic, splenic, or pancreatic injury,


gastric or intestinal injury, intra or retroperitoneal free air, intra or retroperitoneal hematoma, subcutaneous emphysema, and intraluminal or intravascular contrast extravasation.

Statistical AnalysesDemographic properties, trauma localization, laboratory re-sults, physical examination findings, diagnostic study results, treatment plans, and complications were recorded on a da-tabase. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) levels of CT for de-tection of diaphragmatic injuries were compared with those of laparoscopy that is considered the reference method. The relationship between diaphragmatic injuries and other associ-ated signs was explored using the Chi-square test. All statisti-cal analyses were performed using the SPSS 21.0 statistical package (SPSS, Inc., Chicago, IL, USA). A p value of <0.05 was considered statistically significant.

RESULTS

One hundred and two patients were male, 6 of them were female. Mean age of the study population was 29 years (range, 12–61 years). Twenty-three of the 95 cases undergoing diag-nostic laparoscopy had diaphragmatic injury that was laparo-scopically repaired. One of the 7 cases undergoing single-port diagnostic laparoscopy was detected to have a diaphragmatic injury that was primarily repaired (Fig. 1a-c). Of the 6 patients undergoing diagnostic thoracoscopy, one had diaphragmatic injury that was repaired with thoracoscopy. The most com-mon physical examination findings were anterior and lateral injuries (Fig. 1d, e). Mean duration of hospital stay was 5.4 days (range, 1–16 days). No significant correlation was found be-tween injury region and the presence of a diaphragmatic injury. The injury regions and CT findings were presented in Table 1.

CT scans revealed intraabdominal solid organ injury in four-

Table 1. The region of injury and CT findings according to the findings on physical examination, LTI, SDI

Anterior Lateral Posterior Anterior lateral Anterior- Posterolateral LTI LTI LTI LTI posterior LTI LTI

Number of patients 50 25 22 6 2 3

Number of patients detected to have a SDI 10 9 3 2 – 1

Diaphragmatic injury on CT 9 6 3 1 1 –

Pneumothorax 24 11 11 2 1 2

Haemothorax 27 14 11 2 1 2

Solid organ injury 3 6 2 1 2 –

CT: Computed tomography; LTI: Left thoracoabdominal injury; SDI: Surgical diaphragmatic injury.

Figure 1. (a-c)Omentaltissueher-niation through a diaphragmaticdefectthatdevelopedafterlefttho-racoabdominalstabbing.(d, e) The areaofleftthoracoabdominalinjury.

(a)

(d)

(b)

(e)

(c)


teen cases, of which 4 had grade I-II hepatic left lobe injury, 1 had grade III hepatic injury, 2 had grade III splenic injury, 3 had grade II splenic injury, 1 had grade IV splenic injury, 2 had grade I-II left kidney injury, and 1 had pancreas injury; six of them underwent thoracoscopy. A urinalysis was ordered in twenty-seven cases with left posterior thoracic injury. Five patients had hematuria, of which one was macroscopic (grade-II left kidney injury). A repeat urinalysis test 12 hours after the initial test was normal in the other four patients. These additional traumas increased the duration of hospital stay.

The dependent viscera sign was not observed in any patient. Eighteen patients had discontinuous diaphragma sign while dangling diaphragma sign was not observed in any patient. The diagnosis of diaphragmatic injury was confirmed by sur-gery in all cases with a MDCT clearly showing a diaphragmat-ic defect. A false positive result was obtained in four cases. Three out of them were with suspected diaphragmatic dis-continuity and one had thickening of the diaphragm on CT. Focal thickening was present in eight cases, of which only three had confirmed diaphragmatic injury (Fig. 2). Six cases had intraabdominal fatty tissue herniation through a clearly visible diaphragmatic defect, although no case of solid or hol-low organ herniation was seen. Only two cases had mesen-

teric fatty tissue herniation and associated collar sign. All of the six cases with intraabdominal fatty tissue herniation had laparoscopically confirmed diaphragmatic defect (Figs. 3, 4). Twenty-four cases had contiguous injury, in 17 of which a diaphragmatic injury was confirmed. Considering all CT signs combined, CT had a sensitivity of 80% (95% CI: 59%–93%), a specifity of 95% (95% CI: 88%–99%), a PPV of 83% (95% CI: 63%–95%), NPV 94% (95% CI: 87%–98%) (Table 2).The most common finding accompanying diaphragmatic injury was he-mopneumothorax; whereas, the least common findings were retroperitoneal free air, and hematoma (Table 3).

DISCUSSIONManagement of patients with minimal or asymptomatic left thoracoabdominal penetrating injuries is still a difficult task


Figure 3. A42-year-oldmanpresentedwith left thoracoabdomi-nal stabbingwound. (a)Axial thoracoabdominalCTexaminationwith contrast administration shows full-thickness tear in anteriorabdominalwall,intercostalmusclegroups,anddiaphragmaswellas herniation of intraabdominal fatty tissue to subcutaneous tis-suealongthestabbingtract(arrow).(b)Sagittalmultiplanarrefor-mattedimageshowsdiaphragmaticthickeninganddefect(arrow).Bothimagesclearlyshowinjurytractandsurroundingsubcutane-ousairbubbles.ThiscasewascorrectlydiagnosedbyCTpriortooperation.

(a) (b)

Figure 4. A30-year-oldmanpresentedwithleftthoracoabdominalstabbingwound. (a)Axial thoracoabdominalCTexaminationwithcontrastadministrationshowssubcutaneousairbubblesandhema-toma formation in left-anterior abdominalwall aswell asomentalherniationthroughthelargedefectindiaphragm(arrow).(b) An ar-terialphaseaxialCTimagespassingmoreinferiorlydemonstratesalargelacerationandtinypseudoaneurysminleftlobeofliver(arrow).In both images intraabdominal free fluid formationswith a densecharacter consistentwithdiffusehemoperitoneumarenoted.TheoperativefindingsandCTsignswereinagreementinthispatient.

(a) (b)

(a)

(c)

(b)

(d)

Figure 2. A21-year-oldmanpresentedwith left thoracoabdomi-nal stabbingwound (a)Axial thoracoabdominalCTwithcontrastadministrationshowsastabbingtractwithanobliquecourse(ar-row)presentedwithhemorrhagicregionswithinintercostalmusclegroupsand thickenedareas localizedanterior to left diaphragm.(b) Sagittalmultiplanar reformatted image clearly delineates thethickenedsectionofdiaphragm(arrowheads). (c)Therealsoex-istshemothorax in thebasalpartof left thorax. (d)Evaluationofthesectionspassing fromupperabdomenvia lungparenchymalwindowclearlydemonstratesintraabdominalfreeair(blackarrow).CTexaminationofthispatientwaslabeledasfalsepositivewhenlaparoscopicexaminationrevealednodiaphragmaticinjury.


for trauma surgeons working in emergency departments. Al-though there is no doubt that surgical intervention is needed in case of hemodynamic instability or peritoneal irritation, deciding whether diaphragmatic injuries are present is cur-rently the main challenging task in penetrating thoracoab-dominal injuries. A surgeon should promptly decide upon the need for surgery and the diagnostic procedure to be used in a patient with penetrating thoracoabdominal injury. The aim of diagnostic approach is to reduce the rate of unneces-sary operations and not to miss the necessary ones. Studies have shown that physical examination can predict laparotomy need in an accurate and reliable manner.[5,6] After application of the standard resuscitative approach as the initial approach in all patients, our diagnostic algorithm used leucocyte count-ing, serial physical examinations, and other tests to exclude additional intraabdominal pathologies. In this algorithm, the emergence of the signs of diffuse peritonitis was considered a reliable sign for the decision on laparotomy, as also suggested by other studies.[7,8]

Diagnostic laparoscopy is currently used not only for diagnos-

tic purposes, but also for therapeutic purposes.[9–11] Despite its limited role in anterior abdominal injuries, diagnostic lapa-roscopy is a suitable method for laparoscopic assessment and intervention in thoracoabdominal penetrating injuries.[12] We prefer performing diagnostic laparoscopy to detect diaphrag-matic injuries in all patients with left thoracoabdominal inju-ries. In our study, twenty-three of the 95 patients undergoing diagnostic laparoscopy were diagnosed with diaphragmatic injury that were laparoscopically treated. One of the seven patients undergoing single-port diagnostic laparoscopy was detected with diaphragmatic injury that was primarily treated.

Thoracoscopy can be used for diagnostic and therapeutic purposes by experienced surgical teams in selected cases with penetrating trauma.[13] One of the 6 patients undergoing diagnostic thoracoscopy was diagnosed with diaphragmatic injury that was laparoscopically treated.

Despite being regarded as the most valuable imaging modality for diagnosing diaphragmatic traumas, diagnostic role of CT is still flawed by some difficulties. The sensitivity and specificity


Table 2. The diagnostic efficacy of computed tomography for detection of diaphragmatic injury

Diaphragmatic injury

Present Absent Total

Computed tomography Positive 20 4 24

Negative 5 79 84

Total 25 83 108

Sensitivity: 80% Specificity: %95; PPV: 83% NPV: 94%

Table 3. Computed tomography findings accompanying diaphragmatic injury in penetrating thoracoabdominal trauma

Signs Diaphragmatic injury

Positive (n=25) Negative (n=83)

n % n %

Subcutaneous emphysema 6 24 33 40

Subcutaneous haematoma 7 28 18 21

Pneumothorax 6 24 45 54

Haemothorax 16 64 41 49

Solid organ injury 9* 36 5# 1

Mesenteric stranding 8 32 9 1

Intraperitoneal air 6 24 8 1

Intraperitoneal fluid 13 52 14 2

Retroperitoneal air 1 4 2 0

Retroperitoneal fluid 2 8 4 0

*Spleen: 5, liver: 4, #kidney: 2, spleen: 1, liver: 1, pancreas: 1


of CT for the diagnosis of diaphragmatic rupture are 61% to 87% and 72% to 100%, respectively.[3] Previous studies have reported various CT signs facilitating the diagnosis of dia-phragmatic injuries. Discontinuous diaphragm sign, thicken-ing of the diaphragm, hypoattenuated diaphragm, dependent viscera sign, dangling diaphragm sign, collar sign, contiguous injury sign, sinus cut-off sign, and diaphragmatic/peridiaphrag-matic contrast extravasation are the well-defined CT signs of blunt and penetrating traumas.[2,3,14]

Identification of these signs would provide valuable informa-tion in the diagnostic process. Most previous studies con-tained patient populations focused on blunt traumas or mixed series. However, the pathophysiolgies of blunt and penetrating traumas are markedly different, and radiological features may be different.[14] It should be remembered that signs like collar sign, dependent viscera sign, and organ her-niation are more common in larger defects and blunt traumas with concurrent intraabdominal pressure increase (in con-trast to stab wounds). Among these signs, only the collar sign was observed in two cases in our study, which included only left-sided thoracoabdominal injuries. Six patients had intraab-dominal fatty tissue herniation of variable amounts.

In trauma patients, diaphragmatic thickening may occur due to muscle edema or intramuscular hematoma.[2] We ob-served that focal or diffuse diaphragmatic thickening had a low sensitivity and specificity for the detection of diaphrag-matic injury. It has also previously been reported that this was a non-specific sign for penetrating traumas.[2] This may be attributed to possible differences in diaphragmatic thick-ness in its different regions, as well as possible variability in its appearance in different subjects.[14] In addition, it has been reported that this sign is specific for blunt traumas rather than penetrating traumas.[2,3]

A good agreement was found between CT signs and opera-tive findings in all cases with a clearly visualized defect. A diaphragmatic injury extending to both sides of diaphragm was detected (contiguous injury sign) in seventeen patients with a diaphragmatic defect that was later repaired. In our series, diaphragmatic discontinuity and abdominal fatty tissue herniation were the most specific signs, and the contiguous injury sign was the most sensitive sign.

Although it was not the primary focus of our study, we sug-gest, based on our experiences, that evaluation of coronal and sagittal plane images would also be useful and increase the likelihood of diagnosis while evaluating diaphragmatic inju-ries. A retrospective study investigating the efficacy of MDCT in penetrating thoracic trauma reported a higher sensitivity and specifity than previous studies. The sensitivity of CT for exclusion of diaphragmatic injury was reported 94%, which was attributed to imaging with high-resolution reformatted images.[15] That study also reported that the most useful CT finding was “extension of injury tract to diaphragm”. Bodana-

pally et al. have reported that the contiguous injury sign is the most valuable sign (sensitivity, 88%; specificity, 82%) in single-entry wounds.[2]

Our study had some limitations. First, it had a retrospective design, which may be considered an important limitation. Second, no inter-observer variability analysis was done since all CT studies were done by the same radiologist.

ConclusionDespite diagnostic challenges for the examination of pene-trating diaphragmatic injuries with CT, a thorough knowledge about the pathophysiology of penetrating traumas, familiarity with CT signs of these injuries, and three-dimensional recon-struction techniques may improve diagnostic accuracy. Our study showed a high specificity and relatively high sensitivity for MDCT in the detection of diaphragmatic injuries. Visual-izing a diaphragmatic defect and fatty tissue herniation defi-nitely makes the diagnosis of diaphragm injury. Presence of hemopneumothorax in conjunction with intraabdominal free air-fluid or intraabdominal organ injury supports the presence of a diaphragmatic injury even if a diaphragmatic defect is not clearly visualized. Diaphragmatic injuries in left thoracoab-dominal sharp penetrating object injuries can be accurately diagnosed and repaired. However, our study was designed retrospectively in a specific patient population. More pro-spective studies with larger sample size are needed to better define the diagnostic efficacy of CT in left penetrating thora-coabdominal traumas.


REFERENCES

1. Balaguera J, Garcia-Almata M, Segovia J, Aquiriano L, Delgado de Tórres S, Gamarra S, et al. Delayed asymptomatic left traumatic diaphragmatic hernia after abdominal stab wound. The Internet Journal of Surgery 2008;17:2.

2. Bodanapally UK, Shanmuganathan K, Mirvis SE, Sliker CW, Fleiter TR, Sarada K, et al. MDCT diagnosis of penetrating diaphragm injury. Eur Radiol 2009;19:1875–81.

3. Panda A, Kumar A, Gamanagatti S, Patil A, Kumar S, Gupta A. Trau-matic diaphragmatic injury: a review of CT signs and the difference be-tween blunt and penetrating injury. Diagn Interv Radiol 2014;20:121–8.

4. American College of Surgeons. Advanced trauma life support, Chicago, 1997.

5. Clarke DL, Allorto NL, Thomson SR. An audit of failed non-operative management of abdominal stab wounds. Injury 2010;41:488–91.

6. Kent AL, Jeans P, Ewards JR, Byrne PD. Ten year review of thoracic and abdominal penetrating trauma management. Aust N Z J Surg 1993;63:772–9.

7. Navsaria PH, Berli JU, Edu S, Nicol AJ. Non-operative management of abdominal stab wounds--an analysis of 186 patients. S Afr J Surg 2007;45:128–32.

8. Biffl WL, Kaups KL, Cothren CC, Brasel KJ, Dicker RA, Bullard MK, et al. Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. J Trauma 2009;66:1294–



301.

9. O’Malley E, Boyle E, O’Callaghan A, Coffey JC, Walsh SR. Role of lapa-roscopy in penetrating abdominal trauma: a systematic review. World J Surg 2013;37:113–22.

10. Lin HF, Wu JM, Tu CC, Chen HA, Shih HC. Value of diagnostic and therapeutic laparoscopy for abdominal stab wounds. World J Surg 2010;34:1653–62.

11. Sugrue M, Balogh Z, Lynch J, Bardsley J, Sisson G, Weigelt J. Guide-lines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen. ANZ J Surg 2007;77:614–20.

12. Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma. J Trauma

2005;58:789–92.

13. Bagheri R, Tavassoli A, Sadrizadeh A, Mashhadi MR, Shahri F, Shojae-ian R. The role of thoracoscopy for the diagnosis of hidden diaphragmatic injuries in penetrating thoracoabdominal trauma. Interact Cardiovasc Thorac Surg 2009;9:195–8.

14. Hammer MM, Flagg E, Mellnick VM, Cummings KW, Bhalla S, Raptis CA. Computed tomography of blunt and penetrating diaphragmatic in-jury: sensitivity and inter-observer agreement of CT Signs. Emerg Radiol 2014;21:143–9.

15. Stein DM, York GB, Boswell S, Shanmuganathan K, Haan JM, Scalea TM. Accuracy of computed tomography (CT) scan in the detection of penetrating diaphragm injury. J Trauma 2007;63:538–43.


OLGU SUNUMU

Torakoabdominal delici-kesici alet yaralanmalarında bilgisayarlı tomografinin diyafragma yaralanmasını göstermedeki etkinliği, tanısal laparoskopi ile karşılaştırmaDr. Mehmet İlhan,1 Dr. Mesut Bulakçı,2 Dr. Süleyman Bademler,1 Dr. Ali Fuat Kaan Gök,1

Dr. İbrahim Fethi Azamat,1 Dr. Cemalettin Ertekin1

1İstanbulÜniversitesiİstanbulTıpFakültesi,GenelCerrahiAnabilimDalı,TravmaveAcilCerrahiServisi,İstanbul,Türkiye2İstanbulÜniversitesiİstanbulTıpFakültesi,RadyolojiAnabilimDalı,İstanbul

AMAÇ: Sol torakoabdominal delici kesici yaralanması olan, tanısal veya terapotik laparoskopi yapılan hastalarda bilgisayarlı tomografinin (BT) diyaf-ram yaralanmasını saptamadaki etkinliğinin değerlendirilmesi.GEREÇ VE YÖNTEM: Nisan 2010 ile aralık 2014 tarihleri arasında delici-kesici alet yaralanması ile başvuran sol torakoabdominal yaralanması bu-lunan 108 olgu demografik verileri, bıçaklanma bölgesi, ek travma bulgularının varlığı, hemodinamik parametreleri, başvuru süresi, tanı yöntemleri ve tedavi şekli açısından geriye dönük olarak değerlendirildi. Tüm hastaların ameliyat öncesi bilgisayarlı tomografi görüntüleri geriye dönük olarak cerrahi değerlendirme sonuçları bilinmeden değerlendirilmiştir. Hemotoraks, pnömotoraks, batında serbest sıvı ve solid organ yaralanmalarının diyaframa yaralanması ile ilişkisi araştırıldı. Cerrahi girişim öncesinde tüm olgular fizik muayene, hemogram takibi ve hemodinamik değerlendirme ile takip edildi.BULGULAR: Fizik muayene bulgusu olarak en sık anterior sol torakoabdominal yaralanma saptandı. Lateral yaralanması olan 25 olgunun %36’sında cerrahi olarak yaralanma saptandı. Tüm olguların 25’inde (%23.1) diyafragma yaralanması saptandı ve olgulara laparaskopik tamir yapıldı. Tüm BT bulguları cerrahi sonuçları ile birlikte değerlendirildiğinde diyafragma yaralanmasını göstermede sensitivite %80, spesifite %95, PPV %83, NPV %94 olarak hesaplanmıştır. Ortalama hastanede kalış süresi tüm olgularda 5.4 gün (1–16) olarak gözlendi.TARTIŞMA: Bilgisayarlı tomografi ile penetran diyafragma yaralanmalarını değerlendirmede halen güçlükler mevcuttur. Buna rağmen bizim çalışma-mızda BT yüksek spesifite ve negatif prediktif değere sahiptir. Diyafragma defekti ve yağlı doku herniasyonunun tespit edilmesi torakoabdominal ya-ralanmalarda kesin tanıyı koydurmaktadır. Daha fazla sayıda hasta grubu ile ileriye yönelik çalışma yapılması, delici kesici alete bağlı torakoabdominal yaralanması olan hastalarda diyafram yaralanmasının saptanmasında BT’nin rolünü belirlemede faydalı olacaktır.Anahtar sözcükler: ÇKBT; delici kesici alet yaralanması; diyafragma yaralanması; laparoskopi; torakoabdominal.




Comparison of antemortem clinical diagnosis andpostmortem findings in burn-related deathsHarun Tuğcu, M.D.,1 Fatih Zor, M.D.,2 Mehmet Toygar, M.D.,1 Hüseyin Balandız, M.D.1

1DepartmentofForensicMedicine,GulhaneMilitaryMedicalAcademy,Ankara2DepartmentofPlastic,ReconstructiveandAestheticSurgery,GulhaneMilitaryMedicalAcademy,Ankara

ABSTRACT

BACKGROUND: Burn injuries are an important public health problem resulting in high morbidity and mortality. Mortality in burn patients is associated with age, the extent of the burn surface, and the presence of concurrent chronic diseases. Studies have revealed differences between antemortem clinical diagnoses and postmortem findings in burn-related deaths.

METHODS: In the present study, postmortem examination reports and autopsy reports issued by the Department of Forensic Medicine in Gülhane Military Medical Academy between 1 January 1994 and 30 May 2013 were retrospectively reviewed together with patient charts in an attempt to compare postmortem findings and antemortem clinical findings in burn-related deaths.

RESULTS: In a period of approximately 20 years, thirty-one (6.9%) of the deaths among 450 cases were burn-related. Of the inju-ries, 90.3% were caused by flame burns. Mean burn percentage was 70.52%, and the survival of these cases was found to decrease significantly with increasing burn percentage (r=-0.491, p=0.005). According to autopsy findings, pneumonia was the most frequently overlooked antemortem clinical diagnosis, and mortality was associated with systemic organ failures.

CONCLUSION: Burn-related deaths are an important cause of mortality among soldiers. We believe that postmortem findings revealed by autopsies could significantly contribute to the treatment of burn cases, and that interdisciplinary data sharing would be important in this respect.

Key words: Autopsy; burn injury; soldiers.

deaths has still not been fully elucidated.[6] The comparison of antemortem and postmortem findings has revealed differ-ences between antemortem clinical diagnoses and autopsy findings.[6–8]

Autopsy may show unexpected or unrecognized clinical find-ings, and the data obtained from autopsy can be used to elu-cidate future problems experienced by the patients.

In the present study, post-mortem examination reports and autopsy reports issued by the Department of Forensic Medicine in Gülhane Military Medical Academy between 1 January 1994 and 30 May 2013 were retrospectively reviewed together with the patient charts in an attempt to compare postmortem findings and antemortem clinical findings in burn-related deaths.


The Turkish Armed Forces is one of the largest and the strongest military forces with respect to personnel number. The Department of Forensic Medicine in Gülhane Military Medical Academy is the only unit within the body of Turkish Armed Forces that routinely performs autopsies due to sol-


491

Address for correspondence: Hüseyin Balandız, M.D.

GATA Adli Tıp Anabilim Dalı Başkanlığı, 06010 Etlik, Ankara, Turkey



Copyright 2015TJTES

INTRODUCTION

Burn injuries are a significant public health problem associat-ed with high morbidity and mortality.[1–4] In a comprehensive study in Europe, the incidence of major burns was reported to be 0.2-2.9 per 100,000 individuals, with flash burns, scalds, and contact burns being the most common types of burns, and higher mortality being associated with older age, the ex-tent of the burns, and the presence of chronic diseases.[5]

Although burn-related mortality rates have decreased in re-cent years due to advances in the treatments provided by burn centers, the actual cause of mortality in burn-related


Tuğcu et al. Comparison of antemortem clinical diagnosis and postmortem findings in burn-related deaths

dier deaths of a forensic nature.

In the present study, post-mortem examination reports and autopsy reports issued by the Department of Forensic Medi-cine in Gülhane Military Medical Academy between 1 January 1994 and 30 May 2013 for patients, in which cause of death was burn-related, were retrospectively reviewed together with the patient charts. The study was approved by the Eth-ics Committee of Gülhane Military Medical Academy.

In addition to demographic data of the cases, type of burns, burn percentage, and clinical findings were compared and sta-tistical analyzes were performed.

Descriptive statistics included number (%) and mean stan-dard deviation for continuous variables. The Spearman corre-lation coefficient was calculated to indicate correlations, and a p value <0.05 was considered as statistically significant. SPSS 15.0 for Windows Evaluation Version was used in statistical analyses.

RESULTS

Among the four hundred and fifty cases that underwent postmortem and autopsy examinations in the Department of Forensic Medicine in Gülhane Military Medical Academy between 1 January 1994 and 30 May 2013, thirty-one (6.9%) deaths were found to be burn-related. Of these cases, nine-teen (61.3%) were from the ground forces, nine (29%) were from the gendarmerie, two (6.5%) were from the naval forc-es, and one (3.2%) was from the air forces.

All cases were male, and mean age was 22.9±5.9 (min: 20, max: 45) years. Trauma, after sustaining an accident, was the most common finding in 87.1% of the cases, and twelve cas-es (38.7%) underwent autopsy. Of the injuries, 90.3% were caused by flame burns.

Inhalation injury was observed in thirteen cases (41.9%), and mean length of hospital stay after the incident was 13±14.4 (min: 0, max: 70) days. Demographic characteristics of the patients are shown in Table 1.

Burn injuries most commonly occurred in autumn, and there was no significant seasonal difference (p=0.079). Characteris-tics of injuries and the presence of fasciotomy and tracheos-tomy are shown in Table 2.

Mean burn percentage was 70.52%, and the survival ratio of the cases decreased significantly with increasing burn per-centage (r=-0.491, p=0.005). The survival ratio decreased


Table 2. Characteristics of the injuries of the cases

Demographic data of patients and characteristics of injuries

n %

Distribution of burned areas in the body

Head and neck 29 93.5

Trunk 23 74.1

Back 26 83.8

Upper extremities 31 100

Lower extremities 31 100

Manner of death

Suicide 4 12.9

Accident 27 87.1

Type of Burn

Flame burn 27 87.1

Flame burn + Scalding 1 3.2

Electricity burn 3 9.7

Tracheostomy 11 35.5

Fasciotomy 12 38.7

Table 1. Characteristics and demographic features of the cases

Patient characteristics Data

Number of cases 31

Mean age 22.9±5.9

(min: 20, max: 45)

Autopsy 12 (38.7%)

Mean percentage of burn surface 70.52%

Flame burn 90.3%

Inhalation burn 13 (41.9%)

Survival time after burn injury (days) 13±14.4

(min: 0, max: 70)

Figure 1. Relationshipbetweenbodypercentageofburnandsur-vival.

70

60

50

40

30

20

10

0

31–40 41–50 51–60 61–70 71–80 81–90 91–100

Survivaltimeafterburninjury(day)

Thepercentageofburnsurface


with increasing age; however, this relationship was not found to be statistically significant (r=-0.015, p>0.935) (Fig. 1).

The survival period was 14.45 days among patients who re-quired tracheostomy, and 12.20 days among those who did not. Mann-Whitney U test did not indicate a statistically sig-nificant difference between these two groups (p=0.493).

Patients who underwent fasciotomy survived for 8.42 days on average, while patients who did not undergo fasciotomy survived for 15.89 days on average. Mann-Whitney U test did not indicate a statistically significant difference between these two groups (p=0.759).

The comparison of antemortem diagnoses and postmortem

findings in twelve cases who underwent autopsy revealed pneumonia diagnosis in six of the cases (50%) (Table 3).

DISCUSSIONIn developing countries, burn-related deaths often occur within younger age groups.[1,3,9,10] In developed countries, on the other hand, such deaths are more common among chil-dren and the elderly.[7,11] This age difference can be explained by the implementation of more effective preventive measures and greater availability of treatment options in developed countries. Mean age has been reported as 36.6[2] and 40.1[12] years in studies in burn-related injuries and deaths in Turkey. In the present study, mean age was 22.9 years; therefore, burn-re-


Table 3. The comparison of clinical findings and postmortem findings in patients who sustained burn injuries

No Age Type of burn (%)* Day** Clinical course Clinical diagnosis Postmortem findings and treatment

1 21 Flame burn 61 9 Fasciotomy and escharotomy, Inhalation burn, Pneumonia

mechanical ventilation renal failure

2 23 Flame burn 33 7 Escharotomy,

high fever Wound infection Sepsis (Citrobacter

(pseudomonas), Freundii)

Antibiotherapy

3 21 Flame burn 42 33 Escharotomy and grafting, Antibiotherapy Pneumonia

high fever,

growth in culture

(pseudomonas)

4 21 Flame burn 84 4 Fasciotomy – Pulmonary edema

5 21 Flame burn + 80 4 Fasciotomy, Inhalation burn

scalding mechanical ventilation renal failure

6 21 Flame burn 82 12 Fasciotomy, homografting, Inhalation burn, Pneumonia

high fever, renal failure Tubular necrosis

mechanical ventilation

7 21 Flame burn 92 4 Fasciotomy, Inhalation burn Pneumonia

mechanical ventilation

8 21 Flame burn 80 5 Fasciotomy, Inhalation burn, Pulmonary edema

mechanical ventilation renal failure

9 27 High voltage 75 6 Fasciotomy, – Electricity injury findings

electricity burn Mechanical ventilation in skin samples

10 21 High voltage 48 9 Mechanical ventilation Maxillofacial fractures, Electricity injury findings

electricity burn pneumocephalia in skin samples

11 21 Flame burn 70 8 Fasciotomy, grafting Antibiotherapy Pneumonia,

Pulmonary edema

12 22 Flame burn 42 70 Mechanical ventilation ARDS, Pulmonary edema

antibiotherapy Pneumonia

*: Total body burn surface area; **: Length of hospital stay.

lated injuries and deaths are observed more commonly in a younger age group. As it is known, the study center is a military hospital, and most of the patients are military per-sonnel in the army. Higher frequency of burn-related injuries and deaths among the younger population can be explained by the large population of young individuals in Turkey, and the fact that military service is compulsory for all males reaching a certain age.

Burn-related injuries often occur as a result of accidents.[1,2,710,13] Among the burn-related deaths observed in the present study, 87.1% were caused by accidents while 12.9% were caused by suicide. It has been reported that 14–15% of deaths occurring among females in India are associated with burns,[3] and suicide associated burn injuries rank third with a frequency of 11.4%.[10] According to the study by Büyük et al., suicide has been associated with 6.3% of burn cases.[2]

Within a period of 20 years, 6.9% of the deaths evaluated in this study were caused by burns. Similar studies have report-ed a burn-related mortality ratio of 2.0–19.4%.[1,2,9,14] These studies have reported no difference between military and ci-vilian mortality rates, and it has been reported to be ranging between 5% and 10%.[14,15] The fact that burn-related deaths were reported as an important public health concern in In-dia explains the variability in the frequency of burn-related deaths in the literature.[1,3,9]

Flame burn is the most common cause of burns,[1,6,7] and it has been reported to be often accompanied by inhalation burn.[11,14] In parallel to the literature, flame burns were the most common type of burn in the present study, with a frequency of 90.3%, while inhalation burns were observed in thirteen of the cases (41.9%).

Major risk factors for mortality in burn-related injuries in-clude older age, large burn surface area, and presence of concurrent diseases.[5] In the study by Kumar et al., burn per-centage was greater than 40% in 92.52% of the cases[1] while in the study by Krishnan et al.,[11] mean burn percentage was determined as 43.7%. In the literature, various studies have reported a mean length of hospital stay of 10.7 days,[6] 26.4 days,[11] 13.5 days,[14] and 16.9 days.[7] Mean length of hospital stay was thirteen days in the present study. The cases were young patients who did not have concurrent chronic con-ditions that could affect burn-related mortality. Therefore, systemic organ failures that developed following burns were within the main causes of mortality in the current series of the cases.

Mean ratio of the burned area was 70.52% in the present study. Survival ratio decreased with increasing percentage of the burned area (r=-0.491, p=0.005) (Fig. 1). In addition, survival ratio decreased with increasing age; however, the dif-ference was not found to be statistically significant (r=-0.015, p>0.935).

In the study by Kallinen et al., it has been determined that the upper extremities and trunk are the most commonly affected areas of the body, that 38.5% of the patients undergo tra-cheostomy, and that the patients undergo an average of 2–3 operations.[6] All patients evaluated in the present study had burns on the lower and upper extremities (Table 2). Mean survival period was 14.45 days among patients who re-quired tracheostomy, and 12.20 days among those who did not. Using Mann-Whitney U test, no statistically significant difference was identified between tracheostomy and the sur-vival period (p=0.493). Patients who underwent fasciotomy survived for 8.42 days on average, while those who did not, survived for an average of 15.89 days. Mann-Whitney U test showed no statistically significant difference between fasci-otomy and the survival period (p=0.759).

Mortality in burn patients is associated with multiple organ failure, sepsis, prolonged stay in the intensive care unit, and extended use of mechanical ventilation.[6] Multi-organ dys-function and sepsis are associated with burn percentage, age and gender.[1,6,9] According to autopsy findings, pulmonary in-jury and sepsis were found to be the most common reason of death in all age groups. Edema and congestion have been reported to be worsening with increasing age.[16]

Multi-organ failure associated with sepsis was found to be the primary cause of death, and Pseudomonas was the most com-monly reported microorganisms in septic patients. Thanks to the increasing expertise of burn centers, advances in first aid services, and early treatment of burn patients, mortality among severe burn patients has gradually decreased.[11]

It was previously reported that clinically unrecognized find-ings revealed by autopsies could make significant contribu-tions to the treatment of burn cases by clinicians.[6,8,16] Stud-ies have revealed differences between antemortem clinical diagnoses and postmortem findings in burn-related deaths.[6] In the study by Kallinen et al., autopsy has revealed findings in 14.1% of the cases that were not found on antemortem examination, and pneumonia was the most common diag-nosis during autopsy.[6] The autopsy findings in the present study showed that pneumonia was the most common diag-nosis that remained clinically unrecognized. The comparison of antemortem diagnoses and postmortem findings in twelve cases who underwent autopsy revealed pneumonia diagnosis in six of the cases (50%) (Table 3).

In conclusion, burn-related injuries are an important cause of mortality in military populations, as well as the general population. We consider that the findings revealed by autop-sies could make significant contributions to the treatment of burn cases and that interdisciplinary data sharing would be important in this respect.


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REFERENCES

1. Kumar V, Mohanty MK, Kanth S. Fatal burns in Manipal area: a 10 year study. J Forensic Leg Med 2007;14:3–6.

2. Büyük Y, Koçak U. Fire-related fatalities in Istanbul, Turkey: analysis of 320 forensic autopsy cases. J Forensic Leg Med 2009;16:449–54.

3. Sanghavi P, Bhalla K, Das V. Fire-related deaths in India in 2001: a retro-spective analysis of data. Lancet 2009;373:1282–8.

4. Roberts G, Lloyd M, Parker M, Martin R, Philp B, Shelley O, et al. The Baux score is dead. Long live the Baux score: a 27-year retrospective co-hort study of mortality at a regional burns service. J Trauma Acute Care Surg 2012;72:251–6.

5. Brusselaers N, Monstrey S, Vogelaers D, Hoste E, Blot S. Severe burn injury in Europe: a systematic review of the incidence, etiology, morbidity, and mortality. Crit Care 2010;14:R188.

6. Kallinen O, Partanen TA, Maisniemi K, Böhling T, Tukiainen E, Kol-jonen V. Comparison of premortem clinical diagnosis and autopsy find-ings in patients with burns. Burns 2008;34:595–602.

7. Kallinen O, Maisniemi K, Böhling T, Tukiainen E, Koljonen V. Multiple organ failure as a cause of death in patients with severe burns. J Burn Care Res 2012;33:206–11.

8. Fish J, Hartshorne N, Reay D, Heimbach D. The role of autopsy on pa-tients with burns. J Burn Care Rehabil 2000;21:339–44.

9. Sharma BR, Harish D, Singh VP, Bangar S. Septicemia as a cause of death in burns: an autopsy study. Burns 2006;32:545–9.

10. Padubidri JR, Menezes RG, Pant S, Shetty SB. Deaths among wom-en of reproductive age: a forensic autopsy study. J Forensic Leg Med 2013;20:651–4.

11. Krishnan P, Frew Q, Green A, Martin R, Dziewulski P. Cause of death and correlation with autopsy findings in burns patients. Burns 2013;39:583–8.

12. Cömert SS, Acar H, Doğan C, Cağlayan B, Fidan A. Clinical, radio-logical and bronchoscopic evaluation of inhalation injury cases treated at a burn center. [Article in Turkish] Ulus Travma Acil Cerrahi Derg 2012;18:111–7.

13. Tümer AR, Akçan R, Karacaoğlu E, Balseven-Odabaşı A, Keten A, Kanburoğlu C, et al. Postmortem burning of the corpses following homi-cide. J Forensic Leg Med 2012;19:223–8.

14. Gomez R, Murray CK, Hospenthal DR, Cancio LC, Renz EM, Hol-comb JB, et al. Causes of mortality by autopsy findings of combat ca-sualties and civilian patients admitted to a burn unit. J Am Coll Surg 2009;208:348–54.

15. Wolf SE, Kauvar DS, Wade CE, Cancio LC, Renz EP, Horvath EE, et al. Comparison between civilian burns and combat burns from Op-eration Iraqi Freedom and Operation Enduring Freedom. Ann Surg 2006;243:786–95.

16. Pereira CT, Barrow RE, Sterns AM, Hawkins HK, Kimbrough CW, Je-schke MG, et al. Age-dependent differences in survival after severe burns: a unicentric review of 1,674 patients and 179 autopsies over 15 years. J Am Coll Surg 2006;202:536–48.

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OLGU SUNUMU

Yanığa bağlı ölümlerde antemortem klinik tanılar ve postmortem bulguların karşılaştırmasıDr. Harun Tuğcu,1 Dr. Fatih Zor,2 Dr. Mehmet Toygar,1 Dr. Hüseyin Balandız1

1AdliTıpAnabilimDalı,GülhaneAskeriTıpAkademisi,Ankara2Plastik,RekonstrüktifveEstetikCerrahiAnabilimDalı,GülhaneAskeriTıpAkademisi,Ankara

AMAÇ: Yanığa bağlı yaralanmalar, yüksek morbidite ve mortaliteyle sonuçlanabilen önemli bir halk sağlığı sorunudur. Yanık hastalarında mortalite; yaşlılık, yanık alanı yüzdesinin geniş olması ve kronik hastalıkların birlikteliği ile ilişkilidir. Yapılan çalışmalar, yanığa bağlı ölüm olgularında premortem klinik teşhisler ile postmortem bulguların farklılık gösterdiğini ortaya çıkartmıştır.GEREÇ VE YÖNTEM: Bu çalışmada, 1 Ocak 1994 ile 30 Mayıs 2013 tarihleri arasında, Gülhane Askeri Tıp Akademisi Adli Tıp Anabilim Dalı’nda yapılan ölü muayenesi ve otopsi raporları ile hasta dosyaları geriye dönük olarak incelenerek, yanığa bağlı ölümlerde saptanan postmortem bulgular ile antemortem klinik bulguların karşılaştırılması amaçlanmıştır.BULGULAR: Yaklaşık 20 yıllık bir süre zarfında, 450 olgunun 31’inin (%6.9) yanığa bağlı ölüm olduğu saptanmıştır. Yaralanmaların %90.3 oranında alev yanığı sonucu meydana geldiği saptanmıştır. Olguların yanık yüzdesi oranı ortalaması %70.52 olup bu oran arttıkça yaşam süresinin istatistiksel olarak kısaldığı saptanmıştır (r=-0.491, p=0.005). Otopsi bulgularına göre; antemortem olarak atlanan en sık klinik tanının pnömoni olduğu ve mortalitenin sistemik organ yetersizliklerine bağlı olduğu saptanmıştır.TARTIŞMA: Yanığa bağlı ölümler asker popülasyonu açısından önemli bir mortalite nedenidir. Otopsi ile ortaya konulan postmortem bulguların, yanık hastaların tedavisini yürüten klinisyenlere önemli katkılar sağlayacağını ve bu bağlamda disiplinlerarası veri paylaşımının önemli olduğunu de-ğerlendirmekteyiz.Anahtar sözcükler: Asker; otopsi; yanığa bağlı yaralanmalar.



Posterior segment intraocular foreign bodies: the effect of weight and size, early versus late vitrectomy and outcomesZafer Öztaş, M.D.,1 Serhad Nalçacı, M.D.,1 Filiz Afrashi, M.D.,1 Tansu Erakgün, M.D.,2

Jale Menteş, M.D.,1 Cumali Değirmenci, M.D.,1 Cezmi Akkın, M.D.1

1DepartmentofOphthalmology,EgeUniversityFacultyofMedicine,Izmir2DepartmentofOphthalmology,EkolENTHospital,Izmir

ABSTRACT

BACKGROUND: The objective of this study was to identify the effects of weight and size characteristics of posterior segment intraocular foreign bodies (IOFBs) in open globe injuries.

METHODS: Fifty-eight eyes of 58 patients with posterior segment IOFBs were enrolled in the study. All IOFBs were removed by pars plana vitrectomy. Factors including age, gender, best corrected visual acuity (BCVA), nature of IOFBs, weight and dimensions of IOFBs, initial ocular features, timing of IOFB removal, entry site of IOFBs, interventions and complications were evaluated.

RESULTS: Mean age of the patients was 32.7±14.2 years, and mean follow up period was 18±13.3 months. Weight, length, width and thickness of IOFBs were found negatively correlated with initial and final BCVA levels (p<0.05). Weight of IOFBs was significantly greater in eyes with initial hyphema, vitreous hemorrhage, retinal hemorrhage, retinal detachment, and uveal prolapse (p<0.05). Width and thickness of IOFBs were significantly greater in eyes with hyphema, vitreous hemorrhage, retinal hemorrhage and uveal prolapse (p<0.05). Length of IOFBs was significantly longer in eyes with hyphema (p<0.05). Presence of initial or subsequent retinal detach-ment was associated with poor final BCVA (p<0.05). There was no association between the timing of IOFB removal and incidence of endophthalmitis.

CONCLUSION: Greater weight and size of posterior segment IOFBs were associated with worse outcomes in open globe injuries. Protective eyewear has a crucial importance to avoid work-related injuries. In our study, early or late vitrectomy for an IOFB removal had no significant effect on anatomic and visual outcomes. Therefore, vitrectomy can be postponed until optimal conditions are obtained.

Key words: Endophthalmitis; intraocular foreign bodies; pars plana vitrectomy; retinal detachment.

the object, presence of endophthalmitis, and the entry site of penetration.[3] Removal of posterior segment IOFBs by pars plana vitrectomy (PPV) is the main surgical procedure that provides direct viewing and controlled surgery.

The purpose of this study was to identify the impact of weight and size characteristics of posterior segment IOFBs in open globe injuries. To the best of our knowledge, this is the first study that correlates (Spearman) weight and size measurements of posterior segment IOFBs with presenting and final visual acuity levels. Prognostic factors for presenting and final visual acuity, management, and outcomes were also evaluated.


A retrospective chart review was approved by appropriate in-stitutional ethics committees and health authorities and was conducted in accordance with the Declaration of Helsinki. Consecutive medical records of patients with posterior seg-ment IOFBs who presented at our hospital between October


Address for correspondence: Zafer Öztaş, M.D.

Ege Üniversitesi Tıp Fakültesi, Göz Hastalıkları Anabilim Dalı,

3. Kat, Bornova, 35040 İzmir, Turkey



Copyright 2015TJTES

INTRODUCTION

Ocular injuries with posterior segment intraocular foreign bodies (IOFBs) remain a major cause of ocular morbidity.[1,2] Retained IOFBs may lead to sight-threatening conditions, such as endophthalmitis, retinal breaks, retinal detachment, vitreous hemorrhage, and macular scar formation. The sever-ity of injury caused by an IOFB depends on several factors, including characteristics of the foreign body, momentum of



Öztaş et al. Posterior segment intraocular foreign bodies: the effect of weight and size, early versus late vitrectomy and outcomes

2005 and January 2013 were identified. Fifty-eight patients were enrolled for a total of 58 eyes. Of the sixty-five pa-tients diagnosed with posterior segment IOFBs, seven were excluded because of multiple IOFBs. Anterior segment IOFBs were also excluded.

The data collected included age, gender, initial and final best corrected visual acuity (BCVA), weight and dimensions (length, width, thickness) of IOFBs, nature of IOFBs, initial ocular features, time of interval from injury to IOFB removal, entry site of IOFBs, location of IOFBs, interventions, and complications.

Visual acuity was measured with the Snellen decimal system used in our office. Visual acuity values were converted to log-MAR units for statistical analysis. All foreign bodies removed from the eyes were packaged immediately following removal and kept in our clinic for medicolegal reasons. IOFBs were measured with a caliper to determine the greatest diameter in length, width, and thickness. Weights of IOFBs were mea-sured in the laboratory using a precision weighing device.

All eyes underwent IOFB removal with a standard three-port PPV technique. Patients who had a leaking wound underwent primary globe repair prior to PPV. In suitable cases, primary globe repair was combined with PPV. Patients with a self-sealing wound without leakage had PPV as initial intervention. IOFBs were removed through the sclera or anterior segment depending on their characteristics.

Birmingham Eye Trauma Terminology was used for classifi-cation and definition of ocular trauma.[4] Open globe injury indicates a full thickness wound of the eye. An IOFB indicates any open globe injury with a retained foreign body. A self-sealing wound is an entry site of the IOFB that closes tightly without primary globe repair. Ocular Trauma Classification Group was used to describe wound location:[5] Zone 1 in-jury involves the cornea and limbus; zone 2 injury involves the region 5 mm or less posterior to the limbus; and zone 3 involves the region exceeding 5 mm posterior to the limbus. Analysis was performed using SPSS software version 16.0 (SPSS, Inc., Chicago, Illinois, USA). After the test of nor-mality, nonparametric tests were used for statistical analy-sis. Association between the variables was studied using the Mann–Whitney U and Pearson chi-square tests. Continuous variables were compared with Spearman’s rho. A p value of less than 0.05 was considered statistically significant for all tests.

RESULTS

Fifty-eight eyes of 58 patients (53 male, 5 female; mean age, 32.7±14.2 [range, 8–78] years) with posterior segment IOFBs were included into the study. Mean follow-up was 17.9±13.3 (range, 3–60) months. The causes of posterior segment IOFBs were work-related open globe injuries in thirty-nine

eyes (67%), nonwork-related trauma in eight eyes (14%), gun shot in four eyes (7%), and unknown in seven eyes (12%). The majority of IOFBs were metal in fifty-two eyes (90%), stone in three eyes (5%), glass in two eyes (3%), and animal horn in one eye (2%). Table 1 presents initial findings identified in patients with posterior segment IOFBs. In four cases, iris and lens injuries were not assessed initially due to total hyphema. IOFBs were localized to the retinal surface in forty-one eyes (70.7%) and to the vitreous in seventeen eyes (29.3%). IOFB entry points involved zone 1 in forty-one eyes (70.7%), zone 2 in sixteen eyes (27.6%), and zone 3 in one eye (1.7%). For surgical management, primary globe repair was performed prior to removal of the IOFB in 1sixteen eyes (27.6%), and primary globe repair combined with PPV as a single proce-dure was used in twenty-four eyes (41.4%). PPV without pri-mary globe repair was used for patients with a self-sealing wound (18 eyes [31%]). IOFBs were removed through the sclera in forty-eight eyes (82.8%) and through the anterior segment (trans-corneal) in ten eyes (17.2%). We used silicone oil tamponade in forty-five eyes (77.6%) and gas tamponade in nine eyes (15.5%). At the end of the follow-up, crystalline lens was preserved in thirteen eyes (22.4%). Procedures re-sulted in pseudophakia in forty-one eyes (70.7%) and aphakia in four eyes (6.9%). The most frequent complication after the removal of IOFBs was retinal detachment in eleven eyes (18.9%). Retinal detachment occurred subsequently in eight eyes and re-detached in three eyes. Other complications were glaucoma in ten eyes (17.2%), macular scar formation in four eyes (6.9%), aphakia in four eyes (6.9%), corneal decom-pensation and scars in four eyes (6.9%), and phthisis bulbi in two eyes (3.4%).

Mean weight of IOFBs was 46±116 mg (range, 0.1–806; medi-an, 10). Mean measurements of length, width, and thickness of the IOFBs were 3.65±3.45 mm (range, 0.8–19.7; median, 2.6), 2.08±1.51 mm (range, 0.5–8.5; median, 1.8), and 0.89±0.66 mm (range, 0.2–2.6; median, 0.7), respectively. The relation between size of IOFBs and IOFB localization, removal site of

Table 1. Initial findings of the patients

Initial findings Number of eyes

n %

Vitreous hemorrhage 33 56.9

Iris injury 31 53.4

Retinal hemorrhage 29 50.0

Lens injury 26 44.8

Retinal break 25 43.1

Hyphema 20 34.5

Uveal prolapse 13 22.4

Endophthalmitis 9 15.5

Retinal detachment 7 12.0


Table 2. Relation between predictive factors and size of intraocular foreign bodies

Mean Weight-mg Mean Length-mm Mean Width-mm Mean Thickness-mm (range, median) (range, median) (range, median) (range, median)

Localization of IOFBs Vitreous 36±53 3.8±3.3 2.2±1.7 0.9±0.6 (0.1–226, 14.2) (0.8–15, 2.7) (0.5–8.5, 2.7) (0.2–2.6, 0.8) Retina 55±152 3.5±3.6 2±1.3 0.9±0.7 (0.2–80, 9.5) (1.5–19.7, 2.6) (0.7–7.5, 2) (0.2–2.6, 0.6)Removal site Sclera 42±122 3.5±3.4 2±1.3 0.8±0.6 (0.1–806, 9.4) (0.8–19.7, 2.5) (0.5–7.5, 1.8) (0.2–2.6, 2.7) Trans-corneal 66±88 4.3±3.9 2.6±2.2 1.2±0.7 (2–226, 23.2) (1.5–15, 3.2) (0.7–8.5,1.8) (0.5–2.6, 2.7)*

Initial 1indings Endophthalmitis (+) 22±23 4.0±2.7 2±1.2 0.7±0.3 (1–70, 9.4) (2–10.5, 3) (0.7–4.8, 1.8) (0.2–1.2, 0.7) Endophthalmitis (–) 51±126 3.6±3.6 2.1±1.6 0.9±0.7 (0.1–806, 9.6) (0.8–19.7, 2.6) (0.5–8.5, 1.8) (0.2–2.6, 0.7) Iris injury (+) 28±47 2.7±1.3 1.8±1 0.8±0.6 (0.1–213, 8.3) (0.8–6.3, 2.5) (0.5–4.8, 1.6) (0.2–2.6, 0.6) Iris injury (–) 69±171 4.7±4.8 2.4±1.9 0.9±0.6 (0.2–806, 12) (1.1–19.7, 2.9) (0.7–8.5, 1.9) (0.3–2.6, 0.7) Lens injury (+) 37±61 3.5±3 2±1.5 0.9±0.6 (1–226, 11.2) (1.1–15, 2.5) (0.7–8.5, 1.8) (0.2–2.6, 0.6) Lens injury (–) 54±157 3.5±3.9 1.9±1.4 0.9±0.7 (0.1–806, 8) (0.8–19.7, 2.6) (0.5–7.5, 1.8) (0.2–2.6, 0.6) Hyphema (+) 49±54 3.7±1.9 2.4±1 1.3±0.7 (3–213, 28.8)* (1.8–9.5, 3.5)* (0.7–5, 2.1)* (0.4–2.6, 1)*

Hyphema (–) 45±139 3.6±4 1.9 ± 1.7 0.7±0.5 (0.1–806, 5.6) (0.8–19.7, 2.5) (0.5–8.5, 1.5) (0.2–2.6, 0.5) Vitreous hemorrhage (+) 67±149 4±4 2.4±1.7 1±0.7 (2–806, 16)* (1.5–19.7, 2.5) (0.7–8.5, 2)* (0.4–2.6, 0.8)*

Vitreous hemorrhage (–) 19±34 3.2±2.4 1.9±1.7 0.7±0.5 (0.1–138, 5.8) (0.8–10.5, 2.7) (0.5–5, 1.5) (0.2–2.6, 0.5) Retinal hemorrhage (+) 72±16 4±4.3 2.4 ± 1.8 1±0.7 (2–806, 16)* (1.5–19.7, 2.5) (0.7–8.5, 2)* (0.4–2.6, 0.8)*

Retinal hemorrhage (–) 20±34 3.2±2.3 1.7±1.1 0.7±0.5 (0.1–138, 7.5) (0.8–10.5, 2.7) (0.5–5, 1.5) (0.2–2.6, 0.6) Retinal tear (+) 60±166 3.7±3.4 2.1±1.9 0.8±0.6 (0.4–806, 8.3) (1–15, 2.7) (0.6–8.5, 1.9) (0.2–2.6, 0.6) Retinal tear (–) 35±56 3.6±3.6 2±1.2 0.9±0.7 (0.1–269, 9.8) (0.8–19.7, 2.6) (0.5–5, 1.8) (0.2–2.6, 0.8) Retinal detachment (+) 121±115 7±7 3.3±2.7 1.4±1 (1–269, 114)* (1.1–19.7, 3.4) (0.7–8.5, 2.5) (0.3–2.6, 0.8) Retinal detachment (–) 36±114 3.2±2.3 1.9±1.2 0.8±0.6 (0.1–806, 9.4) (0.8–13, 2.6) (0.5–7.5, 1.8) (0.2–2.6, 0.7) Uveal prolapse (+) 106±214 4.4±3.4 3±1.8 1.4±0.8 (6–806, 34.7)* (1.8–13.2, 3) (1.7–7.5, 2)* (0.5–2.6, 1.2)*

Uveal prolapse (–) 29±60 3.4±3.4 1.8±1.3 0.7±0.5 (0.1–269, 6.7) (0.8–19.7, 2.6) (1.5–8.5, 1.5) (0.2–2.6, 0.5)Complications Glaucoma (+) 111±252 3.6±3.5 2.3±2 1±0.8 (2–806, 9.4) (1.5–13.2, 2.5) (0.7–8.5, 1.7) (0.4–2.6, 0.6) Glaucoma (–) 33±56 3.6±3.5 2±1.4 0.9±0.6 (0.1–269, 9.7) (0.8–19.7, 2.7) (0.5–8.5, 1.8) (0.2–2.6, 0.7) Recurrence/new RD (+) 111±241 4.8±4.8 2.8±2.6 0.8±0.7 (0.2–806, 9.5) (1.1–15, 2.7) (0.7–8.5, 2) (0.3–2.5, 0.5) Recurrence/new RD (–) 31±54 3.3±3 1.9±1 0.9±0.6 (0.1–269, 9.6) (0.8–19.7, 2.6) (0.5–5, 1.8) (0.2–2.6, 0.7)Surgical management PPV after primary globe repair 46±68 4.2±4.2 2.4±1.2 1.1±0.6 (4–269, 21) (2–19.7, 3) (0.7–5, 2.3) (0.4–2.6, 0.9) Combined primary globe repair and PPV 77±168 4.1±3.6 2.5±1.9 1.1±0.7 (1–806, 15.5) (1.1–15, 2.8) (0.9–8.5, 2) (0.3–2.6, 0.7) PPV as a single procedure (self-sealing wound) 6±10 2.5±2.1 1.2±0.5 0.5±0.2 (0.1–44, 2.6)* (0.8–10.5, 2)* (0.5–2, 1.1)* (0.2–1, 0.4)*

RD: Retinal detachment; PPV: Pars plana vitrectomy; *p<0.05 with Mann-Whitney U Test.


IOFBs (trans-corneal or sclera), initial findings, complications, and surgical management were evaluated (Mann–Whitney U Test, Table 2). The weight of posterior segment IOFBs was significantly greater in eyes with initial hyphema, vitreous hem-orrhage, retinal hemorrhage, retinal detachment, and uveal prolapse (Mann–Whitney U Test, p<0.001, p=0.021, p=0.048, p=0.049, p=0.002, respectively). The length (longest diameter of an IOFB) of IOFBs was significantly longer in eyes with hy-phema (Mann–Whitney U Test, p=0.024). The width of IOFBs was significantly greater in eyes with initial hyphema, vitreous hemorrhage, retinal hemorrhage, and uveal prolapse (Mann–Whitney U Test, p=0.003, p=0.022, p=0.048, p=0.003, respec-tively). Thicker IOFBs were related to the presence of initial hyphema, vitreous hemorrhage, retinal hemorrhage, and uveal prolapse (Mann–Whitney U Test, p=0.001, p=0.024, p=0.027, p=0.002, respectively). There was a significant association be-tween the removal site and thickness of IOFBs. Thicker IOFBs were removed through the trans-corneal rather than sclera (Mann–Whitney U Test, p=0.037). Eyes with a self-sealing wound that underwent only PPV as the surgical management had lighter and smaller (length, width, and thickness) poste-rior segment IOFBs (Mann–Whitney U Test, p<0.05).

The presenting mean BCVA in decimal units was 0.25±0.28 (logMAR, 1.65±1.25; range, 20/20 to LP), and the final BCVA was 0.32±0.35 (logMAR, 0.61±1.02; range, 20/20 to LP). The difference between initial and final BCVA was significant (Wil-coxon, p<0.001). Initial as well as final BCVA levels were neg-atively correlated with weight and dimensions (length, width, and thickness) of IOFBs (Spearman Correlation, Table 3). The relation between prognostic factors and BCVA indicated that presenting BCVA was poor in patients with initial endo-phthalmitis, lens injury, and retinal hemorrhage (Mann–Whit-ney U Test, p=0.036, p=0.013, p=0.009, respectively) (Table 4). The presence of initial or subsequent (recurrent/new) retinal detachment was associated with poor final BCVA (Mann–Whitney U Test, p=0.045, p=0.003, respectively). None of the other examined prognostic factors, including na-ture of IOFBs, entry points of IOFBs, removal time (delayed or not), removal site (sclera or trans-corneal), localization of IOFBs (retina or vitreous), surgical management, and initial findings, were statistically significant for either presenting or final BCVA (Table 4).

IOFBs were removed from the eyes within two days in 31


Table 4. Association between prognostic factors and visual acuity

Prognostic factors Initial best corrected visual acuity (p) Final best corrected visual acuity (p)

Nature of IOFBs =0.773 =0.364

Removal time (delayed or not) Not-evaluated =0.919

Removal site (sclera or trans-corneal) =0.056 =0.163

Localization of intraocular foreign body =0.740 =0.684

Entry site (zone) of intraocular foreign body =0.281 =0.097

Surgical managementa =0.456 =0.904

Endophthalmitis =0.036* =0.115

Iris injury =0.013* =0.518

Lens injury =0.069 =0.337

Hyphema =0.080 =0.616

Vitreous hemorrhage =0.095 =0.136

Retinal hemorrhage =0.009* =0.094

Initial retinal detachment =0.092 =0.045*

Uveal prolapse =0.851 =0.415

Recurrence/new retinal detachment Not-evaluated =0.003*

BCVA: Best corrected visual acuity; aThe affect of surgical management groups (presented in table 3) on BCVA; *Statistical significance with Mann–Whitney U Test.

Table 3. Correlation between BCVA and intraocular foreign body size

Visual acuity Weight Width Length Thickness

Initial best corrected visual acuity rs=0.435 p=0.001* rs=0.370 p=0.004* rs=0.357 p=0.006* rs=0.434 p=0.001*

Final best corrected visual acuity rs=0.396 p=0.002* rs=0.278 p=0.034* rs=0.361 p=0.005* rs=0.326 p=0.012*

*Statistical significance by Spearman’s correlation.


eyes (53.4%) and removed after two days in 27 eyes (46.6%). Mean time to operation was 10.8±5 days (range, 2–21) in the latter group. The timing of IOFB removal was not as-sociated with incidence of endophthalmitis or final BCVA (Mann–Whitney, p=0.055, p=0.919, respectively). Delaying IOFB removal was not associated with occurrence of reti-nal detachment or glaucoma (chi-square, p=0.905, p=0.114, respectively).

DISCUSSIONAdvances in vitreoretinal instrumentation and surgical tech-niques have improved the success of treatment in open globe injuries with posterior segment IOFBs. The advantages of posterior segment IOFB removal using PPV include removal of vitreous to reduce the risk of retinal detachment, provides direct viewing and controlled surgery resulting in less col-lateral damage, and a possible reduced risk of endophthalmi-tis.[6–8] We analyzed our population of patients with retained posterior segment IOFBs secondary to open globe injuries and evaluated the impact of IOFB-size and weight, prognostic factors, management, and outcomes.

In accordance with previous reports, vast majority of our patients were male (91%) and relatively young (mean age, 32.7 years; median, 31 years).[1,2] Their occupational injuries and a significant cause of ocular morbidity among, otherwise healthy, young males were preventable. This male predomi-nance has been attributed to occupational exposure, danger-ous sports and hobbies, alcohol use, and risk-taking behavior.[9–11] In our population, the most common cause of injuries was work related (67%), as in previous reports.[12–17] Lack of eye protection was the major risk factor in this group as none of our patients were using protective eyewear at the time of injury. Metallic IOFBs have been reported in 60% to 91% of open globe injuries.[18–21] Vast majority of posterior segment IOFBs in this study were metal (90%).

The association between initial findings and size factors were evaluated. Greater weight, width, and thickness of the pos-terior segment IOFBs were associated with initial incidence of hyphema, vitreous hemorrhage, retinal hemorrhage, and uveal prolapse (Table 2). Heavier IOFBs were associated with the presence of initial retinal detachment and the length of posterior segment IOFBs was associated only with hyphema as a notable result. There was a significant association be-tween the removal site and thickness of the IOFBs; thicker IOFBs were removed through the anterior chamber rather than the sclera.

To the best of our knowledge, this is the first study that cor-relates weight and size measurements of posterior segment IOFBs with presenting and final visual acuity levels. Several studies have investigated mass and size factors with grouped variables, and increased size of an IOFB has been a negative predictive factor for visual outcomes.[2,7] Woodcock and col-

leagues[21] have concluded that a greater mass is associated with worse outcomes. In accordance with those studies, we found a significant negative correlation between weight, length, width, and thickness with presenting and final BCVA measurements.

In the management of IOFBs, these particles should be re-moved because of the risk for endophthalmitis and toxic-ity. However, timing of removal is controversial.[2,18,20–24] The general consensus is that a delay in IOFB removal increases the risk for endophthalmitis.[24–29] In contrast to this view, Colyer and colleagues[30] have reported prompt wound clo-sure and systemic antibiotics followed by delayed removal with no reported endophthalmitis. When we compared the groups that underwent IOFB removal within 48 hours (53%) and IOFB removal after 48 hours (47%) for initial incidence of endophthalmitis, there was no significant difference. The latter group had prompt primary globe repair with systemic antibiotics and underwent PPV in 10 days. We believe that delays in IOFB removal may be necessary in patients with corneal edema, severe inflammation, and intact posterior hyaloid as this combination prevents controlled surgery. A current study by Falavarjani and colleagues[31] has reported high anatomical success despite a delay in surgery. There-fore, we recommend the removal of posterior segment IOFBs at the most appropriate time rather than initial in-tervention.

Retinal detachment is an important prognostic factor for anatomical success in ocular injuries with posterior segment IOFBs. In our population, the most common complication after posterior segment IOFB removal was retinal detach-ment (18.9%). Retinal detachment, initial or subsequent, was associated with poor final BCVA. Glaucoma was the second most frequent complication (17.2%) in this population. Al-though most of the eyes responded to medical therapy, one patient underwent glaucoma surgery. The incidence of reti-nal detachment and glaucoma did not increase in the group with delayed vitrectomy. We could not provide anatomical integrity in two (3.4%) eyes because of the large entry site. Postoperative long-term hypotony resulted in phthisis bulbi in these eyes.

A limitation of this study is the lack of further correlations between velocity of IOFBs and study parameters due to the retrospective design of study. Moreover, the velocity of an IOFB is not only associated with the degree of tissue damage but also attributed to be conversely correlated with the risk of endophthalmitis. Thus, additional studies to investigate the association of these factors are required.

In conclusion, weight and dimensions of posterior segment IOFBs are significant predictive factors for visual outcomes in open globe injuries treated with vitrectomy. Heavier IOFBs have a risk of initial retinal detachment. Retinal detachment, initial or subsequent, was an important prognostic factor for



poor final visual acuity. In this study, endophthalmitis and other complications were not related to delayed vitrectomy. Therefore, a delay in IOFB removal after prompt primary globe repair may be an advisable option while waiting for op-timal surgical conditions.


REFERENCES

1. Ehlers JP, Kunimoto DY, Ittoop S, Maguire JI, Ho AC, Regillo CD. Me-tallic intraocular foreign bodies: characteristics, interventions, and prog-nostic factors for visual outcome and globe survival. Am J Ophthalmol 2008;146:427–433.

2. Zhang Y, Zhang M, Jiang C, Qiu HY. Intraocular foreign bodies in china: clinical characteristics, prognostic factors, and visual outcomes in 1,421 eyes. Am J Ophthalmol 2011;152:66–73.

3. Potts AM, Distler JA. Shape factor in the penetration of intraocular for-eign bodies. Am J Ophthalmol 1985;100:183–7.

4. Kuhn F, Morris R, Witherspoon CD. Birmingham Eye Trauma Termi-nology (BETT): terminology and classification of mechanical eye inju-ries. Ophthalmol Clin North Am 2002;15:139–43.

5. Pieramici DJ, Sternberg P Jr, Aaberg TM Sr, Bridges WZ Jr, Capone A Jr, Cardillo JA, et al. A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classification Group. Am J Ophthalmol 1997;123:820–31.

6. Chow DR, Garretson BR, Kuczynski B, Williams GA, Margherio R, Cox MS, et al. External versus internal approach to the removal of metal-lic intraocular foreign bodies. Retina 2000;20:364–9.

7. Wani VB, Al-Ajmi M, Thalib L, Azad RV, Abul M, Al-Ghanim M, et al. Vitrectomy for posterior segment intraocular foreign bodies: visual re-sults and prognostic factors. Retina 2003;23:654–60.

8. Mieler WF, Ellis MK, Williams DF, Han DP. Retained intraocular for-eign bodies and endophthalmitis. Ophthalmology 1990;97:1532–8.

9. McCarty CA, Fu CL, Taylor HR. Epidemiology of ocular trauma in Aus-tralia. Ophthalmology 1999;106:1847–52.

10. Koo L, Kapadia MK, Singh RP, Sheridan R, Hatton MP. Gender dif-ferences in etiology and outcome of open globe injuries. J Trauma 2005;59:175–8.

11. George J, Ali N, Rahman NA, Joshi N. Spectrum of intra-ocular foreign bodies and the outcome of their management in Brunei Darussalam. Int Ophthalmol 2013;33:277–84.

12. Jafari AK, Anvari F, Ameri A, Bozorgui S, Shahverdi N. Epidemiology and sociodemographic aspects of ocular traumatic injuries in Iran. Int Ophthalmol 2010;30:691–6.

13. Chang CH, Chen CL, Ho CK, Lai YH, Hu RC, Yen YL. Hospitalized eye injury in a large industrial city of South-Eastern Asia. Graefes Arch Clin Exp Ophthalmol 2008;246:223–8.

14. Thompson GJ, Mollan SP. Occupational eye injuries: a continuing prob-

lem. Occup Med (Lond) 2009;59:123–5.

15. Mansouri M, Faghihi H, Hajizadeh F, Rasoulinejad SA, Rajabi MT, Ta-batabaey A, et al. Epidemiology of open-globe injuries in Iran: analysis of 2,340 cases in 5 years (report no. 1). Retina 2009;29:1141–9.

16. Bauza AM, Emami P, Son JH, Langer P, Zarbin M, Bhagat N. Work-related open-globe injuries: demographics and clinical characteristics. Eur J Ophthalmol 2013;23:242–8.

17. Lit ES, Young LH. Anterior and posterior segment intraocular foreign bodies. Int Ophthalmol Clin 2002 Summer;42:107–20.

18. Parke DW 3rd, Pathengay A, Flynn HW Jr, Albini T, Schwartz SG. Risk factors for endophthalmitis and retinal detachment with retained intra-ocular foreign bodies. J Ophthalmol 2012;2012:758526.

19. Camacho H, Mejía LF. Extraction of intraocular foreign bodies by pars plana vitrectomy. A retrospective study. Ophthalmologica 1991;202:173–9.

20. Parke DW 3rd, Flynn HW Jr, Fisher YL. Management of intraocular foreign bodies: a clinical flight plan. Can J Ophthalmol 2013;48:8–12.

21. Woodcock MG, Scott RA, Huntbach J, Kirkby GR. Mass and shape as factors in intraocular foreign body injuries. Ophthalmology 2006;113:2262–9.

22. Andreoli CM, Andreoli MT, Kloek CE, Ahuero AE, Vavvas D, Durand ML. Low rate of endophthalmitis in a large series of open globe injuries. Am J Ophthalmol 2009;147:601–8.

23. Thompson JT, Parver LM, Enger CL, Mieler WF, Liggett PE. Infec-tious endophthalmitis after penetrating injuries with retained intra-ocular foreign bodies. National Eye Trauma System. Ophthalmology 1993;100:1468–74.

24. Ahmed Y, Schimel AM, Pathengay A, Colyer MH, Flynn HW Jr. Endo-phthalmitis following open-globe injuries. Eye (Lond) 2012;26:212–7.

25. Bhagat N, Nagori S, Zarbin M. Post-traumatic Infectious Endophthal-mitis. Surv Ophthalmol 2011;56:214–51.

26. Alfaro DV, Roth D, Liggett PE. Posttraumatic endophthalmitis. Caus-ative organisms, treatment, and prevention. Retina 1994;14:206–11.

27. Essex RW, Yi Q, Charles PG, Allen PJ. Post-traumatic endophthalmitis. Ophthalmology 2004;111:2015–22.

28. Duch-Samper AM, Menezo JL, Hurtado-Sarrió M. Endophthalmitis fol-lowing penetrating eye injuries. Acta Ophthalmol Scand 1997;75:104–6.

29. Chaudhry IA, Shamsi FA, Al-Harthi E, Al-Theeb A, Elzaridi E, Ri-ley FC. Incidence and visual outcome of endophthalmitis associated with intraocular foreign bodies. Graefes Arch Clin Exp Ophthalmol 2008;246:181–6.

30. Colyer MH, Weber ED, Weichel ED, Dick JS, Bower KS, Ward TP, et al. Delayed intraocular foreign body removal without endophthalmitis dur-ing Operations Iraqi Freedom and Enduring Freedom. Ophthalmology 2007;114:1439–47.

31. Falavarjani KG, Hashemi M, Modarres M, Parvaresh MM, Naseripour M, Nazari H, et al. Vitrectomy for posterior segment intraocular foreign bodies, visual and anatomical outcomes. Middle East Afr J Ophthalmol 2013;20:244–7.




OLGU SUNUMU

Arka segment göz içi yabancı cisimleri: Ağırlık ve boyut etkisi,erken veya geç vitrektomi ve sonuçlarDr. Zafer Öztaş,1 Dr. Serhad Nalçacı,1 Dr. Filiz Afrashi,1 Dr. Tansu Erakgün,2

Dr. Jale Menteş,1 Dr. Cumali Değirmenci,1 Dr. Cezmi Akkın1

1EgeÜniversitesiTıpFakültesi,GözHastalıklarıAnabilimDalı,İzmir2EkolKulakBurunBoğazHastanesi,GözHastalıklarıKliniği,İzmir

AMAÇ: Arka segment göz içi yabancı cisim (GİYC) ağırlık ve boyut özelliklerinin açık glob yaralanmalarındaki etkilerini belirlemek.GEREÇ VE YÖNTEM: Çalışmaya arka segment GİYC bulunan 58 hastanın 58 gözü dahil edildi. Tüm GİYC’ler pars plana vitrektomi ile çıkarıldı. Yaş, cins, en iyi düzeltilmiş görme keskinliği (EİDGK), GİYC niteliği, ağırlığı ve çapları, başlangıçtaki göz bulguları, GİYC çıkarılma zamanı, GİYC giriş alanı, yapılan müdaheleler ve komplikasyonları içeren faktörler incelendi.BULGULAR: Hastaların ortalama yaşı 32.7±14.2 yıl ve ortalama takip süresi 18±13.3 ay idi. Göz içi yabancı cisim ağırlık, boy, en ve kalınlıkları başlan-gıç ve final EİDGK seviyeleri ile negatif korele bulundu (p<0.05). Başlangıçta hifema, vitreus hemorajisi, retina hemorajisi, retina dekolmanı ve üveal prolapsus bulunan olgulardaki GİYC’ler önemli ölçüde daha ağır bulundu (p<0.05). Hifema, vitreus hemorajisi, retina hemorajisi, retina dekolmanı ve üveal prolapsus bulunan olgulardaki GİYC’ler önemli ölçüde daha enli ve kalın bulundu (p<0.05). Hifemalı gözlerdeki GİYC’ler anlamlı olarak daha uzun bulundu (p<0.05). Başlangıçta veya daha sonra retina dekolmanının olması düşük final görme ile ilşkili bulundu (p<0.05). Göz içi yabancı cisim çıkarılma zamanı ile endoftalmi insidansı arasında ilişki yoktu.TARTIŞMA: Daha ağır ve büyük arka segment GİYC’leri ile birlikte olan açık glob yaralanmaları daha kötü sonuçlara ilişkilidir. İş kazalarından korun-mak için koruyucu gözlük kullanımı kritik bir öneme sahiptir. Bizim çalışmamızda GİYC’nin erken veya geç çıkarılmasının anatomik ve görsel sonuçlar üzerine önemli bir etkisi saptanmamıştır. Bu nedenle uygun koşullar elde edilene kadar vitrektomi ertelenebilir.Anahtar sözcükler: Endoftalmi; göz içi yabancı cisimleri; pars plana vitrektomi; retina dekolmanı.




Comparison of femur intertrochanteric fracture fixation with hemiarthroplasty and proximal femoral nail systemsGökay Görmeli, M.D.,1 Mehmet Fatih Korkmaz, M.D.,1 Cemile Ayşe Görmeli, M.D.,2

Cihan Adanaş, M.D.,3 Turgay Karataş, M.D.,4 Sezai Aykın Şimşek, M.D.5

1DepartmentofOrthopedicsandTraumatology,InonuUniversityFacultyofMedicine,TurgutÖzalMedicalCenter,Malatya2DepartmentofRadiology,InonuUniversityFacultyofMedicine,TurgutÖzalMedicalCenter,Malatya3DepartmentofOrthopedicsandTraumatology,VanTrainingandResearchHospital,Van4DepartmentofGeneralSurgery,MalatyaStateHospital,Malatya5DepartmentofOrthopedicsandTraumatology,AmericanHospital,Istanbul

ABSTRACT

BACKGROUND: The aim of this study was to compare the outcomes of intertrochanteric femur fractures treated with proximal femoral nail (PFN) and bipolar hemiarthroplasty (BPH) in elderly patients.

METHODS: A total of one hundred and forty-three patients with intertrochanteric femur fractures treated surgically between Janu-ary 2008 and January 2012 were included into the study. Patient demographics, type of fracture according to Association for Osteo-synthesis/Association for the Study of Internal Fixation (AO/ASIF) classification, and the American Society of Anesthesiologists (ASA) classification system scores; type of surgical procedure (BPH or PFN), operative details, complications and follow-up scores (Harris Hip Score [HHS]; Mean Mobility Score [MMS]) were recorded.

RESULTS: The preoperative characteristics of the patients in both PFN and BPH groups were similar. BPH had higher operation times, blood loss in operation and mortality rates (p<0.005). Reoperation times were higher in PFN group (p<0.005). There were no differences with regard to the HHS and the reduction in MMS at the last follow-up with a 30.4 (10.9) months follow-up (p>0.05).

CONCLUSION: Although both PFN and BPH had satisfactory outcomes in surgically treated patients with intertrochanteric femur fractures, we recommend intertrochanteric femur fractures in the elderly tobe treated with PFN; which is an effective and appropriate treatment modality with less surgery related trauma and lower mortality rates.

Key words: Bipolar hemiarthroplasty; femur intertrochanteric fracture; Harris Hip Score; mortality; proximal femoral nail.

routines.[3] 50% of these patients require assistance in their daily living activities, and 25% need to receive long-term care after treatment.[4]

Due to problems caused by these fractures and an increase in the number of the elderly population leading to a significant increase in the incidence of these fractures, it is absolutely necessary to use an effective and appropriate treatment mo-dality for such patients. Due to their poor bone quality, it is very difficult to achieve and maintain a stable fixation in elderly patients. Many treatment methods have been used for the reduction of intertrochanteric fractures, including dy-namic hip screw (DHS), proximal femoral nail (PFN), unipolar and bipolar hemiarthroplasty and external fixation. However, it is difficult to achieve and maintain a stable fixation in elderly patients due to their poor bone quality.[5,6] Early mobilization and prompt return to prefracture activity levels are the main goals of surgery. The treatment of this fracture remains a challenge to the surgeon, and there is still controversy about



Address for correspondence: Mehmet Fatih Korkmaz, M.D.

İnönü Üniversitesi Tıp Fakültesi, Turgut Özal Tıp Merkezi, Ortopedi

ve Travmatoloji Anabilim Dalı, Malatya, Turkey



Copyright 2015TJTES

INTRODUCTION

The incidence of hip fractures is rising due to inreasing life expectancy in the elderly population. Also, mortality after femur proximal femur fracture is increasing with a 1-year mortality rate of 14 to 36%.[1,2] One of the major problems with these fractures is patients’ return to their preoperative period level of activity and independence in carrying out daily

Görmeli et al. Comparison of femur intertrochanteric fracture fixation with hemiarthroplasty and proximal femoral nail systems

the ideal treatment modality of hip fractures in elderly pa-tients.

Therefore, the present study was undertaken to compare outcomes of reduction of intertrochanteric fractures using internal fixation with the use of PFN and bipolar hemiarthro-plasty (BPH) in elderly patients.


This retrospective study was approved by the Local Insti-tutional Ethics Board in accordance with the standards of the Declaration of Helsinki. Patients with intertrochanteric femur fractures treated surgically between January 2008 and January 2012 were included into the study. Exclusion crite-ria consisted of a history of osteoarthritis in the hip joint, pathologic fractures, bilateral fractures, age less than 65 years, rheumatoid arthritis, chronic renal failure, fractures secondary to tumour, Paget’s disease or metabolic bone dis-ease.

Patients’ clinical and radiographical features were evaluated at initial presentation, surgery and last follow-up, retrospective-ly. Collected data were demographics, time between injury to surgery, type of fracture according to AO/ASIF classifica-tion, and the American Society of Anesthesiologists (ASA) physical status classification (ASA grade), type of surgical procedure (osteosynthesis with a proximal femoral nail (Ve-ronail®; Orthofix,SRL,Verona,Italy) or cemented or cementh-less bipolar hemiarthroplasty (Spectron® or Echelon® Smith & Nephew, Memphis, TN, USA; Biomet Inc. Warsaw, IN, USA; Ortopro®,Ortopro Tıbbi Aletler, Izmir, Turkey); duration of surgery, blood transfusion, and complications.

All operations were performed by the same group of expe-rienced surgeons. In all cases, antithrombotic prophylaxis was given using low molecular weight heparin (Fraxiparine®; GlaxoSmithKline, Brentford, UK) and antibiotic prophylaxis was provided. Anteroposterior and lateral radiographs were obtained 24–72 hours postoperatively, and analyzed for re-duction and position of the implant.

For patients treated with PFN, the patients were mobilized on the first postoperative day. Partial weight bearing, as tol-erated, or restricted weight bearing was allowed according to the surgeon’s recommendation on the day following sur-gery. Full-weight bearing was allowed at 4th week for patients treated with PFN while full weight bearing was allowed in the first postoperative day for patients treated with BPH. Com-plications were classified as varus collapse, implant related problems (lateral sliding or cut out), secondary fractures, in-fection (deep or superficial), hip dislocation, non-union and systemic problems such as pulmonary embolism, cardiac isch-emia, pneumonia, and urinary tract infection.

Patients were called back for a last follow-up. Thirty-six pa-

tients from the PFN group and 43 patients from the BPH group admitted to the clinic for the last follow-up. Eleven of the patients were dead, 24 of them were living at an another city, 15 of them refused to admit to the clinic and the remain-ing 14 patients could not be reached. Clinical evaluation was made using the Mean mobility score (MMS) and Harris hip scoring system (HHS), which considers pain, walking capacity, and physical examination findings.[7]

Statistical EvaluationThe data were expressed as mean (standard deviation [SD]) depending upon overall variable distribution. Normality was assessed using Shapiro Wilk test. Qualitative data were ana-lyzed with Pearson chi-square test. The data were compared through paired samples t test and unpaired samples t test be-tween the groups. Correlations were estimated Spearman’s rho as appropriate. P<0.05 values were considered as signifi-cant. IBM SPSS statistics version 22.0 for Windows was used for statistical analyses.

RESULTS

A total of one hundred and forty-three patients meeting our study criteria comprised our study population. There was no significant difference between the PFN and BPH group in terms of demographic data, preexisting comorbidities, preop-erative MMS, fracture type, ASA classification, and mean time from injury to surgery (Table 1).

Significantly higher results were achieved in terms of op-eration times in minutes and blood loss and the number of patients needing blood transfusion was higher in the BPH group than in the PFN group (p<0.005). Operative details are shown in Table 2.

Details of postoperative complications are shown in Table 3. PFN group has significantly higher reoperation times and BPH group has significantly higher one-year mortality rates (p<0.05). None of the differences between the two groups was statistically significant in other parameters (p>0.05). Su-perficial wound infection is defined as infection of the wound, in which there is no evidence that the infection extends to the site of the implant, occurred in five patients in the BPH group and in four in the PFN group. Deep wound infection, defined as infection around the implant, occurred in two pa-tients in the hemiarthroplasty group and treated successfully with antibiotherapies. There was no dislocation in the BPH group. In one case, fracture occurred below the implant and was fixated with plate and screws. In two patients, haema-toma occurred and a successful drainage was performed with no further complications. In the PFN group, there was ecto-pic new bone formation at the insertion point of stabilization and compression screw in only one patient without affecting the patient’s condition. Revision surgery (hemiarthroplasty) was needed due to pseudoarthrosis in four and cut-out of the



implant proximally in one, and avascular necrosis in three pa-tients. One-year mortality was significantly higher in the BPH group (19/75 [%25.3]) than in the PFN group (8/68 [%11.7])(<0.005).

Hospital stay was defined as the time from admission to dis-charge, and it was 3.8 (2.6) days for the PFN and 4.4 (2.9) days for the BPH group without any significant difference (p<0.05). Also, there was no correlation between patients’


Table 1. Preoperative data of the patients

Proximal femoral nail group Bipolar hemiarthroplasty group

Number of patients* 68 75

Mean age in years (SD)* 76.2 (7.9) 77.4 (8.4)

Number of men (%)* 27 (39.7) 32 (42.6)

Mean mobility score before fracture (SD)* 3.9 (2) 4.1 (1.7)

Mean ASA score (SD)* 2.82 (0.73) 2.77 (0.88)

Pre-existing cardiovascular disease (%)* 18 (26.5) 19 (28.3)

Pre-existing respiratory disease (%)* 14 (20.6) 12 (16)

Mean time (hours) from injury to surgery (SD)* 26.9 (10.5) 25.4 (9.3)

Fracture classification*

3.1 A.1 (%) 25 (36.7) 30 (40)

3.1 A.2 (%) 33 (48.5) 37 (49.3)

3.1 A.3 (%) 7 (10.2) 8 (10.6)

*No significant difference between proximal femoral nail and bipolar hemiarthroplasty groups (p>0.05).

Table 2. Operative details

Proximal femoral nail group Bipolar hemiarthroplasty group p

Number of patients 68 75 >0.05

Operation with spinal anaesthesia (%) 46 (67.6) 54 (75) >0.05

Mean (SD) operation time in minutes 32.4 (7.1) 48.7 (10.2) <0.005

Intraoperative blood loss in ml 30.6 (12.5) 136.5 (34.2) <0.005

Number of patients transfused (%) 6 (8.8) 41 (54.6) <0.005

Table 3. Postoperative complications and mortality rates

Proximal femoral nail group Bipolar hemiarthroplasty group

Superficial wound infectiona 5 4

Deep wound infection – 2

Pressure soresa 3 5

Pneumoniaa 1 0

Thromboembolic complicationsa 4 6

Neurological complicationa 1 2

Urinary tract infectiona 5 3

Wound haematoma requiring drainage – 2

Reoperationb 8 (11.7) 2 (2.6)

Number of one year mortality (%)b 6 (8.8) 11 (14.6)

a: No significant difference between proximal femoral nail and hemiarthroplasty groups (p>0.05).b: Significant difference between the groups (p<0.05).

ages, ASA scores , operation time, intraoperative blood loss, and HHS (p>0.05).

Thirty-six patients in the PFN group (32.3 (8.9) months fol-low-up) and 43 patients in the BPH group (29.6 [10.3] months follow-up) were available for a last review. There was no sig-nificant difference between the groups in terms of HHS and mean reduction in MMS scores at the last follow-up. Table 4 gives details functional assessment of the patients.

DISCUSSIONThe results of this study showed that both PFN and BPH are good treatment methods with similar satisfactory postopera-tive functional results. Significant shorter operation time, less blood-loss during operation and lower mortality rates seems to be the main advantages of internal fixation method with PFN while lower re-operation rate is the advantage of BPH for patients with intertrochanteric femur fractures.

Similar to our results, studies compiaring operative details have concluded that internal fixation is associated with shorter length of surgery, lower operative blood loss, and need for transfusions.[8–10] The advantages of operative de-tails are balanced with higher reoperation rates for internal fixation group. For the patients treated with PFN, reopera-tion reasons are redisplacement of the fractures, cut out of femoral head, implant breakage and nonunion. Dislocation may occur in patients treated with BPH. Reoperation rates were 11% in a prospective study performed by Saudan et al.;[11] 14.8% in a randomized study performed by Pajarinen et al.[12] Papasimos et al.[13] found 12.5% reoperation rates as well. Our study showed high reoperation rates similar to the literature, and these patients were treated effectively by revision to bipolar hemiarthroplasty. Due to high osteo-porosis rates in the elderly, we believe that internal fixa-tion is appropriate for younger patients with proximal femur fractures. Hemiarthroplasty has a lower risk of secondary surgery for the elderly patients aged with a displaced intra-capsular fracture.

The Cochrane review group has noted 28.6% pseudoarthro-sis and 8.3% avascular necrosis with intracapsular femur frac-tures treated with internal fixation.[14] Our results showed lower psedoarthrosis (7.3%) and avascular necrosis rates

(4.4%). This would be related to short time period from in-jury to surgery.

The choice of treatment methods in this study can be dis-cussed. Studies have concluded that cementless hemiarthro-plasty is preferred over cemented hemiarthroplasty because of reduced operation time and intra-operative blood loss and lower perioperative mortality rate.[15,16] For the ideal internal fixation method, a meta-analysis performed by Zhang et al. hasconcluded that PFN may be a better choice than DHS in the treatment of intertrochanteric fractures.[17] In a study of one hundred consecutive patients treated with PFN, Korkmaz et al. have concluded that PFN is a reliable fixation method for proximal femur fractures.[18] In an another meta-analysis of randomized controlled trials, Huang et al. have concluded that PFN fixations shows the same effectiveness as DHS fixa-tion.[19] According to these studies and metaanalyses, we per-formed cementless hemiarthroplasty for arthroplasty group and preferred PFN for the internal fixation method.

There were no statistically significant differences between the two groups in medical complications such as pressure sores, pneumonia, thromboembolic complications, and neurologic complications reported in a systematic review published by Parker et al.[20] Moreover, length of hospital stay was similar between the internal fixation and hemiarthroplasty group.[9,21] In our study, similar to the literature, we found no signifi-cant difference between the groups in terms of postoperative medical complications and length of hospital stay as shown in Table 3. Yet, our length of hospital stay was shorter than other studies. We discharged patients as soon as possible be-cause of high infection risk related to diabetic wound patients treated by other surgeons in our clinic.

In our study, one-year mortality rates were significantly lower in the PFN group than the BHA group. The BHA group was slightly older than the PFN group (77.4 vs 76.2, p>0.05) but this nonsignificant difference may not be related to higher mortality results as both groups had similar comorbidities and preoperative HHS and MMS. Karaman et al. have con-cluded many factors such as age, ASA score, preoperative comorbidities, type of anaesthesia affects the mortality rates but these are similar for the PFN and BPH group in our study.[22] Our findings are supported by Davison et al. and Kapicio-



Table 4. Follow-up scores

Proximal femoral nail group Hemiarthroplasty group

Number of patients* 36 43

Length of follow-up months (SD)* 32.3 (8.9) 29.6 (10.3)

Harris Hip Score (SD)* 79.7 (7.8) 74.7 (8.8)

Mean reduction in mobility score (SD)* 1.97 (1.05) 2.14 (1.14)

*No significant difference between proximal femoral nail and bipolar hemiarthroplasty groups (p>0.05).

glu et al. who have reported higher mortality rates for ar-throplasty group than internal fixation.[23,24] On the contrary, other studies found no difference in mortality between inter-nal fixation and arthroplasty.[25,26]

There are several limitations to this study. Retrospective nature, small patient group and mid-term follow-up are the main limitations. Long-term analyses were not possible be-cause of short life expectancy in elderly patients. All proce-dures were not performed by the same surgeon which can lead to a variance in the results. However, usage of the same implants, operating room and fluoroscopy can be considered as advantages of this study.

In conclusion, both PFN and BPH appear to produce satisfac-tory outcomes in surgically treated proximal femur fractures. Both groups are associated with their own complications, but although internal fixation with PFN had higher reopera-tion rates, its less surgery related trauma and lower mortal-ity rates are main advantages. Therefore, the clinician should choose the ideal method for each individual patient, but we think internal fixation may be the effective and appropriate treatment modality for elderly patients with extracapsular proximal femur fractures.


REFERENCES

1. Vestergaard P, Rejnmark L, Mosekilde L. Has mortality after a hip frac-ture increased? J Am Geriatr Soc 2007;55:1720–6.

2. Kesmezacar H, Ayhan E, Unlu MC, Seker A, Karaca S. Predictors of mortality in elderly patients with an intertrochanteric or a femoral neck fracture. J Trauma 2010;68:153–8.

3. Blomfeldt R, Törnkvist H, Eriksson K, Söderqvist A, Ponzer S, Tide-rmark J. A randomised controlled trial comparing bipolar hemiarthro-plasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. J Bone Joint Surg Br 2007;89:160–5.

4. Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE. Outcomes after dis-placed fractures of the femoral neck. A meta-analysis of one hundred and six published reports. J Bone Joint Surg Am 1994;76:15–25.

5. Seyfettinoğlu F, Ersan O, Kovalak E, Duygun F, Ozsar B, Ateş Y. Fixation of femoral neck fractures with three screws: results and complications. Acta Orthop Traumatol Turc 2011;45:6–13.

6. Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P 3rd, Obrem-skey W, Koval KJ, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am 2003;85:1673–81.

7. Harris WH. Traumatic arthritis of the hip after dislocation and acetabu-lar fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am 1969;51:737–55.

8. Parker MJ, Khan RJ, Crawford J, Pryor GA. Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients. J Bone Joint Surg Br 2002;84:1150–5.

9. Parker MJ, Pryor GA. Internal fixation or arthroplasty for displaced cer-vical hip fractures in the elderly: a randomised controlled trial of 208 pa-tients. Acta Orthop Scand 2000;71:440–6.

10. Puolakka TJ, Laine HJ, Tarvainen T, Aho H. Thompson hemiarthro-

plasty is superior to Ullevaal screws in treating displaced femoral neck fractures in patients over 75 years. A prospective randomized study with two-year follow-up. Ann Chir Gynaecol 2001;90:225–8.

11. Saudan M, Lübbeke A, Sadowski C, Riand N, Stern R, Hoffmeyer P. Per-trochanteric fractures: is there an advantage to an intramedullary nail?: a randomized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail. J Orthop Trauma 2002;16:386–93.

12. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertro-chanteric femoral fractures treated with a dynamic hip screw or a proxi-mal femoral nail. A randomised study comparing post-operative rehabili-tation. J Bone Joint Surg Br 2005;87:76–81.

13. Papasimos S, Koutsojannis CM, Panagopoulos A, Megas P, Lambiris E. A randomised comparison of AMBI, TGN and PFN for treat-ment of unstable trochanteric fractures. Arch Orthop Trauma Surg. 2005;125:462–8.

14. Masson M, Parker MJ, Fleischer S. Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Data-base Syst Rev 2006;4:CD001708.

15. Ng ZD, Krishna L. Cemented versus cementless hemiarthroplasty for femoral neck fractures in the elderly. J Orthop Surg (Hong Kong) 2014;22:186–9.

16. Cankaya D, Ozkurt B, Tabak AY. Cemented calcar replacement versus ce-mentless hemiarthroplasty for unstable intertrochanteric femur fractures in the elderly. Ulus Travma Acil Cerrahi Derg 2013;19:548-53.

17. Zhang K, Zhang S, Yang J, Dong W, Wang S, Cheng Y, et al. Proximal femoral nail vs. dynamic hip screw in treatment of intertrochanteric frac-tures: a meta-analysis. Med Sci Monit 2014;20:1628–33.

18. Korkmaz MF, Erdem MN, Disli Z, Selcuk EB, Karakaplan M, Gogus A. Outcomes of trochanteric femoral fractures treated with proximal femoral nail: an analysis of 100 consecutive cases. Clin Interv Aging 2014;9:569–74.

19. Huang X, Leung F, Xiang Z, Tan PY, Yang J, Wei DQ, et al. Proximal femoral nail versus dynamic hip screw fixation for trochanteric fractures: a meta-analysis of randomized controlled trials. ScientificWorldJournal 2013;2013:805805.

20. Parker MJ, Handoll HH. Replacement arthroplasty versus internal fixation for extracapsular hip fractures. Cochrane Database Syst Rev 2000;2:CD000086.

21. van Dortmont LM, Douw CM, van Breukelen AM, Laurens DR, Mulder PG, Wereldsma JC, et al. Cannulated screws versus hemiarthroplasty for displaced intracapsular femoral neck fractures in demented patients. Ann Chir Gynaecol 2000;89:132–7.

22. Karaman Ö, Özkazanlı G, Orak MM, Mutlu S, Mutlu H, Çalışkan G, et al. Factors affecting postoperative mortality in patients older than 65 years undergoing surgery for hip fracture. Ulus Travma Acil Cerrahi Derg 2015;21:44–50.

23. Davison JN, Calder SJ, Anderson GH, Ward G, Jagger C, Harper WM, et al. Treatment for displaced intracapsular fracture of the proximal fe-mur. A prospective, randomised trial in patients aged 65 to 79 years. J Bone Joint Surg Br 2001;83:206–12.

24. Kapicioglu M, Ersen A, Saglam Y, Akgul T, Kizilkurt T, Yazicioglu O. Hip fractures in extremely old patients. J Orthop 2014;11:136–41.

25. Johansson T, Jacobsson SA, Ivarsson I, Knutsson A, Wahlström O. In-ternal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures: a prospective randomized study of 100 hips. Acta Orthop Scand 2000;71:597–602.

26. Rogmark C, Carlsson A, Johnell O, Sernbo I. A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at two years. J Bone Joint Surg Br 2002;84:183–8.




OLGU SUNUMU

Femur intertrokanterik kırıklarının tedavisinde proksimal femur çivisive hemiartroplasti sistemlerinin karşılaştırılmasıDr. Gökay Görmeli,1 Dr. Mehmet Fatih Korkmaz,1 Dr. Cemile Ayşe Görmeli,2

Dr. Cihan Adanaş,3 Dr. Turgay Karataş,4 Dr. Sezai Aykın Şimşek5

1İnönüÜniversitesiTıpFakültesi,TurgutÖzalTıpMerkezi,OrtopediveTravmatolojiAnabilimDalı,Malatya2İnönüÜniversitesiTıpFakültesi,TurgutÖzalTıpMerkezi,RadyolojiAnabilimDalı;Malatya3VanBölgeEğitimveAraştırmaHastanesi,OrtopediveTravmatolojiKliniği,Van4MalatyaDevletHastanesi,GenelCerrahiKliniği,Malatya5AmericanHospital,OrtopediveTravmatolojiKliniği,İstanbul

AMAÇ: Çalışmamızın amacı intertrokanterik femur kırığı olan yaşlı hastalarda proksimal femur çivisi (PFÇ) ve bipolar hemiartroplasti (BPH) ile tedavinin sonuçlarını karşılaştırmaktı.GEREÇ VE YÖNTEM: Çalışmaya Ocak 2008–Ocak 2012 arasında femur intertrokanterik kırığı nedeni ile tedavi edilen 143 hasta dahil edildi. Hasta-ların demografik verileri; AO/ASIF (Association for Osteosynthesis/Association for the Study of Internal Fixation) sınıflamasına göre kırık tipi; ASA (American Society of Anesthesiologists) skorları; cerrahi yöntem (PFÇ veya BPH); cerrahinin detayları; komplikasyonlar ve takip sonuçları (Harris Kalça Skoru, Ortalama Hareketlilik Skoru) kaydedildi.BULGULAR: Cerrahi öncesi veriler PFÇ ve BPH grubunda benzerdi. Bipolar hemiartroplasti grubunda cerrahi süresi daha uzun; cerrahi sırasındaki kan kaybı ve mortalite oranları daha yüksekti (p<0.005). 30.4 (10.9) aylık takip sonucunda Ortalama Hareketlilik Skoru’ndaki azalma ve Harris Kalça Skoru’nda anlamlı fark yoktu (p>0.05).TARTIŞMA: Cerrahi tedavi uygulanan femur intertrokanterik kırıklı yaşlı hastalarda PFÇ ve BPH sonuçlarının her ikisi de tatmin edici olsada; daha az cerrahi ile ilişkili travma ve düşük mortalite oranları ile PFÇ’nin bu hastalarda daha etkili ve uygun tedavi yöntemi olarak tercih edilebileceğini düşünmekteyiz.Anahtar sözcükler: Bipolar hemiartroplasti; femur intertokanterik kırığı; Harris kalça skoru; mortalite; proksimal femur çivisi.




Dilemma in pediatric mandible fractures:resorbable or metallic plates?Gaye Taylan Filinte, M.D.,1 İsmail Mithat Akan, M.D.,2 Gülçin Nujen Ayçiçek Çardak, M.D.,1

Özay Özkaya Mutlu, M.D.,3 Tayfun Aköz, M.D.4

1DepartmentofPlastic,ReconstructiveandAestheticSurgery,Dr.LutfiKirdarKartalTrainingandResearchHospital,Istanbul2DepartmentofPlastic,ReconstructiveandAestheticSurgery,MedipolUniversityFacultyofMedicine,Istanbul3DepartmentofPlastic,ReconstructiveandAestheticSurgery,OkmeydaniTrainingandResearchHospital,Istanbul4DepartmentofPlastic,ReconstructiveandAestheticSurgery,MaltepeUniversityFacultyofMedicine,Istanbul

ABSTRACT

BACKGROUND: The aim of this study was to compare the efficiency of resorbable and metallic plates in open reduction and inter-nal fixation of mandible fractures in children.

METHODS: Thirty-one patients (mean age, 8.05 years; range 20 months-14 years) were operated on various fractures of the man-dible (26 [60.4%] symphysis- parasymphysis, 12 [27.9%] condylar-subcondylar fractures, 5 [11.6%] angulus and ramus fractures). Twelve patients were treated with resorbable plates and 19 patients with metallic plates. Mean follow-up time was 41 months (11–74 months) in the metallic hardware group and was 22 months (8–35 months) in the resorbable plate group. Both groups were investigated for primary bone healing, complications, number of operations, and mandibular growth. The results were discussed below.

RESULTS: Both groups demonstrated primary bone healing. Minor complications were similar in both groups. The metallic group involved secondary operations for plate removal. Mandibular growth was satisfactory in both groups.

CONCLUSION: Resorbable plates cost more than the metallic ones; however, when the secondary operations are included in the total cost, resorbable plates were favourable. As mandibular growth and complication parameters are similar in both groups, resorb-able plates are favored due to avoidance of potential odontogenic injury, elimination of long-term foreign body retention and provi-sion of adequate stability for rapid bone healing. However, learning curve and concerns for decreased stability against heavy forces of mastication accompanied with the resorbable plates when compared to the metallic ones should be kept in mind.

Key words: Mandibular fractures; metallic plates; resorbable plates.

the hardware are all the factors taken into consideration.

Majority of pediatric mandibular fractures can be managed with closed techniques using short periods of maxilloman-dibular fixation or training elastics alone.[5] Performing open reduction and internal fixation of mandibular fractures in pe-diatric patients may not always be necessary. Lingual splints have been used successfully for pediatric mandibular fractures.[6–8] It is an effective and safe procedure in selected cases.[9]

High osteogenic potential of pediatric mandible allows non-surgical management to be successful in younger patients with conservative approaches.[10] Maxillofacial surgeons generally justify the use of plate- and screw-type internal fixation to be reserved for difficult fractures.[5] Specific subsets of man-dibular fractures, including displaced fractures of the body or angle, fractures of the condylar neck with significant barriers to movement, complex fractures, and fractures in non-toothbear-ing areas necessiate open reduction and internal fixation.[11]



Address for correspondence: Gaye Taylan Filinte, M.D.

Gözenç Sokak, Babadan Apartmanı., No: 2, D: 1, Erenköy,

34738 İstanbul, Turkey

Tel: +90 216 - 441 39 00/1908 E-mail: [email protected]


Copyright 2015TJTES

INTRODUCTION

Management of pediatric mandible fracture is substantially different from adult injuries. Evaluation and approach of pe-diatric mandibular fractures require several issues to be con-sidered. Presence of tooth buds and potential injury to future growth are among the issues complicating management.[1–4] Duration of the operation, general anesthesia, and type of

Taylan Filinte et al. Dilemma in pediatric mandible fractures: resorbable or metallic plates?

The use of resorbable plates is an increasingly attractive op-tion in the treatment of pediatric mandibular fractures.[11] It is both well-tolerated and effective. It enables realignment and stable positioning of rapidly healing fracture segments while obviating any future issues secondary to long-term metal re-tention (Fig. 1).[12]

Major concerns for using resorbable materials in the maxillo-facial region are the strength of the material and its ability to withstand masticatory forces, and the extent of inflammation as the materials begin to degrade.[13]

We used both systems of metallic and resorbable hardware for fixation of pediatric mandible fractures. Limited number of cases and follow-up demonstrated no difference between the stability and healing capacity of the two systems. Resorb-able materials have the advantage of avoidance of secondary removal operations. Limited number of long-term studies and high cost when compared to the metallic hardware are among the drawbacks of biodegradable systems. However, ongoing studies demonstrating the advantages of the resorb-able plates indicate that they are going to be preferred more in the future.


The study consisted of thirty-one pediatric mandible fracture cases arriving to our clinic between 2000 and 2011. Resorb-able plates (2.0 mm PLLA/PGA Lactosorb system, Jacksonville, Florida, USA) were used in twelve patients (ages, 20 months-11 years; mean, 6.9 years) and metallic plates in nineteen (ages, 4–14 years; mean, 9.2 years). Follow up of the metallic plate group was 41 months (11–74 months) and of the resorbable

plate group was 22 months (8–35 months). Both groups were compared according to infection rates, primary bone healing, mandibular growth and need for secondary surgery.

RESULTS

Thirty-one patients with 43 fractures of the mandible were enrolled in the study. Patient age ranged from 20 months to 14 years with a mean of 8.05 years.. Fractures included 26 (60.4%) symphysis-parasymphysis fractures, 12 (27.9%) con-dylar-subcondylar fractures, and 5 (11.6%) angulus and ramus fractures. Metallic plates and screws were used in nineteen (62.7%) patients with 27 fractures and resorbable plates and screws in twelve (37.2%) patients with 16 fractures. Inter-maxiller fixation were used in nine patients with metallic plates and in six patients with resorbable plates.

Fracture UnionNo mobility in any fracture site was noted in either groups at the follow-up period. Follow-up was 41 months (11–74 months) in the metallic plate group and 22 months (8–35 months) in the resorbable plate group. There was no facial asymmetry in both groups in the follow-up period (Figs 2, 3).

InfectionTwo of the 19 patients with metallic hardware demonstrated clinical signs of infection. One of the two responded well to oral antibiotherapy. However, the other one developed a sub-mental fistula and recieved drainage and incision and finally plate removal at the postoperative 13th week. No infection was noted at the resorbable plate group. One patient with resorbable plate demonstrated granuloma formation at the subcutaneous tissue in the 4th postoperative month, which was excised with local anesthesia.

MalunionMinor occlusal deformity was noted in one patient at the sec-ond week control which was corrected by an additional one-week use of light guiding elastics. The parasymphysis fracture of the patient was reconstructed with metallic hardware.

Revisional SurgeryThere was no need for revisional surgery for fracture healing


Figure 1. Upperleft;Intraoperativeviewoftheresorbableplateforfixationofparasymphysisfractureofthemandibleina3-year-oldpatient.Upperright;A1-yearfollow-uplateralcraniography.Lower;A 1-year follow-up panoramic radiograph. Note the well-healedfracturesites.

Figure 2. Left; Two resorbable plates for a parasymphysis andsymphysisfracturesofthemandibleina4-year-oldpatient.Right;An18-monthfollow-upradiographshowingfracturealignment.


in both groups. Fistula that developed after infection in one patient was excised and sutured. Granuloma fomation was excised in the resorbable plate group.

PainOne patient with symphysis fracture and metallic plate dem-onstrated discomfort due to mild pain with plate feeling un-der the skin.

DISCUSSIONDiagnosis and management of mandible fractures in the pe-diatric patient population can pose multiple challenges to the oral and maxillofacial surgeon.[14] There are some principles that must be addressed when dealing with pediatric mandi-ble fractures. Pediatric mandible is a dynamic structure that undergoes significant changes during development. In order to avoid undesirable outcomes, management of mandibular trauma requires knowledge of these changes over time.[15] Presence of multiple tooth buds throughout the substance of the mandible as well as the potential injury to future growth complicate the management of these fractures.[1] One of the main principles is to use the least amount of foreign material.[16] The use of rigid fixation in children is controversial and may cause growth retardation along cranial suture lines. Con-servative approaches with non-surgical management may be successful in pediatric population due to the high osteogenic potential in this population.[10] Children demonstrate a good healing capacity.. These younger patients have the potential for restitutional remodeling, as opposed to sclerotic, func-tional remodeling seen in adults.[1] The majority of pediatric

mandibular fractures can be managed with closed techniques using short periods of maxillomandibular fixation or training elastics alone. Generally, the use of plate- and screw-type in-ternal fixation is reserved for difficult fractures.[5] Lingual splint has been reported for the reduction, stabilization and fixation of a mandibular body fracture with a successful result.[9]

Pediatric mandible fractures, which are seen less frequently compared to those of adults, require a specific and differ-ent treatment. Although less invasive methods are preferred mostly, internal fixation with open reduction should be con-sidered when required.[17] Rigid fixation of mandibular frac-tures results in a faster bone healing, both by compression and lack of mobility between fracture segments.[18–23] Smartt et al. have demonstrated that open reduction and internal fixation, when used judiciously, are indispensable in the treatment of specific subsets of mandibular fractures, including displaced fractures of the body or angle, fractures of the condylar neck with significant barriers to movement, complex fractures, and fractures in non-toothbearing areas. Open reduction should be performed cautiously, with minimal manipulation of over-lying soft tissues. When performed properly, it is a safe and versatile treatment modality.[11]

Metal plate-screw systems enable adequate fixation in bone healing process. Yet, their effects like limiting bone growth es-pecially in pediatric age group have prompted investigators to look for alternative fixation materials in the reconstruction of trauma and craniofacial anomalies.[24,25]

The ideal fixation system for stabilisation of an osteotomy or bone fracture would provide adequate strength initially to permit bone healing during function, and then, decrease in strength so that there isincreasing physiological force trans-ference to the bone. Biodegradable polymers can provide that while metals cannot.[13]

The most attractive characteristic of resorbable plates is that they obviate any potential impediments to long-term metal retention. They enable realignment and stable positioning of rapidly healing fracture segments. They are also quite well tolerated in this population.[14] Yerit et al. have demonstrat-ed advantages of resorbabale materials in pediatric patients especially by faster mobilization and the avoidance of sec-ondary removal operations. Primary healing of the fractured mandible was observed in all of the thirteen patients, and malocclusion and growth restrictions did not occur.[26] Tita-nium plates need to be removed; whereas, resorbable plates do not. Resorbable plates are radiolucent and allow full vi-sualization of the fractures on postoperative radiographs.[23] They provide proper strength, and then, harmlessly degrade over time, until the load can be safely transferred to the healed bone. As there is no need for a removal operation, these biodegradable devices reduce the total treatment and rehabilitation time of the patient. Besides, they reduce costs related to this type of trauma.[23]


Figure 3. Upper;A 4-month follow-up of a symphysis-parasym-physisfracturewithscrewsitesvisibleonpanoramicradiograph.Lower;Thescrewsitesarehealedwith lessvisibleholesafteratotalof9-monthfollow-up.

The use of resorbable plates and screws for fixation of pe-diatric facial fractures is both well tolerated and effective. It enables realignment and stable positioning of rapidly healing fracture segments while obviating any future issues to long-term metal retention.[12]

Mandibular growth is not affected as demonstrated by the present and several other studies.[23] Complication rates are comparable with nonresorbable plate fixation.

As we are experienced more with the use of resorbable hardware, we observed that the fixation strength of the re-sorbable hardware is not as powerful as that of the metallic hardware. Our first cases were reconstructed with 2-mm re-sorbable plates. It may be difficult to place the plates of this thickness in children younger than 5 years of age. It is also quite difficult to place the plates beneath the nerve in cases of parasymphysis fractures. Usually, there is not enough place for two plates. We hesitated using 1.5 mm plates, but there are examples of its usage in the literature.[12]

Muscle activity in mandibular ramus is considerable,[13] and it is better to advice the patients to be cautious while chew-ing, especially in the first 4 weeks. Children’s adaptability to masticatory function increases with the development.[27] Due to traumatic stress and pain, children usually adapt to soft diet better than adults. We did not offer a different diet to patients with the resorbable hardware. Both groups followed the same principles postoperatively. However, if concerns about resorbale plate stability occurs, some pre-cautions can be taken; additional intermaxiller fixation to open reduction, prolongation of soft diet regimen, and/or more visits postoperatively to earlier detection of the plate instability.

It is not faulty to say that we use resorbable plates to make unfavorable fractures favorable and keep the fracture edges in proper position. This is a kind of conservative approach, that is, we are in between a rigid fixation with metallic plates and maxillomandibular fixation alone.

The pediatric patient’s ability to heal and recovery of function are much beter compared to adults. Despite these advan-tages, certain unique characteristics should be appreciated.[12] With a meticulous approach to these patients, final success is not so far away. The dilemma of pediatric mandible frac-tures is to choose the right therapy with the right hardware. Resorbable plates have been favoured in our clinic since we began to use them. We believe that with more studies per-formed in the future, resorbable plates will be preferred more than metallic plates and will be the first line in treatment of rigid fixation of mandibular fractures in the pediatric popula-tion.


REFERENCES

1. Cole P, Kaufman Y, Izaddoost S, Hatef DA, Hollier L. Principles of pediatric mandibular fracture management. Plast Reconstr Surg 2009;123:1022–4.

2. Ferreira PC, Amarante JM, Silva PN, Rodrigues JM, Choupina MP, Silva AC, et al. Retrospective study of 1251 maxillofacial fractures in children and adolescents. Plast Reconstr Surg 2005;115:1500–8.

3. Davison SP, Clifton MS, Davison MN, Hedrick M, Sotereanos G. Pedi-atric mandibular fractures: a free hand technique. Arch Facial Plast Surg 2001;3:185–190.

4. Demianczuk AN1, Verchere C, Phillips JH. The effect on facial growth of pediatric mandibular fractures. J Craniofac Surg 1999;10:323–8.

5. Kushner GM, Tiwana PS. Fractures of the growing mandible. Atlas Oral Maxillofac Surg Clin North Am 2009;17:81–91.

6. Hofer O. Newer knowledge in oral surgery. Fracture of the jaws. Zbl Zahn-Mund-Kieferheilk 1939;13:9–11.

7. Kruger E, Schilli W. Mandibular fractures. In: Oral and maxillofacial traumatology, vol. 1. Chicago: Quintessence Publishing 1982:211–393.

8. Hardin JC Jr. Proceedings: Triple fractures of the mandible with flar-ing rami. Their treatment with lingual splints. Arch Otolaryngol 1973;98:387–8.

9. Binahmed A, Sansalone C, Garbedian J, Sándor GK. The lingual splint: an often forgotten method for fixating pediatric mandibular fractures. J Can Dent Assoc 2007;73:521–4.

10. Kocabay C, Ataç MS, Oner B, Güngör N. The conservative treatment of pediatric mandibular fracture with prefabricated surgical splint: a case report. Dent Traumatol 2007;23:247–50.

11. Smartt JM Jr, Low DW, Bartlett SP. The pediatric mandible: II. Manage-ment of traumatic injury or fracture. Plast Reconstr Surg 2005;116:28–41.

12. Eppley BL. Use of resorbable plates and screws in pediatric facial frac-tures. J Oral Maxillofac Surg 2005;63:385–91.

13. Turvey TA, Proffit WP, Phillips C. Biodegradable fixation for craniomax-illofacial surgery: a 10-year experience involving 761 operations and 745 patients. Int J Oral Maxillofac Surg 2011;40:244–9.

14. Poore MC, Penna KJ. The use of resorbable hardware for fixation of pe-diatric mandible fracture. Case report. N Y State Dent J 2008;74:58–61.

15. Smartt JM Jr, Low DW, Bartlett SP. The pediatric mandible: I. A primer on growth and development. Plast Reconstr Surg 2005;116:14–23.

16. Alagöz MS, Uysal AC, Sensoz O. An alternative method in mandibu-lar fracture treatment: bone graft use instead of a plate. J Craniofac Surg 2008;19:411–20.

17. Eskitascioglu T, Ozyazgan I, Coruh A, Gunay GK, Yuksel E. Retrospec-tive analysis of two hundred thirty-five pediatric mandibular fracture cases. Ann Plast Surg 2009;63:522–30.

18. Cabrini Gabrielli MA, Real Gabrielli MF, Marcantonio E, Hochuli-Viei-ra E. Fixation of mandibular fractures with 2.0-mm miniplates: review of 191 cases. J Oral Maxillofac Surg 2003;61:430–6.

19. Ellis E 3rd, Walker L. Treatment of mandibular angle fractures using two noncompression miniplates. J Oral Maxillofac Surg 1994;52:1032–7.

20. Ellis E 3rd, Walker LR. Treatment of mandibular angle fractures using one noncompression miniplate. J Oral Maxillofac Surg 1996;54:864–72.

21. Lamphier J, Ziccardi V, Ruvo A, Janel M. Complications of man-dibular fractures in an urban teaching center. J Oral Maxillofac Surg 2003;61:745–50.

22. Cawood JI. Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg 1985;23:77–91.

23. Laughlin RM, Block MS, Wilk R, Malloy RB, Kent JN. Resorbable



plates for the fixation of mandibular fractures: a prospective study. J Oral Maxillofac Surg 2007;65:89–96.

24. Cavuşoğlu T, Yavuzer R, Başterzi Y, Tuncer S, Latifoğlu O. Resorbable plate-screw systems: clinical applications. Ulus Travma Acil Cerrahi Derg 2005;11:43–8.

25. Fearon JA, Munro IR, Bruce DA. Observations on the use of rigid fixa-tion for craniofacial deformities in infants and young children. Plast Re-

constr Surg 1995;95:634–8.

26. Yerit KC, Hainich S, Enislidis G, Turhani D, Klug C, Wittwer G, et al. Biodegradable fixation of mandibular fractures in children: stability and early results. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:17–24.

27. Matsubara T, Ono Y, Takagi Y. A study on developmental changes of masticatory function in children. J Med Dent Sci 2006;53:141–8.



OLGU SUNUMU

Pediatrik mandibula kırıklarındaki ikilem: Eriyen plaklar mı yoksa metal plaklar mı?Dr. Gaye Taylan Filinte,1 Dr. İsmail Mithat Akan,2 Dr. Gülçin Nujen Ayçiçek Çardak,1Dr. Özay Özkaya Mutlu,3 Dr. Tayfun Aköz4

1Dr.LütfiKırdarKartalEğitimveAraştırmaHastanesi,PlastikRekonstrüktifveEstetikCerrahiKliniği,İstanbul2MedipolÜniversitesiTıpFakültesi,PlastikRekonstrüktifveEstetikCerrahiAnabilimDalı,İstanbul3OkmeydanıEğitimveAraştırmaHastanesi,PlastikRekonstrüktifveEstetikCerrahiKliniği,İstanbul4MaltepeÜniversitesiTıpFakültesi,PlastikRekonstrüktifveEstetikCerrahiAnabilimDalı,İstanbul

AMAÇ: Bu çalışmanın amacı çocuklardaki açık redüksiyon ve internal fiksasyon ile tedavi edilen mandibula kırıklarında, emilebilen ve metal plakların etkinliğini karşılaştırmaktır.GEREÇ VE YÖNTEM: Yaşları 20 ay-14 yıl (ortalama 8.05 yıl) arasında değişen 31 hasta mandibulanın farklı yerlerindeki kırıklar nedeniyle ameliyat edildi (26 [%60.4] simfisiz-parasimfisiz, 12 [%27.9] kondil-subkondil, 5 [%11.6] angulus ve ramus). On iki hasta eriyen plaklarla, 19 hasta ise metal plaklarla (titanyum) tedavi edildi. Ortalama takip süresi metal donanım kullanılan grupta 41 ay (11–74 ay), eriyen plak kullanılan grupta ise 22 ay’dı (8–35 ay). Her iki grup primer kemik iyileşmesi, komplikasyonlar, ameliyat sayısı ve mandibuladaki büyüme açısından incelendi. Bulgular aşağıda tartışıldı.BULGULAR: Her iki grupta primer kemik iyileşmesi saptandı. Her iki gruptaki minör komplikasyonlar benzerdi. Metal donanım kullanılan grupta pak çıkartılması için ikinci operasyonlar gerçekleştirildi. Her iki gruptaki mandibula gelişimi tatmin ediciydi.TARTIŞMA: Eriyen plaklar metal donanımlı plaklardan daha pahalı oldukları görüldü. İkinci operasyonların maliyeti göz önünde bulundurulduğunda ise eriyen plaklar daha avantajlıydı. Mandibula büyümesi ve komplikasyon parametreleri heriki grupta benzer olduğundan, eriyen plaklar; olası diş hasarının önlenmesi, uzun süreli yabancı cisim varlığının olmaması ve hızlı kemik iyileşmesi için gerekli olan yeterli sabitlik sağlaması gibi hususlara bağlı olarak tercih edilmektedir. Buna rağmen, emilebilir plakların kullanılması hususunda bir öğrenme periyodunun gerekliliği ve metal plaklarla karşılaştırıldığında, çiğneme kaslarının karşıt gücüne karşı düşük sabitlik sağladıkları gibi endişeler akılda tutulmalıdır.Anahtar sözcükler: Eriyen plaklar; mandibula kırıkları; metal plaklar.



Toraks travması takibinde dikkat edilmesi gereken durum: Diyafragma yaralanmalarıDr. Fatih Meteroğlu,1 Dr. Atalay Şahin,1 Dr. İsmail Başyiğit,2 Dr. Menduh Oruç,1

Dr. Serdar Monıs,1 Dr. Ahmet Sızlanan,1 Dr. Serdar Onat,1 Dr. Refik Ülkü1

1DicleÜniversitesiTıpFakültesi,GöğüsCerrahisiAnabilimDalı,Diyarbakır2DicleÜniversitesiTıpFakültesi,KalpDamarCerrahisiAnabilimDalı,Diyarbakır

ÖZET

AMAÇ: Penetran ve künt toraks travmalarında dikkatli incelenmediği ve şüphelenilmediği zaman gözden kaçabilen diyafragma yaralan-malarını vurgulamak istedik.

GEREÇ VE YÖNTEM: Ocak 2000–Haziran 2013 yılları arası künt ve penetran toraks travması ile başvuran 1349 olgudan travmatik diyafragma rüptürü olan 53 hastanın dosyaları incelendi. Hastaların yaşı, cinsiyeti, yandaş yaralanmaları, cerrahi yaklaşım şekli, ameliyat sonrası morbidite ve mortalite oranları ve hastanede kalış sürelerine bakıldı.

BULGULAR: Künt veya penetran toraks travması sonucu kliniğimizde tedavi edilen 1349 olgudan, travmatik diyafragmatik yaralanma (TDY) olan 48’i erkek, beşi kadın olgu değerlendirildi. Yaş ortalamaları 31.06 (4–65 yıl) ve 35.80 (4–50 yıl) idi. Cerrahi yaklaşım olarak torakotomi %66, laparotomi %20.75 ve laparotomi+torakotomi ise %13.20 olguda uygulandı. Torakotomi öncesi tanı amaçlı video-yardımlı torakoskopi (VATS) %15.09 hastada uygulandı. Diyafragma 31 olguda sol ve 22 olguda sağ tarafta onarıldı. Morbidite olarak pulmoner komplikasyonlar künt travmalarda daha fazla görüldü (%37.73). Mortalite ise sadece penetran travmalı üç olguda gözlendi. Ortalama hastanede yatış süresi 8.75 gündü (dağılım 4–15 gün). Olgular ortalama 28.13 ay olarak (3–60 ay) takip edildi. Yaralanma türü, cinsiyet ve yaş açısından gruplar arasında istatistik olarak anlamlı farklılık saptanmazken (p=0.05); künt travmalı hastalarda morbidite anlamlı bulundu.

SONUÇ: Künt veya penetran olsun toraksı ilgilendiren travmalarda mutlaka diyafragmaya yönelik inceleme yapılmalı, diyafragma ile ilgili bir şüphe varsa mutlaka değerlendirilmelidir.

Anahtar sözcükler: Diyafragma; künt; penetran; yaralanma.

GİRİŞ

Travmatik diyafragma yaralanması (TDY), toraks ve abdome-nin hem künt hem de penetran travmaları sonucunda ortaya çıkabilir. Rüptür gelişim oranı genellikle %1–5 arasında değiş-mektedir.[1] Travmatik diyafragma yaralanması sıklıkla çoğul organ yaralanmaları ile birliktedir. Künt travmalarda intraab-dominal basıncın ani artmasına bağlı olarak gelişen diyafrag-ma rüptürleri çoğunlukla sol tarafta olup sol/sağ rüptür oranı 5/1’dir. Sağ tarafta karaciğer diyafragmayı belli bir dereceye

kadar korur. Penetran TDY özellikle alt göğüs veya üst batın bölgesine isabet eden, genellikle kesici delici alet veya ateşli si-lah yaralanmalarından ve künt travmalardan sonra olmaktadır.

Travmatik diyafragma yaralanması olduğunda yaralanmanın büyüklüğü, orijini ve yerleşimine bağlı olarak klinik tablosu değişkenlik göstermektedir. Hemen müdahale gerektiren eş-lik eden daha ciddi diğer lezyonlar tarafından maskelenmesi tanısını zorlaştırmakta ve geciktirmektedir.[2] Küçük lezyonlar özellikle penetran yaralanmalara bağlı olarak ortaya çıkanlar ve sağ hemi-diyafragmayı etkileyen durumların tanısı atlana-bilir ve tanınmaları uzun zaman alabilir. İntermammarian hat altındaki ve göbek üstündeki yaralanmalar yüksek şüphe uyan-dırmalıdır.

Klinik tabloda solunum sıkıntısı, kardiyak bulgular, trakea de-viyasyonu, bağırsak seslerinin toraksta duyulması gibi bulgular olabilir. En önemlisi travma hastalarında diyafragma rüptürün-den şüphe etmektir. Tanıda, direkt göğüs grafiği, ultrasonog-rafi, bilgisayarlı tomografi, floroskopi, mide ve kolon grafileri

O R İ J İ N A L Ç A L I Ş M A

Sorumlu yazar: Dr. Atalay Şahin,

Dicle Üniversitesi Hastanesi, Kampüs, Yenişehir, 21280 Diyarbakır.

Tel: +90 412 - 248 80 01 E-posta: [email protected]

Ulus Travma Acil Cerrahi Derg2015;21(6):514–519doi: 10.5505/tjtes.2015.30660

Telif hakkı 2015 TJTES

Ulus Travma Acil Cerrahi Derg, Kasım 2015, Cilt. 21, Sayı. 6514

Ulus Travma Acil Cerrahi Derg, Kasım 2015, Cilt. 21, Sayı. 6 515

Meteroğlu ve ark. Toraks travması takibinde dikkat edilmesi gereken durum: Diyafragma yaralanmaları

ve video yardımlı torakoskopi yöntemleri yardımcı olur. Bazı olgularda tanıyı kolaylaştıran abdominal herniasyon görülme-yebilir ve ilk göğüs grafisi tanısal olmayabilir.

Tanı konulduktan sonra inkarserasyon, strangülasyon gibi komplikasyonlar gelişmeden rüptür cerrahi olarak onarılma-lıdır. Akut dönemde, özellikle sol taraf yaralanmalarında ilave batın içi organ yaralanması olabileceğinden dolayı laparotomi tercih edilir. Sağ tarafta eğer batın içi yaralanma düşünülmü-yorsa torakotomi yapılabilir. Geç tanı konmuş rüptürlerde, adezyonlar nedeni ile torakotomi tercih edilmektedir.

Torakal yaralanmalarda diyafragma yaralanmalarının önemi ve sonuçlarını vurgulamayı amaçladık.

GEREÇ VE YÖNTEM

2000–2013 yılları arası toraks travması sonrası acil servisten kliniğimize başvuran 1349 hastanın dosyaları yerel etik kurul 26.03.2014–163 sayılı kararı ile geriye dönük olarak irdelendi. Bu olgulardan diyafragma yaralanması olan 53 (%3.93) olgu değerlendirmeye alındı. Bu hastalar, demografik özellikleri,

cinsiyet, travma türü, zaman, bulgular, tanı, yer, uygulanan cer-rahi, morbidite ve mortalite açısından değerlendirildiler. Ya-ralanmaların çoğu torakoabdominal alt sınırı olan arkus kos-talisin üstünde idi. Tanı için hastalara direkt grafileri yanında bilgisayarlı tomografi, (toraks ve alt torakoabdominal bölge) ultrasonografi ve kontraslı incelemeler yapıldı. Ancak şüphe uyandıran ve halen kesin tanıya gidilmeyen bazı olgularımızda torakoskopi yapıldı.

Elde edilen sayısal değerlerin istatistiksel analizleri SPSS for Windows (15.0) bilgisayar programı ile yapıldı. Hastaların cin-siyet ve yaşlarının mukayesesi için Student’s t, cinsiyet ile künt ve penetran yaralanma türünün mukayesesi için Fisher exact ve yandaş yaralanmalar ile komplikasyonlar için tek değişkenli Ki-kare testi kullanıldı. P<0.05 istatistiksel olarak anlamlı ka-bul edildi.

BULGULAR

2000–2013 yılları arası künt veya penetran toraks travması sonucu kliniğimizde tedavi edilen 1349 olgudan TDY olan 48 erkek ve beş kadın olgunun yaş ortalamaları 31.06±14.52

Tablo 2. Penetran ve künt travma olgularının özellikleri

n % Cinsiyet Sağ\Sol Eşlik eden organ Eşlik eden Ameliyat sonrası p Mortalite p Erkek\Kadın yaralanması organ kaybı morbidite

Penetran 45 84.90 40\5 20\25 Sağ orta lob: 1 Sağ orta lob: 1 Yara yeri enf: 4 =0.000 3 =0.456

Karaciğer: 2 Splenektomi: 1 Atelektazi: 1

Sağ atrium+İMA: 6 Pnömoni: 1

Kalp+Sol İMA: 1

Dalak: 1

Subklaviyan ven+VCİ: 1

Toraks duvarı defek: 1

Kot fraktürü: 2

Künt 8 15.10 8\0 5\3 Kot fraktür: 2

Mide+kolon yaralan: 1 0 Atelektazi: 6

Uzamış hava kaçağı: 3

Pnömoni: 4

VCİ: Vena kava inferior; İMA: İnternal mammariyan arter.

Tablo 1. Travmatik diyafragma yaralanmalarının özellikleri

Hasta sayısı (erkek/kadın) 48/5

Lokasyon Sağ Sol n % p

Penetran Kesici delici alet yaralanması 12 21 33 62.26 0.49

Ateşli silahlı yaralanması 8 4 12 22.64

Künt Trafik kazası 4 1 5 9.43

Diğer: İş kazası 1 2 3 5.66


(4–60 yıl) ve 35.80±14.26 (18–53 yıl) idi. Bazı hastalarda TDY’ye eşlik eden organ yaralanmaları da mevcuttu. Hastala-rın %84.90’ında yaralanma nedeni penetran travma idi. Yara-

lanmalar intermammarian hat ve arkus kostarum arasında idi. Künt travma nedenleri arasında ise araç içi ve dışı trafik kaza-ları ile iş kazaları vardı. Tanıda fizik muayene bulguları daha çok dispne, göğüs ve karında ağrı idi.

Erkek olgularda kesici delici alete bağlı TDY sağ tarafta 11, sol tarafta 17 ve ateşli silahlı yaralanmaya bağlı sağda sekiz, solda dört olguda gözlendi. Trafik kazasına bağlı yaralanma sağda dört, solda bir olguda izlendi. Diğer künt travmalara bağlı olarak sağda bir, solda iki olguda görüldü. Kadın olgularda ise kesici delici alet yaralanmasına bağlı TDY sağda bir ve sol-da ise dört olguda idi (Tablo 1). Tüm olgularımıza olayı takip eden ilk 24–48 saat içinde müdahale edildi. Olayın şekline ve yerine göre tüm olgularımıza akciğer grafisi, bilgisayarlı toraks tomografisi, (toraks ve alt torakoabdominal) ultrasonografi çekilmiştir. Ancak şüphe uyandıran ve halen kesin tanıya gi-dilmeyen sekiz olguda torakoskopi yapıldı. Eşlik eden diğer yaralanmalar arasında en çok abdominal organ yaralanmaları vardı (Tablo 2).

Cerrahi yaklaşım olarak olguların %66’sına (n=35) tora-kotomi uygulandı. Laparotomi %20.75 (n=11) olguda ve laparotomi+torakotomi ise %13.2 (n=7) olguda yapıldı. Diyaf-ragma primer olarak emilmeyen sutur ile onarıldı ve prostetik malzeme kullanılmadı (Şekil 1, 2a, b). Torakotomi öncesi tanı amaçlı video-yardımlı torakoskopi (VATS) sekiz hastada uy-gulandı.

Morbidite olarak pulmoner komplikasyonlar künt travmalarda daha fazla görüldü. Mortalite ise sadece penetran yaralanmaya bağlı üç olguda gözlendi. İstatistiksel olarak mortalite de an-lamlı bir fark bulunmaz iken, morbidite de ise künt travmada anlamlı çıktı (Tablo 2). İkisi ateşli silahlı yaralanma, diğeri de kesici delici alet yaralanması idi. Bu olgularda kalp ve majör damar yaralanması vardı (%5.66).

Sonuçlar değerlendirildiğinde yaralanma türü, cinsiyet ve yaş açısından gruplar (künt, ateşli silahlı yaralanma ve kesici deli-ci alet yaralanması) arasında istatistik olarak anlamlı farklılık saptanmazken, künt travmalı hastalarda morbidite anlamlı bu-lundu.

Tüm olgular ortalama 28.13 ay olarak (3–60 ay) takibi yapıldı. Bu takip süresinde olgulara solunum fonksiyon testleri ve ak-

Şekil 1. Tomografidediyafragmabütünlüğününolmaması.

Şekil 2. (a) Peroperatifdiyafragmayırtılmasınıngörünümü.(b)Pe-roperatifdiyafragmayırtılmasınınonarımı.

(a)

(b)

Şekil 3. Diyafragma yaralanması sonucu gözlenen postoperatifkomplikasyonlar

1

4

Atelektazi%10

Havakaçağı%10

Yaraenfeksiyonu

%8

Pnömoni%6

Ampiyem%2

Apse%2

1

4

1

3 3

1 1

KüntPenetran


ciğer grafiğiyle kontrolleri yapıldı. Klinik değişiklikler, iyileşme süreçleri ve gelişen komplikasyonlar açısından değerlendirildi. Atelektazi, uzamış hava kaçağı ve yara yeri enfeksiyonu gibi komplikasyonlar daha çok künt travmalı hastalarda görüldü (Şekil 3).

TARTIŞMA

Künt travma hastalarının %0.8–7’sinde, penetran travma has-talarının %10–15’inde TDY oluşur.[3] Tüm diyafram yaralanma-larının %75’inin künt, %25’inin penetran travma ile oluştuğu bildirilmektedir.[4,5] Olgularımızın %15’i künt, %85’i penetran travma grubunda idi.

Penetran diyafragma yaralanmaları alt göğüs veya üst abdo-men kısmına isabet eden ön, yan veya arka taraftan olabilen kesici delici veya ateşli silah yaralanmalarına bağlı gelişir.

Diyafragma bölgesindeki bıçaklı veya ateşli silahlı yaralanma-ları daha küçük defektler oluşturabilir. Delici alet yaralan-maları sonucu oluşan travmalar, başlangıçta fark edilememe eğilimindedir; bununla birlikte uzun dönemde ciddi kompli-kasyonlara da yol açma potansiyeline sahiptir. Sol taraf ya-ralanmaların sayısının çok olması birçok saldırganın sağ elini kullanıyor olmasında etkisi vardır. Sağ elle yapılan saldırılar mağduru daha çok sol taraftan yaralamaktadır.[6] Nitekim bi-zim olgularda da sol tarafta fazla görülmektedir. Künt trav-malar konjenital olarak zayıf olan posterior diyafragma böl-gesinde rüptüre neden olabilir. Bu tür yaralanmalar basınç değişikliği sonucu olarak meydana gelir ve aniden yükselen intra-abdominal basıncın iletimi nedeniyle oluşur. Motorlu araç kazaları ve yüksekten düşme gibi yüksek enerjili meka-nizmalar sonucu oluşan kazalarda diyafragmada büyük hasar gelişir ve solunum mekaniğinde oluşan aksama sonucu tanı erken konulabilir.[4,7]

Diyafragma yaralanmaları belirti vermeden sinsi seyredebi-lir. Travmalı hastada diyafragma yaralanmasının klinik tablo-da baskın olması beklemez.[6] Dolayısıyla TDY’nin tanısı akut dönemde kolaylıkla atlanabilir. Geç dönem olgularda herniye olan organların radyolojik görüntüsü, pnömotoraks olarak yanlış yorumlanabilir.[8] Göğüs yaralanması olan bir kişide ab-dominal şikâyetlerin olması şüphe uyandırır. Fakat yaralanma-nın batın ya da yan tarafta olması ve aynı zamanda hastada göğüs bulgularının olması diyafragma yaralanmasının kuvvetli bulgularıdır. Bununla birlikte birçok hastada giriş kavitesi ha-ricinde diyafragma yaralanmasına ait bir bulgu izlenmez ve diyafragmatik yaralanma eksplorasyon yapılana kadar şüpheli kalır. Bazı hastalarda da diğer yaralanmalar için eksplorasyon endikasyonu konmayınca diyafragma yaralanması tamamen at-lanmış olabilir. Bu durum genelde kesici ve delici alet yaralan-malarından sonra olur. Çünkü ateşli silah yaralanmaları sıklıkla abdominal veya torasik eksplorasyon gerektirirler.[9]

Derin ekspiryum ve inspiryum ile diyafragma 4.–8. kaburga arasında hareket eder. Dolayısıyla bu bölgeye olan kesici ve

delici alet veya ateşli silahlı yaralanmalarda mutlaka diyafragma yaralanması ekarte edilmelidir. Aksi halde küçük yaralanmalar uzun vadede ciddi komplikasyonlara neden olabilir.[10,11]

Diyafragma bölgesindeki bıçaklı veya ateşli silahlı yaralan-maları daha küçük defekler oluşturabilir. Delici alet yaralan-maları sonucu oluşan travmalar, başlangıçta sessiz seyretme eğilimindedir; bununla birlikte uzun dönemde ciddi kompli-kasyonlara da yol açma potansiyele sahiptir.[6] Çünkü batın içi pozitif ve toraks içi negatif basınçtan dolayı batın organ-ları toraksa geçebilir. Bu da uzun vadede kolon, mide, dalak ve hatta omentum nekrozlarına neden olabilir.[10] Bu da bize torakoskopi ve\veya laparaskopinin önemini ortaya koymak-tadır. Miller ve ark.[12] 93 hastalık penetran travmaya bağlı diyafragma yaralanması çalışmalarında, olguların %43’ünde göğüs radyografisinin normal, %57’sinde ise anormal olduğu-nu belirtmişlerdir. Göğüs radyografisinde görülen anormal-likler hemotoraks, pnömo-toraks veya her ikisi, herniye olan abdominal organın görüntüsü ve pnömoperitoneum olabilir. Radyografinin, 185 hastalık çalışmasında hastaların 1/3’ünde normal olduğunu belirtmiştir.[9] Kliniğimizde acil operasyona alınanlar hariç tüm olgulara iki yönlü akciğer grafisi ve BT çekildi.

Gövdedeki bütün yaralanmalarda diyafragma yaralanmasından şüphe edilmesi gerekir. Özellikle de meme başlarından göbeğe kadar olan mesafede diyafragma yaralanması olasılığı daha faz-ladır. Diyafragma yaralanması veya organ yaralanmasına ait bir şüphe yok ise ilk etapta eksplorasyona ihtiyaç yoktur. Fakat bazı kesici yaralanmalarından sonra diyafragma yırtığı atlana-bilmektedir.[13] Diyafragma veya sol alt lob bölgesinde devam eden anormal göğüs grafisi durumunda laparoskopi veya vi-deo-torakoskopi diagnostik olabilir.[14,15] Penetran sol torako-abdominal yaralanmalarda, tanıda diagnostik laparoskopi veya torakoskopi tercih edilmelidir.

Akut diyafragma yaralanmasında, diyafragmatik yaralanma varsa akut dönemde omuz ağrısı, epigastrik ağrı, kusma ve yüzeysel solunum olabilir ve tanıya rahat gidilebilir. Ancak kü-çük olan yaralanmalarda ise semptom veya bulgu olmayabilir. Tüm incelemelere rağmen hala şüphe varsa aynı seansta to-rakoskopi ve\veya laparaskopi yapılmalıdır. Bu durumda hem morbidite hemde mortalite oranı önemli derecede düşür-mektedir.[11]

Diyafragmatik yaralanmar, özellikle geçikmiş olgular, ölüme yol açabilir. Birlikte olan organ yaralanmaları değişik oranlarda ölümle sonuçlanır. Symbas ve ark.[16] 185 penetran diyafragma yaralanmalı hastada mortalite oranını %2.2 olarak belirtmiştir. Kliniğimizde kesici-delici alet yaralanmasına bağlı primer diyaf-ragma yaralanması olan 53 olgudan üçünde mortalite görüldü. Nel ve Warren[14] penetran yaralanmalı 55 hastada torakosko-pi ile diyafragma yaralanması değerlendirmişler ve bu yönte-mi %100 sensitif ve %90 spesifik, doğruluk derecesinde %94 olarak rapor etmişlerdir. Diğer bazı araştırıcılarda bu bulguları teyit etmişlerdir.[15]



Bizim çalışmamızda travmaya sekonder TDY %3.92 idi ve eşlik eden organ yaralanmaları mevcuttu (Tablo 2). Tüm olgularımı-za 24–48 saat içinde müdahale edildi. Tüm incelemelere rağ-men tanı konulamayan ve şüphe uyandıran sekiz olguya tanı amaçlı torakoskopi yapılarak diyafragma rüptür tanısı konul-muş ve diyafragma primer olarak onarılmıştır.

Travmada diyafragmaya yönelik cerrahi yaklaşım, yaralanmanın lokalizasyonu ve ameliyat süresine bağlı olarak değişmektedir. Travma sonrası en kısa zamanda onarılan diyafram yaralanma-larında yaklaşım, laparatomi veya laparaskopi yoluyla olmak-tadır. Bu yaklaşım detaylı bir batın içi inceleme ve abdominal organların redüksiyonu açısından kolaylık sağlamaktadır.[6,17,18] İntratorasik organ yaralanması veya majör bir kanama yoksa abdominal yaklaşım bulgu vermeyen bir abdominal organ ya-ralanmasını ortaya çıkarmak için ve her iki diyafragmayı gör-mek açısından tercih edilir. Torakotomi ile her iki diyafragmayı görmek mümkün değildir. Diyafragma yaralanmalarında lapa-roskopi gibi video yardımlı torakoskopi de tanı ve tedavide başarıyla kullanılmaktadır.[19,20] Akut yaralanmada diyafragma bütünlüğü bozulmadıysa non-absorbabl (0 veya 1 numara) sütür kullanılmalıdır. Ancak geniş defekt veya kronik olguda defekti güçlendirmek için prostetik meş ile desteklenmelidir.[11] Kliniğimizde tanı konulduğunda ve batında sorun olmayan olgulara torakotomi, eşlik eden batın yaralanmalarında ise la-paratomi ile cerrahi müdahale yapıldı.

Sonuç olarak; TDY’nin tanısı akut dönemde kolaylıkla atlana-bilir. Geç dönem olgularda herniye olan organların radyolojik görüntüsü, pnömotoraks olarak yanlış yorumlanabilir. Geç dönem travmatik TDY artmış morbidite ve mortaliteye neden olacaktır. Bu nedenle travmalı hastalarda özellikle alt göğüs ve üst karın yaralanmalarında TDY şüphesini akılda tutmak, radyolojik tanı yöntemleriyle tekrar olguları değerlendirmek, torakoskopiden kaçınmamak, eşlik eden patolojiler nedeniy-le yapılan laparotomi ve torakotomilerde diyaframı dikkatlice gözden geçirmek gerekir.

Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR

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

2. Turhan K, Makay O, Cakan A, Samancilar O, Firat O, Icoz G, et al. Traumatic diaphragmatic rupture: look to see. Eur J Cardiothorac Surg 2008;33:1082–5.

3. Mihos P, Potaris K, Gakidis J, Paraskevopoulos J, Varvatsoulis P, Goug-outas B, et al. Traumatic rupture of the diaphragm: experience with 65 patients. Injury 2003;34:169–72.

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

5. Schumpelick V, Steinau G, Schlüper I, Prescher A. Surgical embryol-ogy and anatomy of the diaphragm with surgical applications. Surg Clin North Am 2000;80:213–39.

6. Limmer KK, Kernstine KH, Granish Jr FW, Weiss LM. Erişkin göğüs cerrahisi (Çeviri editörü: Yüksel M) :Sugarbaker D, Bueno R, Krasna MJ, Mentzer SJ, Zellos L. Diaframanın malign veya benign hastalıkları. No-bel Tıp Kitapları. İstanbul 2011;127. s. 1054–67.

7. Lee WC, Chen RJ, Fang JF, Wang CC, Chen HY, Chen SC, et al. Rupture of the diaphragm after blunt trauma. Eur J Surg 1994;160:479–83.

8. Sanli M, Işik AF, Tunçözgür B, Meteroğlu F, Elbeyli L. Diagnosis that should be remembered during evaluation of trauma patients: diaphrag-matic rupture. [Article in Turkish] Ulus Travma Acil Cerrahi Derg 2009;15:71–6.

9. Symbas PN. Diaphragmatic Injuries. In: Shields TW, LoCicero III J, Ponn RB, Rusch VW; eds. General Thoracic Surgery. 6th ed. Philadel-phia: Lippincott Williams&Wilkins 2005:1006–14.

10. Chatzoulis G, Papachristos IC, Daliakopoulos SI, Chatzoulis K, Lam-pridis S, Svarnas G, et al. Septic shock with tension fecothorax as a delayed presentation of a gunshot diaphragmatic rupture. J Thorac Dis 2013;5:195–8.

11. Hanna WC, Ferri LE. Acute traumatic diaphragmatic injury. Thorac Surg Clin 2009;19:485–9.

12. Miller L, Bennett EV Jr, Root HD, Trinkle JK, Grover FL. Management of penetrating and blunt diaphragmatic injury. J Trauma 1984;24:403–9.

13. Sözüer EM, Ok E, Avşaroğullari L, Küçük C, Kerek M. Traumatic dia-phragmatic ruptures. Ulus Travma Derg 2001;7:176–80.

14. Nel JH, Warren BL. Thoracoscopic evaluation of the diaphragm in pa-tients with knife wounds of the left lower chest. Br J Surg 1994;81:713–4.

15. Freeman RK, Al-Dossari G, Hutcheson KA, Huber L, Jessen ME, Meyer DM, et al. Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma. Ann Thorac Surg 2001;72:342–7.

16. Symbas PN, Vlasis SE, Hatcher C Jr. Blunt and penetrating diaphrag-matic injuries with or without herniation of organs into the chest. Ann Thorac Surg 1986;42:158–62.

17. Smith RS, Fry WR, Tsoi EK, Morabito DJ, Koehler RH, Reinganum SJ, et al. Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury. Am J Surg 1993;166:690–5.

18. Martinez M, Briz JE, Carillo EH. Video thoracoscopy expedites the diag-nosis and treatment of penetrating diaphragmatic injuries. Surg Endosc 2001;15:28-33.

19. Yoo DG, Kim CW, Park CB, Ahn JH. Traumatic right diaphragmatic rupture combined with avulsion of the right kidney and herniation of the liver into the thorax. Korean J Thorac Cardiovasc Surg 2011;44:76–9.

20. Yucel T, Gonullu D, Matur R, Akinci H, Ozkan SG, Kuroglu E, et al. Laparoscopic management of left thoracoabdominal stab wounds: a pro-spective study. Surg Laparosc Endosc Percutan Tech 2010;20:42–5.




OLGU SUNUMU

Diaphragmatic injury: condition be noticed in the management of thoracic traumaFatih Meteroğlu, M.D.,1 Atalay Şahin, M.D.,1 İsmail Başyiğit, M.D.,2 Menduh Oruç, M.D.,1Serdar Monıs, M.D.,1 Ahmet Sızlanan, M.D.,1 Serdar Onat, M.D.,1 Refik Ülkü, M.D.1

1DepartmentofThoracicSurgery,DicleUniversityFacultyofMedicine,Diyarbakır2DepartmentofCardivascularSurgery,DicleUniversityFacultyofMedicine,Diyarbakır

BACKGROUND: The aim of the present study was to emphasize diaphragmatic injuries that can be overlooked in chest traumas.METHODS: Between January 2000 and June 2013, fifty-three patients with traumatic diaphragmatic laceration were evaluted among 1349 patients who had chest injuries. Patients were examined regarding age, gender, associated injuries, surgical interventions, postoperative morbidity, mortality and length of hospital stays.RESULTS: Of them, fifty-three cases had diaphragmatic lacerations. There were forty-eight male and five female patients, with a mean age of 31.06 (4–60) years and 35.80 (18–50) years. Thoracotomy in 66%, laparotomy in 20.75% and laparotomy+thoracotomy in 13.20% of the cases were performed. Video-assisted thoracoscopy was carried out in 15.09% of the patients. Diaphragm was repaired on the left in thirty-one cases and in the right in twenty-two cases. Pulmonary complications like morbidity was mostly seen in 37.73% of blunt trauma. Mortality was seen in three cases of penetrating trauma. Mean hospital duration was 8.75 days (range, 4–15 days). Patients were followed for a mean duration of 28.13 months (range, 3–60 months). There was no significant statistical difference between types of injury, ages and gender of cases (p=0.05); whereas, morbidity rate was important in patients with blunt trauma.DISCUSSION: Diaphragmatic lacerations should be kept in mind when penetrating and blunt injuries to the thorax are evaluated.Key words: Blunt; diaphragm; injury; penetrating.


ORIGINAL ARTICLE - ABSTRACT


Solitary caecum diverticulitis mimicking acute appendicitisSemih Hot, M.D., Seracettin Eğin, M.D., Berk Gökçek, M.D., Metin Yeşiltaş,M.D., Ali Alemdar, M.D., Arzu Akan, M.D., Servet Rüştü Karahan, M.D.

DepartmentofGeneralSurgery,OkmeydanıTrainingandResearchHospital,İstanbul

ABSTRACT

Solitary cecum diverticulum is a benign formation, but it can be complicated with inflammation, perforation and bleeding. Cecum diverticulitis (CD) is the most common complication of caecal diverticulum and it has the highest incidence among Asians, but it is a rare condition in the western world. The incidence of colonic diverticular disease can vary according to national origin, cultural struc-ture and nutritional habits. CD is not common in our country, but it is an important situation because of its clinical similarity with the commonly seen acute right side abdominal diseases like acute appendicitis. Preoperative diagnosis is difficult, and hence, the actual fre-quency is not known. The treatment of CD can vary from medical therapy to right hemi colectomy. In this study, we presented ten CD cases on whom surgical resection was performed in our surgery unit during the last 8 years. Our purpose was to increase the aware-ness of surgeons about this situation, and so, make them pay attention for not having their first experience in the operating room.

Key words: Acute abdomen; cecum diverticulitis; diverticular disease of the colon.

seen in 10–20% of the patients according to complications like inflammation, perforation, hemorrhage and rarely intes-tinal obstruction.[5,6] Acute appendicitis is the most common false diagnosis for CD.[5] In fact, patients who have CD suffer from prolonged complaints accompanied by intermittent or chronic symptoms. The pain of CD begins from the right side of the abdomen or at right lower quadrant rather than peri-umblical region and remains, vomiting is not common. Preop-erative diagnosis is difficult, and CD should be kept in mind for patients with right lower quadrant pain.[7]

This study aimed to present our experience in the surgical management of ten cases of CD over an 8-year period. Our purpose was to increase the awareness of surgeons about this situation, and so, make them pay attention for not having their first experience in the operating room.

CASE SERIES

A retrospective analysis of the surgical treatment of acute diverticulitis of the caecumperformed between November 2005 and November 2013 within the Emergency Surgical De-partment of the Okmeydanı Training and Research Hospital was carried out. Patients who received only medical therapy were excluded from the study. Patients were identified from the hospital’s operating records based on the final postopera-tive diagnosis. The search revealed ten patients that under-went surgery for diverticular disease of the caecum. In all cases, the correct diagnosis of diverticulitis was con-firmed by histopathological examination. The data collected

C A S E S E R I E S

Address for correspondence: Seracettin Eğin, M.D.

Erenköy Bengi Sokak, No: 6/14, Gençay Apartmanı,

Kadıköy, İstanbul, Turkey



Copyright 2015TJTES

INTRODUCTION

Cecum diverticulum can be seen with widespread colon diver-ticulosis as an acquired lesion. Alternatively, it may appear as solitary cecum diverticulum known as congenital originated. The prevalence of diverticular disease of the cecum is based on variable factors like national origin, cultural background and nutritional habits.[1] In the Western world, diverticulum is basically located in the distal colon, sigmoid colon is involved in 90% of the patients, and on the other hand, right side in-volvement is only seen in 5% of the patients.[2] However, right side involvement is very noticeable in Asian countries.[3] In addition, in a review of a large series where barium enema was used, solitary cecum diverticulum incidence was found to beonly 0.1%. Additionally, in only 5% of these cases, cecum was involved with generalized diverticulosis.[4]

The most common complication of cecum diverticulum is cecum diverticulitis (CD). Patients with cecum diverticulum are usually asymptomatic; however, clinical symptoms can be



Hot et al. Solitary caecum diverticulitis mimicking acute appendicitis

included age, gender, presenting signs, symptoms, and clini-cal parameters. Preoperative laboratory values, including full blood count, renal panel and urine analysis were also record-ed. In addition, indication for surgery, operative findings and interventions, perioperative complications, operative proce-dures performed, postoperative mortality and morbidity, and length of hospital stay were documented.

RESULTS

Ten cases of CD were identified. The clinical data of these ten cases are summarized in Table 1. Patient age ranged from 21 to 79 years (mean, 38.9 years). There were 5 female and 5 male patients. Nine patients were admitted to hospital with a presumed clinical diagnosis of acute appendicitis. All cases presented with abdominal pain that localized in the right iliac fossa (7 out of 10), diffuse abdominal pain (2 out of 10) or hypogastrium (1 out of 10). Fever (>38 °C) was present in six out of 10 patients. Further symptoms were palpable ab-dominal mass (1 out of 10), nausea (7out of 10), and vomiting (2 out of 10). Moreover, no urinary symptoms or history of inflammatory bowel diseases presented. The duration of the symptoms until admission to the clinic ranged between 12h and 4 days (mean 36h).

Eight patients had leukocytosis with polymorphonucleo-sis. Leucocyte count ranged from 8,500 to 18,100/dl (mean 12,800/dl). Only one patient had a history of appendectomy.Preoperative abdominal ultrasonography (US) were per-formed in all patients. US showed inflammation findings in the right iliac fossa (5 out of 10), a mass in the lower cecum (1 out of 10), free fluid between intestinal loops in the right lower quadrant and mesenchymal lymphadenopathy (1 out of 10) and normal findings (3 out of 10). Preoperative abdominal computed tomography (CT) scans were performed in three cases, showingcircumferential thickening of the right colon with surrounding inflammatory changes.

All patients were applied intravenous therapy (antibiotic-sec-

ond generation cephalosporin-, fluids, antiemetic -as needed for patient comfort-) and were also ordered a fasting from food and fluids in the preoperative period. The decision for surgical treatment was made for ten patients who had acute abdomen signs, persistant complaints, and unimproved labo-ratory findings despite the applied medical treatment. All pa-tients with the diagnosis of acute abdomen were operated within the first 24-48h of admission. In nine patients, our ini-tial diagnosis was acute appendicitis. In the patient who had a history of appendectomy, we considered CD or Meckel’s diverticulitis as a probable diagnosis for acute abdomen. A McBurney’s incision was conducted in nine patients while a lower right quadrant transverse incision was performed in one patient. In one of these cases, tube cecostomy was ad-ditionally performed due to vulnerable caecal wall, utilizing a thick Foley catheter (Fig. 1a). One patient had a perforated small diverticulum with limited inflammatory reaction. This patient was subjected to closure of the ruptured site in two layers with interrupted Vicryl 3/0 sutures and drainage of the region. All patients were treated successfully with di-

Table 1. The clinic data of 10 patients

Age (yr) 21–79 (38.9)

Gender ratio 5/5 (50%)

Duration time 12h–4d (36h)

Abdominal pain

Right illiac fossa 70%

Diffuse 20%

Hypogastrium 10%

Nause 70%

Vomiting 20%

Leukocytosis ratio 80%

White blood cells (x103/L) 8.5–18.1 (mean 12.8)

Mean hospital stay 5 d

(a) (b)

Figure 1. (a)Photographofperforatedceacaldiverticula.(b)Histopathologicalappearanceofperforatedceacaldiverticula(He-matoxylineosin,x40).


verticulectomy. Nine patients were additionally subjected to appendectomy. Pathological examination showed single cae-cal diverticula with diverticulitis (Fig. 1b). The postoperative course of all patients was uneventful. Oral feeding was start-ed after the mobilization of the bowel. From the moment of diagnosis, the average stay in hospital was five days, and no death or serious postoperative complication was observed. At (long term) follow up (mean 5,1 years, range 1–8 years) all patients were alive.

DISCUSSIONMost solitary cecum diverticulum casesoriginate from the anterior aspect of the cecum, and they generally perforate when they are inflamated and cause peritonitis. On the other hand, posteriorly localized CD does not cause peritonitis and can be confused with perforated cancer as it may generate a mass. More than 70% of CD cases have false diagnosis when they are taken to surgery because of acute appendicitis.[5,8]

Although contrast enema is useful for the diagnosis of cecum diverticulum, its usage is limited as it can cause perforation in asymptomatic patients during acute exacerbation. Recently recommended diagnostic methods for differentiation of CD from acute abdomen pathologies before the surgery are CT, US, and magnetic resonance imaging (MRI).[9]

Although US was performed to all cases presented in our study, any specific finding related to CD was not determined. However, US is operator dependent, not as accurate as CT for identifying alternative diagnosis, and not as useful for sur-gical planning when intervention is required. Furthermore, US may be totally unsuccessful, and may not show the colon in obese patients or in patients with bowel gas. Although CT is a safer diagnostic procedure rather than US in CD diag-nosis,[8] CT scans were performed in only three cases in our study since we did not consider CD primarily. Additionally, CT can eliminate complications and have prognostic impor-tance in response to medical treatment and relapse. Besides, CT is helpful for the percutaneous drainage of abscess.[10,11] Recently, a study reported that multi-detector CT has be-come the best imaging modality to evaluate patients present-ing with right lower quadrant abdominal pain or suspected acute cecal pathology.[12] MRI can be a valuable alternative to CT in young or pregnant patients who have suspected appen-dicitis and an uncertain US result.[13]

Low incidence of nausea, vomiting, and anorexia; also variable point of maximum tenderness of abdominal pain during palpa-tion examination are important clinical findings that make us think of CD rather than acute appendicitis.[14] In our study, nausea and vomiting complaints were also rare. True preop-erative clinical diagnosis occurs in 4% to 16% of CD cases, and the reported incidence of finding CD during presumed appendectomy is quoted at 1 in 300 cases.[14] In our study, we performed almost 8000 appendectomies in the same 8-year

period. The frequency of CD was low (1 in 800 appendec-tomies). We believe that the reason for this is excluding pa-tients who received medical treatment only.

In nine out of 10 patients, a McBurney incision was per-formed; whereas, in a 22-year-oldfemale patient, the abdo-men was reached via a lower right quadrant transverse inci-sion which provided a better cosmetic result in our study. We recommend a McBurney incision in the presence of sus-picious signs of acute appendicitis. This incision may be ex-tended, if necessary, intraoperatively. Treatment of CD is still controversial, varying from conservative therapy to aggres-sive surgery.[6,15,16] There is no consensus among surgeons as to the best option. There are studies recommending conser-vative medical treatment or only diverticulectomy, if tech-nically possible, for the treatment of CD cases, and these studies havereported that excisional treatment prevent the relapse of the symptoms.[15] In the presence of excess inflam-matory changes, multiple diverticulum and caecal phlegmon or if cancer cannot be excluded; aggressive resection like right hemicolectomy should be considered. Because, in these patients, surgical treatment can be applied safely without any major complication.[8,15] Laparoscopic or open surgical proce-dures may be performed. In 1994, the first laparoscopic di-verticulectomy was performed.[17] After that, several reports have demonstrated that laparoscopic resection is feasible in experienced hands.[18]

In our study, all patients were treated successfully with diver-ticulectomy. If there is no intense inflammation and the area comprising of the diverticulum may be separated from the normal encircling area, diverticulectomy (with local resection of the diverticulum) may be safely performed. However, we performed tube cecostomy in one case due to vulnerable caecal wall, utilizing a thick Foley catheter. We recommend tube cecostomy as a safe and effective method of preventing cecal fistula formation and as a necessity for decompressing the distal colon in certain cases, depending on the presence of perforation, patient status and the size of the cavity after diverticulectomy.

In conclusion, CD is a rare cause of acute abdomen in our country. Generally, it cannot be distinguished from acute ap-pendicitis clinically and surgeon meets healthy appendicitis and CD. In some cases, they can come with a mass in the right iliac fossa and awareness of the surgeon is very impor-tant in this situation. If intraoperative diagnosis is indefinite and especially cancer cannot be eliminated, then limited right hemicolectomy and ileocolic resection can be recommended. The purpose of this study was to increase awareness for CD in patients who have a mass in their right iliac fossa and who have acute appendicitis diagnosis with suspicious clinic. Ac-cording to our expertise, if the diagnosis is reliable, then, di-verticulectomy and appendectomy can be an adequate treat-ment in the cases of solitary CD when inflammation is not so severe.



REFERENCES

1. Cecal diverticula. In: Zinner MJ, Schwartz SI, Ellis H, editors. Maingot’s Abdominal Operations. 10th ed. 1997. Vol. II. P. 1246.

2. Jung SH, Kim JH. A case of solitary rectal diverticulum presenting with a retrorectal mass. Gut Liver 2010;4:394–7.

3. Azzam N, Aljebreen AM, Alharbi O, Almadi MA. Prevalence and clinical features of colonic diverticulosis in a Middle Eastern population. World J Gastrointest Endosc 2013;5:391–7.

4. Kurer MA. Solitary caecal diverticulitis as an unusual cause of a right iliac fossa mass: a case report. J Med Case Rep 2007;1:132.

5. Cole M, Ayantunde AA, Payne J. Caecal diverticulitis presenting as acute appendicitis: a case report. World J Emerg Surg 2009;4:29.

6. Connolly D, McGookin RR, Gidwani A, Brown MG. Inflamed solitary caecal diverticulum - it is not appendicitis, what should I do? Ann R Coll Surg Engl 2006;88:672–4.

7. Griffiths EA, Date RS. Acute presentation of a solitary caecal diverticu-lum: a case report. J Med Case Rep 2007;1:129.

8. Papapolychroniadis C, Kaimakis D, Fotiadis P, Karamanlis E, Stefopou-lou M, Kouskouras K, et al. Perforated diverticulum of the caecum. A difficult preoperative diagnosis. Report of 2 cases and review of the litera-ture. Tech Coloproctol 2004;8 Suppl 1:116–8.

9. Puylaert JB. Ultrasound of colon diverticulitis. Dig Dis 2012;30:56–9.

10. Cuomo R, Barbara G, Pace F, Annese V, Bassotti G, Binda GA, et al. Italian consensus conference for colonic diverticulosis and diverticular disease. United European Gastroenterol J 2014;2:413–42.

11. Janes SE, Meagher A, Frizelle FA. Management of diverticulitis. BMJ 2006;332:271–5.

12. Heller MT, Bhargava P. MDCT of acute cecal conditions. Emerg Radiol 2014;21:75–82.

13. Cobben LP, Groot I, Blickman JG, Puylaert JB. Right colonic diverticuli-tis: MR appearance. Abdom Imaging 2003;28:794–8.

14. Telem DA, Buch KE, Nguyen SQ, Chin EH, Weber KJ, Divino CM. Current recommendations on diagnosis and management of right-sided diverticulitis. Gastroenterol Res Pract 2009;2009:359485.

15. Mudatsakis N, Nikolaou M, Krithinakis K, Matalliotakis M, Politis N, Andreadakis E. Solitary cecal diverticulitis: an unusual cause of acute right iliac fossa pain-a case report and review of the literature. Case Rep Surg 2014;2014:131452.

16. Karatepe O, Gulcicek OB, Adas G, Battal M, Ozdenkaya Y, Kurtulus I, et al. Cecal diverticulitis mimicking acute Appendicitis: a report of 4 cases. World J Emerg Surg 2008;3:16.

17. Rubio PA. Laparoscopic resection of a solitary cecal diverticulum. J Lapa-roendosc Surg 1994;4:281–5.

18. Uwechue RU, Richards ER, Kurer M. Stapled diverticulectomy for soli-tary caecal diverticulitis. Ann R Coll Surg Engl 2012;94:e235–6.


OLGU SUNUMU

Akut apendisite benzeyen soliter çekum divertikülitiDr. Semih Hot, Dr. Seracettin Eğin, Dr. Berk Gökçek, Dr. Metin Yeşiltaş,Dr. Ali Alemdar, Dr. Arzu Akan, Dr. Servet Rüştü KarahanOkmeydanıEğitimveAraştırmaHastanesi,GenelCerrahiKliniği,İstanbul

Soliter çekum divertikülü benign bir oluşumdur ama enflamasyon, perforasyon ve kanama ile komplike bir hale gelebilir. Çekal divertiküllerin en yaygın komplikasyonu olan çekum divertiküliti (ÇD), Asyalılar arasında yüksek insidansa sahip, ama Batı dünyasında ender bir durumdur. Kolonik divertiküler hastalığın insidansı ulusal kökene, kültürel yapı ve beslenme alışkanlığına göre değişir. Çekum divertiküliti ülkemizde yaygın değildir, ama akut apandisit gibi diğer sık görülen akut sağ taraf karın hastalıklarına klinik açıdan çok benzediği için önemli bir durumdur. Cerrahi öncesi tanısı zordur ve bu nedenle güncel sıklığı bilinmez. Çekum divertikülitinin tedavisi tıbbi tedaviden sağ hemikolektomiye kadar değişir. Bu çalışmada son sekiz yılda acil birimimizde cerrahi rezeksiyon uygulanan 10 ÇD olgusunu sunduk. Amacımız cerrahlar arasında bu duruma olan farkındalığı artırarak, ilk deneyimlerinin ameliyathanede olmaması için özen göstermeleridir.Anahtar sözcükler: Akut karın; çekum divertiküliti, kolonun divertiküler hastalığı.


OLGU SERİSİ - ÖZET


Penetrating brain injury with a bike key: a case reportJoe M Das, M.Ch., Satheesh Chandra, M.Ch., Rajmohan B Prabhakar, M.Ch.

DepartmentofNeurosurgery,GovernmentMedicalCollege,Thiruvananthapuram,India

ABSTRACT

Penetrating brain injury (PBI) may be caused by low-velocity or high-velocity objects. Several objects are known to cause such injury ranging from knives to rooster pecks. However, an assault with the key of a bike causing PBI has not been reported in the literature. The objective of this study was to report the case of a 21-year-old male patient, who presented after an assault with a bike key. The key was impacted in the left parietal region. Left parietal craniotomy was done and the key was removed. There was an underlying parenchymal contusion, which was excised. On post-operative day two, the patient developed motor aphasia, which subsided in subsequent days with antiedema measures. At the first month follow-up, the patient was having normal speech and consciousness. Prompt treatment of penetrating brain injury is important and angiography is not always necessary for PBI.

Key words: Bike key; left frontal contusion; penetrating brain injury; post-traumatic seizure.

INTRODUCTION

Penetrating brain injury (PBI) is a relatively rare cause of trau-matic head injury. PBI in civilian population is commonly low-velocity, high-energy type and can be caused by almost all sharp and blunt objects under the sun. The weapons range from knives and chopsticks to scissors and door keys.[1] To date, there have only been two case reports of PBI caused with a key.[2,3] Bike key used as a weapon is being reported for the first time in the literature. This study aimed to discuss the clinical presentation and successful management of such injury.

CASE REPORT

A 21-year-old male, with no addictions or comorbidities, pre-sented to our emergency service with history of assault with the key of a bike on his head. He was hit by an unknown per-son at night while he was reaching the bike stand to take his

bike. He presented four hours after the incident and had no history of loss of consciousness, vomiting or seizures. At pre-sentation, his Glasgow Coma Scale (GCS) was 15/15 without any neurological deficit and pupils were bilaterally equal and reacting. A key was seen partially penetrating his left parietal scalp (2 cm posterior to coronal suture and 5 cm away from midline) through a lacerated horizontal wound measuring 10 mm × 5 mm (Fig. 1). There was no evidence of any other injury.

X-ray image of the skull showed the key in the left parietal re-gion with a portion of it intracranially (Figs. 2a, b). Computed tomography (CT) of the brain showed a metallic foreign body penetrating the left parietal bone and 1 cm of adjacent paren-chyma. (Figs 3a, b). CT cerebral angiography was deferred as we did not expect a major vessel injury at such a location.

The patient underwent left parietal craniotomy and removal of foreign body, six hours post-trauma. A horse-shoe flap was made, centering the key, based temporally. Craniotomy was done along the line of skin incision and osteo-cutaneous flap was raised, during which the key came along. The key was removed (Fig. 4) and dura hitched at the edges of crani-otomy. There was a dural breach measuring 8 mm × 3 mm. Dura was opened in a U-shaped fashion, based superiorly, which revealed an underlying 10 mm × 5 mm sized contu-sion. Contusectomy was done and hemostasis was achieved with bipolar forceps and oxidized regenerated cellulose. Brain surface was washed with saline. The dural defect edges were freshened, and the dural opening was closed in a water-tight manner with pericranial flap. The bone edges through which

C A S E R E P O R T

Address for correspondence: Joe M Das, M.Ch.

Senior Resident, Department of Neurosurgery, Government

Medical College, Thiruvananthapuram, India - 695011

Tel: +91 9447092342 E-mail: [email protected]


Copyright 2015TJTES


Das et al. Penetrating brain injury with a bike key

the key came were punched out till clean. The bone flap was replaced, and the wound was closed in layers after freshening the edges. A drain was kept in the subgaleal plane.

Post-operatively, the patient had an uneventful recovery to his pre-operative neurological status. The drain was removed on post-operative day (POD) 2. Post-operative brain CT was normal except for a small pneumocephalus at the surgical site (Fig. 5). The patient was continued on intravenous antibiot-ics and oral anticonvulsant. However, on POD 4, the patient developed motor aphasia. Brain CT was repeated, which showed only the same findings as in the previous one. On POD 6, the patient threw right-sided focal seizures, which lasted for 2 minutes; followed by recovery. Anticonvulsant dosage was stepped up. By POD 12, the patient regained his speech and was discharged on POD 14. Oral antibiotic and anticonvulsant were continued for one more week. At POD 45 follow-up, the patient had normal neurological status and had no further seizures.


Figure 1. Clinicalpictureshowingakeypenetratingtheleftparietalregion.

Figure 2. (a)PlainX-rayskullAPviewshowingtheinferiorlybentkey in the left parietal region. (b) Plain X-ray skull lateral viewshowingthebentkey.

(a) (b)

(a)

(b)

Figure 3. (a)Plaincomputedtomogram(CT)ofbrainshowingthemetallicforeignbodywithmetalartefacts.(b)Plaincomputedto-mogram(CT)ofhead-bonewindow-showingtheforeignbodypenetratingintracranially.

Figure 4. Theretrievedkey.

Figure 5. Plaincomputedtomogramofbraintakenonpost-opera-tiveday2,showingmildpneumocephalusatthesurgicalsite.

Das et al. Penetrating brain injury with a bike key

DISCUSSION

Medical reports of stab wounds of the brain date from as early as 1806.[4] Penetration most commonly occurs through thin bones of the skull - orbital surfaces of frontal bones and squamous part of temporal bone.[5]

PBI is associated with high risk of morbidity and mortality due to associated vascular injury, infection, seizures, and ce-rebrospinal fluid leakage. The best imaging modality for this type of trauma is non-contrast cranial and maxillofacial CT scan. In case of suspicion for vascular injury, an angiography should also be performed to evaluate traumatic aneurysm, which can develop soon after a penetrating injury. Prophylac-tic antibiotics and antiseizure medications (for the first week) are to be given.[6]

The goals of surgical intervention in patients with these inju-ries are to:-1) Remove the penetrating item from the brain parenchyma.2) Remove necrotic tissue, debris and other potential con-

taminants.3) Evacuation of any haematomas occurring from the injury

and secure hemostasis.4) Ensure watertight closure of the dura to prevent CSF

leakage.[7]

The key of a vehicle (bike or car) is a weapon which is handy and always within reach, especially among youngsters. High incidences of stab on the left side of skull are probably due to right-handedness of the assailant except when the victim is hit from the back.[8] An easily accessible area in the scalp with a short object like a key is the parietal region. The problem with computed tomography of the brain in this case is that the region of interest will be overlapped with metal artefacts, and a separate bone window might be needed. We had to el-evate the scalp along with the skull in this case so as to avoid early removal of the foreign body and prevent expansion of underlying hematoma, if any. Motor aphasia which the patient developed during the post-operative period might have been due to edema extending to inferior frontal gyrus.

An era has arisen in which people need to wear helmet, not only while riding a bike, but also before going to the bike stand; as no one knows when, where or with what, you might get attacked on the head!

Protection of the brain within a strong bony enclosure is an extremely conserved feature of vertebrate evolution.[9] This report adds to a novel man-made weapon, which can be used to penetrate the nature-made protective covering of the deli-cate brain. This is the third case report of cranial penetration with a key.

ConsentWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


REFERENCES

1. Miscusi M, Arangio P, De Martino L, De-Giorgio F, Cascone P, Raco A. An unusual case of orbito-frontal rod fence stab injury with a good outcome. BMC Surg 2013;13:31.

2. Tiwair SM, Singh RG, Dharker SR, Chaurasia BD. Unusual craniocere-bral injury by a key. Surg Neurol 1978;9:267.

3. Seex K, Koppel D, Fitzpatrick M, Pyott A. Trans-orbital penetrating head injury with a door key. J Craniomaxillofac Surg 1997;25:353–5.

4. Mason F. Case of a young man who had a pitchfork driven into his head four inches who speedily got well. (Mar 10, 1806) Lancet 1870;13:700–1.

5. De Villiers JC. Stab wounds of the brain and skull. In: Vinken PJ, Bruyn GW, eds. Handbook of clinical neurology. Vol 23. New York, NY: Else-vier Science Publishing; 1975. p. 407–503.

6. Management and prognosis of penetrating brain injury. J Trauma 2001;51:1–86.

7. Regunath K, Awang S, Siti SB, Premananda MR, Tan WM, Ha-ron RH. Penetrating injury to the head: case reviews. Med J Malaysia 2012;67:622–4.

8. van Dellen JR, Lipschitz R. Stab wounds of the skull. Surg Neurol 1978;10:110–4.

9. Skoch J, Ansay TL, Lemole GM. Injury to the Temporal Lobe via Medial Transorbital Entry of a Toothbrush. J Neurol Surg Rep 2013;74:23–8.


OLGU SUNUMU - ÖZET

Bisiklet anahtarıyla penetran beyin yaralanması: Bir olgu sunumuDr. Joe M Das, Dr. Satheesh Chandra, Dr. Rajmohan B PrabhakarDevletTıpFakültesi,NöroşirürjiAnabilimDalı,Thiruvananthapuram,Hindistan

Penetran beyin yaralanmasına (PBY) düşük veya hızlı ivmeli nesneler neden olabilmektedir. Bıçaklar ve horoz gagası gibi birkaç nesnenin bu çeşit yaralanmalara neden olduğu bilinmektedir. Ancak literatürde bisiklet anahtarıyla saldırı sonucu oluşan PBY bildirilmemiştir. Bu çalışmanın amacı bir bisiklet anahtarıyla saldırı sonrası gelen 21 yaşındaki bir erkek hastayı raporlamaktı. Anahtar sol pariyetal bölgeye takılı kalmış ve sol pariyetal krani-yotomiyle çıkartılmıştır. Altta yatan parankimal kontüzyon eksize edilmiştir. Ameliyat sonrası ikinci gün hastada motor afazi gelişmiş ve daha sonraki günlerde ödem çözücü önlemlerle geçmişti. Birinci aylık izlemde hasta normal konuşma ve bilincine kavuşmuştu. Penetran beyin yaralanmalarının hemen tedavi edilmesi önemli olup PBY için her zaman anjiyografi gerekmemektedir.Anahtar sözcükler: Bisiklet anahtarı; penetran beyin yaralanması; posttravmatik nöbet; sol frontal kontüzyon.


Blunt cardiac injury: case report of salvaged traumaticright atrial ruptureMuna Al Ayyan, M.D., Tanim Aziz, M.D., Amgad El Sherif, M.D., Omar Bekdache, M.D.

DepartmentofSurgery,TawamHospital–JohnsHopkinsAffiliate-AlAin,UnitedArabEmirates

ABSTRACT

The incidence of cardiac rupture following blunt trauma is rare, occurring in 0.3%–0.5% of all blunt trauma patients. It can be fatal at the trauma scene, and is frequently missed in the emergency room setting. The severity of a cardiac trauma is based on the mechanism and degree of the force applied. The objective of this study was to report the case of a 32-year-old male patient who was involved in a motor vehicle collision and presented to the emergency room with signs of hypovolemic shock. The patient was found to have severe chest trauma associated with massive hemothorax requiring immediate intervention. The patient had an emergent thoracotomy reveal-ing a right atrial injury. Repair of the atrial injury reversed the state of shock. The patient was discharged after 35 days of hospitalization in good condition.

Key words: Blunt cardiac injury (BCI); non-penetrating cardiac injuries; traumatic atrial rupture.

INTRODUCTION

Traumatic thoracic injuries are a leading cause of death. The incidence of cardiac rupture following blunt trauma is rare, occurring in 0.3%–0.5% of all blunt trauma patients. It can be fatal at the trauma scene, and is frequently missed in ER set-ting. The severity of a cardiac trauma is based on the mecha-nism and degree of the force applied.[1–4] Prompt diagnosis and treatment can improve chances of survival.

CASE REPORT

In this study, the case of a 32-year-old man who sustained blunt cardiac injury secondary to motor vehicle collision was reported. The patient was a non-restrained driver and was brought to the emergency room with signs of hypovolemic shock. Initial evaluation of the chest showed right sided flail chest and hemothorax requiring drainage. Clinically, no signs of tension pneumothorax or cardiac tamponade were ob-

served. Abdominal exam was within normal limits and Fo-cused Assessment Sonography for Trauma ‘FAST’ scan was negative. Immediately after chest tube insertion, 1.7 liter of fresh blood was drained. The patient was vigorously resusci-tated with blood products and IV fluids and was rushed to the operating theater for an emergent thoracotomy.

A right posterolateral thoracotomy was quickly performed. After entering the thoracic cavity, a paraesophageal posterior mediastinal hematoma was encountered, which was associ-ated with severe multiple right lung contusions and multiple ribs fractures with sharp ends protruding into the pleural cav-ity. Despite continuous resuscitation, the patient continued to be hemodynamically unstable. Exploration of the medi-astinal hematoma was performed, which thenrevealed the presence of active bleeding coming from a small tear in the pericardium. Further surgical opening of the pericardial tear revealed an injury to the free anterior wall of the right atrium that was actively bleeding with each cardiac contraction. Con-trol was made by the application of a small satinsky clamp (Fig. 1a). The injury was successfully repaired using interrupt-ed 4/0 prolene stitches on pledgets with hemostatic closure resulting in a regain of the hemodynamic stability (Fig. 1b).

The patient was transferred to the intensive care unit for close post-operative care. His hospital stay was remarkable for the development of pneumonia, bilateral pleural effusions, recurrent pericardial effusion, and a left wrist drop second-ary to positional compression, all of which were treated with

C A S E R E P O R T


Address for correspondence: Omar Bekdache, M.D.

Tawam Street 15258 Al Ain, United Arab Emirates

Tel: +971 - 3 - 7677444 E-mail: [email protected]


Copyright 2015TJTES

Ayyan et al. Blunt cardiac injury: case report of salvaged traumatic right atrial rupture

favorable outcome. The patient was discharged home after thirty-five days in stable condition in terms of his cardiopul-monary status.

DISCUSSION

Traumatic thoracic injuries are infrequently associated with cardiac injuries. Prompt diagnosis and treatment can improve chances of survival by nearly 80% for patients suffering from this type of devastating injury. Unfortunately, there is no uni-versally accepted diagnostic criteria for the assessment of atrial rupture as there has been many documented presen-tations for such an injury in the literature. The diagnosis of blunt cardiac injury remains difficult due to other associated injuries that divert the physician’s attention, as well as the lack of specific physical findings and the lack of specificity of nonin-vasive tests available in an emergency room for the diagnosis of such an injury.

The mechanism of blunt cardiac injury is often the result of a high-speed impact. The most common source of such an impact is a motor vehicle collision; however, bicycle crashes, falls, blast injuries, sports related injuries, and assaults can all result in blunt injury to the heart. Blunt trauma can also cause secondary penetrating cardiac injury, which can be seen when a sternal fracture results in right ventricular perforation, or fractured ribs lacerating the right or left ventricle.[3,5–8]

The right heart is the most common site of blunt cardiac in-jury. Concurrent injuries to more than one chamber has been documented in over 50% of blunt cardiac injury patients. Of those patients who experience rupture of a cardiac chamber, only a small fraction reaches the emergency room alive.[9–16] Initial evaluation of the patients at risk for blunt cardiac in-jury should include an appropriate history and physical exam, combined with obtaining a chest radiograph and a 12-lead Electrocardiogram. A 24-hour period of observation, which

includes electrocardiogram telemetry, should be employed if the patient suspected to have blunt cardiac injury is hemo-dynamically stable and has one of the following: an abnormal electrocardiogram, an age greater than 55 years or history of cardiac disease. If the patient is suspected to have blunt cardiac injury, has any unexplained hypotension or evidence of cardiac dysfunction, the patient should be admitted to an intensive care unit. There is no clear evidence about the role of cardiac enzymes in patients with blunt cardiac injury.[14,19]

Electrocardiogram changes that correspond to clinically sig-nificant blunt cardiac injury are usually present at the time of admission. These changes; however, are occasionally detected after admission, but usually within the first 24 hours after in-jury. The findings are usually nonspecific, since similar changes occur in the setting of several metabolic abnormalities associ-ated with significant trauma, such as hypoxia, hypovolemia, acidosis, and electrolyte imbalances.[13–18]

Multiple studies have shown that cardiac enzymes lack the specificity for the risk of developing complications second-ary to blunt cardiac injury. More recently, cardiac Troponin I (cTnI) and cardiac Troponin T (cTnT) have been used to screen for blunt cardiac injury. The specificity of both cTnI and cTnT for blunt cardiac injury (BCI) is greater than CPK and CK–MB, since neither cTnI nor cTnT is released with skeletal muscle injury. The sensitivity of cTnI and cTnT may not exceed CPK and CK-MB; however, the specificity was 97% and 100%, respectively.[8,9,12–16]

Echocardiography plays an important role in the assessment of cardiac function after blunt cardiac injury. Additionally, echocardiography assists in the diagnosis of non-cardiac inju-ries, including aortic rupture, intracardiac thrombi, pericardial effusion, and pleural effusion. Unfortunately, echocardiogra-phy has little utility as a screening test for clinically significant blunt cardiac injury in the hemodynamically stable patient.


Figure 1. (a) Vascularclampappliedtotheatrialrupturearea.(b)Completehemostaticclosuresutureline.

(a) (b)


[11,19] It is worth mentioning that the experience of a general surgeon who works in a hospital lacking surgical cardiovascu-lar section plays a vital role in order to evaluate and deter-mine the proper treatment for patients experiencing cardiac and/ or vascular issues.[20]

There are only few studies that have evaluated the long-term effects of blunt cardiac injury. These studies have shown that long term cardiac function is not affected. Lindstaedt et al. have demonstrated in their prospective study of 118 patients with blunt thoracic injury that blunt cardiac injury was identi-fied in only 14 patients using a combination of echocardio-graphic, cardiac enzyme, and electrocardiographic criteria. Echocardiographic hypokinesis or akinesis was detected in 13 patients during hospitalization for their injuries. None of the blunt cardiac injury patients required treatment for a complication related to their cardiac injury. Follow-up elec-trocardiography, echocardiography, and a bicycle ergometry evaluated the patients 3 and 12 months after injury. Three of the 14 patients with blunt cardiac injury were lost to follow. One patient was found to have a left ventricular thrombus 12 months after injury. Echocardiographic evidence of akinesis or hypokinesis was present in only 4 out of 11 patients at 1-year follow-up. These results appear to indicate that blunt cardiac injury patients who do not develop acute complica-tions will have acceptable cardiac function within the first year of their injury.[21,22]

A study of nearly 10,000 trauma patients admitted to the Shock Trauma Center of the Maryland Institute for Emer-gency Medical Systems with blunt trauma showed an inci-dence of 0.14% for right atrial rupture. Once cardiac rup-ture is suspected, surgical management is indicated. Although some centers advocate emergency department thoracotomy rather than subxiphoid approach for decompression of pos-sible traumatic cardiac tamponade, some centers recommend subxiphoid pericardial drainage in the emergency room in pa-tients who only have little chance to survive without any in-tervention, such as a cardiac arrest patient with a pericardial effusion. When cardiac injuries are first identified on explor-atory thoracotomy for a massive haemothorax, shifting to median sternotomy should be performed without hesitation if the visualization is limited and surgical assistance is difficult. Onan et al. have recruited 104 patients over 10 years suffer-ing thoracic traumatic injuries. They have found that overall morbidity is approximately 43.2%. They have noted that atel-ectasis is the first cause of morbidity followed by respiratory failure. The overall mortality was approximately 18%, which is eventually affected by the hemodynamic stability of the pa-tient and their timing.[23]

In our case, the pericardium was luckily injured and opened to the mediastinal pleura leading to the decompression of the continuously accumulating cardiac tamponade venting into the right chest and helping in maintaining an acceptable cardiac activity. The wide right posterolateral thoracotomy

exposed the right cardiac chambers appropriately leading to the successful repair of the injury and the favorable outcome.

Patients with cardiac rupture who arrive to the emergency department with persistent vital signs belong to a selective group who has a chance of survival. It should be as well kept in mind the rarity of such injuries and the need of education of such cases to the emergency department personnel as well as the trauma team due to the very high mortality rate. The first step in managing these injuries is to have a high index of suspicion. Although adjuncts such as electrocardiograms, echocardiogram and cardiac markers are helpful, they do not provide definite diagnosis at the trauma bay. These tests can be performed in a hemodynamically stable patient, but those unstable with a higher suspicion of blunt cardiac injury would preferentially be operatively assessed. Immediate, adequate, and safe surgery is also very important for the success of the management of such a rare injury.


REFERENCES

1. Fujiwara K, Naito Y, Komai H, Yokochi H, Enomoto K, Shinozaki M. Right atrial rupture in blunt chest trauma. Jpn J Thorac Cardiovasc Surg 2001;49:476–8.

2. Martin TD, Flynn TC, Rowlands BJ, Ward RE, Fischer RP. Blunt cardiac rupture. J Trauma 1984;24:287–90.

3. Fulda G, Brathwaite CE, Rodriguez A, Turney SZ, Dunham CM, Cow-ley RA. Blunt traumatic rupture of the heart and pericardium: a ten-year experience (1979-1989). J Trauma 1991;31:167–73.

4. Perchinsky MJ, Long WB, Hill JG. Blunt cardiac rupture. The Emanuel Trauma Center experience. Arch Surg 1995;130:852–7

5. Parmley LF, Manıon WC, Mattıngly TW. Nonpenetrating traumatic in-jury of the heart. Circulation 1958;18:371–96.

6. Scorpio RJ, Wesson DE, Smith CR, Hu X, Spence LJ. Blunt cardiac inju-ries in children: a postmortem study. J Trauma 1996;41:306–9.

7. Patetsios P, Priovolos S, Slesinger TL, Sclafani SJ, O’Neill PA. Lacera-tions of the left ventricle from rib fractures after blunt trauma. J Trauma 2000;49:771–3.

8. Sutherland GR, Driedger AA, Holliday RL, Cheung HW, Sibbald WJ. Frequency of myocardial injury after blunt chest trauma as evaluated by radionuclide angiography. Am J Cardiol 1983;52:1099–103.

9. Prêtre R, Chilcott M. Blunt trauma to the heart and great vessels. N Engl J Med 1997;336:626–32.

10. Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin 2004;20:57–70.

11. Karalis DG, Victor MF, Davis GA, McAllister MP, Covalesky VA, Ross JJ Jr, et al. The role of echocardiography in blunt chest trauma: a transthoracic and transesophageal echocardiographic study. J Trauma 1994;36:53–8.

12. Kato K, Kushimoto S, Mashiko K, Henmi H, Yamamoto Y, Otsuka T. Blunt traumatic rupture of the heart: an experience in Tokyo. J Trauma 1994;36:859–64.

13. Paone RF, Peacock JB, Smith DL. Diagnosis of myocardial contusion. South Med J 1993;86:867–70.

14. Foil MB, Mackersie RC, Furst SR, Davis JW, Swanson MS, Hoyt DB, et al. The asymptomatic patient with suspected myocardial contusion. Am J Surg 1990;160:638–43.

15. Potkin RT, Werner JA, Trobaugh GB, Chestnut CH 3rd, Carrico CJ,




OLGU SUNUMU - ÖZET

Künt kardiyak yaralanma: Tamir edilebilir travmatik sağ atriyal yaralanma olgusuDr. Muna Al Ayyan, Dr. Tanim Aziz, Dr. Amgad El Sherif, Dr. Omar BekdacheTawamHastanesi-(JohnsHopkins)-CerrahiKliniği,AlAin,BirleşikArapEmirlikleri

Künt travma sonrası kardiyak rüptür insidansı nadirdir ve tüm künt travma hastalarının %0.3 ile 0.5’inde görülür. Bu travma olay yerinde ölümcül ola-bilir ve sık olarak acil servis ortamında tanı atlanabilir. Kardiyak travma şiddeti maruz kalınan kuvvettin şiddeti ve mekanizmasına bağlı olarak değişir. Burada hipovolemik şok belirtileri ile acil servise başvuran, motorlu araç çarpışmasına karışmış, 32 yaşındaki erkek olguyu sunmaktayız. Hastanın göğüs travmasına bağlı acil müdahele gerektiren hemotoraksı olduğu tespit edildi. Hastaya sağ atriyal yaralanmayı ortaya çıkaran acil torakotomi yapıldı. Atriyal yaralanma tamiri hastanın şok durumunundan kurtulmasına yardımcı olmuştur. Hasta 35 gün sonra iyi durumda hastaneden taburcu edilmiştir.Anahtar sözcükler: Künt kardiyak yaralanma; non-penetran kalp yaralanmaları; travmatik atriyal rüptür.


Hallstrom A, et al. Evaluation of noninvasive tests of cardiac damage in suspected cardiac contusion. Circulation 1982;66:627–31.

16. Healey MA, Brown R, Fleiszer D. Blunt cardiac injury: is this diagnosis necessary? J Trauma 1990;30:137–46.

17. Walsh P, Marks G, Aranguri C, Williams J, Rothenberg SJ, Dang C, et al. Use of V4R in patients who sustain blunt chest trauma. J Trauma 2001;51:60–3.

18. Mooney R, Niemann JT, Bessen HA, Mena I, French S, Laks MM. Con-ventional and right precordial ECGs, creatine kinase, and radionuclide angiography in post- Ann Emerg Med 1988;17:890–4.

19. Cachecho R, Grindlinger GA, Lee VW. The clinical significance of myo-cardial contusion. J Trauma 1992;33:68–73.

20. Kamalı S, Aydın MT, Akan A, Karatepe O, Sarı A, Yüney E. Penetrating cardiac injury: factors affecting outcome. Ulus Travma Acil Cerrahi Derg 2011;17:225–30.

21. Sturaitis M, McCallum D, Sutherland G, Cheung H, Driedger AA, Sib-bald WJ. Lack of significant long-term sequelae following traumatic myo-cardial contusion. Arch Intern Med 1986;146:1765–9.

22. Lindstaedt M, Germing A, Lawo T, von Dryander S, Jaeger D, Muhr G, et al. Acute and long-term clinical significance of myocardial contusion following blunt thoracic trauma: results of a prospective study. J Trauma 2002;52:479–85.

23. Onan B, Demirhan R, Öz K, Onan IS. Cardiac and great vessel injuries after chest trauma: our 10-year experience. Ulus Travma Acil Cerrahi Derg 2011;17:423–9.

Twistin’ the night away: gallbladder torsion accompanying large bowel malignancySumer Shikhare, F.R.C.R.,1 Michael Clarke, F.RANZCR.,1 Trishna Shimpi, F.R.C.R.1

Cheah Yee Lee, ABSC (US)2

1DepartmentofDiagnosticRadiology,KhooTeckPuatHospital,AlexandraHealth,Singapore2DepartmentofSurgery,HepatobiliaryandPancreaticSurgery,KhooTeckPuatHospital,AlexandraHealth,Singapore

ABSTRACT

Gallbladder (GB) torsion is a rare surgical emergency seen in the elderly. It occurs due to the rotation of the gallbladder along the axis of the cystic artery and cystic duct. This study aimed to report a case of an acute GB torsion in an elderly female patient diagnosed by multi-detector computed tomography (MDCT). The clinical and imaging features of GB torsion, which can be used to assist in the preoperative diagnosis, were also discussed with emphasis on CT criteria.

Key words: Computed tomography; gallbladder torsion; large bowel malignancy; preoperative diagnosis.

INTRODUCTION

Gallbladder (GB) torsion is an extremely rare condition seen in the elderly population.[1] A patient with GB torsion requires prompt surgical intervention due to the potential risk of necrosis and perforation. However, pre-operative diagnosis of GB torsion is nearly impossible owing to the vague clinical presentation. With advancement in imaging modalities, pre-operative radiological diagnosis of GB tor-sion has now become possible. In this study, it was aimed to report one such case where an elderly female patient presented with non-specific abdominal pain and was found to have GB torsion and transverse colon malignancy on con-trast enhanced MDCT scan.

CASE REPORT

An 86-year-old woman came to the emergency department of our hospital with complaints of generalized colicky abdominal pain and vomiting. The patient had no significant past surgi-

cal history. Her vital signs were normal. Physical examination demonstrated tenderness and guarding in the right iliac fos-sae region with negative Murphy’s and Rovsing’s sign. Labora-tory investigations showed hemoglobin of 11.6 g/dL (11.5 to 15.0), a leukocyte count of 16.66x109/L (4.00 to 11.00) and C-reactive protein of 30.9 mg/L (1 to 5). Liver function tests and bilirubin were normal. A contrast enhanced MDCT scan of her abdomen showed transverse colon mass causing bowel obstruction (Fig. 1). It also demonstrated a markedly distended gallbladder with pericholecystic fluid. No gallstones were pres-ent. Furthermore, the MDCT images clearly revealed twisted cystic duct and gallbladder mesentery giving “whirl sign”, in addition to well enhancing cystic duct (Figs. 2a, b). These find-ings favored the diagnosis of gallbladder torsion. The patient underwent emergency laparotomy and was found to have torsed and gangrenous gallbladder (Fig. 2c). The gallbladder was untwisted and dissected from the liver bed using a Bovie diathermy. Transverse colon segmental resection was also per-formed with colostomy. Pathological examination revealed ex-tensive transmural necrosis of gallbladder wall, consistent with infarction. There was no evidence of malignancy. Specimen of the transverse colon revealed moderately-differentiated ade-nocarcinoma. The patient recovered without any surgical com-plications and was discharged about two weeks after surgery. Follow-up MDCT study after three months revealed multiple hepatic metastases secondary to colonic malignancy (Fig. 3).

DISCUSSION

GB torsion was first described by Wendel in 1898, and it is a

C A S E R E P O R T


Address for correspondence: Sumer Shikhare, F.R.C.R.

90 Yishun Central, 76842, Singapore

Tel: +65 9725 4904 E-mail: [email protected]


Copyright 2015TJTES

Shikhare et al. Twistin’ the night away: gallbladder torsion accompanying large bowel malignancy

rare condition, being reported in only 1 of 365,520 hospital admissions.[2] The incidence of GB torsion increases with age and is more common in elderly women, with a male to female ratio of 1:3.[1,3] GB torsion occurs when it rotates along the long axis of the cystic artery and cystic duct. Predisposing factors for this rotation are either short/absent mesentery or long mesentery resulting in a free floating gallbladder. Other

recognized factors are loss of tissue elasticity and weaken-ing of abdominal ligaments. Factors which accelerate torsion include increased or violent peristalsis of the bowel loops on right side of the abdomen, adhesions, kypho-scoliosis, and cystic artery calcification.[2,4] Strikingly in our case, the pa-tient was an elderly with violent peristalsis due to obstructive transverse colon mass.


Figure 2. (a) Sagittal reformatted andaxial contrast enhancedMDCTscanof upper abdomendemonstrates twisted cystic duct andgallbladdermesenterygivinga“whirlsign”(arrow).Additionallyitalsorevealsanenhancingcysticduct(curvedarrow);(b)Diagrammaticrepresentationofmechanismofgallbladdertorsion.(c)Intra-operativephotographofgallbladdertorsionshowspointoftorsion(arrow)and‘x’markingbodyofgallbladder.

(a)

(b) (c)

Figure 1. AcontrastenhancedMDCTscanoftheabdomendem-onstratesobstructingtransversecolonmass.

Figure 3. ThreemonthsfollowupcontrastenhancedMDCTscanoftheabdomendemonstratesmultiplehepaticmetastases.

Shikhare et al. Twistin’ the night away: gallbladder torsion accompanying large bowel malignancy

GB torsion is categorized into two types based on the de-gree of rotation: (i) incomplete (<180 degrees) and (ii) com-plete (>180 degrees).The incomplete variety presents with intermittent symptoms of biliary colic, while the complete torsion causes vascular strangulation leading to gangrenous cholecystitis.[1,4]

Patients with GB torsion commonly present with non-spe-cific signs and symptoms, such as acute onset abdominal pain with or without vomiting.[4] Clinical presentation mimics oth-er intra-abdominal conditions like acute cholecystitis or acute appendicitis. Physical examination in some cases may reveal a tender mobile mass compatible with a freely mobile gallblad-der.[4] Our patient presented with features of bowel obstruc-tion and abdominal pain. Liver function tests are usually nor-mal. Onset of gangrenous cholecystitis is generally marked by the increase in C-reactive protein and white blood cells count, as seen in our case.[4] Imaging investigations play an important role and can give a definitive diagnosis of GB tor-sion pre-operatively.[4] On ultrasound and MDCT images, the gallbladder is usually located inferior to its normal anatomical position, is grossly distended and has diffusely thickened and edematous wall with associated pericholecystic free fluid.[4] These findings are non-specific and non-conclusive and can be seen in other conditions like acute cholecystitis. Kitagawa H et al. have postulated three criteria to help diagnose GB tor-sion on MDCT imaging: (i) horizontal position of the gallblad-der along its long axis, (ii) fluid in between the liver bed and gallbladder, and (iii) well-enhanced cystic duct on the right side of the gallbladder.[3,4] A rare, but more specific finding on MDCT, which strongly supports the diagnosis of torsion, is “whirl sign”, as seen in our case. The whirl sign has been

described by Tajima Y et al. and represents twisted pedicle of the cystic duct and mesentery.[5] Magnetic resonance imaging allows easy detection of the hemorrhagic infarct and necro-sis within the gallbladder wall, seen as high signal intensity on T1- weighted images.[4] If undiagnosed, the commonest complication is perforation, as torsion causes impaired ve-nous drainage consequently causing gallbladder ischemia and necrosis. Hence, it is imperative to diagnose this entity at an early stage followed by prompt surgical intervention which may help reduce the mortality to less than 5%.[4] The diag-nosis of GB torsion requires emergency cholecystectomy.[4]

In conclusion, if there is strong clinical suspicion and MDCT reveals features of acalculus cholecystitis, “whirl sign” and an ab-normal horizontal location of the gallbladder, definitive diagno-sis of GB torsion can be made, and hence, avoid surgical delay.


REFERENCES

1. Caliskan K, Parlakgumus A, Koc Z, Nursal TZ. Acute torsion of the gallbladder: a case report. Cases J 2009;2:6641.

2. Boonstra EA, van Etten B, Prins TR, Sieders E, van Leeuwen BL. Tor-sion of the gallbladder. J Gastrointest Surg 2012;16:882–4.

3. Kitagawa H, Nakada K, Enami T, Yamaguchi T, Kawaguchi F, Nakada M, et al. Two cases of torsion of the gallbladder diagnosed preoperatively. J Pediatr Surg 1997;32:1567–9.

4. Janakan G, Ayantunde AA, Hoque H. Acute gallbladder torsion: an un-expected intraoperative finding. World J Emerg Surg 2008;3:9.

5. Tajima Y, Tsuneoka N, Kuroki T, Kanematsu T. Clinical images. Gall-bladder torsion showing a “whirl sign” on a multidetector computed to-mography scan. Am J Surg 2009;197:9–10.


OLGU SUNUMU - ÖZET

Geceyi zehir etmek, kalın bağırsak malinitesinin eşlik ettiği safra kesesi torsiyonuDr. Sumer Shikhare,1 Dr. Michael Clarke,1 Dr. Trishna Shimpi,1 Dr. Cheah Yee Lee2

1AlexandraSağlık,KhooTeckPuatHastanesi,TanısalRadyolojiBölümü,Singapur2AlexandraSağlık,KhooTeckPuatHastanesi,CerrahiKliniği,Hepato-Pankreato-BilierCerrahiBölümü,Singapur

Safra kesesi (SK) torsiyonu yaşlılarda seyrek görülen acil bir durumdur. Safra kesesinin kist arter ve kanalı ekseni çevresinde dönmesi nedeniyle oluşur. Bu çalışma yaşlı bir kadın hastada multidedektörlü bilgisayarlı tomografi (BT) ile tanı konmuş bir akut SK torsiyonu olgusunu raporlamayı amaçlamıştır. Safra kesesi torsiyonunun ameliyat öncesi tanısına yardımcı olmak için kullanılabilen klinik ve görüntüleme özellikleri BT kriterleri vurgulanarak tartışılmıştır.Anahtar sözcükler: Ameliyat öncesi tanı; bilgisayarlı tomografi; kalın bağırsak malinitesi; safra kesesi torsiyonu.


Chilaiditi’s syndrome complicated by colon perforation:a case reportTuran Acar, M.D., Erdinç Kamer, M.D., Nihan Acar, M.D., Ahmet Er, M.D., Mustafa Peşkersoy, M.D.

DepartmentofSurgery,IzmirKatipCelebiUniversityAtaturkTrainingandResearchHospital,Izmir

ABSTRACT

Hepatodiaphragmatic interposition of the small or large intestine is known as Chilaiditi syndrome, whichis a rare disease diagnosed incidentally. Chilaiditi syndrome is typically asymptomatic, but it can be associated with symptoms ranging from intermittent, mild ab-dominal pain to acute intestinal obstruction, constipation, chest pain and breathlessness. A 54-year-old male patient was admitted to the hospital with a history of abdominal pain, nausea and vomiting. Chest X-ray revealed an elevation of the right hemidiaphragma caused by the presence of a dilated colonic loop below. The patient underwent urgent surgery with perforation as preliminary diagnosis. The pa-tient underwent right hemicolectomy and ileocolic anastomosis because of the intestinal obstruction related to Chilaiditi’s Syndrome. Due to the rarity of this syndrome and typical radiological findings, this case was aimed to be presented.

Key words: Abdominal pain; Chilaiditi’s syndrome; surgery.

INTRODUCTION

Interposition of the bowel (usually transverse colon or he-patic flexura) or the small intestine between the liver and diaphragm, which is a rare anomaly, was first defined by the Greek radiologist Demetrius Chilaiditi in 1910.[1,2] It is inci-dentally seen 0.025–0.28% in the general population.[3] Its incidence increases with advancing age and it is seen rarer in children when compared to adults. It is more frequently seen in male patients. Chilaiditi syndrome can cause a variety of symptoms including abdominal pain, nausea, vomiting, and small bowel obstruction. Specific symptoms and presentation of Chilaiditi syndrome can vary greatly from one person to another. The cause of Chilaiditi syndrome is not fully under-stood.

The objective of this study was to report a case that present-ed with intestinal obstruction caused by Chilaiditi syndrome and review the relevant literature.

CASE REPORT

A 54-year-oldmale patient was admitted to the Emergency Department of Surgery, Izmir Katip Celebi University Ataturk Training and Research Hospital with a 24-hour history of right upper abdominal pain, nausea and vomiting. Although the se-verity had been altering, these complaints had persisted for 6 months. Physical examination revealed epigastric and right up-per abdominal tenderness and rigidity; no rebound tenderness was identified. In addition, auscultation revealed hypoactive bowel sounds. Complete blood count and blood biochemistry were normal except hipoalbuminemia (2,1 g/dL) and leukocy-tosis (17000 mm/dl). Plain chest radiography demonstrated the elevation of the right diaphragm and right subdiaphragmatic air (Fig. 1). Abdominal computed tomography (CT) scan reported dilatation related to gastric outlet obstruction, dilatated small bowel loops and hepatic flexura, intraperitoneal free air and fluid, which may be related to perforation (Figs. 2a, b). Accord-ing to these findings, the patient underwent urgent surgery with a preliminary diagnosis of perforation. During explora-tion, the stomach was lying to pelvis, and advanced dilatation of the small intestines and stomach was observed. Besides, ascending and transverse colon was located between the liver and diaphragm, and segmental necrosis and focal microperfo-rations were seen. The patient underwent right hemicolecto-my and ileocolic anastomosis because of the intestinal obstruc-tion related to Chilaiditi syndrome (Fig. 3). Starting from the ninth day, the patient defecated. His postoperative course was uneventful and was discharged on the tenth day. The patient was followed up for four months and remained asymtomatic.

C A S E R E P O R T

Address for correspondence: Turan Acar, M.D.

172 Sokak, No: 3/1, Daire: 3, Basın Sitesi, İzmir, Turkey



Copyright 2015TJTES


Acar et al. Chilaiditi’s syndrome complicated by colon perforation

DISCUSSION

Intestinal interposition is a medical condition where a seg-ment of the bowel is temporarily or permanently interposed between two organs. Among these, the hepatodiaphragmatic interposition is termed Chilaiditi sign. Chilaiditi sign is usually asympomatic, and when accompanied by clinical symptoms, it is termed as Chilaiditi syndrome, whichis an extremely rare disorder. Normally, the suspensory ligament of the liver, me-socolon, liver, and the falciform ligament limit the surround-ing space around the liver and prevent colonic interposition. Chilaiditi syndrome may be congenital or acquired. It can be caused by obesity, multiple pregnancies; liver related prob-lems such as ptotic or small liver, cirrhosis; diaphragmatic problems such as degeneration of diaphragm muscles, phrenic nerve paralysis, tuberculosis or increased intrathoracic pres-sure caused by emphysema; colonic factors such as anormal enlargement of colon, suspensory ligament abnormality or agenesis and congenital malposition or malrotation.[4–6]

Median age of the patients at presentation was 60 years in the literature. Male to female ratio was 4:3.[2,3] Chilaiditi syn-drome is most commonly seen in the elderly with a cadence of 1%, but there have been cases where it was presented in patients as young as 5 months in the literature.[6,7] Our patient was a 54-year-old male who corresponded to the in-formation in the literature.

Most patients do not have any complaints, and the disorder is detected in radiological examinations incidentally.However, it can cause acute, chronic or repetitive digestive complaints such as abdominal pain, vomiting, constipation, swelling, an-orexia, respiratory distress, and chest pain. Moreover, it may cause situations such as volvulus, incarceration, and perfora-tion that require urgent surgical intervention.[8,9] There is a high risk of perforation during liver biopsy or colonoscopy in patients who have not been diagnosed.[6] Our patient had intestinal obstruction findings such as severe abdominal pain, vomiting, and distention.


Figure 1. Theelevationoftherighthemidiaphragmandairunderthediaphragmdrawattentiontotheanterior-posteriorchestX-ray.

Figure 3. Intra-operativepicturesofabowelmicroperforation(in-dicatedbythearrow).

Figure 2. (a)AxialCT/(b)CoronalCT:Intestinallooptransposedbetweenthediaphragmandliver(indicatedbythearrow).

(a)

(b)

Acar et al. Chilaiditi’s syndrome complicated by colon perforation

Diagnosis of Chiliaditi syndrome with only history, physical exam and blood work is almost impossible, and it is usually diagnosed after radiological imaging studies. It is diagnosed with routine chest radiography and direct abdomen radiog-raphy incidentally. CT and ultrasonography (US) are required for differential diagnosis.[10,11] The first step is to rule out the possibility of pneumoperitoneum. CT plays an important role when performed to differentiate it from perforation. On CT, recognizing the colonic haustra behind the liver is diagnos-tic for Chilidiati syndrome. US is also useful in differentiating Chilidiati syndrome from pneumoperitoneum, which usually requires an immediate surgical intervention.[2,11] Pleural effu-sion and atelectasis related to Chiliaditi syndrome may occur. In differential diagnosis, subdiaphramatic rupture, posterior liver lesions and retroperitoneal masses must be considered.

Treatment for Chilidiati syndrome is generally conservative, including bed rest, high fiber diet, intravenous hydration, na-sogastric decompression, enema, cathartics, and laxatives.[11,12] However, surgery must be performed to prevent possible com-plications in patients with chronic complaints, or when com-plications such as ischemia, perforation, intestinal obstruction are suspected. When the literature is reviewed, complications of Chiliaditi syndrome requiring urgent surgery can be listed as cecal and colonic volvulus, subphrenic appendicitis, internal her-nia, and cecum perforation.[1,12–16] Saber and Boros have previ-ously reported that 26% of the patients require operative man-agement.[11] There is no clear consensus on the best surgical approach. A variety of procedures described in the literature include colon resection, hepatopexy, colopexy, right hemicolec-tomy, sigmoidectomy, and subtotal colectomy.[1,6,8] Otherwise, emergency surgery is performed as was in our case. In conclusion, Chilaiditi syndrome is usually asymptomatic. It is a rarely considered differential diagnosis with vague symp-toms that make the diagnosis difficult. Colonic distention may cause stomachache, vomiting, and shortness of breath. It is mostly diagnosed with X-rayrequested for another reason. Ultrasonography and CT may be required for differential di-agnosis. Treatment is usually conservative, but it should be noted that an urgent surgery may have to be performed due

to complications. Yet, a proper work-up and keeping in mind the possibility of Chilaiditi syndrome may prevent the patient from undergoing unnecessary surgery.


REFERENCES

1. Farkas R, Moalem J, Hammond J. Chilaiditi’s sign in a blunt trauma pa-tient: a case report and review of the literature. J Trauma 2008;65:1540–2.

2. Weng WH, Liu DR, Feng CC, Que RS. Colonic interposition between the liver and left diaphragm - management of Chilaiditi syndrome: A case report and literature review. Oncol Lett 2014 ;7:1657–60.

3. Aldoss IT, Abuzetun JY, Nusair M, Suker M, Porter J. Chilaiditi syn-drome complicated by cecal perforation. South Med J 2009;102:841–3.

4. Cetinkaya E, Razi CH, Gunduz M. Chilaiditi’s syndrome: case report. T Klin J Pediatr 2004;13:33–6.

5. Moaven O, Hodin RA. Chilaiditi syndrome: a rare entity with important differential diagnoses. Gastroenterol Hepatol (N Y) 2012;8:276–8.

6. Yin AX, Park GH, Garnett GM, Balfour JF. Chilaiditi syndrome precipi-tated by colonoscopy: a case report and review of the literature. Hawaii J Med Public Health 2012;71:158–62.

7. Huang WC, Teng CS, Tseng MH, Lin WJ, Wang CC. Chilaiditi’s syn-drome in children. Acta Paediatr Taiwan 2007;48:77–83.

8. Kurt Y, Demirbas S, Bilgin G, Aydin Y, Akin L, Yildiz M, et al. Colonic volvulus associated with Chilaiditi’s syndrome: report of a case. Surg To-day 2004;34:613–5.

9. Sorrentino D, Bazzocchi M, Badano L, Toso F, Giagu P. Heart-touching Chilaiditi’s syndrome. World J Gastroenterol 2005;11:4607–9.

10. Kamiyoshihara M, Ibe T, Takeyoshi I. Chilaiditi’s sign mimicking a trau-matic diaphragmatic hernia. Ann Thorac Surg 2009;87:959–61.

11. Saber AA, Boros MJ. Chilaiditi’s syndrome: what should every surgeon know? Am Surg 2005;71:261–3.

12. Platz TA, Barker M, Carlo J, Lord J. Chilaiditi syndrome--an interest-ing complication in a bariatric surgery patient. Surg Obes Relat Dis 2006;2:57–60.

13. Keles S, Artac H, Reisli I, Alp H, Koc O. Chilaiditi syndrome as a cause of respiratory distress. Eur J Pediatr 2006;165:367–9.

14. Altomare DF, Rinaldi M, Petrolino M, Sallustio PL, Guglielmi A, Pan-narale OC. Chilaiditi’s syndrome. Successful surgical correction by colo-pexy. Tech Coloproctol 2001;5:173–5.

15. Alva S, Shetty-Alva N, Longo WE. Image of the month. Chilaiditi sign or syndrome. Arch Surg 2008;143:93–4.

16. Ansari H, Lay J. Chilaiditi syndrome and associated caecal volvulus. ANZ J Surg 2011;81:484–5.


OLGU SUNUMU - ÖZET

Kolon perforasyonu yapan Chilaiditi Sendromu: Bir olgu sunumuDr. Turan Acar, Dr. Erdinç Kamer, Dr. Nihan Acar, Dr. Ahmet Er, Dr. Mustafa PeşkersoyİzmirKatipÇelebiÜniversitesiAtatürkEğitimveAraştırmaHastanesi,GenelCerrahiKliniği,İzmir

Chilaiditi sendromu, ince kalın bağırsakların hepatodiafragmatik interpozisyonu durumudur. Nadir görülür ve olguların çoğuna tesadüfen tanı konur. Sıklıkla semptomsuz olmakla birlikte aralıklarla ortaya çıkan hafif abdominal ağrı, intestinal obstrüksiyon, kabızlık, göğüs ağrısı, nefes darlığı gibi semptomlarla da ortaya çıkabilir. Karın ağrısı, bulantı ve kusma öyküsüyle hastaneye başvuran 54 yaşında erkek hastanın çekilen akciğer grafisinde dilate kalın bağırsak ansının alttan basısı sonucu sağ diyafragmanın yükselmiş olduğu gözlendi. Hasta perforasyon ön tanısıyla acil operasyona alındı. Chilaiditi’s sendromunun neden olduğu intestinal obstrüksiyon nedeniyle sağ hemikolektomi ve ileokolik anastomoz uygulandı. Nadir görülen bir sendrom olması ve tipik radyolojik bulgular nedeniyle bu olguyu sunmayı amaçladık.Anahtar sözcükler: Cerrahi; Chilaiditi sendromu; karın ağrısı.


Abdullayev R see 2015;21(1):15–21

Abu–Zidan FM see 2015;21(2):134–138

Acar E see 2015;21(6):463–468

Acar N see 2015;21(6):534–536

Acar N see 2015;21(5):366–372

Acar T see 2015;21(6):534–536

Adam G see 2015;21(1):39–43

Adanaş C see 2015;21(6):503–508

Afrashi F see 2015;21(6):496–502

Aggarwal S see 2015;21(5):397–401

Ağca B see 2015;21(2):160–162

Ahmad B see 2015;21(2):102–106

Akan A see 2015;21(6):520–523

Akan İM see 2015;21(6):509–513

Akar İ see 2015;21(4):303–305

Akarsu C see 2015;21(3):220–222

Akbal E see 2015;21(1):39–43

Akçam T see 2015;21(3):168–174

Akdeniz F see 2015;21(1):57–62

Akgül MH see 2015;21(6):425–431

Akgül O see 2015;21(6):425–431

Akıncı M see 2015;21(4):256–260

Akkaya T see 2015;21(5):344–351

Akkın C see 2015;21(6):496–502

Aköz T see 2015;21(6):509–513

Aksoy M see 2015;21(5):392–396

Aksungur N see 2015;21(5):380–384

Aktimur R see 2015;21(1):51–56

Aladağ NB see 2015;21(3):193–196

Alagöz F see 2015;21(4):291–296

Alagöz F see 2015;21(6):450–456

Alemdar A see 2015;21(2):157–159

Alemdar A see 2015;21(6):520–523

Alexa O see 2015;21(2):152–156

Alhan D see 2015;21(6):457–462

Alış H see 2015;21(3):220–222

Alimoğlu O see 2015;21(6):477–483

Aliustaoğlu S see 2015;21(3):204–208

Allahverdi E see 2015;21(1):9–14

Allahverdi TD see 2015;21(1):9–14

Allegri A see 2015;21(5):373–379

Altınbaş Y see 2015;21(1):71–74

Altuncı YA see 2015;21(5):323–336

Ansaloni L see 2015;21(5):373–379

Arat A see 2015;21(4):271–278

Arat YÖ see 2015;21(4):271–278

Arslan Ş see 2015;21(5):380–384

Arslan U see 2015;21(2):157–159

Ashoori S see 2015;21(1):22–26

Aslan C see 2015;21(4):303–305Astarcıoğlu MA see 2015;21(3):193–196Asuman Çelikbilek A see 2015;21(2):96–101Atak İ see 2015;21(6):477–483Atalar H see 2015;21(2):119–126Atamanalp SS see 2015;21(5):380–384Atilla A see 2015;21(1):34–38Avşar S see 2015;21(3):231–234Avunduk MC see 2015;21(6):419–424Ayçiçek Çardak GN see 2015;21(6):509–513Aydın Candan A see 2015;21(2):96–101Aydın K see 2015;21(4):271–278Aydoğdu İO see 2015;21(4):297–299Aykan A see 2015;21(3):231–234Aykan A see 2015;21(6):457–462Aykan AÇ see 2015;21(3):193–196Aykut S see 2015;21(4):279–284Ayrık C see 2015;21(3):175–181Ayyan Ma see 2015;21(6):527–530Azamat İF see 2015;21(6):484–490Aziz T see 2015;21(6):527–530

Bademler S see 2015;21(5):392–396Bademler S see 2015;21(6):484–490Baktıroğlu L see 2015;21(2):90–95Balandız H see 2015;21(6):491–495Balas Ş see 2015;21(4):256–260Balcı Y see 2015;21(6):463–468Bali İ see 2015;21(6):446–449Baş G see 2015;21(6):477–483Başarslan SK see 2015;21(4):235–240Başpınar B see 2015;21(5):414–417Başyiğit İ see 2015;21(6):514–519Beden Ü see 2015;21(4):297–299Behera P see 2015;21(5):397–401Bekçibaşı M see 2015;21(4):261–265Bekdache O see 2015;21(6):527–530Belen AD see 2015;21(6):450–456Belotti E see 2015;21(5):373–379Beşir Y see 2015;21(4):266–270Beydilli H see 2015;21(6):463–468Bhurhanudeen KA see 2015;21(1):63–67Bilsel K see 2015;21(5):385–391Birgi E see 2015;21(4):285–290Birsen O see 2015;21(3):182–186Boz B see 2015;21(3):175–181Bozkurt F see 2015;21(4):261–265Bozkurt H see 2015;21(1):51–56Bulakçı M see 2015;21(6):484–490Büdeyri A see 2015;21(2):90–95

Canyiğit M see 2015;21(4):285–290

Ceresoli M see 2015;21(5):373–379

Ceylan A see 2015;21(1):34–38

Chandra S see 2015;21(6):524–526

Chen G see 2015;21(5):337–343

Chen J see 2015;21(2):149–151

Chen K–T see 2015;21(1):68–70

Chen KJ see 2015;21(5):337–343

Chen Q see 2015;21(2):107–112

Chen YT see 2015;21(1):68–70

Chiu CK see 2015;21(1):63–67

Clarke M see 2015;21(6):531–533

Coccolini F see 2015;21(5):373–379

Colombi R see 2015;21(5):373–379

Çağsar M see 2015;21(6):440–445

Çalıkoğlu Ç see 2015;21(6):425–431

Çalışkan G see 2015;21(1):44–50

Çavuşoğlu T see 2015;21(5):323–336

Çeber M see 2015;21(4):303–305

Çeçen GS see 2015;21(3):209–215

Çelik B see 2015;21(5):405–409

Çelik H see 2015;21(4):291–296

Çelik MF see 2015;21(3):220–222

Çetin H see 2015;21(4):285–290

Çetin Uyanıkgil EÖ see 2015;21(5):323–336

Çetinkünar S see 2015;21(1):51–56

Çevik AA see 2015;21(5):366–372

Çınar K see 2015;21(4):291–296

Çikot M see 2015;21(3):220–222

Çoruh A see 2015;21(2):79–89

Dağlıoğlu E see 2015;21(6):450–456

Dalcı K see 2015;21(3):168–174

Dalgıç A see 2015;21(6):450–456

Das JM see 2015;21(6):524–526

Değirmenci C see 2015;21(6):496–502

Demiroğlu M see 2015;21(4):279–284

Demiröz ŞM see 2015;21(4):306–308

Deprem T see 2015;21(1):9–14

Dereli Y see 2015;21(3):228–230

Deryol R see 2015;21(4):256–260

Deveci Ö see 2015;21(4):261–265

Dikici F see 2015;21(5):392–396

Dikmen G see 2015;21(5):392–396

Dinpanah H see 2015;21(1):22–26

Divanlıoğlu D see 2015;21(6):450–456

Doğru O see 2015;21(2):139–142

Doğu Y see 2015;21(4):235–240

Turkish Journal of Trauma & Emergency SurgeryAuthor Index Vol. 21

INDEX

Ulus Travma Acil Cerrahi Derg Author Index Vol. 21

Ulus Travma Acil Cerrahi Derg, Kasım 2015, Vol. 21, No. 6 537



Döner E see 2015;21(5):366–372Dural AC see 2015;21(3):220–222Durmaz HA see 2015;21(4):285–290Durusu M see 2015;21(2):127–133

Ege T see 2015;21(1):75–78Eğin S see 2015;21(6):520–523Eid HO see 2015;21(2):134–138Eker T see 2015;21(4):300–302Ekici MA see 2015;21(4):235–240Elmadağ NM see 2015;21(5):385–391Elmalı N see 2015;21(3):209–215Emir S see 2015;21(6):446–449Er E see 2015;21(6):534–536Erakgün T see 2015;21(6):496–502Eray İC see 2015;21(3):168–174Erbabacan E see 2015;21(5):358–365Erbaş M see 2015;21(6):463–468Erbil B see 2015;21(4):248–255Erdem H see 2015;21(1):51–56Erdem MN see 2015;21(2):113–118Erden T see 2015;21(5):385–391Erdur B see 2015;21(3):175–181Erduran M see 2015;21(2):90–95Eren F see 2015;21(5):402–404Ergin A see 2015;21(3):175–181Erguder İB see 2015;21(1):1–8Ergun O see 2015;21(4):256–260Ergun O see 2015;21(4):285–290Eroğlu A see 2015;21(4):300–302Eroğlu M see 2015;21(3):223–227Ersoy Z see 2015;21(5):352–357Ertekin C see 2015;21(6):484–490Esen Hasturk A see 2015;21(1):1–8Eun Seok Hong ES see 2015;21(2):143–148Evirgen O see 2015;21(1):1–8Eygi B see 2015;21(4):266–270Eyi YE see 2015;21(2):127–133

Fersahoğlu MM see 2015;21(2):160–162Filinte GT see 2015;21(6):509–513

Göçmez C see 2015;21(4):235–240Gök AFK see 2015;21(6):484–490Gökalp G see 2015;21(4):266–270Gökalp O see 2015;21(4):266–270Gökçek B see 2015;21(6):520–523Gökkaya A see 2015;21(3):223–227Gökler C see 2015;21(5):352–357Göksel S see 2015;21(1):15–21Görmeli CA see 2015;21(6):503–508Görmeli G see 2015;21(2):113–118Görmeli G see 2015;21(6):503–508Guldogan CE see 2015;21(1):27–33Gül MA see 2015;21(5):380–384Gülabi D see 2015;21(3):209–215Gümüş N see 2015;21(3):187–192Günay C see 2015;21(1):75–78

Günay C see 2015;21(2):119–126Günay SH see 2015;21(2):119–126Günerhan Y see 2015;21(1):9–14Gürbüz A see 2015;21(4):266–270Gürçay AG see 2015;21(4):291–296Gürün AU see 2015;21(4):279–284Gürz S see 2015;21(5):405–409Güven H see 2015;21(2):157–159Güvenç Y see 2015;21(4):291–296Güzey S see 2015;21(3):231–234Güzey S see 2015;21(6):457–462

Haijun Z see 2015;21(4):241–247Hakan Ak H see 2015;21(2):96–101Hamzaoğlu EC see 2015;21(4):297–299Han GF see 2015;21(5):337–343Hasdemir H see 2015;21(3):193–196Hatipoglu F see 2015;21(1):15–21Hatipoglu S see 2015;21(1):15–21Havıtçıoğlu H see 2015;21(2):90–95Havva Koçak H see 2015;21(2):96–101Hayirli N see 2015;21(1):1–8He T see 2015;21(2):107–112Hefny AF see 2015;21(2):134–138Hekimoğlu B see 2015;21(4):256–260Hekimoğlu B see 2015;21(4):285–290Hıdıroğlu M see 2015;21(4):285–290Hocagil AC see 2015;21(5):344–351Hocagil H see 2015;21(5):344–351Hongjie D see 2015;21(4):241–247Horasanli B see 2015;21(1):1–8Hoşoğlu S see 2015;21(4):261–265Hot S see 2015;21(6):520–523Huang Y see 2015;21(2):107–112

Işık Ş see 2015;21(6):463–468

İlhan M see 2015;21(6):484–490İlker Alaca İ see 2015;21(2):96–101İnce CH see 2015;21(3):204–208İnce İ see 2015;21(4):303–305İner H see 2015;21(4):266–270İrkorucu O see 2015;21(1):51–56İsmail Demir İ see 2015;21(2):96–101İsmail Gülşen İ see 2015;21(2):96–101İşcan Y see 2015;21(2):160–162

Jiake C see 2015;21(4):241–247

Kabay B see 2015;21(3):182–186Kalaycı O see 2015;21(5):410–413Kaldırım Ü see 2015;21(2):127–133Kamalı S see 2015;21(2):157–159Kamaşak K see 2015;21(4):235–240Kamer E see 2015;21(6):534–536Kang Hyun Lee KH see 2015;21(2):143–148Karabey F see 2015;21(5):323–336

Karaca MA see 2015;21(4):248–255Karacabey S see 2015;21(5):344–351Karadeniz E see 2015;21(5):380–384Karagöz H see 2015;21(5):402–404Karahan SR see 2015;21(6):520–523Karakaplan M see 2015;21(2):113–118Karakaşlı A see 2015;21(2):90–95Karakuş Ö see 2015;21(1):44–50Karaman Ö see 2015;21(1):44–50Karaören G see 2015;21(5):358–365Karataş A see 2015;21(6):425–431Karataş T see 2015;21(2):113–118Karataş T see 2015;21(6):503–508Karateke F see 2015;21(5):352–357Karateke F see 2015;21(6):446–449Karayel FA see 2015;21(5):414–417Karbeyaz K see 2015;21(2):127–133Karip AB see 2015;21(2):160–162Kartal ND see 2015;21(4):248–255Katrancı AO see 2015;21(1):34–38Kaya İ see 2015;21(4):303–305Kaya Özdoğan H see 2015;21(5):352–357Kaya Ş see 2015;21(5):366–372Kayapınar M see 2015;21(6):419–424Kelahmetoğlu O see 2015;21(4):297–299Kertmen H see 2015;21(1):1–8Khan A see 2015;21(2):102–106Khan MM see 2015;21(2):102–106Kılıç SS see 2015;21(1):34–38Kısaoğlu A see 2015;21(5):380–384Kıyan S see 2015;21(5):323–336Kim H see 2015;21(2):143–148Kismet K see 2015;21(1):27–33Koca O see 2015;21(1):57–62Koçak E see 2015;21(1):39–43Korkmaz M see 2015;21(6):450–456Korkmaz MF see 2015;21(2):113–118Korkmaz MF see 2015;21(6):503–508Korkut E see 2015;21(5):380–384Köklü S see 2015;21(1):39–43Köksal H see 2015;21(2):139–142Köksal N see 2015;21(1):9–14Köktürk F see 2015;21(6):440–445Kömür İ see 2015;21(5):414–417Köze BŞ see 2015;21(1):71–74Kulaçoğlu H see 2015;21(4):256–260Kumar V see 2015;21(5):397–401Kunt MM see 2015;21(4):248–255Kurban S see 2015;21(2):139–142Kuvvetli A see 2015;21(5):352–357Kuvvetli A see 2015;21(6):446–449Küçüker A see 2015;21(4):285–290Külahçı Y see 2015;21(1):75–78Kürklü M see 2015;21(1):75–78

Lai XN see 2015;21(5):337–343Lee CY see 2015;21(6):531–533Lin Y–S see 2015;21(1):68–70

Lunca S see 2015;21(2):152–156

Majidi A see 2015;21(1):22–26Manfredi R see 2015;21(5):373–379Maraş Z see 2015;21(2):113–118Margarito F see 2015;21(5):373–379Massoud EİE see 2015;21(3):197–203Meena UK see 2015;21(5):397–401Memişoğlu K see 2015;21(2):160–162Menekşe E see 2015;21(6):446–449Menkü A see 2015;21(4):235–240Menteş J see 2015;21(6):496–502Merhan O see 2015;21(1):9–14Merli C see 2015;21(5):373–379Meteroğlu F see 2015;21(6):514–519Meyancı Köksal G see 2015;21(5):358–365Monıs S see 2015;21(6):514–519Montori G see 2015;21(5):373–379Moo Eob Ahn ME see 2015;21(2):143–148Morosanu C see 2015;21(2):152–156Motamed H see 2015;21(1):22–26Mun S see 2015;21(6):432–439Mutlu H see 2015;21(1):44–50Mutlu S see 2015;21(1):44–50

Nalçacı S see 2015;21(6):496–502Narin F see 2015;21(4):291–296Ng TS see 2015;21(1):63–67Nışancı M see 2015;21(6):457–462Nurülke B see 2015;21(1):71–74

Odabaşı M see 2015;21(4):309–314Okoh AK see 2015;21(3):168–174Onat S see 2015;21(6):514–519Orak MM see 2015;21(1):44–50Oruç C see 2015;21(6):446–449Oruç M see 2015;21(6):514–519

Öken ÖF see 2015;21(2):119–126Öksüz S see 2015;21(5):402–404Öncel M see 2015;21(3):228–230Ösün A see 2015;21(6):450–456Öz H see 2015;21(5):358–365Özaltun P see 2015;21(5):352–357Özban M see 2015;21(3):182–186Özcabı Y see 2015;21(2):160–162Özcan Ç see 2015;21(4):279–284Özdemirel RÖ see 2015;21(5):414–417Özden A see 2015;21(3):182–186Özden E see 2015;21(4):279–284Özdoğan M see 2015;21(5):352–357Özdoğan M see 2015;21(6):446–449Özerhan İH see 2015;21(6):457–462Özkan R see 2015;21(5):366–372Özkaya Mutlu Ö see 2015;21(6):509–513Özkazanlı G see 2015;21(1):44–50Özmen MM see 2015;21(4):248–255Özoğul B see 2015;21(5):380–384

Özok G see 2015;21(2):79–89Özpek A see 2015;21(6):477–483Özşaker E see 2015;21(1):71–74Öztaş Z see 2015;21(6):496–502Öztürk E see 2015;21(4):248–255Öztürk K see 2015;21(4):279–284Öztürk N see 2015;21(5):380–384Öztürk S see 2015;21(3):231–234Öztürk S see 2015;21(6):457–462Özyazıcı S see 2015;21(5):352–357Özyazıcı S see 2015;21(6):446–449

Pamukcu C see 2015;21(4):309–314Parsak CP see 2015;21(3):168–174Pehlivanoğlu G see 2015;21(3):209–215Pekel Ö see 2015;21(1):15–21Peker İ see 2015;21(4):266–270Pertea M see 2015;21(2):152–156Peşkersoy M see 2015;21(6):534–536Piazzalunga D see 2015;21(5):373–379Pirzirenli MG see 2015;21(5):405–409Pisano M see 2015;21(5):373–379Polat H see 2015;21(3):163–167Polat Ö see 2015;21(6):450–456Prabhakar RB see 2015;21(6):524–526

Rafiq MS see 2015;21(2):102–106Rencüzoğulları A see 2015;21(3):168–174Reyhan E see 2015;21(1):51–56

Sabuncuoğlu MZ see 2015;21(1):27–33Sağlam F see 2015;21(2):157–159Sağlam Y see 2015;21(5):392–396Saibaba B see 2015;21(5):397–401Sakman G see 2015;21(3):168–174Sanrı E see 2015;21(5):344–351Sarak T see 2015;21(3):216–219Savacı N see 2015;21(6):419–424Savran B see 2015;21(6):463–468Sayan M see 2015;21(4):306–308Saydam M see 2015;21(2):79–89Saygı B see 2015;21(1):44–50Seçer M see 2015;21(4):291–296Selçuk EB see 2015;21(2):113–118Semerciöz A see 2015;21(3):223–227Sever C see 2015;21(5):402–404Seyhan N see 2015;21(6):419–424Sezer Y see 2015;21(3):204–208Sherif AE see 2015;21(6):527–530Shikhare S see 2015;21(6):531–533Shimpi T see 2015;21(6):531–533Sızlanan A see 2015;21(6):514–519Sivrikoz C see 2015;21(5):366–372Sivrikoz E see 2015;21(2):157–159Soker G see 2015;21(1):51–56Sozen S see 2015;21(1):51–56Sönmez M see 2015;21(6):450–456Sözen İ see 2015;21(1):27–33

Sülü B see 2015;21(1):9–14Sürücü ZP see 2015;21(5):405–409

Şahin A see 2015;21(3):193–196Şahin A see 2015;21(6):514–519Şahin E see 2015;21(6):469–476Şahin İ see 2015;21(6):457–462Şahin TT see 2015;21(4):248–255Şam B see 2015;21(5):414–417Şeker GE see 2015;21(4):256–260Şen H see 2015;21(3):204–208Şen Tanrıkulu C see 2015;21(6):440–445Şenel E see 2015;21(2):79–89Şenel M see 2015;21(3):182–186Şener E see 2015;21(4):285–290Şimşek G see 2015;21(5):344–351Şimşek SA see 2015;21(6):503–508Şimşek T see 2015;21(4):297–299

Tabatabaey A see 2015;21(1):22–26Tamer Karaaslan T see 2015;21(2):96–101Tanrıkulu Y see 2015;21(6):440–445Tatar İG see 2015;21(4):256–260Tatar İG see 2015;21(4):285–290Tekin R see 2015;21(4):261–265Teköz A see 2015;21(3):209–215Temi V see 2015;21(6):440–445Tevfik Yılmaz T see 2015;21(2):96–101Tokur M see 2015;21(4):306–308Tomak L see 2015;21(1):34–38Topaloğlu S see 2015;21(5):410–413Toprak H see 2015;21(5):385–391Toygar M see 2015;21(2):127–133Toygar M see 2015;21(6):491–495Tugay Atalay T see 2015;21(2):96–101Tuğcu H see 2015;21(6):491–495Tunalı Y see 2015;21(5):358–365Tuncer SK see 2015;21(2):127–133Turhan AN see 2015;21(1):15–21Turkoglu E see 2015;21(1):1–8Türk H see 2015;21(1):57–62Türk Ö see 2015;21(3):163–167Türkçüer İ see 2015;21(3):175–181Türkkan S see 2015;21(1):75–78

Uçkun ÖM see 2015;21(4):291–296Uçkun ÖM see 2015;21(6):450–456Uğuz E see 2015;21(4):285–290Ulutabanca H see 2015;21(4):235–240Ulutaş M see 2015;21(4):291–296Uyanıkgil Y see 2015;21(5):323–336Uysal C see 2015;21(4):261–265Uysal O see 2015;21(3):163–167Uzer G see 2015;21(5):385–391

Ülkü A see 2015;21(3):168–174Ülkü R see 2015;21(6):514–519Ülkür E see 2015;21(5):402–404


Ulus Travma Acil Cerrahi Derg, Kasım 2015, Vol. 21, No. 6 539

Ün S see 2015;21(1):57–62Ünsal MG see 2015;21(3):220–222

Varol S see 2015;21(4):261–265Vehid S see 2015;21(5):358–365Vural A see 2015;21(3):216–219Vural S see 2015;21(1):9–14Vural S see 2015;21(3):216–219

Wang AM see 2015;21(5):337–343Wang C–T see 2015;21(1):68–70Wang S see 2015;21(2):149–151Wang ZM see 2015;21(5):337–343Wazir NN see 2015;21(1):63–67Wu SY see 2015;21(5):337–343Wu Y see 2015;21(2):107–112

Xing C see 2015;21(2):107–112

Yalav O see 2015;21(3):168–174Yalçın B see 2015;21(6):440–445

Yan J see 2015;21(2):149–151Yandı M see 2015;21(5):410–413Yastı AÇ see 2015;21(2):79–89Yastı AÇ see 2015;21(3):216–219Yasti AÇ see 2015;21(1):27–33Yaşar B see 2015;21(3):163–167Yavuz M see 2015;21(1):71–74Yavuz OY see 2015;21(2):119–126Yayla S see 2015;21(1):9–14Yazar Ş see 2015;21(3):223–227Yazıcı A see 2015;21(5):410–413Yazıcı YA see 2015;21(3):204–208Yeong Cheol Kim YC see 2015;21(2):143–148Yeşiltaş M see 2015;21(6):520–523Yıldırım AE see 2015;21(4):291–296Yıldırım AE see 2015;21(6):450–456Yıldırım M see 2015;21(1):57–62Yıldız BŞ see 2015;21(3):193–196Yıldız DV see 2015;21(2):90–95Yıldız F see 2015;21(5):385–391Yıldız M see 2015;21(3):193–196

Yılık L see 2015;21(4):266–270Yılmaz F see 2015;21(6):450–456Yılmaz G see 2015;21(6):440–445Yılmaz KB see 2015;21(4):256–260Yılmaz Y see 2015;21(1):57–62Yilmaz ER see 2015;21(1):1–8Yonghui Y see 2015;21(4):241–247Yorgancı K see 2015;21(2):79–89Yücel M see 2015;21(6):477–483Yüksel A see 2015;21(3):175–181

Zehir R see 2015;21(6):469–476Zehir S see 2015;21(6):469–476Zhang S see 2015;21(5):337–343Zhao K see 2015;21(2):107–112Zhong H see 2015;21(2):149–151Zhou H see 2015;21(2):149–151Zhu B see 2015;21(2):107–112Zor F see 2015;21(6):457–462Zor F see 2015;21(6):491–495



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