Travma 2018 / 1

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

ISSN 1306 - 696X

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

Dolay K, et al. p. 71

Volume 24 | Number 1 | January 2018

Volume 24 | Number 1 | January 2018

www.tjtes.org

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi Editor-in-Chief Recep Güloğlu Editors Kaya Sarıbeyoğlu (Managing Editor) M. Mahir Özmen Hakan Yanar Former Editors Ömer Türel, Cemalettin Ertekin, Korhan Taviloğlu Section Editors Anaesthesiology & ICU Güniz Meyancı Köksal, Mert Şentürk Cardiac Surgery Münacettin Ceviz, Murat Güvener Neurosurgery Ahmet Deniz Belen, Mehmet Yaşar Kaynar Ophtalmology Cem Mocan, Halil Ateş Ortopedics and Traumatology Mahmut Nedim Doral, Mehmet Can Ünlü Plastic and Reconstructive Surgery Ufuk Emekli, Figen Özgür Pediatric Surgery Aydın Yagmurlu, Ebru Yeşildağ Thoracic Surgery Alper Toker, Akif Turna Urology Ali Atan, Öner Şanlı Vascular Surgery Cüneyt Köksoy, Mehmet Kurtoğlu

www.tjtes.org

THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ President (Başkan) Vice President (2. Başkan) Secretary General (Genel Sekreter) Treasurer (Sayman) Members (Yönetim Kurulu Üyeleri)

Kaya Sarıbeyoğlu M. Mahir Özmen Hakan Yanar Ali Fuat Kaan Gök Osman Şimşek Orhan Alimoğlu Mehmet Eryılmaz

CORRESPONDENCE İLETİŞİM Ulusal Travma ve Acil Cerrahi Derneği Şehremini Mah., Köprülü Mehmet Paşa Sok. Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul, Turkey

Tel: +90 212 - 588 62 46 Fax (Faks): +90 212 - 586 18 04 e-mail (e-posta): travma@travma.org.tr Web: www.travma.org.tr

ISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ YAYIN ORGANI Owner (Ulusal Travma ve Acil Cerrahi Derneği adına Sahibi) Editorial Director (Yazı İşleri Müdürü) Managing Editor (Yayın Koordinatörü) Publication Secretary (Yayın Sekreteri) Emblem (Amblem) Correspondence address (Yazışma adresi)

Tel Fax (Faks)

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

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

Publisher (Yayımcı): KARE Yayıncılık (KARE Publishing) • www.kareyayincilik.com • Design (Tasarım): Ali Cangül • Graphics (Grafikler): Edibe Çomaktekin • Linguistic Editor (İngilizce Editörü): Suzan Atwood • Redaction (Redaksiyon): Erman Aytaç • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): January (Ocak) 2018 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)

KARE P U B L I S H I N G

www.tjtes.org

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

tion, called “Upload Your Files”.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ulusal Travma ve Acil Cerrahi Dergisi TÜBİTAK TR Dizinde taranmaktadır, ayrıca uluslararası indekslerde, 2001 yılından itibaren Index Medicus, PubMed’de, 2005 yılından itibaren EMBASE’de, 2007 yılından itibaren Web of Science, Science Citation Index-Expanded’de (SCI-E), 2014 yılından itibaren de EBSCOhost indeksinde dizinlenmektedir. 2016 Journal Citation Report IF puanımız artarak 0.473 olmuştur. Dergide araştırma yazılarına öncelik verilmekte, bu nedenle derleme veya olgu sunumu türündeki yazılarda seçim ölçütleri daha dar tutulmaktadır. PUBMED’de dergi “Ulus Travma Acil Cerrahi Derg” kısaltması ile yer almaktadır.

Dergiye yazı teslimi, çalışmanın daha önce yayınlanmadığı (özet ya da bir sunu, inceleme, ya da tezin bir parçası şeklinde yayınlanması dışında), başka bir yerde yayınlanmasının düşünülmediği ve Ulusal Travma ve Acil Cerrahi Dergisi’nde yayınlanmasının tüm yazarlar tarafından uygun bulunduğu anlamına gelmektedir. Yazar(lar), çalışmanın yayınlanmasının kabulünden başlayarak, yazıya ait her hakkı Ulusal Travma ve Acil Cerrahi Derneği’ne devretmektedir(ler). Yazar(lar), izin almaksızın çalışmayı başka bir dilde ya da yerde yayınlamayacaklarını kabul eder(ler). Gönderilen yazı daha önce herhangi bir toplantıda sunulmuş ise, toplantı adı, tarihi ve düzenlendiği şehir belirtilmelidir.

Dergide İngilizce yazılmış makaleler yayınlanır. Tüm yazılar önce editör tarafından ön değerlendirmeye alınır; daha sonra incelenmesi için danışma kurulu üyelerine gönderilir.

Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; gerektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamamlanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “manuscript editing” sürecine alınır; bu aşamada tüm bilgilerin doğruluğu için ayrıntılı kontrol ve denetimden geçirilir; yayın öncesi şekline getirilerek yazarların kontrolüne ve onayına sunulur. Editörün, kabul edilmeyen yazıların bütününü ya da bir bölümünü (tablo, resim, vs.) iade etme zorunluluğu yoktur.

Açık Erişim İlkesi: Tam metinlere erişim ücretsizdir. Yayınlanan basılı materyali tam metni indirmek için herhangi bir ücret alınmaz.

Yazıların hazırlanması: Tüm yazılı metinler 12 punto büyüklükte “Times New Roman” yazı karakterinde iki satır aralıklı olarak yazılmalıdır. Sayfada her iki tarafta uygun miktarda boşluk bırakılmalı ve ana metindeki sayfalar numaralandırılmalıdır. Journal Agent sisteminde, başvuru mektubu, başlık, yazarlar ve kurumları, iletişim adresi, Türkçe özet ve yazının İngilizce başlığı ve özeti ilgili aşamalarda yüklenecektir. İngilizce yazılan çalışmalara da Türkçe özet eklenmesi gerekmektedir. Yazının ana metnindeyse şu sıra kullanılacaktır: Giriş, Gereç ve Yöntem, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekiller.

Başvuru mektubu: Bu mektupta yazının tüm yazarlar tarafından okunduğu, onaylandığı ve orijinal bir çalışma ürünü olduğu ifade edilmeli ve yazar isimlerinin yanında imzaları bulunmalıdır. Başvuru mektubu ayrı bir dosya olarak, Journal Agent sisteminin “Yeni Makale Gönder” bölümünde, 10. aşamada yer alan dosya yükleme aşamasında yollanmalıdır.

Başlık sayfası: Yazının başlığı, yazarların adı, soyadı ve ünvanları, çalışmanın yapıldığı kurumun adı ve şehri, eğer varsa çalışmayı destekleyen fon ve kuruluşların açık adları bu sayfada yer almalıdır. Bu sayfaya ayrıca “yazışmadan sorumlu” yazarın isim, açık adres, telefon, faks, mobil telefon ve e-posta bilgileri eklenmelidir. Özet: Çalışmanın gereç ve yöntemini ve bulgularını tanıtıcı olmalıdır.

Türkçe özet, Amaç, Gereç ve Yöntem, Bulgular, Sonuç ve Anahtar Sözcükler başlıklarını; İngilizce özet Background, Methods, Results, Conclusion ve Key words başlıklarını içermelidir. İngilizce olarak hazırlanan çalışmalarda da Türkçe özet yer almalıdır. Özetler başlıklar hariç 190210 sözcük olmalıdır.

Tablo, şekil, grafik ve resimler: Şekillere ait numara ve açıklayıcı bilgiler ana metinde ilgili bölüme yazılmalıdır. Mikroskobik şekillerde resmi açıklayıcı bilgilere ek olarak, büyütme oranı ve kullanılan boyama tekniği de belirtilmelidir. Yazarlara ait olmayan, başka kaynaklarca daha önce yayınlanmış tüm resim, şekil ve tablolar için yayın hakkına sahip kişilerden izin alınmalı ve izin belgesi dergi editörlüğüne ayrıca açıklamasıyla

birlikte gönderilmelidir. Hastaların görüntülendiği fotoğraflara, hastanın ve/veya velisinin imzaladığı bir izin belgesi eşlik etmeli veya fotoğrafta hastanın yüzü tanınmayacak şekilde kapatılmış olmalıdır. Renkli resim ve şekillerin basımı için karar hakemler ve editöre aittir. Yazarlar renkli baskının hazırlık aşamasındaki tutarını ödemeyi kabul etmelidirler.

Kaynaklar: Metin içindeki kullanım sırasına göre düzenlenmelidir. Makale içinde geçen kaynak numaraları köşeli parantezle ve küçültülmeden belirtilmelidir. Kaynak listesinde yalnızca yayınlanmış ya da yayınlanması kabul edilmiş çalışmalar yer almalıdır. Kaynak bildirme “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” (http:// www.icmje.org) adlı kılavuzun en son güncellenmiş şekline (Şubat 2006) uymalıdır. Dergi adları Index Medicus’a uygun şekilde kısaltılmalıdır. Altı ya da daha az sayıda olduğunda tüm yazar adları verilmeli, daha çok yazar durumunda altıncı yazarın arkasından “et al.” ya da “ve ark.” eklenmelidir. Kaynakların dizilme şekli ve noktalamalar aşağıdaki örneklere uygun olmalıdır: Dergi metni için örnek: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5.

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

Sizlerin çalışmalarınızda kaynak olarak yararlanabilmeniz için www.travma.org.tr adresli web sayfamızda eski yayınlara tam metin olarak ulaşabileceğiniz bir arama motoru vardır.

Derleme yazıları: Bu tür makaleler editörler kurulu tarafından gerek olduğunda, konu hakkında birikimi olan ve bu birikimi literatüre de yansımış kişilerden talep edilecek ve dergi yazım kurallarına uygunluğu saptandıktan sonra değerlendirmeye alınacaktır. Derleme makaleleri; başlık, Türkçe özet, İngilizce başlık ve özet, alt başlıklarla bölümlendirilmiş metin ile kaynakları içermelidir. Tablo, şekil, grafik veya resim varsa yukarıda belirtildiği şekilde gönderilmelidir.

Olgu sunumları: Derginin her sayısında sınırlı sayıda olgu sunumuna yer verilmektedir. Olgu bildirilerinin kabulünde, az görülürlük, eğitici olma, ilginç olma önemli ölçüt değerlerdir. Ayrıca bu tür yazıların olabildiğince kısa hazırlanması gerekir. Olgu sunumları başlık, Türkçe özet, İngilizce başlık ve özet, olgu sunumu, tartışma ve kaynaklar bölümlerinden oluşmalıdır. Bu tür çalışmalarda en fazla 5 yazara yer verilmesine özen gösterilmelidir.

Editöre mektuplar: Editöre mektuplar basılı dergide ve PUBMED’de yer almamakta, ancak derginin web sitesinde yayınlanmaktadır. Bu mektuplar için dergi yönetimi tarafından yayın belgesi verilmemektedir.

Daha önce basılmış yazılarla ilgili görüş, katkı, eleştiriler ya da farklı bir konu üzerindeki deneyim ve düşünceler için editöre mektup yazılabilir.

Bu tür yazılar 500 sözcüğü geçmemeli ve tıbbi etik kurallara uygun olarak kaleme alınmış olmalıdır. Mektup basılmış bir yazı hakkında ise, söz konusu yayına ait yıl, sayı, sayfa numaraları, yazı başlığı ve yazarların adları belirtilmelidir. Mektup bir konuda deneyim, düşünce hakkında ise verilen bilgiler doğrultusunda dergi kurallarına uyumlu olarak kaynaklar da belirtilmelidir.

Bilgilendirerek onay alma - Etik: Deneysel çalışmaların sonuçlarını bildiren yazılarda, çalışmanın yapıldığı gönüllü ya da hastalara uygulanacak prosedür(lerin) özelliği tümüyle anlatıldıktan sonra, onaylarının alındığını gösterir bir cümle bulunmalıdır. Yazarlar, bu tür bir çalışma söz konusu olduğunda, uluslararası alanda kabul edilen kılavuzlara ve T.C. Sağlık Bakanlığı tarafından getirilen yönetmelik ve yazılarda belirtilen hükümlere uyulduğunu belirtmeli ve kurumdan aldıkları Etik Komitesi onayını göndermelidir. Hayvanlar üzerinde yapılan çalışmalarda ağrı, acı ve rahatsızlık verilmemesi için neler yapıldığı açık bir şekilde belirtilmelidir.

Yazı gönderme - Yazıların gönderilmesi: Ulusal Travma ve Acil Cerrahi Dergisi yalnızca www.travma.org.tr adresindeki internet sitesinden on-line olarak gönderilen yazıları kabul etmekte, posta yoluyla yollanan yazıları değerlendirmeye almamaktadır. Tüm yazılar ilgili adresteki “Online Makale Gönderme” ikonuna tıklandığında ulaşılan Journal Agent sisteminden yollanmaktadır. Sistem her aşamada kullanıcıyı bilgilendiren özelliktedir.

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

Number - Sayı 1 January - Ocak 2018

Contents - İçindekiler Deneysel Çalışma - Experimental Experimental Studies - DeneyselStudy Çalışma 1-8 Melatonin exhibits supportive effects on oxidants and anastomotic healing during intestinal ischemia/reperfusion injury

Melatonin iskemi/reperfüzyon hasarı sırasında oksidanlar ve anastomoz iyileşmesi üzerine olumlu etkiler gösterir Özkan N, Ersoy ÖF, Özsoy Z, Çakır E 9-15 Evaluation of tourniquet application in a simulated tactical environment

Bir simülasyon taktik ortamında turnike uygulamasının değerlendirilmesi Sanak T, Brzozowski R, Dabrowski M, Kozak M, Dabrowska A, Sip M, Naylor K, Torres K 16-19 Which common test should be used to assess spleen autotransplant effect?

Dalak ototransplatının etkisini değerlendirme? Hangi sık kullanılan testi seçelim?

Soltani E, Aliakbarian M, Ghaffarzadegan K

Original Articles - Orijinal Çalışma 20-24 Is nighttime laparoscopic general surgery under general anesthesia safe?

Gece genel anestezi altında yapılan laparoskopik genel cerrahi olguları güvenli mi?

Koltka AK, İlhan M, Ali A, Gök AFK, Sivrikoz N, Yanar TH, Günay MK, Ertekin C 25-30 A retrospective analysis of 2713 hospitalized burn patients in a burns center in Turkey

Türkiye’deki bir yanık merkezinde yatarak tedavi gören 2713 hastanın geriye dönük analizi Albayrak Y, Temiz A, Albayrak A, Peksöz R, Albayrak F, Tanrıkulu Y 31-38 Characteristics of pediatric and adult cases with open globe injury and factors affecting visual outcomes: A retrospective analysis of 294 cases from Turkey

Açık göz yaralanmalarının çocuk ve erişkin yaş gruplarındaki karakteristikleri ve görsel prognozu etkileyen risk faktörleri: Türkiye’den 294 olgunun geriye dönük analizi Kutlutürk Karagöz I, Söğütlü Sarı E, Kubaloğlu A, Elbay A, Çallı Ü, Pinero DP, Yusuf Özertürk Y, Yazıcıoğlu T 39-42 Health results of a coup attempt: evaluation of all patients admitted to hospitals in Istanbul due to injuries sustained during the July 15, 2016 coup attempt

Darbe girişiminin sağlık bilançosu: 15 Temmuz darbe girişimine bağlı yaralanmalar nedeni ile İstanbul’daki hastanelere başvuran tüm hastaların değerlendirilmesi Tayfur İ, Afacan MA, Erdoğan MÖ, Çolak Ş, Söğüt Ö, Genç Yavuz B, Bozan K 43-48 Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects

Dorsal el defektlerinin yumuşak doku onarımı için posterior interosseöz arter flebi ile ters akımlı adipofasyal radyal ön kol flebinin kıyaslanması Akdağ O, Yıldıran G, Sütçü M, Karameşe M 49-55 Clinical features, diagnosis, and treatment of traumatic pulmonary pseudocysts

Travmatik pulmoner psödokistlerde klinik özellikler, tanı ve tedavi yöntemleri Hazer S, Orhan Söylemez UP

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

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

Number - Sayı 1 January - Ocak 2018

Contents - İçindekiler

56-60 Analyses of combat-related injuries to the maxillofacial and cervical regions and experiences in an operational field hospital

Maksillofasiyal ve servikal bölgelerde savaşa bağlı yaralanmaların analizi ve operasyonel saha hastanesindeki deneyimler Aşık MB, Akay S, Eksert S 61-65 Operative and non-operative management of children with abdominal gunshot injuries

Batın ateşli silah yaralanması olan çocuklarda; Cerrahi ve cerrahi olmayan yaklaşımımız Arslan MŞ, Zeytun H, Arslan S, Basuguy E, Okur MH, Aydoğdu B, Göya C, Uygun İ, Otçu S 66-70 Fundus-first technique and partial cholecystectomy for difficult laparoscopic cholecystectomies Zor kolesistektomiler için teknik çözümler: Fundus-first tekniği ve parsiyel kolesistektomi Sormaz İC, Soytaş Y, Gök AFK, Özgür İ, Avtan L

Case Series - Olgu Serisi 71-73 Endoscopic diagnosis and treatment of biliary obstruction due to acute cholangitis and acute pancreatitis secondary to Fasciola hepatica infection

Fasciola hepatica’ya ikincil akut kolanjit ve akut pankreatitin yol açtığı biliyer obstrüksiyonun endoskopik tanı ve tedavisi Dolay K, Hasbahçeci M, Hatipoğlu E, Ümit Malya F, Akçakaya A

Case Report - Olgu Sunumu 75-77 Pediatric dural venous sinus thrombosis following closed head injury: an easily overlooked diagnosis with devastating consequences

Kapalı kafa travması sonrası pediyatrik dural venöz sinüs trombozu: Kötü sonuçları olan ve kolayca atlanan bir ta Das JM, Sapkota R, Shrestha B 78-81 Extension of a coronary intramural hematoma after blunt chest trauma

Künt göğüs travması sonrası koroner intramüral hematomun yayılması Park MR, Min MK, Ryu JH, Lee DS, Lee KH 82-84 Neurological recovery after traumatic Cauda Equina syndrome due to glass fragments: An unusual case

Cam parçacıkları nedeniyle oluşan travma kaynaklı Kauda Equina sendromunda tam nörolojik iyileşme: Olağandışı olgu Şenoğlu M, Karadağ A, Türk Ç, Demirçivi Özer F 85-87 An unexpected long-term complication of genital burn in a child: Secondary cryptorchidism

Yanık skarına bağlı gelişen sekonder kriptorşidizm olgusu Öksüz M, Deliağa H, Topkara A, Koçak ÖF

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Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

EDITORIAL

Dear readers of the Turkish Journal of Trauma and Emergency Surgery, We are proud to share with you and are happy to mention that our journal, which holds a nationally and internationally significant place in its field, will celebrate its 24th year; this is thanks to the sincere efforts and a variety of innovations introduced each year by our journal. As always, we look forward to publishing your successful studies in our journal; these studies contribute to the improvement of national standards in the field of trauma and emergency surgery.

Today, there are around 50 journals in the SCI-E, including our journal in our country.

Even long-term, we are working diligently and diligently to become the target of our high-level journals to be covered by the SCI. To look back over this year: in total, 54 research articles, 16 experimental studies, and 24 case series and/or case reports have been published in our journal’s issues in 2017, in addition to the one compilation and short report that are included in each issue.

Fifteen of these studies were received from countries other than Turkey. Our journal’s impact factor has increased to 0.473, compared to the previous year, according to Journal Citation Reports 2017. We aim at an impact factor of 1 and above within the next two years. With your contributions, we accelerate our progress toward this goal and attach increased importance to our studies.

The control of the similarity rates using iThenticate before the articles are submitted for reviewing process has contributed to our researchers’ efforts and our journal’s power. Our journal is now indexed in Europe PMC (http://europepmc.org) after being included in the United States-centered PubMed. With this index, which is intensely used by European researchers, our journal’s level of being cited and availability will increase.

As we approach the end of 2017, we want to inform you and share our happiness with you about a new development. After the Digital Object Identifier (DOI) developed for articles, we are about to integrate the ORCID system, in which each author can obtain a unique and individually defined identity, into our journal’s peer-reviewed JournalAgent journal acceptance system. Thus, our journal will also begin as of 2018 to use the ORCID record system, which has rapidly gained importance in the international publishing community. This will prevent confusions that arise from similar author names. After the DOI, authors will reinforce their ownership of the articles they write using the ORCID, which is a powerful system. We would like to note that we always pay close attention to and are open to the different suggestions offered by you, our distinguished colleagues.

We wish you wellness and success, and we hope to meet for improvement of studies in trauma and emergency surgery in our country and around the world, making us all proud.

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

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 23, No. 1

ix

EDİTÖRDEN

Ulusal Travma ve Acil Cerrahi Dergisi’nin değerli okurları, Ulusal ve uluslararası veri tabanlarında başarılı bir yerdeki dergimizin çok samimi çabalarla her geçen yıl farklı yeniliklerle dolu 24. yılına giriyor olmasından duyduğumuz gururu sizlerle paylaşmaktan mutluluk duyuyoruz. Travma ve acil cerrahi alanında ulusal standartların yükselmesine katkı sağlayacak başarılı çalışmalarınızı dergimize bekliyoruz.

Günümüzde ülkemizde dergimizde dahil olmak üzere SCI-E kapsamında 50 civarında dergi bulunmaktadır. Uzun vadeli bile olsa titiz ve gayretle çalışarak hedefimiz üst seviye dergiler seviyesine çıkarak SCI kapsamında olmaktır.

Geçen yılımızı kısaca gözden geçirirsek; dergimizin 2017 yılı sayılarında 54 araştırma makalesi 16 deneysel çalışma 24 olgu serisi ve/veya olgu sunumu birer derleme ve kısa rapor yayınlanmıştır, bu çalışmaların 15’i yurtdışından gelmiştir. 2017 Journal Citation Reports sonucunda dergimizin impact factor’ü (IF) geçen yıllara göre artışla 0.473 olmuştur. Önümüzdeki iki yıl içinde IF 1 ve üstünü hedeflemekteyiz, çalışmalarımıza bu yönde hız verdik.

Makalelerin hakem sürecine girmeden iThenticate ile kontrolü sonucu benzerlik oranlarının kontrol altına alınması dergimize güç katmıştır. Dergimiz bildiğiniz Amerika merkezli PubMed ardından Europe PMC (http://europepmc.org) dizininde de taranmaya başlamıştır, Avrupa merkezli araştırıcıların yoğun olarak kullandığı bu dizinle dergimizin atıf ve bulunurluğu üst seviyeye taşınacaktır.

2017 yılı sonuna yaklaştığımız şu günlerde sizleri yeni bir gelişmeden haberdar etmek istiyoruz. Makaleler için oluşturulan digital object identifier’den (DOI) sonra, artık her yazarın kendi adı için alabileceği tek olarak tanımlanmış kimlik numarası sistemi’ni (ORCID) dergimizin JournalAgent hakemli makale kabul sistemiyle entegrasyonu sağlanmak üzeredir. Bu şekilde 2018 yılından itibaren uluslararası akademik yayıncılık camiasında hızla yer bulan ORCID kayıt sistemi dergimizde de kullanılmaya başlayacaktır.

Yazar isim benzerliğinden kaynaklanan karışıklıkların önüne geçilmiş olacak, her yazar kendi makalesinde sahipliğini DOİ gibi güçlü bir sistem ardından ORCID ile pekiştirmiş olacaktır.

Editörler kurulu olarak önümüzdeki yıllarda ülkemizde ve dünyada travma ve acil cerrahi alanında daha kaliteli çalışmalarla sizleri buluşturabilme dileğiyle hepinize sağlık ve başarılar diliyoruz.

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

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Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

EXPERIMENTAL STUDY

Melatonin exhibits supportive effects on oxidants and anastomotic healing during intestinal ischemia/reperfusion injury Namık Özkan, M.D.,1 Ömer Faik Ersoy, M.D.,1 Zeki Özsoy, M.D.,1 Ebru Çakır, M.D.2 1

Department of General Surgery, Gaziosmanpaşa University Faculty of Medicine, Tokat-Turkey

2

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

ABSTRACT BACKGROUND: The aim of this study was to investigate the effects of melatonin on intestinal anastomosis after intestinal ischemia/ reperfusion injury (IRI).

METHODS: Thirty Wistar albino rats of both sexes were divided into 3 groups: sham, control, and treatment. IRI was performed by clamping the superior mesenteric artery (SMA) for 30 minutes, followed by reperfusion. The sham rats received only manipulation of the SMA. Melatonin (10 mg/kg) was administered to the treatment group, and the control group was given a vehicle injection. Both the treatment group and the control group further underwent ileal resection of a 1-cm segment and anastomosis. On the postoperative seventh day, the anastomotic burst pressure, hydroxyproline level, histological indices of wound healing, and oxidative parameters of catalase (CAT), superoxide dismutase (SOD), total glutathione (T-GSH), and glutathione peroxidase (GSH-Px) levels were measured.

A one-way analysis of variance and chi-square test were used for the categorical data.

RESULTS: Melatonin treatment led to a significantly higher burst pressure (p=0.027 and p<0.001, respectively). The 2 antioxidant enzymes, CAT and SOD, were at the highest level in the sham and melatonin groups and the lowest level in the control group (p=0.001 and p=0.002, respectively). Melatonin treatment resulted in a significantly higher level of both enzymes compared with the control group (p=0.026 and 0.003, respectively). The GSHpx and total GSH levels were slightly elevated in the treated rats, but the difference was not statistically significant (p=0.205 and 0.216, respectively). Fibroblast infiltration, capillary formation, and epithelialization were significantly better in the melatonin-treated animals. The granulocyte and mononuclear infiltration scores were similar between all groups.

CONCLUSION: It was concluded that melatonin had marked effects on intestinal anastomotic healing during intestinal IRI. Keywords: Anastomosis; ischemia/reperfusion injury; melatonin.

INTRODUCTION Despite the evidence of marked progression in perioperative care and technical advancements, anastomotic leaks still constitute serious problems with marked levels of morbidity and mortality.[1] Anastomotic safety is affected by several factors, including the surgeon’s experience, suture material and tightness, blood supply, and the nutritional and medical status of the patient.[2] However, sufficient tissue oxygenation may be the most important factor. In addition to mesenteric embolism, bowel obstruction and trauma are related to intesti-

nal ischemia/reperfusion injury (IRI), which should be treated immediately.[2,3] Several studies have reported that intestinal IRI also leads to delays in intestinal anastomotic healing due to local or systemic effects.[2–4] Intestinal ischemia/reperfusion (IR) causes an exaggerated systemic response via the release of gutderived toxins or inflammatory mediators, such as reactive oxygen species (ROS), cytokines, arachidonic acid products, and the expression of adhesion molecules during reperfusion.

[5] Thus, tissue injuries increase throughout reperfusion.[6]

Cite this article as: Özkan N, Ersoy ÖF, Özsoy Z, Çakır E. Melatonin exhibits supportive effects on oxidants and anastomotic healing during intestinal ischemia/reperfusion injury. Ulus Travma Acil Cerrahi Derg 2018;24:1-8 Address for correspondence: Zeki Özsoy, M.D. Gaziosmanpaşa Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, 60100 Tokat, Turkey.

Tel: +90 356 - 212 95 00 E-mail: zekiserkanozsoy@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(1):1–8 DOI: 10.5505/tjtes.2017.23539 Submitted: 13.06.2016 Accepted: 06.04.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Özkan et al. Effects of melatonin on intestinal anastomotic healing

Recent studies have shown that antioxidants, such as Nacetylcysteine, superoxide dismutase (SOD), catalase (CAT), selenium, and vitamins E and C, can prevent IR-associated adverse effects of oxygen radicals and ROS and improve wound healing.[7,8] Melatonin, the pineal hormone, is a powerful antioxidant and free radical scavenger of ROS, including the hydroxyl and peroxyl radicals, as well as singlet oxygen and nitric oxide.[9] Melatonin exerts a tissue protective effect by increasing the antioxidant enzyme levels via its specific receptors and protects the cell from death.[10] Other beneficial effects of melatonin are mitogen activated protein kinase (MAPK) and nuclear factor-kappa (NF-K) activation, iNOS expression, and nitrite production.[11] NF-K plays a role in the modulation of DNA transcription, which is a critical point in the regulation of cellular processes, such as DNA repair, and situations requiring cellular growth, such as sepsis. Melatonin also inhibits lipopolysaccharide induced increase in MAPK activation, which promotes tissue inflammation and injury.[12] Melatonin has also been reported to play a preventive role in IRI in the heart, kidney, liver, lung, and intestines.[13] For these reasons, in the present study, we evaluated the effects of melatonin on intestinal anastomoses during intestinal IRI.

MATERIALS AND METHODS Procedure and Evaluation Ethical committee approval for the experimental protocol was obtained from Gaziosmanpasa University Faculty of Medicine before initiating the study. All rats received professional human care at Gaziosmanpasa University Experimental research center. Thirty Wistar albino rats of both sexes, weighing 250–320 g, were fasted for 12 h before experiments but had free access to water only. All rats were housed at 2–3 per wire cage with a 12:12-h light:dark cycle, kept at a constant temperature of 22°C–23°C, and fed with standard rat chow. The rats were divided into three groups (sham, control, and treatment groups; n=10 in each group).

Surgery and Experimental Protocol Before the operative process, anesthesia was induced by an intraperitoneal injection of ketamine hydrochloride (75 mg/ kg; Ketalar, 500-mg flacon; Pfizer, Istanbul) and xylazine hydrochloride (10 mg/kg; Rompun 2% flacon; Bayer, Istanbul).

After skin preparation, a midline laparotomy of 2–3 cm was made. The superior mesenteric artery (SMA) was denuded from its attachments and occluded immediately distal to the aorta with collateral interruption for 30 min using an atraumatic microvascular clamp as described elsewhere.[14–17] Group 1 (Sham): The SMA and ileal branches were dissected free, but not occluded.

Group 2 (Control): A vehicle (1% alcohol in saline; 1 ml/kg) injection was intraperitoneally administered to the Control group 30 min prior to the operation.[15] The SMA and ileal branches were dissected free and occluded.

2

Group 3 (Melatonin treatment): Melatonin (Sigma, St. Louis, MO, USA) was dissolved in absolute ethanol, and further dilutions were made using saline. The final concentration of ethanol was 1%. Melatonin (10 mg/kg) was intraperitoneally administered to the treatment group 30 min prior to the operation.[15] The SMA and ileal branches were dissected free and occluded.

During the ischemic episode, the abdominal incision was temporarily closed to prevent hypothermia. Both the control and treatment groups further underwent a reperfusion by releasing the clamps, followed by ileal resection. A 1-cm segment of ileum was resected 5 cm proximal to the cecum.

The resected segment was reconstructed by a single layered, end-to-end ileo-ileal anastomosis using 5–0 polypropylene (Prolene, Ethicon) interrupted inverting sutures.[18] The fascia and skin were closed by 4–0 monofilament polypropylene (Prolene, Ethicon) running sutures. All animals were resuscitated using a subcutaneous injection of saline (8–10 ml/kg) to the dorsal area.

Blood and Tissue Sample Collection The rats in the sham, control, and treatment groups were sacrificed on the seventh day as per the study design. Blood and tissue samples were obtained for biochemical analysis and histopathological evaluation of anastomotic tissue. The rats were sacrificed in accordance with laboratory conditions by intraperitoneally administering a high-dose of the anesthetic pentothal (200-mg/kg thiopental sodium, 0.5 G IE Ulugay, Istanbul).

Burst Pressure (BP) A laparotomy through the previous incision was made, and a 5–6 cm portion of a ileal segment with anastomosis was resected. The luminal content was cleaned by gentle saline flushing. One end of the ileal segment was tightly sutured with 3–0 silk, and the other end was attached to a mercury manometer using a tubing piece with an infusion pump. The intestinal segment was place in a saline-filled container, and air was pumped at a constant pressure of 10 mmHg/s. The pressure at which the reading suddenly declined or air bubbles were observed was recorded as BP, as previously described.[19] The possible upper limit of the apparatus was 300 mmHg. Measurements higher than 300 mmHg were accepted as 300 mmHg.

Determination of Hydroxyproline Levels Hydroxyproline levels were determined using Reddy and Enwemeka’s technique with some modification. The samples (50–100 µg) in 4 N NaOH were hydrolyzed by autoclaving at 120°C for 20 min. The hydrolysate was then cooled, neutralized with 4 N HCl, and centrifuged at 12,000 ×g for 10 min. Further, 1 mL of chloramine-T was added to 1 mL of supernatants and mixed gently, and the oxidation was allowed to proceed for 20 min at room temperature. Next, 1 mL of Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Özkan et al. Effects of melatonin on intestinal anastomotic healing

Ehrlich’s reagent was added to each sample and mixed gently, and the chromophore was allowed to develop by incubating the samples at 65°C for 15 min. The absorbance of each sample was read at 560 nm using a spectrophotometer.

Hydroxyproline levels were calculated from L-hydroxyproline standard curve, and results were expressed in micrograms of hydroxyproline per milligram of wet tissues.[20]

Histopathology For histopathological analyses, the anastomosis-site specimens were fixed in 10% neutral buffered formalin and embedded in paraffin. Paraffin-embedded tissues were sectioned at 5 µm and stained with hematoxylin and eosin. The specimens were examined by a blinded pathologist. During histopathological analysis, we semi-quantitatively assessed healing parameters (fibroblast infiltration, capillary formation, and epithelization) and inflammatory changes (granulocyte and mononuclear cell infiltration) in each specimen by giving a score of 0–3 for each parameter, as mentioned by Nursal et al.[21]

of enzyme catalyzing the degradation of 1 μmol of H2O2 per min at 37°C and specific activity corresponding to transformation of substrate (in μmol) (H2O2, min/mg protein).[23]

SOD Assay SOD (Cu, Zn-SOD) activity in the supernatant fraction was measured using xanthine oxidase/cytochrome c method,[24] where 1 unit of activity is the amount of enzyme needed to cause half-maximal inhibition of cytochrome c reduction. The amount of SOD in the extract was determined as unit of enzyme/mg protein, utilizing a commercial SOD as the standard.

Glutathione Peroxidase (GSH-Px) Assay GSH-Px activity was determined using a coupled assay with glutathione reductase by measuring the rate of NADPH oxidation at 340 nm using H2O2 as the substrate.[25] Specific activity is given as the amount of NADPH (μmol) disappeared per min per mg protein.

Total Glutathione (GSH) Assay

Determination of Protein Levels and Homogenization Protein levels in the tissues were measured by the Bradford method.[22] The absorbance was measured at 595 nm using a UV-VIS spectrophotometer. Bovine serum albumin was used as the protein standard. Tissues for enzyme activity studies were homogenized (PCV Kinematica Status Homogenizator) in ice-cold phosphate-buffered saline (pH 7.4). The homogenate was sonified in three cycles (20-s sonications and 40-s pause on ice) using an ultrasonifier (Bronson sonifier 450). The homogenate was centrifuged (15,000 ×g, 10 min, 4°C), and cell-free supernatant was immediately subjected to enzyme assay.

CAT Assay CAT activity was measured at 37°C using the rate of disappearance of hydrogen peroxide (H2O2) at 240 nm (ε240=40 M−1 cm−1). One unit of CAT activity is defined as the amount

The formation of 5-thio-2-nitrobenzoate is followed spectrophotometrically at 412 nm.[23] The amount of GSH in the extract was determined as nmol/mg protein using a commercial GSH as the standard.

Statistical Analysis Statistical evaluation of numeric variables was performed by one-way ANOVA, followed by post hoc Tukey. Non-numeric variables were evaluated using χ2 test. A p value of <0.05 was considered to be statistically significant.

RESULTS No intraoperative or postoperative death occurred in the rats, and we did not observe any infective complication in the sham, control, and melatonin groups during 7-day follow-up.

All results are shown in Table 1.

A graphical demonstration of BPs and hydroxyproline (OH-

Table 1. Quantitative values of burst pressures, OH-proline levels, and antioxidant levels in all groups

Sham group

Treatment group (Melatonin)

Control group

Mean±SD Mean±SD Mean±SD

Burst pressures (mmHg)

221±24.70

OH-proline levels (μg/mg) Catalase

7.27±0.69 475.83±88.19

216.00±21.18 6.74±0.46 429.61±55.94

p

181.25±33.56

<0.05

5.39±0.51

<0.001

343.11±61.19 <0.05

SOD

5.31±0.66

5.48±1.30

3.87±0.88 <0.05

GSH-px

11.90±3.12

12.55±3.68

14.54±3.22

>0.05

Total GSH

15.09±2.49

15.73±2.88

17.05±1.96

>0.05

OH-proline: Hydroxyproline; SOD: Superoxide dismutase; GSH: Glutathione; SD: Standard deviation.

Melatonin application during intestinal IR resulted in better anastomotic healing, as proven by higher burst pressures, OH-proline levels, and catalase and SOD levels. Of particular interest, GSH-px and total GSH levels were slightly high in melatonin-treated rats. However, these differences were not significant.

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

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Özkan et al. Effects of melatonin on intestinal anastomotic healing

proline) levels are shown in Figure 1. Both the sham- and melatonin-treated rats exhibited significantly higher BPs than the control rats (221±24.7, 216±21.2, and 181.25±33.56 mmHg, respectively; p=0.009). The post hoc evaluation revealed that the sham and melatonin groups were significantly higher than the control group (p=0.011 and 0.027, respectively), but there was no difference between the sham and treatment groups (p=0.906). The mean OH-proline levels were markedly higher in the sham and melatonin groups than in the control group (7.27±0.7, 6.74±0.46, and 5.39±0.51 μg/ mg, respectively; p<0.001).

The highest levels of the two antioxidant enzymes CAT and SOD were observed in the sham and melatonin groups and the lowest levels were observed in the control group (p=0.001 and 0.002, respectively). The levels of these enzymes showed similar results in the sham and melatonin groups (p=0.317

and 0.919, respectively). However, melatonin application led to significantly elevated levels of CAT and SOD compared with the levels in the control group (p=0.026 and 0.003, respectively) (Fig. 2). The other two enzymes, GSH-Px and GSH showed alterations similar to those of CAT and SOD. Their levels were the highest in the control group and lowest in the sham group. However, statistical analyses revealed no significant difference in GSH-Px and GSH levels between the control and sham groups (p=0.205 and 0.216, respectively) (Fig. 3).

Fibroblast infiltration was significantly different among the groups (p=0.007). An evaluation within the groups showed similar values in the sham and treatment groups. However, both the sham and treatment groups showed a significant difference in fibroblast infiltration compared with the controls (p=0.024 and 0.012, respectively). Similarly, capillary forma10.00 Hydroxyproline (mg/mg wet tissue)

Burst pressure (mmHg)

300.00

200.00

100.00

0.00

Sham

Control Group

8.00

6.00

4.00

2.00

0.00

Treatment

Sham

Control Group

Treatment

Figure 1. Burst pressures and anastomotic OH-proline levels. Footnote of Figure 1: Burst pressures and OH-proline levels in sham- and melatonin-treated rats were similar (p=0.109) but higher than those the untreated controls. Melatonin application markedly increased both burst pressures and OH-proline levels over those in the controls.

8.00

Superoxide dismutase (U/mg)

Catalase (U/mg)

600.00

400.00

200.00

0.00

Sham

Control Group

Treatment

6.00

4.00

2.00

0.00

Sham

Control Group

Treatment

Figure 2. CAT and SOD levels in all groups. Footnote of Figure 2: Melatonin application significantly increased the levels of the antioxidant enzymes CAT (p=0.001) and SOD (p=0.002).

4

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

300.00

25.00

200.00

20.00

Total glutathione (nmol/mg)

Burst pressure (mmHg)

Ă&#x2013;zkan et al. Effects of melatonin on intestinal anastomotic healing

200.00

200.00

100.00

15.00

10.00

5.00

0.00

Sham

Control Group

Treatment

0.00

Sham

Control Group

Treatment

Figure 3. Glutathione peroxidase and total glutathione levels.

4 2

Capillary formation Mild Moderate Severe

6 Count

Count

6

0

8

Fibroblast infiltration Mild Moderate Severe

4 2

Sham

Control Group

Treatment

0

10

Ephitelization Negative Positive

8

Count

8

6 4 2

Sham

Control Group

Treatment

0

Sham

Control Group

Treatment

Figure 4. Fibroblast proliferation, capillary formation, and epithelization. Footnote of Figure 4: Fibroblastic proliferation was significantly improved in the treatment group, p=0.012. Capillary formation, an indicator of wound healing, increased over time in the treatment group, with significant difference, p=0.021. Epithelization showed significantly better results in the treatment group, p=0.015.

tion and epithelization were significantly higher in the sham and treatment groups than in the control group. Graphical analyses of predictive histological parameters are shown in Figure 4. Granulocyte and mononuclear infiltration scores were similar between all groups (p=0.278 and 0.485, respectively).

DISCUSSION IRI is an important clinical problem that is associated with high rates of morbidity and mortality in surgery. In many vascular operations (e.g., embolectomy for SMA occlusion, repair of traumatic vascular lacerations or abdominal aortic aneurysm, treatment of hypovolemia due to bleeding, and organ transplantations), a concomitant gastrointestinal anastomosis may be necessary. The construction of a gastrointestinal anastomosis during these situations may be hazardous, in part because of the reperfusion of ischemic tissues. IR has a negative effect on the healing of intestinal anastomoses. Preoperative or intraoperative IRIs may also affect wound healUlus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

ing and decrease anastomotic durability.[3] Most of the general factors suggest that the vasoconstrictive effects are the cause of local ischemia and dehiscence of an anastomosis. Perfusion and the state of local oxygenation are some of the most important factors for healing gastrointestinal anastomoses. The wound healing process is fast in optimally perfused tissue, and sufficient oxygen should reach the wound for proper healing.

Related to this issue, Kologlu et al.[19] investigated and compared the effects of local IRI and remote IRI on the healing of colonic anastomoses. They concluded that segmental small intestinal, unilateral lower extremity, and unilateral renal IR significantly delay anastomotic healing in the right colon. Similarly, Kuzu et al.[3] showed that reperfusion stress after SMA ischemia cause a delay in the anastomotic healing process in the left colon.

Many materials and drugs, such as resveratrol, thymoquinone, and melatonin, have been evaluated with regard to their protective effects on intestinal IRI.[26,27] Ozban et al.[17] concluded 5

Özkan et al. Effects of melatonin on intestinal anastomotic healing

that melatonin prevents the harmful effects of IRI on intestinal tissues in a rat model of SMA occlusion. Similarly, our study showed that melatonin, when administered prior to ischemia, has protective effects on intestinal anastomotic healing in a rat model of SMA occlusion.

In the present study, we used a rat model of small bowel anastomosis in the setting of IRI. We hypothesized that IRI would be responsible for most of the anastomotic leaks and that melatonin could prevent the adverse effects of IRI and improve anastomotic healing. Melatonin, which has a short half-life, was administered 30 min prior to the procedure.

Furthermore, to see the effect of melatonin on intestinal anastomosis, the rats were sacrificed at the end of 7 days.[3,15] Although many methods to assess anastomotic healing have been defined, the most frequently used techniques are BP and tensile strength measurements.[4,28] An optimal tissue perfusion and oxygen delivery is essential for fibroblasts, macrophages, lysine, and proline hydroxylation for collagen synthesis. In the present study, for assessing anastomotic healing, we preferred intestinal BPs, a technique in which force is applied in all directions. Mechanical properties of anastomoses have also been assessed by measuring the hydroxyproline (OH-proline) levels. In vertebrates, almost the entire OH-proline content is present in collagen.[28] Collagen is the essential structural protein of the connective tissue and is responsible for the stability of the anastomosis and the elasticity of the tissue.[29] Therefore, we used the OHproline level as an indicator of collagen metabolism. Our results demonstrated that melatonin has supportive effects on mechanical properties of anastomotic healing during IRI. Higher BPs in conjunction with higher OH-proline levels are confirmative of higher anastomotic strength in melatonintreated rats. The improvements in mechanical properties of anastomotic healing in the melatonin group also paralleled the histological indices of wound healing, including fibroblast infiltration, capillary formation, and epithelization. These results suggest the ability of melatonin to prevent IRI in a rat model of intestinal anastomotic wound healing.

The beneficial effects of melatonin in IRI are further supported by the higher antioxidant enzyme activity in the treatment group. Reperfusion can be simplified as an oxygen burst in tissues undergoing reoxygenation. This is associated with a high rate of free radical generation and, if not faced with antioxidant systems, can lead to severe tissue damage. Experimental evidence suggests that ROS generation is significantly responsible for tissue damage during IRI.[6] Therefore, documentation of the protective activity of melatonin treatment prior to ischemia in conjunction with higher activities of the main antioxidative enzymes, CAT, SOD, and GSH-Px, allowed us to suggest that systemic melatonin treatment leads to increased anastomotic antioxidant enzyme activities.

It has been previously reported that melatonin is an effective free radical scavenger[9,13] and acts as a positive regulator for 6

main enzymes of the antioxidant system, including SOD, CAT, GSH-Px, and GSH reductase.[13] Our data paralleled these reports. We detected significant improvements in SOD and CAT levels in melatonin-treated rats. Melatonin-treated rats subjected to IR had more than 40% higher SOD activities than the control rats. A less significant difference of 25% was noted for CAT levels. These results are in accordance with previous reports showing that melatonin treatment significantly stimulates several antioxidant enzymes.[13] The remaining enzyme GSH-Px and total GSH levels were also improved, but these differences were not significant compared with the levels in the control rats. The data in the literature also fails to demonstrate an effect of melatonin on GSH-Px activity following IRI. Recent studies have documented the protective role of melatonin on gastrointestinal mucosal healing. Celinski et al.[30] have shown beneficial effects of melatonin on the healing of gastric and duodenal ulcers and burn patients. They concluded that melatonin added to omeprazole treatment significantly accelerates the healing rate of Helicobacter pylori-infected chronic gastroduodenal ulcers over that obtained with omeprazole alone, and this likely depends on the significant increase in plasma melatonin and, possibly, leptin levels. Cabeza et al.[31] have reported that the free radical scavenger properties of melatonin mainly include superoxide anions, which are probably derived from the xanthine oxidase pathway, and that the increase in antioxidative enzymes significantly contributes to mediating the protection by the hormone against IR gastric injury.

Intestinal ischemia is a life-threatening abdominal emergency with an overall mortality rate of 60%–80%.[8] Restoration of the oxygen supply to ischemic tissues is essential for tissue repair because oxygen is critical to energy production and toxic metabolite removal. Some of the function lost after ischemia may be regained by reperfusion of the tissue, but reperfusion also accelerates the formation of oxygen-derived ROS. Therefore, in the clinical scenario of a patient suffering from acute mesenteric ischemia, a potentially therapeutic agent that is expected to block the deleterious effects of reperfusion, such as release of free oxygen radicals, should be given before restoring arterial flow. Therefore, in our experimental model, melatonin was administered 30 min before the start of reperfusion in the treatment group; the aim of this technique was to ensure that melatonin was in the animal’s circulation. Adverse effects of melatonin are few, and it is generally regarded as safe in recommended dosages. In humans, for most non-sleep-related disorders, dosages of 10–50 mg daily have been safe and effective.[32] We used a melatonin dose of 10 mg/kg 30 min prior to the start of reperfusion, which was similar to that in other research in which experimental IR rat model investigations were performed with melatonin.[33] This dosage and timing seem to be reasonable when considering the relatively short serum half-life (30–60 min) and the total amount of melatonin in the gastrointestinal tract (up 400 times more than that in the pineal gland).[32] Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Özkan et al. Effects of melatonin on intestinal anastomotic healing

This study had some limitations. Despite the previously mentioned immune regulatory effects of melatonin, we could not demonstrate a difference between granulocyte and mononuclear cell infiltration scores. We could have tried to confirm our results with cytokine levels. However, this point remains to be proven in further studies. The lack of molecular biology studies is another limitation of our study. Despite these limitations, our results clearly showed that melatonin had systemic preventive effects on IRI during the wound healing process in ileal anastomoses in rats. These findings are promising in terms of the potential use of this drug in the treatment of patients undergoing intestinal anastomoses, under conditions in which remote ischemia may be a concern.

Conclusion Our study showed that melatonin, when given prior to ischemia, has protective effects on intestinal anastomotic healing in a rat model of SMA occlusion. We believe that the effects are mainly based on its lipophilic nature and broad spectrum antioxidant characteristics. Melatonin is both a direct free radical scavenger and an indirect antioxidant because of its ability to promote the activities of a variety of antioxidative enzymes. Melatonin can be a suitable agent for use as a free radical scavenger during surgical operations associated with significant IRI. We believe that further clinical studies are needed to reveal the effectiveness of melatonin as a therapeutic agent in the clinical setting in mesenteric IRI.

Acknowledgment This study was supported by Research Fund Unit of Gaziosmanpasa University.

Conflict of interest: None declared.

REFERENCES 1. Güenaga KF, Matos D, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2011:CD001544.

2. Posma LA, Bleichrodt RP, van Goor H, Hendriks T. A prolonged interval between deep intestinal ischemia and anastomotic construction does not impair wound strength in the rat. Int J Colorectal Dis 2007;22:1485–91.

3. Kuzu MA, Tanik A, Kale IT, Aşlar AK, Köksoy C, Terzi C. Effect of ischemia/reperfusion as a systemic phenomenon on anastomotic healing in the left colon. World J Surg 2000;24:990–4.

4. Colak T, Turkmenoglu O, Dag A, Polat A, Comelekoglu U, Bagdatoglu O, et al. The effect of remote ischemic preconditioning on healing of colonic anastomoses. J Surg Res 2007;143:200–5.

5. Lucchesi BR. Complement, neutrophils and free radicals: mediators of reperfusion injury. Arzneimittelforschung 1994;44:420–32.

6. Ates B, Yilmaz I, Geckil H, Iraz M, Birincioglu M, Fiskin K. Protective role of melatonin given either before ischemia or prior to reperfusion on intestinal ischemia-reperfusion damage. J Pineal Res 2004;37:149–52.

7. Bulbuller N, Dogru O, Yekeler H, Cetinkaya Z, Ilhan N, Kirkil C. Effect of melatonin on wound healing in normal and pinealectomized rats. J Surg Res 2005;123:3–7.

8. Yasuhara H. Acute mesenteric ischemia: the challenge of gastroenterology. Surg Today 2005;35:185–95.

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9. García JJ, López-Pingarrón L, Almeida-Souza P, Tres A, Escudero P, García-Gil FA, et al. Protective effects of melatonin in reducing oxidative stress and in preserving the fluidity of biological membranes: a review. J Pineal Res 2014;56:225–37.

10. Théroux P. Protection of the myocardial cell during ischemia. Am J Cardiol 1999;83:3G–9G. 11. Li JH, Yu JP, Yu HG, Xu XM, Yu LL, Liu J, et al. Melatonin reduces inflammatory injury through inhibiting NF-kappaB activation in rats with colitis. Mediators Inflamm 2005;2005:185–93.

12. De Filippis D, Iuvone T, Esposito G, Steardo L, Arnold GH, Paul AP, et al. Melatonin reverses lipopolysaccharide-induced gastro-intestinal motility disturbances through the inhibition of oxidative stress. J Pineal Res 2008;44:45–51.

13. Singh M, Jadhav HR. Melatonin: functions and ligands. Drug Discov Today 2014;19:1410–8.

14. Li JY, Yin HZ, Gu X, Zhou Y, Zhang WH, Qin YM. Melatonin protects liver from intestine ischemia reperfusion injury in rats. World J Gastroenterol 2008;14:7392–6.

15. Paskaloğlu K, Sener G, Kapucu C, Ayanoğlu-Dülger G. Melatonin treatment protects against sepsis-induced functional and biochemical changes in rat ileum and urinary bladder. Life Sci 2004;74:1093–104.

16. Li JY, Yin HZ, Gu X, Zhou Y, Zhang WH, Qin YM. Melatonin protects liver from intestine ischemia reperfusion injury in rats. World J Gastroenterol 2008;14:7392–6.

17. Ozban M, Aydin C, Cevahir N, Yenisey C, Birsen O, Gumrukcu G, et al. The effect of melatonin on bacterial translocation following ischemia/ reperfusion injury in a rat model of superior mesenteric artery occlusion.

BMC Surg 2015;15:18.

18. Cihan AO, Bicakci U, Tander B, Rizalar R, Kandemir B, Ariturk E, et al. Effects of intraperitoneal nitroglycerin on the strength and healing attitude of anastomosis of rat intestines with ischemia-reperfusion injury.

Afr J Paediatr Surg 2011;8:206–10.

19. Kologlu M, Yorganci K, Renda N, Sayek I. Effect of local and remote ischemia-reperfusion injury on healing of colonic anastomoses. Surgery 2000;128:99–104.

20. Reddy GK, Enwemeka CS. A simplified method for the analysis of hydroxyproline in biological tissues. Clin Biochem 1996;29:225–9.

21. Nursal TZ, Bal N, Anarat R, Colakoglu T, Noyan T, Moray G, et al. Effects of a static magnetic field on wound healing: results in experimental rat colon anastomoses. Am J Surg 2006;192:76 -81.

22. Bradford MM. A rapid and sensitive method for the quantitation of microgram quantities of protein utilizing the principle of protein-dye binding. Anal Biochem 1976;72:248–54.

23. Luck H. Methods of enzymatic analysis. New York USA; Verlag Chemie and Academic Press: 1963. pp 885–8.

24. McCord JM, Fridovich I. Superoxide dismutase. An enzymic function for erythrocuprein (hemocuprein). J Biol Chem 1969;244:6049–55.

25. Lawrence RA, Burk RF. Glutathione peroxidase activity in selenium-deficient rat liver. Biochem Biophys Res Commun 1976;71:952–8.

26. Ozkan OV, Yuzbasioglu MF, Ciralik H, Kurutas EB, Yonden Z, Aydin M, et al. Resveratrol, a natural antioxidant, attenuates intestinal ischemia/ reperfusion injury in rats. Tohoku J Exp Med 2009;218:251–8.

27. Tas U, Ayan M, Sogut E, Kuloglu T, Uysal M, Tanriverdi HI, et al. Protective effects of thymoquinone and melatonin on intestinal ischemiareperfusion injury. Saudi J Gastroenterol 2015;21:284–9.

28. Koruda MJ, Rolandelli RH. Experimental studies on the healing of colonic anastomoses. J Surg Res 1990;48:504–15.

29. Eker T, Genc V, Sevim Y, Cumaogullari O, Ozcelik M, Kocaay AF, et al. The effects of ventilation with high density oxygen on the strength of gastrointestinal anastomosis. Ann Surg Treat Res 2015;89:17–22.

30. Celinski K, Konturek PC, Konturek SJ, Slomka M, Cichoz-Lach H, Brzozowski T, et al. Effects of melatonin and tryptophan on healing of

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J Physiol Pharmacol 2011;62:521–6.

31. Cabeza J, Motilva V, Martín MJ, de la Lastra CA. Mechanisms involved in gastric protection of melatonin against oxidant stress by ischemia-reperfusion in rats. Life Sci 2001;68:1405–15.

32. Acuña-Castroviejo D, Escames G, Venegas C, Díaz-Casado ME, Lima-

Cabello E, López LC, et al. Extrapineal melatonin: sources, regulation, and potential functions. Cell Mol Life Sci 2014;71:2997–3025.

33. Ding K, Wang H, Xu J, Li T, Zhang L, Ding Y, et al. Melatonin stimulates antioxidant enzymes and reduces oxidative stress in experimental traumatic brain injury: the Nrf2-ARE signaling pathway as a potential mechanism. Free Radic Biol Med 2014;73:1–11.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Melatonin iskemi/reperfüzyon hasarı sırasında oksidanlar ve anastomoz iyileşmesi üzerine olumlu etkiler gösterir Dr. Namık Özkan,1 Dr. Ömer Faik Ersoy,1 Dr. Zeki Özsoy,1 Dr. Ebru Çakır2 1 2

Gaziosmanpaşa Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Tokat Atatürk Göğüs Hastalıkları Eğitim ve Araştırma Hastanesi, Patoloji Kliniği, Ankara

AMAÇ: Melatoninin iskemi/reperfüzyon hasarında (İRH) intestinal anastomoz iyileşmesi üzerine etkisini araştırmayı amaçladık.

GEREÇ VE YÖNTEM: Otuz Wistar-Albino sıçan üç gruba (Sham, kontrol ve tedavi) ayrıldı. Süperior mezenterik arter (SMA) klemplenip 30 dakika sonrasında açılarak İRH oluşturuldu. Sham grubunda sadece SMA manüplasyonu yapıldı. Tedavi grubuna melatonin (10 mg/kg) ve kontrol grubunda salin verildi. Tedavi ve kontrol gruplarında ek olarak 1 cm ileal segment rezeke edilerek anostomoz yapıldı. Ameliyat sonrası yedinci günde anastomotik patlama basıncı, hidroksiprolin seviyeleri, yara iyileşmesinin histolojik göstergeleri ve oksidatif parametrelerin düzeyleri araştırıldı. İstatistik için tek yönlü varyans analizi ve ki kare testi kullanıldı.

BULGULAR: Melatonin tedavisi patlama basıncında anlamlı yüksekliğe yol açtı (sırasıyla, p=0.027 ve p<0.00). Katalaz ve süperoksit dismütaz enzim seviyeleri sham ve melatonin gruplarında en yüksek, kontrol grubunda ise en düşüktü (sırasıyla, p=0.001 ve p=0.002). Melatonin tedavisi her iki enzim düzeylerinde anlamlı yüksekliğe yol açtı (sırasıyla, p=0.026 ve p=0.003). Glutatyon peroksidaz ve total glutatyon düzeylerinde tedavi grubunda hafifçe artış görülse de bu fark anlamlı değildi (sırasıyla, p=0.205 ve 0.216). Fibroblast infiltrasyonu, kapiller formasyon ve epitelizasyon melatoninle tedavi edilen sıçanlarda anlamlı olarak daha iyiydi. Granülosit ve mononükleer infiltrasyon skorları tüm gruplarda benzerdi.

TARTIŞMA: Deneysel modelde İRH sırasında melatonin uygulamasının intestinal anastomoz iyileşmesi üzerine belirgin olumlu etkileri olduğunu düşünüyoruz.

Anahtar sözcükler: Anastomoz; iskemi/reperfüzyon hasarı; melatonin.

Ulus Travma Acil Cerrahi Derg 2018;24(1):1–8

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doi: 10.5505/tjtes.2017.23539

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

EXPERIMENTAL STUDY

Evaluation of tourniquet application in a simulated tactical environment Tomasz Sanak, MSc, PhD,1 Robert Brzozowski, PhD,2 Marek Dabrowski, MPH,3 Magdalena Kozak, M.D.,2 Agata Dabrowska, MSc, MPH,3 Maciej Sip, MSc, MPH,3 Katarzyna Naylor, MSC, MPH,4 Kamil Torres, M.D., PhD4 1

Department of Disaster Medicine and Emergency, Faculty of Anesthesiology and Intensive Therapy, Collegium Medicum,

Jagiellonian University, Krakow-Poland 2

Department of Battlefield Medicine, Military Institute of Medicine In Warsav-Poland

3

Department of Disaster and Emergency Medicine, Poznan University of Medical Science, Poznan-Poland

4

Department of Didactics and Medical Simulation, Chair of Human Anatomy, Medical University of Lublin-Poland

ABSTRACT BACKGROUND: Application of a tourniquet in a tactical environment is implemented in two ways: the so-called self-aid, which is the application of a tourniquet by the injured, and the so-called buddy aid, which is the application of a tourniquet by the person provide aid. This study aimed to test the quality of tourniquet use in a simulated situation, close quarter battle.

METHODS: The study involved 24 injured operators and 72 operators in the whole simulation, implying 12 sections of six individuals.

To validate the application of tourniquets, the recommendations of the Committee of Tactical Combat Care of the Injured were used, and ultrasound with Doppler function was employed to assess the hemodynamic effect of applying tourniquets.

RESULTS: Native flow was observed in 15 operators; in three people, a trace flow was noticed, whereas in six people, a full flow was observed. No significant difference was found between the qualities of tourniquet application by the operators themselves compared with those of tourniquet application by another person. The median distance of tourniquet application from the armpit was 9.5 cm for self-aid and buddy aid. In 16 participants the outer arrangement of tourniquets was observed, and in only eight participants tourniquets were correctly located on the internal part of the arm. In 18 participants, tourniquets were not correctly prepared for use in the tactical environment, whereas in only six participants, they were correctly prepared. Most operators with a negative ultrasound flow revealed negative distal observed pulse (DOP). Positive DOP occurred in the majority of operators with full ultrasound flow.

CONCLUSION: The application of tourniquets poses a challenge even in case of specialized units; therefore, there is a need to provide regular training for implementing that procedure.

Keywords: Care under fire; hemorrhage; tactical field care; tourniquet.

INTRODUCTION Tourniquets may be used in the tactical environment during one of three phases.

The time and quality of provided assessments influence life or death dilemma and decide on the success of the conducted mission and its effectiveness.[1]

In Phase I or the so-called care under fire (CUF), the priority is to take the fire initiative and execution of tactical and operational objectives. In this phase, known as the death zone, it is practically impossible to apply advanced emergency procedures, and stopping bleeding is limited to tourniquet application by the victim, known as the so-called self-aid, or by the operator who is in the vicinity, known as the so-called buddy aid (if it is possible depending on the tactical situation). It

Cite this article as: Sanak T, Brzozowski R, Dabrowski M, Kozak M, Dabrowska A, Sip M, et al. Evaluation of tourniquet application in a simulated Tactical environment. Ulus Travma Acil Cerrahi Derg 2018;24:9-15 Address for correspondence: Katarzyna Naylor, M.D. Al. RacĹ&#x201A;awickie 1 Lublin - Poland.

Tel: 0048509716631 E-mail: katarzyna.naylor@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(1):9â&#x20AC;&#x201C;15 DOI: 10.5505/tjtes.2017.84899 Submitted: 15.03.2017 Accepted: 17.04.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Sanak et al. Evaluation of tourniquet application in a simulated tactical environment

should be noted that 60% of deaths on the battlefield is associated with massive hemorrhage from the limbs in this phase.

Phase II or the so-called tactical field care is defined as the seemingly safe zone. The trauma examination undertaken according to the MARCHE (M-massive bleeding, A-airway, R- respiratory management, C-circulation, H-hypothermia, E-everything else) scheme provides the possibility of changing tourniquets to hemostatic dressings. However, if the examination leads to the identification of an active bleeding source, it should be stopped in the first place with tourniquets.

In Phase III or the so-called tactical evacuation, the priority is to transport injured people to a field hospital with surgical protection as soon as possible.[1] Any use of tourniquets when not subjected to CUF is dictated by the inability to control bleeding by other means (bandages, gaze, etc.).[2]

Types of Tourniquets Combat Application Tourniquet (CAT) CAT is a part of the individual medical package of each soldier who is involved in Polish Military Contingents. CAT comprises the Velcro tape having a width of 4 cm, inside which there is another tape constituting the “stringer mechanism.” At the distal end, there is a double buckle through which the pare needs to be threaded, two holes in each situation of buddy aid type (assistance provided by other people) and one hole in the situation when the victim assists itself. Application of tourniquets in the tactical environment is not easy, particularly when the operator is required to obey the discipline of light or sound. As a result of the training course according to the program Tactical Combat Casualty Care, each operator should acquire the so-called muscle memory to quickly apply the tourniquet as soon as bleeding appears. Muscle memory refers to the automaticity of the action that is implemented, devoid of any hesitation. CAT, available in both the right and left hands of the operator, should be placed on a tactical vest.

Proper preparation for action means threading the Velcro tape through one hole, so that it is ready for the so-called self-aid.

Application of tourniquet. Tourniquets should always be applied in the way that the rod and strap are placed on the inside part of the leg. Such actions are crucial during the evacuation process because they protect against possible undoing of tourniquets.[3,4] Special Operations Forces Tactical Tourniquet-Wide (SOFTT-W) SOFTT-W is currently the second most common tourniquet among individual equipment of the operators. The advantage of this tourniquet is its durable material. The tourniquet and buckle in “stringer mechanism” are made of steel, which allow generating high-force pressure on blood vessels. As in the case of CAT, SOFTT-W must be located within both the 10

left and right hands of the operator to make “self-application” possible. Tourniquets should also be placed on each of the inner part of the leg.[5]

Hemostatic Effect The use of tourniquets in each phase of assistance in the tactical environment should be associated with stopping bleeding.

Tourniquets should be applied as high as possible on the limb in the CUF zone. Obtaining the hemostatic effect is associated with the closure of the artery light through the external compressive force of tourniquets. The operators, as a result of the learning process, should use tourniquets in such a way that the compression force stops the bleeding and eliminates pulse in the distal parts of the leg (upper limb, radial artery; lower limb, popliteal artery).[4,5] The research reviews the value and need of training for acquiring/sustaining skills in tourniquet application among military professionals.

MATERIALS AND METHODS This study was based on the data gathered during the VI AllPolish Competition in Tactical Medicine “Paramedic 2013.”

The competition participants were assessed using a questionnaire that comprised 10 questions concerning knowledge and assessment of providing immediate assistance in combat emergency situations, bleeding, and airway patency.

The questionnaire was based on the literature in the field, collecting data on the tourniquet application and methods of airway management. The five enclosed questions regarding bleeding managements included issues concerning self-aid and buddy aid. The questions were related to the type of aid, limb chosen to provide aid, and technical aspects of applying the tourniquet such as the positioning of the tourniquet and distance between the wound and tourniquet. Database and statistical calculations were performed using the computer software Statistica version 10 (StatSoft Poland, Tibco Statistica Inc.). Quantitative parameters were presented as means, median values, and standard deviations; qualitative parameters were presented as numbers and percentages. Normality of distribution of a quantitative variable was assessed using Shapiro–Wilk test. Regarding qualitative variables, Pearson’s chi-square test was performed to compare the proportion of indicators used for one population, and chi-square test of maximum likelihood and Fisher’s exact test were performed to compare the association of the two populations. To assess the association between ultrasound flow and DOP, the chisquare independence test of maximum likelihood was used.

The significance level for all tests was set at α values of 0.05.

The survey that assessed the effectiveness of tourniquets was conducted in the practice station called “tourniquets” during the VI All-Polish Competition Tactical Medicine Paramedic 2013” and was filled out by the judging panel.

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Sanak et al. Evaluation of tourniquet application in a simulated tactical environment

Except for the subjective assessment of professionals judges of the event, employees of Warsaw Military Institute, and Medical University of Poznań concerning the tourniquet placement; the blood flow in vessels of distal extremities was measured using ultrasonography (USG; NanoMaxx Portable Ultrasound Machine SonoSite). For vascular imaging, a probe and the Power Doppler function were employed. After assembling the tourniquet (upper/lower extremity), Doppler echocardiography was used to examine the absence of blood flow in the arteries in the distal parts of the limbs. Full flow or microflow was a proof of incorrect tourniquet application.

The lack of blood flow was a proof of correct tourniquet application (Fig. 1 and Fig. 2).

Scenario of the Simulation Task The task aimed to investigate the tactical environment and interior of the building by six operator teams. The tactical situations required from operators to move in the so-called car (a short distance one behind the other) around the building. The interior of the rooms was heavily obscured; thus,

the operators used a fixed light source at the entrance. After entering the section of the building fire, contact was initiated, which resulted in two operators being injured in the upper limb at the elbow height. The first of the operators was still under fire and he applied the tourniquet by himself.

The other tourniquet was placed after the enemy was neutralized by his colleagues. In this scenario, only one officer, a representative of the Ministry of Justice used its knees to pre-stop the source of bleeding.

Testing the Quality of Tourniquet Application in CUF The study involved 24 operators who applied tourniquets and 72 in total participating in the tactical events (Table 1). Twelve operators implemented the so-called self-aid, wherein they applied a tourniquet themselves, and the remaining 12 operators had the tourniquet placed by other rescuer (buddy aid).

USG In 15 operators, negative ultrasound flow was observed, and Table 1. Sociodemographic data of the investigated group and the tactical experienced before the study Investigated group of participants

(n=72)

Age

a) 20–25 years

a) 4

b) 26–30 years

b) 36

c) 31–35 years

c) 18

d) >36 years

d) 14

Years of service

Figure 1. Radial artery with a lack of blood flow using Doppler echocardiography.

a) 0–4 years

a) 21

b) 5–9 years

b) 22

c) 10–14 years

c) 24

d) >14 years

d) 5

When was your last participation in TCCC course?

a) 1 year ago

a) 20

b) 2 years ago

b) 15

c) 3 years ago

c) 9

d) >4 years ago

d) 20

e) Never

e) 8

Have you ever experienced delivering first aid in tactical conditions?

a) Yes, during the implementation

a) 16

of the tactical order

b) Yes, but in situation not connected

b) 0

to implementing an order Figure 2. Radial artery with micro blood flow using Doppler echocardiography.

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

c) I have but in a non-tactical condition

c) 27

d) I have never experienced delivering first aid

d) 29

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Sanak et al. Evaluation of tourniquet application in a simulated tactical environment

Table 2. Data for ultrasound flow USG

All

Self-aid

Negative 15

Buddy aid

8

7

Only two operators presented with a proper distance of the tourniquet from the armpit (<5 cm). In 14 operators, the distance of the tourniquet from the armpit ranged from 5 to 10 cm. In eight operators, the distance was >10 cm.

Trace 3 2

1

Tourniquet

Full flow

4

In 16 operators, the tourniquet was externally applied, and only in eight operators, the tourniquet was internally applied.

The differences in proportion are not statistically significant (chi-square, 2.67; df, 1; p=0.102471).

6

2

Total 24 12

12

USG: Ultrasonography.

in three people, trace ultrasound flow was observed. Only six operators revealed full ultrasound flow (Table 2). The differences in proportion are statistically significant (chi-square, 9.75; df, 1; p=0.007).

There were more operators providing buddy aid (four people) than the operators employing self-aid (two people) whose ultrasound showed full blood flow. There were more buddy aid operators with negative ultrasound flow and trace ultrasound flow than self-aid operators (by one person) (Table 1). Comparison of ultrasound flow relative to the type of assistance provided showed no statistically significant difference between self-aid and buddy aid in ultrasound flows (chi-square, 1.09; df, 2; p=0.58).

Negative Doppler flow [distal observed pulse (DOP)] was observed in 18 operators, and positive DOP was observed only in six operators. The differences in proportion are statistically significant (chi-square, 6; df, 1; p=0.01).

Tourniquets were internally applied by more operators using buddy aid (six people) than those using self-aid (two people).

However, tourniquets were externally applied by more operators using self-aid” (10 people) than those using buddy aid (six people). Comparison of tourniquet placement when the type of assistance provided was taken into account, showed no statistically significant difference between self-aid and buddy aid (Fisher’s exact test; p=0.19303).

Preparation of Tourniquets In 18 operators, tourniquets were incorrectly prepared (negative) (Fig. 4). There was determined a statistical relationship between the correctly and incorrectly prepared tourniquets (chi-square, 6; df, 1; p=0.014306).

Tourniquets were correctly prepared (positive) by more operators using buddy aid (four persons) than those using self11 10 9 8 7 Number

The number of self-aid and buddy aid operators in whom DOP was negative (nine persons) and positive (three persons) was the same (Table 3). There was no statistical significance in case of DOP comparison and the type of assistance provided: participant implementing self-aid or buddy aid (Fisher’s exact test; p=1.0).

For all operators, the distance of the tourniquet from the armpit had a normal distribution (W=0.97245; p=0.72753).

Most operators (10 persons) presented with the distance of the tourniquet from the armpit ranging from 7.5 to 10 cm.

12

5 4 3

Distance of the Tourniquet From the Armpit

2 1 0

0.0

2.5

5.0

7.5

10.0

12.5

15.0

17.5

Distance from the armpit (cm)

Figure 3. Histogram of tourniquet distance from the armpit for all operators.

15 Number

For all operators, the average distance of the tourniquet from the armpit was 9.7±3.6 cm (self-aid operators, 10.3±3.6 cm; buddy aid operators, 9.2±3.7 cm). The minimum distance of the tourniquet from the armpit was 2 cm and maximum was 17 cm. The median value indicates that in approximately half of the operators’ distance of the tourniquet from the armpit was <9.5 cm and that in others it was >9.5 cm. The lower quartile indicates that 25% operators showed that the distance of the tourniquet from the armpit was <7.5 cm, and the upper quartile indicated that in 25% of the operators, the distance was >12 cm (Fig. 3).

6

Preparation of tourniquet

10

Self aid Body aid

5 0

Negative

Positive

Figure 4. Preparation of the tourniquet and the type of assistance provided.

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Sanak et al. Evaluation of tourniquet application in a simulated tactical environment

-aid (two persons). Tourniquets were incorrectly prepared (negative) by more operators using self-aid (10 persons) than those using buddy aid (eight persons). Comparison of tourniquet preparation in the terms of assistance provided showed no statistically significant difference between self-aid and buddy aid (Fisherâ&#x20AC;&#x2122;s exact test; p=0.64041).

Forces Most operators were from Ministry of Internal Affairs (MIA; 19 people). Two operators were from Ministry of Justice (MJ), two from the Shooter Group, and one from Ministry of National Defence (MND; Table 4). The differences in proportion are statistically significant (chi-square, 37.67; df, 3; p=0.00).

Table 3. DOP and type of assistance provided DOP

All

Self-aid

Negative 18

Buddy aid

9

9

Position 6 3

3

Total 24 12

12

DOP: Distal observed pulse.

Table 4. Representatives of given forces Forces

All

Self-aid

Buddy aid

Ministry of Internal Affairs

19

9

10

More MIA operators used buddy aid (10 persons) than those using self-aid (nine people). No MND operator used buddy aid. The same number (1 each) of MJ and Shooter Group operators used self-aid and buddy aid. Comparison of forces in the terms of the type of assistance provided showed no statistically significant difference between self-aid and buddy aid (chi-square, 1.43; df, 3; p=0.69).

Shooter

2 1

1

Total

24 12

12

Tourniquet Type

Table 5. Two-way table

Most operators (19 participants) chose CAT, whereas three other operators used SOFTT-W. One operator used CAT and then approximately 3 cm above that type of a tourniquet applied onother one, SOFTT-W. One operator used an improvised tourniquet. The differences in types of used tourniquets are statistically significant (chi-square, 38; df, 3; p=0.00).

USG

Ministry of Justice

2

1

1

Ministry of National Defence

1

1

0

Distal observed pulse

Line in total

Negative Position

Negative 14

1

15

Trace 3 0 3 Full flow

1

5

6

Total 18 6 24

More operators used CAT for self-aid (10 people) than those who used CAT for buddy aid (nine people). In addition, more operators used SOFTT-W for self-aid (two persons) than those who used SOFTT-W for buddy aid (one person). None of the operators providing self-aid decided to place an improvised tourniquet or firstly used CAT tourniquet and then SOFTT-W tourniquet. Comparison of the type of tourniquet to that of assistance provided showed no statistically significant difference between self-aid and buddy aid (chi-square, 3.17; df, 3; p=0.36687).

Dependence Between USG and DOP Flow There was a statistically significant association between USG and DOP flows (chi-square, 14.24; df, 2; p=0.00081).

Most operators with negative ultrasound flow had negative DOP. Most operators with full ultrasound flow had positive DOP (Table 5).

DISCUSSION This study clearly proved that tourniquet application was a demanding procedure, requiring constant training. Tourniquet application is an important ability to possess as activUlus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

USG: Ultrasonography.

ities conducted on the battlefield, owing to their nature, are associated with life-threatening injuries such as hemorrhages. To improve the techniques of providing assistance and to minimize situations that may pose a direct threat to life, military and medical personnel constantly analyzes previously recorded accidents and incidents in the field of combat medicine. Corresponding analysis was performed in the study conducted by members of the medical corps of Israel Defense Forces during years 2002â&#x20AC;&#x201C;2009. There were more than 4.5 thousand soldiers, of which approximately 850 were fatal.

Soldiers living in a war zone are exposed to several types of injuries, majority of which are accompanied by major bleeding.[6] Many publications have emphasized that hemorrhage remains the leading cause of death on the battlefield.[7,8] The Committee of Tactical Combat Care of the Injured indicated hemorrhages to be a cause of approximately 60% of so-called avoidable deaths. Therefore, it is important to train medical and military personnel in the field of rapid response and the provision of necessary assistance to victims exposed to blood loss.[6,8] In addition, our study proves the difficulty of 13

Sanak et al. Evaluation of tourniquet application in a simulated tactical environment

tourniquet application even by experienced combat participants. Although the military is constantly developing new uniforms for their soldiers to ensure the greatest possible body protection, protection cannot be provided for hands or feet without depleting effectiveness and mobility, leaving those areas highly vulnerable to any damage.[7,9] This a reason for the need of an extensive and regular training to perfect the ability of tourniquet application among soldiers because each of them is equipped with a tactical stasis in case of this type of injury. Moreover, the effectiveness and circumstances of the use of tourniquets often depends on the application efficiency.[7,8,10,11] Walters et al.[12] confirmed the equal effectiveness of CAT, Emergency & Military Tourniquet, and SOFTT by using Doppler auscultation at the popliteal artery. However, except for the equipment effectiveness, a rescuer skills are a valid factor. Therefore, repeated training regarding its usage is important. That is the reason behind the need of designing training concerning tourniquets application. In our study, tactical stasis bands were used by most security services in the world. Thus, the tourniquets are often the subject of testing and analysis. The conducted experiments with various types of tourniquets demonstrated the advantages of CAT over other tourniquets, with the main advantages highlighted by the users being its high efficiency and the application speed.

[4,13] To determine the factors that influence the effectiveness of stasis, both CAT and other tourniquets, were evaluated in terms of pulse disappearance and diminished blood flow using Doppler ultrasound function,[2,8,14] similar to our study.

For these tests, researchers from Ankara involved 145 people who applied the band under ultrasound control. CAT proved to be the most efficient among all hemorrhage controlling techniques.[4] Walters et al. tested the effectiveness of seventh self-applied types of bands. They summarized that three of seven examined tourniquets completely inhibited the blood flow, and other generally available bands should not be used, even if there is a chance that it may cause more damages. Among the winning stasis were the ones used in our study; CAT and SOFTT.[15] Appropriate location plays an essential role. Uniforms equipped with special pockets for quick and uncomplicated access to the stasis significantly reduces the time required for self-use.[16,17] The tourniquet was used only after other methods of bleeding control failed. It presented tourniquet application when providing assistance to a soldier in the danger zone even when under fire.[11,13] The use of a personal first aid kit also increases the effectiveness of established tourniquets.[18] There is no doubt that despite disadvantages of tourniquet use, tourniquets greatly increase the chances of survival of victims.[10,17,18,19] The use of tourniquets is not exclusively reserved for military institutions. Because of the easy and quick access to specialist care, in case of massive hemorrhage in case of civil casualties, assistance is provided in stages, the last of which is the tourniquet application.[20,21] During the bombing attack in Boston, two explosives filled with bearing balls were detonated, killing three people and injuring 264. Eservices 14

decided to apply tourniquets for 27 victims in a form of improvised bands.[20,22,23]

Conclusions • There is no noticeable difference in the effectiveness of self-applied tourniquets and that of tourniquets applied with the help of another person; therefore, people knowing the application technique are able to correctly use tourniquets in both situations.

• Doppler outcomes revealed incorrect results in terms of technically appropriately fitted tourniquets. Therefore, there is a need for involving that tourniquet application technique in future training.

• There is a need to ensure regular training in case of tourniquet use to maintain the correct application procedure, particularly for units that have tourniquets at their disposal.

Conflict of interest: None declared.

REFERENCES 1. Savage E, Forestier C, Withers N, Tien H, Pannell D. Tactical combat casualty care in the Canadian Forces: lessons learned from the Afghan war. Can J Surg 2011;54:S118–23.

2. Walters TJ, Mabry RL. Issues related to the use of tourniquets on the battlefield. Mil Med 2005;170:770–5.

3. Wall PL, Sahr SM, Buising CM. Different width and tightening system: Emergency tourniquets on distal limb segments. J Spec Oper Med 2015;15:28–38.

4. Lyles WE 3rd, Kragh JF Jr, Aden JK 3rd, Dubick MA. Testing tourniquet use in a Manikin Model: Two improvised techniques. J Spec Oper Med 2015;15:21–6.

5. Davinson JP, Kragh JF Jr, Aden JK 3rd, DeLorenzo RA, Dubick MA. Laboratory testing of emergency tourniquets exposed to prolonged heat.

J Spec Oper Med 2015;15:34–8.

6. Katzenell U, Ash N, Tapia AL, Campino GA, Glassberg E. Analysis of the causes of death of casualties in field military setting. Mil Med 2012;177:1065–8.

7. Taylor DM, Vater GM, Parker PJ. An evaluation of two tourniquet systems for the control of prehospital lower limb hemorrhage. J Trauma 2011;71:591–5.

8. Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma.

J Trauma 2008;64:S38–49.

9. Taylor DM, Coleman M, Parker PJ. The evaluation of an abdominal aortic tourniquet for the control of pelvic and lower limb hemorrhage. Mil Med 2013;178:1196–201.

10. Doyle GS, Taillac PP. Tourniquets: a review of current use with proposals for expanded prehospital use. Prehosp Emerg Care 2008;12:241–56.

11. Lee C, Porter KM, Hodgetts TJ. Tourniquet use in the civilian prehospital setting. Emerg Med J 2007;24:584–7.

12. Walters TJ, Wenke JC, Kauvar DS, McManus JG, Holcomb JB, Baer DG. Effectiveness of self-applied tourniquets in human volunteers. Prehosp Emerg Care 2005;9:416–22.

13. Schreckengaust R, Littlejohn L, Zarow GJ. Effects of training and simulated combat stress on leg tourniquet application accuracy, time, and effectiveness. Mil Med 2014;179:114–20.

14. Ünlü A, Petrone P, Guvenc I, Kaymak S, Arslan G, Kaya E, et al. Combat application tourniquet (CAT) eradicates popliteal pulses effectively by correcting the windlass turn degrees: a trial on 145 participants. Eur J

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Sanak et al. Evaluation of tourniquet application in a simulated tactical environment Trauma Emerg Surg 2015 Oct 26. [Epub ahead of print].

15. Walters TJ, Wenke JC, Kauvar DS, McManus JG, Holcomb JB, Baer DG. Effectiveness of self-applied tourniquets in human volunteers. Prehosp Emerg Care 2005;9:416–22.

16. Higgs AR, Maughon MJ, Ruland RT, Reade MC. Effect of uniform design on the speed of combat tourniquet application: A simulation study.

Mil Med 2016;181:753–5.

17. Kragh JF Jr, Littrel ML, Jones JA, Walters TJ, Baer DG, Wade CE, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. J Emerg Med 2011;41:590–7.

18. Weppner J, Lang M, Sunday R, Debiasse N. Efficacy of tourniquets exposed to the afghanistan combat environment stored in individual first aid kits versus on the exterior of plate carriers. Mil Med 2013;178:334– 7.

19. Guo JY, Liu Y, Ma YL, Pi HY, Wang JR. Evaluation of emergency tourniquets for prehospital use in China. Chin J Traumatol 2011;14:151–5.

20. Kue RC, Temin ES, Weiner SG, Gates J, Coleman MH, Fisher J, et al.

Tourniquet Use in a Civilian Emergency Medical Services Setting: A Descriptive Analysis of the Boston EMS Experience. Prehosp Emerg Care 2015;19:399–404.

21. Inaba K, Siboni S, Resnick S, Zhu J, Wong MD, Haltmeier T, et al.

Tourniquet use for civilian extremity trauma. J Trauma Acute Care Surg 2015;79:232–7.

22. King DR, Larentzakis A, Ramly EP; Boston Trauma Collaborative.

Tourniquet use at the Boston Marathon bombing: Lost in translation. J Trauma Acute Care Surg 2015;78:594–9.

23. Niven M, Castle N. Use of tourniquets in combat and civilian trauma situations. Emerg Nurse 2010;18:32–6.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Bir simülasyon taktik ortamında turnike uygulamasının değerlendirilmesi Tomasz Sanak,1 Robert Brzozowski,2 Marek Dabrowski,3 Magdalena Kozak,2 Agata Dabrowska,3 Maciej Sip,3 Katarzyna Naylor,4 Kamil Torres4 Jagiellonian Üniversitesi Tıp Koleji Anesteziyoloji ve Yoğun Bakım Tedavisi Fakültesi, Afet ve Acil Tıp Enstitüsü, Krakov-Polonya Sahra Tıbbı Anabilim Dalı, Askeri Tıp Enstitüsü, Varşova-Polonya Afet ve Acil Tıp Anabilim Dalı, Poznan Tıp Bilimleri Üniversitesi, Poznan-Polonya 4 Lublin Tıp Üniversitesi, Eğitbilim ve Medikal Simülasyon Anabilim Dalı, İnsan Anatomisi Kürsüsü, Krakov-Polonya 1 2 3

AMAÇ: Taktiksel ortamda turnike uygulaması iki şekilde yürütülmüştür: “kendi kendine yardım” denilen yaralının kendisine turnike uygulaması ve “arkadaş yardımı” denilen bir yardımcının turnike uygulaması. Bu çalışmanın amacı bir yakın harp simülasyon ortamında turnike kullanımının kalitesini test etmekti.

GEREÇ VE YÖNTEM: Çalışmaya 24 “yaralı” ve tüm simülasyon çalışmasında 72 uygulayıcı, altışarlı 12 bölüm şeklinde katıldı. Turnike uygulamalarını valide etmek için Yaralıların Taktiksel Savaş Ortamında Tedavisi Komitesi’nin önerilerinden yararlanılmış turnike uygulamasının hemodinamik etkisini değerlendirmek için Doppler ultrason kullanıldı.

BULGULAR: Sonuçlar 15 uygulayıcıda kan akımı durdurulmuş, üç hastada çok az kan akım ve altı kişide kısıtlamasız kan akımı olduğunu göstermiştir.

Kişilerin kendine veya başka biri tarafından uygulanan turnike prosedürlerinin kaliteleri arasında herhangi bir anlamlı farklılık yoktu. Turnike ile koltuk altı arasındaki ortalama mesafe kendi kendine veya başkasının uyguladığı turnikelerde 9.5 cm idi. On altı olguda turnikenin kol dışından bağlandığı, yalnızca sekiz olguda doğru biçimde kol içinden bağlandığı gözlenmiştir. On sekiz olguda taktiksel ortamda turnike doğru yerleştirilmemiş, yalnızca altı olguda doğru yerleştirilmiştir. Ultrasonda negatif akım görülen uygulayıcıların çoğunda DOP de negatifti. Ultrasonda tam kesintisiz akımın görüldüğü uygulayıcıların çoğunda pozitif DOP saptanmıştır.

TARTIŞMA: Turnikelerin uygulanması uzmanlaşmış birimlerde bile zorluk yarattığından bu işlemin uygulanmasına yönelik düzenli eğitim verilmesi gerekir.

Anahtar sözcükler: Ateş altında tıbbi bakım; kanama; taktiksel alan tedavisi; turnike.

Ulus Travma Acil Cerrahi Derg 2018;24(1):9–15

doi: 10.5505/tjtes.2017.84899

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15

EXPERIMENTAL STUDY

Which common test should be used to assess spleen autotransplant effect?

Ehsan Soltani, M.D.,1 Mohsen Aliakbarian, M.D.,2 Kamran Ghaffarzadegan, M.D.3 1

Department of General Surgery, Acute Care Surgery Research Center, Taleghani University Hospital,

Mashhad University of Medical Sciences, Mashhad-Iran 2

Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad-Iran

3

Department of Pathology, Research and Education Department, Razavi Hospital, Mashhad-Iran

ABSTRACT BACKGROUND: Historically, total splenectomy was the only choice of treatment for traumatic splenic injuries. However, nonoperative management and spleen-preserving surgical techniques are preferred in modern medicine. In some situations in which the surgeon has to perform splenectomy, spleen autotransplant may preserve the splenic function. Selecting the best method for evaluating the splenic autotransplant effect has been debated for several years. In this study, we compared three common tests in evaluating the implanted spleen function.

METHODS: Participants included 10 patients who were candidates for laparotomy and splenectomy. After performing splenectomy, we implanted five pieces of the spleen in the greater omentum of each patient. After 3 months, the implanted spleen function was evaluated by nuclear red blood cell (RBC) scan, serum immunoglobulin (Ig) M level, and presence of Howell–Jolly (HJ) bodies in the peripheral blood smear.

RESULTS: All patients had normal peripheral blood smear. The IgM level was lower than normal in one patient, and scintigraphy did not demonstrate the transplanted spleen in another patient.

CONCLUSION: All these tests may have comparable results, but because of availability and low cost of peripheral blood smear, which is also easily performed, it can be considered as the first option to evaluate the implanted spleen function.

Keywords: IgM level; nuclear red blood cell scan; spleen autotransplant; spleen function; splenectomy.

INTRODUCTION Spleen is a lymphoid organ and plays an important role in the immune system, especially in filtration processes, phagocytosis, and immunoglobulin production.[1,2] Historically, total splenectomy was the only treatment option for splenic injuries. For a long time, the general belief was that living without the spleen does not cause any significant consequences.[1,3–5] An increased knowledge of the importance of the immunological functions of the spleen and recognition of

overwhelming postsplenectomy infection resulted in the development of spleen-preserving procedures such as splenorrhaphy and partial splenectomy. However, in cases of shattered spleens and complete hilum avulsion, the only choice is total splenectomy in which reimplanting spleen in the omentum is the suggested procedure.[1,3,6,7] In order to prevent hematological and immunological disorders, 10% and 25% of the splenic tissue should be preserved, respectively.[2,8] Smaller fragments are insufficient to prevent encapsulated bacterial infections.[9,10]

Cite this article as: Soltani E, Aliakbarian M, Ghaffarzadegan K. Which common test should be used to assess spleen autotransplant effect? Ulus Travma Acil Cerrahi Derg 2018;24:16-9 Address for correspondence: Mohsen Aliakbarian, M.D. Surgical Oncology Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

Tel: +989155111367 E-mail: aliakbarianm@mums.ac.ir Ulus Travma Acil Cerrahi Derg 2018;24(1):16–19 DOI: 10.5505/tjtes.2017.05683 Submitted: 28.12.2015 Accepted: 06.04.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

16

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Soltani et al. Which common test should be used to assess spleen autotransplant effect?

While splenectomy is inevitable in some trauma cases, spleen autotransplantation is well-accepted as one of the standard procedures, especially in young patients to preserve their splenic function.[11,12] The evaluation of active and functional autotransplanted spleen slices is usually based on the nuclear red blood cell (RBC) scan, serum immunoglobulin (Ig) M level, and capability of these fragments in the blood filtration of Howell–Jolly (HJ) bodies.[13–16] The aim of this study was to evaluate the falsenegative and false-positive rates of these tests after spleen autotransplantation.

MATERIALS AND METHODS This prospective study was conducted from September 2011 to June 2014. The study was approved by the ethics committee of Mashhad University of Medical Sciences. Participants included 10 patients (8 males and 2 females) with traumatic splenic rupture in whom total splenectomy was performed.

Patients with other concomitant abdominal injuries and those who were not accessible for follow-up were excluded from the study. After completion of the splenectomy, the spleen was cut into five fragments (3×40×40 mm), which were implanted into the omentum. No drain was used.

All patients were operated by the same surgeon. Vaccinations against pneumococcus, meningococcus, Haemophilus influenza, and influenza viruses were administered. Moreover, the patients were informed about the risks and symptoms of overwhelming postsplenectomy infection. Ten days postoperatively, the patients were visited by the surgeons and were recommended to restrict their sports activities for 4 weeks. Three months later, the success rate of the autotransplantation was evaluated by measuring the serum IgM level, examining the peripheral blood smears (PBS) for detection of HJ bodies, and using scintigraphy (nuclear RBC scan). All examinations were performed in a standardized manner in the same teaching hospital.

Table 1. Results of different types of examination in

evaluating the implanted spleen function Patient

Age Gender

PBS

Ig M level Nuclear scan

1

17 Male Normal Normal Positive

2

19 Male Normal Normal Positive

3

22 Male Normal Abnormal Positive

4

17 Male Normal Normal Positive

5

25 Female Normal Normal

Negative

6

19 Male Normal Normal Positive

7

30 Male Normal Normal Positive

8

16 Female Normal Normal

9

21 Male Normal Normal Positive

Positive

10

21 Male Normal Normal Positive

PBS: Peripheral blood smear; IgM: Immunoglobulin M.

PBS and the implanted spleen was functional. At this time, only in one patient, the IgM level decreased. This patient was a 22-year-old male whose PBS and nuclear RBC scan findings were normal. The nuclear RBC scan did not show detectable absorption in the implantation area in a 25-year-old woman with normal PBS and IgM level (Fig. 1). Table 1 demonstrates the results of different types of examination used in the evaluation of the implanted spleen function.

DISCUSSION Today, because of improvements in roads’ and vehicle’s safety

RESULTS The mean age of the patients was 20.7 (16–30) years. Abdominal blunt trauma was the main reason for splenic rupture in the participants. The causes of trauma were road traffic accidents in 80%, civil strife in 10%, and falls in 10%. The mean hospital stay was 4 (3–5) days. No significant complications including deep or portal vein thrombosis, severe thrombocytosis, hematoma, intra-abdominal bleeding, and surgical site infection were observed. Chronic vague mid-abdominal pain was the chief complaint in six patients, which was resolved in all patients during the follow-up period.

Results of the examinations performed 3 months postoperatively indicated normal peripheral blood smear in all patients, which means that the HJ bodies were not detected in their Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Figure 1. Nuclear RBC scan in a 25-year-old woman with normal PBS and IgM level.

17

Soltani et al. Which common test should be used to assess spleen autotransplant effect?

and more restrictive traffic rules, the number of emergent laparotomies for trauma has decreased. In addition, our knowledge about the importance of spleen’s immune function has led to the development of new management methods such as non-operative therapy and spleen-preserving surgeries such as splenic artery embolization, splenic artery binding, splenorrhaphy, and partial splenectomy.[6,17–19] Moreover, when total splenectomy is mandatory or inevitable, splenic autotransplantation is recommended.[20,21] Preserving the spleen can prevent reduction in antibodies, which without transplantation decreases up to less than one-tenth of those in healthy individuals.[22] In addition, the chemotaxis ability of not only antibodies but also macrophages and neutrophils reduces in patients without spleen,[1,23] which can be prevented by new treatment methods. Recent studies have revealed the role of the spleen in preventing atherosclerosis by lipid metabolism, which highlights the importance of spleen preservation.[24] Since 1986 when spleen autotransplantation was performed in animals, several reports of human spleen autotransplantation have been presented.[1,25–27] Although the effectiveness of spleen autotransplantation on different parts of the body, such as the omentum, peritoneal cavity, retroperitoneum, intraportal, abdominal muscle, armpits, and liver, has been proven, the greater omentum has been favored as the appropriate location for autotransplantation.[1,2,6,21,25,28] There are some advantages and disadvantages of selecting the omentum. The advantages include suitable compliance, free space for implanted spleen slices to grow, and efficient revascularization. The disadvantages attributed to the selection of this location are intrabdominal implant migration, increasing the rate of intrabdominal adhesions, and abscesses formation.

[1,2,4,8,21]

The next step after spleen autotransplantation is evaluating the effectiveness and success of the operation. Because blood filtration is an important function of the spleen, determining the presence of HJ bodies is recognized as a method for evaluating the viability of the implanted spleen. The spleen acts as a voluminous filter removing senescent and altered erythrocytes and particles such as HJ, Heinz, and Pappenheimer bodies.[3,30,31] Although the presence of HJ bodies in PBS is not pathognomonic, it is considered as suggestive of splenic dysfunction or aspleny.[3,32] It is known that although in patients with slight hypospleny, HJ bodies may not be present, their presence denotes a degree of splenic dysfunction and represents the risk of fulminant infection onset.[3] In this study, all patients had normal PBS, which showed that the filtration function of the spleen slices was acceptable.

Because of the main role of Ig production in the spleen, we expect that by enough regeneration of the spleen slices, the plasma or serum IgM level will elevate to normal levels. This has been suggested in previous studies, and normal IgM levels suggest normal function of the regenerated implants.[32,33] In our study, only in one patient, enough IgM level was not 18

observed. The patient’s other tests were normal, which suggested that the implants were alive and functional.

Furthermore, as the normal spleen tissue can absorb nuclear RBCs by 99mTc-denatured red blood cells, scintigraphy has been one of the popular tests for evaluating implants.[29,33,34] In our study, only one patient had negative nuclear RBC scan, although results of other tests were satisfactory or normal.

Our findings demonstrate that all these three tests could be acceptable for evaluating alive and functional autotransplanted spleen slices, and each one can be substituted if the others are not available.

According to our findings, positive and negative predictive values of these three tests are comparable. However, considering cost–benefit and availability, PBS may be the best option. However, when the test results are ambiguous or not predicted, we should re-examine the results through an alternative method.

Despite the limitations of our study, including small sample size, we recommend using PBS as the first option in paraclinical evaluation of alive and functional implanted spleen due to its availability and low cost, which can be easily performed.

Finally, to achieve a comprehensive conclusion, we suggest a larger multicentric study to be planned appropriately.

Acknowledgments The authors would especially like to acknowledge the statistical consultation provided by Dr. M. Afzal Aghaei. Sincere gratitude is extended to Ms. A. Yaseri and Ms. M. Hassanpour for editing the manuscript.

Conflict of interest: None declared.

REFERENCES 1. Karahan O, Eryilmaz MA, Okus A, Ay S, Unlu Y, Cayci M, et al. Evaluating the effectiveness of spleen autotransplantation into the liver and the omentum. Bratisl Lek Listy 2013;114:610–5.

2. Braga AA, Malagó R, Anacleto TP, Silva CR, Andreollo NA, Fernandes FL. Histological aspects of autologous transplantation of different fragments of the spleen in rats. Acta Cir Bras 2012;27:880–4.

3. Marques RG, Lucena SB, Caetano CE, de Sousa VO, Portela MC, Petroianu A. Blood clearance of Howell-Jolly bodies in an experimental autogenic splenic implant model. Br J Surg 2014;101:820–7.

4. Taviloglu K, Günay K, Ertekin C, Calis A, Türel O. Abdominal stab wounds: the role of selective management. Eur J Surg 1998;164:17–21.

5. Cadili A, de Gara C. Complications of splenectomy. Am J Med 2008;121:371–5.

6. User Y, Aydin NK, Cemşit F. Morfologic evoluation of experimental systemic splenic cell autotransplantation. Turk J Trauma Emerg Surg 1997;3:96–100.

7. Malagó R, Reis NS, Araújo MR, Andreollo NA. Late histological aspects of spleen autologous transplantation in rats. Acta Cir Bras 2008;23:274– 81.

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Soltani et al. Which common test should be used to assess spleen autotransplant effect?

8. Menteş C, Erdemir A, Tuncay E, Gezen CF, Onuray F, Vural S. Our approach to splenic traumas according to years. Kartal Train Res Hosp J Med 2004;15:1–4.

9. Petroianu A, Petroianu LP. Splenic autotransplantation for treatment of portal hypertension. Can J Surg 2005;48:382–6.

10. Petroianu A, Cabezas-Andrade MA, Berindoague Neto R. Laparoscopic subtotal splenectomy. Surg Laparosc Endosc Percutan Tech 2008;18:94– 7.

11. Mattox KL, Moore EE, Feliciano DV, editors. Trauma. 7th ed. McGrawHill Professional; New York: p. 576.

12. Cothren C, Biffl WL, Moore EE. Trauma. In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE, editors. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Professional: New York; p. 206.

13. Piccardo A, Santoro E, Masini R, Bartolomeo S, Pramaggiore P, Boschi M. A splenic autograft in posttraumatic splenectomies. Minerva Chir 1999;54:31–5.

14. Resende V, Petroianu A. Functions of the splenic remnant after subtotal splenectomy for treatment of severe splenic injuries. Am J Surg 2003;185:311–5.

15. Knezević S, Stefanović D, Petrović M, Djordjević Z, Matić S, Artiko V, et al. Autotransplantation of the spleen. Acta Chir Iugosl 2002;49:101–6.

16. Revuelta Alvarez S, Fernandez-Escalante C, Casanova Rituerto D, Lopez Espadas F, Martin Fernandez J. Assessment of post-splenectomy residual splenic function. Splenic autotransplants. Int Surg 1987;72:149–53.

17. Grandić L, Pogorelić Z, Banović J, Perko Z, Boschi V, Ilić N, et al. Advantages of the spared surgical treatment of the spleen injuries in the clinical conditions. Hepatogastroenterology 2008;55:2256–8.

18. Jovanović M, Jovanović J. The role of splenic implants in spleen injuries and postoperative immunity. Med Pregl 2004;57:265–8.

19. Resende V, Petroianu A, Junior WC. Autotransplantation for treatment of severe splenic lesions. Emerg Radiol 2002;9:208–12.

20. Karagülle E, Hoşcoşkun Z, Kutlu AK, Kaya M, Baydar S. The effectiveness of splenic autotransplantation: an experimental study. Ulus Travma Acil Cerrahi Derg 2007;13:13–9.

21. Teixeira FM, Fernandes BF, Rezende AB, Machado RR, Alves CC,

Perobelli SM, et al. Staphylococcus aureus infection after splenectomy and splenic autotransplantation in BALB/c mice. Clin Exp Immunol 2008;154:255–63.

22. Amlot PL, Hayes AE. Impaired human antibody response to the thymus-independent antigen, DNP-Ficoll, after splenectomy. Implications for post-splenectomy infections. Lancet 1985;1:1008–11.

23. Davidson RN, Wall RA. Prevention and management of infections in patients without a spleen. Clin Microbiol Infect 2001;7:657–60.

24. Fatouros M, Bourantas K, Bairaktari E, Elisaf M, Tsolas O, Cassioumis D. Role of the spleen in lipid metabolism. Br J Surg 1995;82:1675–7.

25. Miko I, Brath E, Nemeth N, Furka A, Sipka S Jr, Peto K, et al. Spleen autotransplantation. Morphological and functional follow-up after spleen autotransplantation in mice: a research summary. Microsurgery 2007;27:312–6.

26. Jovanović M, Stojanović M, Stanojević G, Stojiljković M, Jovanović J, Kostov M, et al. Experimental and clinical possibilities of transplantation of the injured and totally devascularized spleen. Acta Chir Iugosl 2002;49:85–91.

27. O’Connor GS, Geelhoed GW. Splenic trauma and salvage. Am Surg 1986;52:456–62.

28. Knezević S, Stefanović D, Petrović M, Djordjević Z, Matić S, Artiko V, et al. Autotransplantation of the spleen. Acta Chir Iugosl 2002;49:101–6.

29. Kraft O, Zobac S. Scintigraphic determination of the function of an autotransplanted spleen. Rozhl Chir 1990;69:600–4.

30. Brendolan A, Rosado MM, Carsetti R, Selleri L, Dear TN. Development and function of the mammalian spleen. Bioessays 2007;29:166–77.

31. Solis M, Perrin J, Guédenet JC, Lesesve JF. RBCs inclusions after splenectomy: not only Howell-Jolly bodies. Ann Biol Clin (Paris) 2013;71:185–9.

32. Sears DA, Udden MM. Howell-Jolly bodies: a brief historical review. Am J Med Sci 2012;343:407–9.

33. Mizrahi S, Barzilai A. Functional value of omental autotransplanted splenic tissue in rabbits. Isr J Med Sci 1988;24:706–9.

34. Daliri M, Shafiei S, Zakavi SR, Dabbagh Kakhki VR, Sadeghi R. Application of 99mTc-denatured red blood cells scintigraphy in the evaluation of post-traumatic spleen auto-transplantation. Rev Esp Med Nucl Imagen Mol 2013;32:209–10.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Dalak ototransplatının etkisini değerlendirme? Hangi sık kullanılan testi seçelim?

Dr. Ehsan Soltani,1 Dr. Mohsen Aliakbarian,2 Dr. Kamran Ghaffarzadegan3 1 2 3

Meşhet Tıp Bilimleri Üniversitesi, Talegani Üniversite Hastanesi, Genel Cerrahi Anabilim Dalı Akut Cerrahi Tedavi Araştırma Merkezi, Meşhet-İran Meşhet Tıp Bilimleri Üniversitesi, Cerrahi Onkoloji Araştırma Merkezi, Meşhet-İran Razavi Hastanesi, Patoloji Anabilim Dalı, Eğitim ve Araştırma Bölümü, Meşhet-İran

AMAÇ: Eskiden total splenektomi travmatik dalak yaralanmalarında tek seçimdi. Ancak modern tıpta cerrahidışı tedavi ve dalağı koruyucu teknikler tercih edilmektedir. Cerrahın splenektomi uygulamaya sevk edildiği bazı durumlarda dalağın ototransplantasyonu dalak fonksiyonunu koruyabilir.

Dalak ototransplantı etkisini en iyi değerlendirme yönteminin seçimi yıllarca tartışma konusu olmuştur. Bu çalışmada implante edilmiş dalağın fonksiyonunu değerlendirmede çokça kullanılan üç testi karşılaştırdık.

GEREÇ VE YÖNTEM: Laparotomi ve splenektomi adayı 10 hasta çalışma katılımcılarını oluşturmuştu. Splenektomi yaptıktan sonra her hastanın omentum majusu içine beş dalak parçası implante ettik. Üç ay sonra implante edilmiş dalağın fonksiyonu nükleer eritrosit sintigrafisi, periferik kanda serum immünoglobülin M (IgM) düzeyif ve Howell-Jolly (HJ) cisimciklerinin varlığıyla değerlendirildi.

BULGULAR: Hastaların hepsinde periferik kandan yapılan yayma testi patolojik değildi. Yalnızca bir olguda IgM düzeyi normalden düşüktü, başka birinde sintigrafi nakledilen böbreği göstermemişti.

TARTIŞMA: Bu testlerin tümünde benzer sonuçlar alınabilir. Ancak bulunabilirliği, düşük maliyeti ve kolayca uygulanabilirliği nedeniyle periferik kandan yayma preparatının implante edilmiş dalak fonksiyonunu değerlendirmede ilk seçenek olduğu düşünülebilir.

Anahtar sözcükler: Dalak fonksiyonu; dalak ototransplantı, IgM düzeyi; nükleer eritrosit taraması; splenektomi.

Ulus Travma Acil Cerrahi Derg 2018;24(1):16–19

doi: 10.5505/tjtes.2017.05683

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

19

ORIG I N A L A R T IC L E

Is nighttime laparoscopic general surgery under general anesthesia safe?

Ahmet Kemalettin Koltka, M.D.,1 Mehmet İlhan, M.D.,2 Achmet Ali, M.D.,1 Ali Fuat Kaan Gök, M.D.,2 Nükhet Sivrikoz, M.D.,1 Teoman Hakan Yanar, M.D.,2 Mustafa Kayıhan Günay, M.D.,2 Cemalettin Ertekin, M.D.2 1

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

2

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

ABSTRACT BACKGROUND: Fatigue and sleep deprivation can affect rational decision-making and motor skills, which can decrease medical performance and quality of patient care. The aim of the present study was to investigate the association between times of the day when laparoscopic general surgery under general anesthesia was performed and their adverse outcomes.

METHODS: All laparoscopic cholecystectomies and appendectomies performed at the emergency surgery department of a tertiary university hospital from 01. 01. 2016 to 12. 31. 2016 were included. Operation times were divided into three groups: 08.01–17.00 (G1: daytime), 17.01–23.00 (G2: early after-hours), and 23.01–08.00 (G3: nighttime). The files of the included patients were evaluated for intraoperative and postoperative surgery and anesthesia-related complications.

RESULTS: We used multiple regression analyses of variance with the occurrence of intraoperative complications as a dependent variable and comorbidities, age, gender, body mass index (BMI), ASA score, and operation time group as independent variables. This revealed that nighttime operation (p<0.001; OR, 6.7; CI, 2.6–16.9) and older age (p=0.004; OR, 1.04; CI, 1.01–1.08) were the risk factor for intraoperative complications. The same analysis was performed for determining a risk factor for postoperative complications, and none of the dependent variables were found to be associated with the occurrence of postoperative complications.

CONCLUSION: Nighttime surgery and older patient age increased the risk of intraoperative complications without serious morbidity or mortality, but no association was observed between the independent variables and the occurrence of postoperative complications.

Keywords: General anesthesia; intraoperative complication; laparoscopic general surgery; operation time; postoperative complication.

INTRODUCTION Night shifts are an inevitable part of residency and may also be unavoidable for consultant doctors in centers with high patient population. To work after normal working hours as an on-call physician leads to fatigue and sleep deprivation, which is valid both for residents and consultants. Fatigue and sleep deprivation may increase the risk of malpractices.[1–3] There are several reports from different surgical fields reporting worse outcomes for surgeries performed during after-hours or nighttime.[4–7] There are also reports from different coun-

tries reporting that the risk of anesthesia-related incidents increase in anesthesia performed after-hours, and fatigue-related errors were reported by 86% of respondents in a nationwide survey.[8,9] In a study using the psychomotor vigilance performance task, Gander et al.[10] found that increasing time at work was generally associated with declining performance and that this performance decline occurred only across the night shift for the fastest 10% of responses; and, they also found that acute sleep loss increased median reaction times.

However, such data are indirectly collected, and the relationship between the time of day and adverse events or patient

Cite this article as: Koltka AK, İlhan M, Ali A, Gök AFK, Sivrikoz N, Yanar TH, et al. Is nighttime laparoscopic general surgery under general anesthesia safe? Ulus Travma Acil Cerrahi Derg 2018;24:20-4 Address for correspondence: Ahmet Kemalettin Koltka, M.D. İstanbul Üniversitesi İstanbul Tıp Fakültesi, Anesteziyoloji Anabilim Dalı, Çapa Klinikleri, 34093 Fatih, İstanbul, Turkey.

Tel: +90 212 - 414 20 00 E-mail: koltkak@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(1):20–24 DOI: 10.5505/tjtes.2017.95079 Submitted: 04.08.2017 Accepted: 04.10.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Koltka et al. Is nighttime laparoscopic general surgery under general anesthesia safe?

outcomes has hardly been evaluated because in modern anesthesia practice, adverse outcomes are relatively low.[11] As an exception, Aya et al.[12] identified a greater risk of unintended dural puncture when epidural placement was performed at nighttime than when it was performed at daytime.

Laparoscopic cholecystectomies are one of the most commonly performed surgeries in our hospital, and if the diagnosis is acute cholecystitis, it is performed as an emergent/ urgent surgery because some patients can benefit from operations performed within 24 h.[13–15] Acute appendicitis is one of the most common clinical presentations that require emergent surgery, with a lifetime incidence of approximately 8%.[16] Laparoscopic appendectomy is a safe surgical procedure, and due to the fear of perforation, urgent/emergent surgery is accepted as a standard treatment option.[17,18] The aim of the present study was to investigate the association between different time periods of the day (daytime, early after-hours, and nighttime) at which urgent surgery was performed and morbidity or mortality during the intraoperative and postoperative periods. We hypothesized that urgent nighttime surgery is associated with higher intraoperative and postoperative morbidity and also causes longer hospital stays and more unplanned critical care admissions.

MATERIALS AND METHODS This retrospective study was performed at the emergency surgery department of a tertiary university hospital. After getting approval from local research ethics board (file no 2017/640), the emergency surgery departmental records and anesthesia medical records of the patients were evaluated retrospectively. The age, gender, body mass index (BMI), comorbidities (hypertension, diabetes, ischemic heart disease, chronic obstructive pulmonary disease, obstructive sleep apnea, and chronic renal failure), American Society of Anesthesiology (ASA) score, and operation times [Group I (daytime), Group II (early after-hours), and Group III (nighttime)] were evaluated. Within the anesthesia archives, intra- and postoperative complications, such as hypotension, arrhythmias, desaturation, CO2 retention, and unplanned admission to intensive care unit, were found and recorded. Surgical reports expressing any intraoperative surgical complication (conversion to open surgery, bleeding, damage to vital organs, etc.) were noted. The length of hospital stay, discharge delays, postoperative complications (such as wound infection, need of gallstone extraction with ERCP, reoperation, bleeding, etc.), and readmissions to the hospital for late-term complications were evaluated and recorded. Patients with missing data were excluded from the study.

Distribution of each quantitative dataset was assessed for kurtosis and skewness, with −1.5 to +1.5 accepted as the normal distribution. Normally distributed quantitative data are presented as a mean±standard deviation. Two normally Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

distributed quantitative data were compared using unpaired t-tests. Qualitative data are presented as frequencies and percentages. All qualitative data were compared using chisquare test. In addition, multiple regression analyses were used to determine risk factors. All statistical analyses were performed using IBM SPSS for Windows, Version 20.0 (IBM Corp., Armonk, NY, USA), and p<0.05 was considered to indicate statistically significant difference.

RESULTS Data of 525 patients were screened. Three patients with missing data were excluded; thus, a total 522 patients were included in the study, 281 (53%) of whom were men and 241 (47%) were women. The average age and BMI of patients were 42.4±17.2 years and 28.7±6.2 kg/m2, respectively. Comorbidities and type of operation were listed in Table 1. In total, 401 (77%) patients were operated by a resident surgeon, and 121 (23%) were operated by a consultant surgeon. The anesthesia procedure was performed by two resident anesthesiologists in 226 (43%) surgeries and by a consultant anesthesiologist with a resident anesthesiologist in 296 (57%) surgeries. Intraoperative and postoperative complications had occurred in 161 (30.8%) and 48 (9.2%) surgeries, respectively.

Analysis of patients according to operation times revealed that 282 patients were in Group I (daytime), 78 were in Group II (early after-hours), and 162 were in Group III (nighttime).

Intraoperative complications occurred more often in Group III, and consultant doctors of both surgery and anesthesia took part in Group I (Table 2). We used multiple regression analyses of variance with the occurrence of intraoperative complications as a dependent variable and comorbidities, Table 1. Patients’ comorbidities and type of surgery Variables

n %

Diabetes mellitus

42

8

Ischemic heart disease

45

8.6

Chronic obstructive pulmonary disease

45

8.6

Hypertension

121 24

Chronic kidney disease

6

1

Obstructive sleep apnea syndrome

45

8.6

Type of operation Appendectomy

268 51.3

254

Cholecystectomy

48.7

ASA status I

275

53

II

158

30

III

86

16

IV

3

1

ASA: American Society of Anesthesiologists classification.

21

Koltka et al. Is nighttime laparoscopic general surgery under general anesthesia safe?

Table 2. Complication rate according to operation time

Group I Group II Group III (n=282) (n=78) (n=162)

n %

n %

n %

Consultant surgeon attending

98

34

12

15

11

7

<0.001*

Consultant anesthesist attending

235

83

24

31

37

23

<0.001*

Intraoperative complication

54 20

29 37

77 48 <0.001*

Postoperative complication

17

6

11

14

20

12

0.055

Readmission to hospital

7

3

4

5

8

5

0.500

Mortality rate

None

None

None

p

1.000

Statistical difference between groups (p<0.05).

*

age, gender, BMI, ASA score, and operation time group as independent variables. This revealed that Group III (p<0.001; OR, 6.7; CI, 2.6â&#x20AC;&#x201C;16.9) and older age (p=0.004; OR, 1.04; CI, 1.01â&#x20AC;&#x201C;1.08) were among the risk factors for intraoperative complications (Table 3). In addition, we performed analysis

for determining a risk factor for postoperative complications and found that none of the dependent variables were associated with the occurrence of postoperative complications (Table 4).

DISCUSSION Table 3. Intraoperative complications Variables Transient hypotension

n % 151

28.9

Tachycardia

5 0.95

Arrhythmia

2 (0.4

Bradycardia

1 0.2

Hypertension

1 0.2

Hypoxia

1 0.2

Conversion to open surgery Total

1

0.2

162

Two patients experienced more than one complication.

Table 4. Postoperative complications Variables

n %

Infection/abscess

17 3.26

Pancreatitis

6 1.15

ERCP requirement

6

1.15

Reoperation

6 1.15

Minor bleeding

4

0.77

Rehospitalization due to abdominal pain

3

0.59

Brid ileus

3

0.59

Bilioma

1 0.2

Pneumonia

1

0.2

Upper respiratory tract infection

1

0.2

Total 48 ERCP: Endoscopic retrograde cholangiopancreatography.

22

The main finding of the present study is that performing nighttime surgery increased the risk of intraoperative complications. In addition, older age was found to be a significant risk factor for intraoperative complications.

When we reassessed the present data, we found that most of the intraoperative complications were due to anesthesia mismanagement and nighttime surgery was a risk factor for intraoperative complications. Little data is available on this topic. However, several manuscripts have reported that anesthesia residents are chronically sleepy and 32% of them can recall a fatigue-related clinical error in the last 6 months of their practice.[10,19] In an audit performed in a university hospital, the authors reported that the risk of incidents increased in anesthesia performed after-hours and stated that the most common cardiovascular incident is hypotension due to several etiologies and the incidents most commonly occurs during the induction and maintenance phases.[8] The combination of ASA 1 and ASA 2 patients covered up 78% of the patient population in that study, which is quite similar to the ASA scores of the patients in the present study (83% were ASA 1 or 2). The results of this audit support our findings.

Fortunately, most if not all intraoperative complications led to minor effects or no adverse outcome in our patients because none of them had required unplanned intensive care admission or had experienced serious perioperative adverse events, such as myocardial infarction or acute renal failure.

The possible reasons of this may be several. First, in our department, the vast majority anesthesia procedures are performed by a team of two doctors (one staff anesthesiologist or a senior resident with a junior resident). We have implemented anesthesia safety checklists focusing on moniUlus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Koltka et al. Is nighttime laparoscopic general surgery under general anesthesia safe?

toring application, allergies, anesthesia preparation, etc. All residents are trained to manage critical situations, such as difficult mask ventilation or intubation, and a manual crisis booklet is attached to all anesthesia machines. A study performed by Arbous et al.[20] confirmed that the presence of two anesthetists instead of one decreases the risk of complications during emergent anesthesia, which is consistent with the findings of the present study. As we did not focus on the reasons of complications, we can only speculate about them.

We believe some of them may be due to judgment errors and faulty techniques, which may be easily attributed to fatigue and sleep deprivation. In a simulation study of rested versus sleep-deprived anesthesiologists, Howard et al.[21] found that subjects’ performance on clinically relevant tasks and probes during simulated cases showed modest impairment when sleep-deprived and that individuals in both states made clinically relevant errors with a trend toward more errors when sleep-deprived. In their audit, Saito et al.[8] stated that inappropriate speeds of drug injection are one of the reasons for errors in critical events, and these results indirectly support our speculations.[8,21] In addition, Arbous et al.[20] found that compared with indirect availability, direct availability of the anesthesiologist during maintenance was associated with a significantly lower risk; in the present study, direct availability of the staff anesthesiologist was less during nighttime surgery, and this may be one of the reasons for increased risk of intraoperative complications.

The most frequent postoperative complications in the study were infection/abscess (3.26%), pancreatitis (1.15%), ERCP requirement (1.15%), and reoperation (1.15%). In a study focusing on a similar patient population, Yaghoubian et al.[22] found abscess rate of 2.5% in the daytime appendectomy group, which is quite similar to the combined data of the present study. Although Yaghoubian et al. found the abscess rate in nighttime appendectomy group to be 1.5%, the patients in the present study were older and had higher rates of comorbidity (for example, the rate of diabetes was 8% in the present study vs 4% and 3.2% in the daytime and nighttime appendectomy groups, respectively), which may explain the difference. Yaghoubian et al.[22] found that nighttime surgery was not a risk factor for surgical complications, which is consistent with the results of the present study.

The reoperation rate was 1.15% in the present study. In a series of 1607 patients, Guevara et al.[23] found a reoperation incidence of 5.9%, which is higher than that in our study.

Although elective cholecystectomy, emergency cholecystectomy, and appendectomy were among the most common surgeries performed, other operations, such as colon, rectum, and gastric resections and elective and emergency hernia repairs were included in their study, and the mean age was 61 years, which is greater than that in our study. Therefore, all these differences together may easily explain their higher reoperation rates.

This study has several limitations. First, it was a retrospective Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

study using the data of a single center. We could not determine whether the surgery start times of some high-risk patients were postponed to daytime by surgeons or anesthesiologists in order to increase patient safety or to lower the risk of complications. Although we could identify readmissions of patients due to postoperative complications, we could not ensure whether all patients with postoperative complications had been admitted to our hospital. The amount of sleep loss is an important factor, and there are several descriptions of sleep deprivation.[24,25] However, in the present study, we did not evaluate the complication rates and sleep deprivation.

The anesthesia team and/or surgical team could be sleep-deprived, and this might change the complication rates.

In summary, nighttime surgery increased the risk of intraoperative complications without serious morbidity or mortality after laparoscopic cholecystectomy and appendectomy under general anesthesia. With increasing age, the risk for intraoperative complications was found to increase directly.

No correlation was observed between nighttime surgery and postoperative complications.

Conflict of interest: None declared.

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13. Gelbard R, Karamanos E, Teixeira PG, Beale E, Talving P, Inaba K, et al. Effect of delaying same-admission cholecystectomy on outcomes in patients with diabetes. Br J Surg 2014;101:74–8.

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15. Jarrar MS, Chouchène I, Fadhl H, Ghrissi R, Elghali A, Ferhi F, et al.

Early versus delayed laparoscopic cholecystectomy for lithiasic acute cholecystitis during emergency admissions. Results of a monocentric experience and review of the literature. Tunis Med 2016;94:519–24.

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Acute care surgery performed by sleep deprived residents: are outcomes affected? J Surg Res 2010;163:192–6.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Gece genel anestezi altında yapılan laparoskopik genel cerrahi olguları güvenli mi?

Dr. Ahmet Kemalettin Koltka,1 Dr. Mehmet İlhan,2 Dr. Achmet Ali,1 Dr. Ali Fuat Kaan Gök,2 Dr. Nükhet Sivrikoz,1 Dr. Teoman Hakan Yanar,2 Dr. Mustafa Kayıhan Günay,2 Dr. Cemalettin Ertekin2 1 2

İstanbul Üniversitesi İstanbul Tıp Fakültesi, Anesteziyoloji Anabilim Dalı, İstanbul İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul

AMAÇ: Yorgunluk ve uykusuzluk doğru karar verme yetisini ve motor becerileri etkileyerek tıbbi performansı ve hasta bakım kalitesini düşürebilir.

Bu çalışmanın amacı, farklı zamanlarda genel anestezi altında yapılan laparoskopik genel cerrahi olguları ile istenmeyen sonuçlar arasında ilişki olup olmadığını araştırmaktır.

GEREÇ VE YÖNTEM: Üçüncü düzey bir üniversite hastanesinin acil servisinde 01.01.2016–31.12.2016 tarihleri arasında ameliyat edilen tüm laparoskopik kolesistektomi ve apendektomi olguları çalışmaya dahil edildi. Ameliyat zamanları üçe ayrıldı: 08.01–17.00 arası (G1: gündüz), 17.01–23.00 arası (G2: erken mesai sonrası) ve 23.01–08.00 arası (G3: gece). Çalışmaya dahil edilen hastaların dosyaları taranarak ameliyatta ve ameliyat sonrası dönemlerde anestezi veya cerrahiye ait komplikasyon yaşayıp yaşamadıkları incelendi.

BULGULAR: Bağımsız değişkenler olan yandaş hastalıklar, yaş, cinsiyet, vücut kitle indeksi, ASA skoru ve ameliyat zamanı ile bağımlı değişken olan ameliyat sırasında komplikasyon sıklığı arasındaki ilişki multipl regresyon analizi yapılarak değerlendirildi. Gece yapılan ameliyatlar (p<0.001 OR: 6.7 CI [2.6–16.9]) ve yüksek yaşın (p=0.004 OR: 1.04 CI [1.01–1.08]) ameliyat sırasında komplikasyon sıklığı için risk faktörü olduğu saptandı. Aynı değerlendirme ameliyat sonrası komplikasyonlar için yapıldığında yukarıdaki bağımsız değişkenler ile ameliyat sonrası komplikasyon sıklığı arasında ilişki olmadığı saptandı.

TARTIŞMA: Gece yapılan ameliyatlarda ve yaşlı hastalarda ameliyat sırasında komplikasyon riski ciddi morbidite veya mortalite artışına neden olmadan artmaktayken ameliyat sonrası komplikasyon sıklığında artışa neden olan bir bağımsız değişken bulunmamıştır.

Anahtar sözcükler: Ameliyat zamanı; ameliyat sırasında komplikasyon; ameliyat sonrası komplikasyon; genel anestezi; laparoskopik cerrahi.

Ulus Travma Acil Cerrahi Derg 2018;24(1):20–24

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doi: 10.5505/tjtes.2017.95079

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

ORIG I N A L A R T IC L E

A retrospective analysis of 2713 hospitalized burn patients in a burns center in Turkey Yavuz Albayrak, M.D.,1 Ayetullah Temiz, M.D.,1 Ayşe Albayrak, M.D.,2 Rıfat Peksöz, M.D.,1 Fatih Albayrak, M.D.,3 Yusuf Tanrıkulu, M.D.4 1

Department of General Surgery, Erzurum Region Training and Research Hospital, Erzurum-Turkey

2

Department of Infectious Diseases and Clinical Microbiology, Atatürk University Faculty of Medicine, Erzurum-Turkey

3

Department of Internal Medicine, Faculty of Medicine, Atatürk University Faculty of Medicine, Erzurum-Turkey

4

Department of General Surgery, KTO Karatay University Faculty of Medicine, Konya-Turkey

ABSTRACT BACKGROUND: Burn trauma is a significant health problem that has physical, psychological, and economic repercussions on affected patients. The aim of this study was to present epidemiological and demographic characteristics of patients treated over an 8-year period at a reference burn treatment center located in the northeast of Turkey and serving a population of approximately four million people.

METHODS: Each patient’s medical record was reviewed, and demographic features, source of burns, place of residence, total body surface area (TBSA), surgical treatment, duration of hospital stay, and mortality rates were analyzed.

RESULTS: The most frequent cause of burn was scalding from hot liquids (2013 cases, 74.2%). Freeze burn was observed in 16 (0.6%) cases due to climatic conditions of the region where our burn center is located. Grouping based on TBSA revealed that 88.7% patients had TBSA of 0%–15%, 8% patients had TBSA of 15%–30%, and 3.3% patients had TBSA ≥ %30.The most common microorganism was Pseudomonas aeruginosa. A total of 24 patients (0.9%; 8 males, 16 females) died, including 7 children and 17 adults.

CONCLUSION: Removal of tandirs and replacement with high ovens, restriction of cheese and butter production under primitive circumstances, encouraging cheese and butter production via dairy farm systems, and raising people’s awareness through training programs could greatly reduce the number of the burn accidents occurring in this region.

Keywords: Burn injury; freeze burn; scalding.

INTRODUCTION Burn trauma is a significant health problem that has physical, psychological, and economic repercussions on affected patients. Physical and psychological consequences of a burn trauma proportionally increase with the extent of the burn area. Burns may have various causes, including fires, scalding agents, chemicals, electricity, and radiation. In developed countries, all of these agents cause burns of variable severity, but late-stage deformities can, in general, be predicted.

[1] However, the incidence and causes of burn trauma are di-

rectly associated with the economic development of the region in which the burn occurs. For example, the region where our burn center is located within the Erzurum province is at a much lower socioeconomic level than many other regions of Turkey. The cold climate of the region also means prolonged use of heating equipment and hence, an increase in the frequency of burn traumas. The aim of this study was to present epidemiological and demographic characteristics of patients treated over an 8-year period at a reference burn treatment center located in the northeast of Turkey and serving a population of approximately four million people.

Cite this article as: Albayrak Y, Temiz A, Albayrak A, Peksöz R, Albayrak F, Tanrıkulu Y. A retrospective analysis of 2713 hospitalized burn patients in a burns center in Turkey. Ulus Travma Acil Cerrahi Derg 2018;24:25-30 Address for correspondence: Yavuz Albayrak, M.D. Erzurum Bölge Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, 25040 Erzurum, Turkey.

Tel: +90 442 - 242 22 75 E-mail: yavuzalbayrakdr@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(1):25–30 DOI: 10.5505/tjtes.2017.82342 Submitted: 15.04.2017 Accepted: 24.05.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

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Albayrak et al. A retrospective analysis of 2713 hospitalized burn patients in a burns center in Turkey

Causes of Burns The most frequent cause of burn was scalding from hot liquids (2013 cases, 74.2%). The other causes, in order of descending frequency, were flame (327 cases, 12.1%); electricity (144 cases, 5.3%); and contact with hot surfaces/materials, such as a stove or iron (105 cases, 3.9%), tandir (73 cases, 2.7%), and chemical (35 cases, 1.2%) burns. Freeze burn was observed in 16 (0.6%) cases because of climatic conditions of the region where our burn center is located. There is no inhalation injury in the study. The factors leading to burns are shown in Fig. 2.

Extent of Burns The percentage of TBSA ranged from 1% to 100%, with a mean of 7.50%±8.24%. In all patients based on TBSA revealed 350

338 304

300

283

267

200

257

176

166

150

162

134

84

Ju Au ly Se gu pt st em b O er ct o N ov ber e D mb ec er em be r

ay

ne

Ju

ril

M

Ap

ry

ch

ar

M

ar nu

br

Ja

ua

y

50

Months

Figure 1. The monthly distribution of the number of patients with burns.

Cause

RESULTS

Hot water Flame Electrical (Home) Electrical (Industry) Chemical material Tandir Cold Hot subject Herbal

3.9%

1.1%

Age and Sex A total of 2713 acute burn patients were admitted to the Burns Unit of Erzurum Region Training and Research Hospital between September 2008 and December 2016. The median age was 16.3±19.6 years, with a range of 1 month to 87 years.

Pediatric patients (0–14 years) accounted for 1755 (64.7%) and adults accounted for 958 (35.3%) admissions. There were 1493 (55%) males and 1220 (45%) females, for a male to female ratio of 1.22:1.

296

246

250

Fe

The Erzurum Regional Education and Research Hospital burn treatment center, where this study was conducted, consists of a total of 16 beds, of which four are intensive care beds. The center also houses two medical dressing rooms and operating theaters. This study received approval from the Erzurum Regional Education and Research Hospital ethical committee (dated 21/02/2017 and numbered 02–15). The staff included one surgeon, one practitioner with burn course certification, an anesthesiologist, 10 nurses specialized in burn care, and three technicians. In the 99-month period between September 2008 and December 2016, 9077 patients presented to our hospital with different causes of burns. Of these, 6364 had no indications for inpatient treatment; therefore, they were treated on an outpatient basis. The remaining 2713 patients underwent inpatient treatment. The criteria for inpatient treatment was affected total body surface area (TBSA) (10% in children and >15% in adults); burns on the face, hand, foot, perineum, or major joints; circular burns on extremities; full-thickness burns over 5% of TBSA; and electrical, chemical, and inhalation burns. Files of 2713 patients who were hospitalized and treated at our center between September 2008 and December 2016 were downloaded from the electronic archive for review. Each patient’s medical record was reviewed, and demographic features, source of burns, place of residence, TBSA, surgical treatment, duration of hospital stay, and mortality rates were analyzed. The patients were divided into three groups: those with burns on 0%–15% of TBSA, 15%–30% of TBSA, and ≥30% of TBSA. Causes of burns were divided into seven groups: electrical, scald, contact, chemical, tandir, cold, and flame burns. The severity of the burn was classified as TBSA, which was described as a percentage.[2] The length of hospital stay was classified in days, including the days of admission and discharge. The patients were divided into three groups based on their economic levels: those with a monthly income of <USD 400, those with a monthly income of USD 400–800, and those with a monthly income of >USD 800.

lowest number of hospitalized and treated patients in March and April. The monthly admissions data are shown in Fig. 1.

Count

MATERIALS AND METHODS

0.6%

0.1%

5.0%

12.1% 74.1%

Monthly Admissions Our burn center received the highest number of hospitalized and treated patients in July, August, and December, and the 26

Figure 2. Pie chart representation of the etiological reasons for burns.

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Albayrak et al. A retrospective analysis of 2713 hospitalized burn patients in a burns center in Turkey

Table 1. Microorganisms growing in the burn injury cultures of the patients with burns Causative organisms in patients n

% (in all patients)

% (in positive cultures)

Pseudomonas aeruginosa

189 7

16.7

Staphylococcus epidermidis

160 5.9

14.1

Methicillin-sensitive Staphylococcus aureus

95 3.5

8.4

Methicillin-resistant coagulase-negative staphylococcus

85

3.1

7.5

Methicillin-sensitive coagulase-negative staphylococcus

79

2.9

7.0

Enterococcus sp.

53

2

4.7

Escherichia coli

44 1.6

3.9

Acinetobacter sp.

38 1.4

3.3

Others

392 14.4

34.4

that 88.7%, 8%, and 3.3% patients had TBSA of 0%–15%, 15%– 30%, and >30%, respectively. Among children, 1551 (88.4%), 155 (8.8%), and 49 (2.8%) had TBSA of 0%–15%, 15%–30%, and >30%, respectively. Among adults, 855 (89.2%), 63 (6.6%), and 40 (4.2%) had TBSA of 0%–15%, 15%–30%, and >30%, respectively. A total of 459 patients (16.9%) had burns only to the lower extremities, 429 patients (15.8%) had burns only to the upper extremities, 207 patients (7.6%) had burn injuries only to the head and neck region, 194 patients (7.1%) had burn injuries only to the major joints, 22 patients (0.8%) had burn injuries only to the genital region, and 1402 patients (51.8%) had burn injuries to multiple regions.

Burn Management Treatment of the burn injuries in these 2713 patients included silver sulfadiazine or nitrofurazone in 2345 (86.4%), net dressing containing chlorhexidine in 841 (31%), hydrotherapy in 1410 (52%), grafts in 137 (5%), debridement in 85 (3.1%), grafting and debridement in the same session in 48 (1.8%), fasciotomy in 20 (0.7%), and extremity amputation in 16 (0.6%) patients.

Microorganisms growing in the injury cultures of the patients: Among the 2713 patients, 1135 patients (41.8%) had positive growth in their injury cultures. The most common microorganism was Pseudomonas aeruginosa in 189 patients (16.7%), followed by Staphylococcus epidermidis in 160 (14.1%), methicillin-sensitive S. aureus (MSSA) in 95 (8.4%), methicillin-resistant coagulase-negative staphylococcus in 85 (7.5%), methicillin-sensitive coagulase-negative staphylococcus in 79 (7.0%), Enterococcus sp. in 53 (4.7%), Escherichia coli in 44 (3.9%), Acinetobacter sp. 38 (3.3%) and other organisms in 392 (34.5%). The microorganisms growing in the injury cultures are shown in Table 1.

Social and Economic Factors A total of 1744 patients (64.3%) had incomes < American dollars (USD) 400, 947 (34.9%) had monthly incomes beUlus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

tween USD 400 and 800, and 22 patients (0.8%) had incomes > USD 800.

Lengths of Hospital Stay Lengths of hospital stay were 1–117 days, with a mean stay of 12.9±10.4 days. The mean hospital stays were 12.1±8.8 days for children and 14.3±12.6 days for adults.

The place where the burn event occurred and its judicial side: Places where the burn events occurred were houses (90.4%), outdoors (6.3%), workplaces (2.2%), and vehicles (1.1%). A total of 2691 patients (99.2%) suffered from burned by accident, whereas 22 patients (0.8%) suffered from burned intentionally.

Post-Burn Interventions A total of 570 (21%) patients were treated with tap water right after the burn. A total of 146 (5.4%) patients who came to our hospital had some type of substance applied to their burns [toothpaste, potato, yogurt, molasses (a type of jam made from hot grape juice), or shoe polish].

Patient Discharge from the Clinic and Mortality A total of 1645 (60.6%) patients were discharged upon recovery, whereas 1014 (37.4%) were discharged without completing their treatment upon the request of the patient or the patient’s relatives. Of the patients who were discharged upon their own request, 87.2% were discharged earlier to take care of their families and 6.7% of them desired discharge to avoid separation from their spouses. A total of 30 (1.1%) patients were referred to another center for several reasons. A total of 24 patients (0.9%; 8 males and 16 females) died, including 7 children and 17 adults. Among the dead patients, 8 had scalding burns, 14 had flash burns, and 2 had tandour burns. Two of the deceased patients had TBSA of 15%–30% and 22 patients had TBSA of >40%. The patient group which had TBSA of >40% had a mortality rate of 57.9%.

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Albayrak et al. A retrospective analysis of 2713 hospitalized burn patients in a burns center in Turkey

DISCUSSION A burn is one of the most severe types of injuries. The causes and demographic features associated with burn injury differ in each country. Our burn center is located in the Erzurum province in the northeast of Turkey, and as the only burn center in this region, it serves a population of 3,217,531 persons in the Erzincan, Bayburt, Gümüşhane, Artvin, Kars, Ardahan, Iğdır, Ağrı, Muş, and Bingöl provinces surrounding Erzurum.[3] The percentage of male patients was higher than that of female patients, in agreement with the results of previous studies,[4–7] although some studies have shown a higher percentage of female patients.[4,8,9] In our study, children constituted the group most affected by burn injury as 64.7% of our cases were aged <15 years, similar to that observed in other studies.[10,11] The highest numbers of patient hospitalizations to our burn center occurred in July, August, December, and January. The climate conditions of the region that our burn center serves necessitates the use of coal burning stoves as a heating equipment in the winter. In the summer, ovens called tandirs (Fig. 3) are used in the rural areas. Another reason for the increase in burn cases during summer is falling into milk boilers used to produce cheese and butter. One study reported that the highest number of burn traumas occurred in winter,[12] whereas another study showed that the highest number of burn cases occurred in summer.[13] Our view is that these reported differences are related to differences in the lifestyles, socioeconomic status, and cultural status of the people living in this region.

The lengths of hospital stays for adult patients were longer because their TBSA was higher than that of pediatric patients. This finding agreed with that of a previous study that reported a longer hospital stay for adult patients with high TBSA than for pediatric patients.[14] The most frequent reason for burns in patients admitted to our center was scalding; followed by flash burns. Burns in women and children due to falls into the tandirs used to bake bread were also observed quite frequently in our region.

Tandir burns usually led to third degree burns and spontaneous finger and toe amputations, and the patients usually needed grafting surgeries for recovery.[15] Similarly, very severe burns occur because oft children falling into the milk boilers used for butter and cheese production in our region.

Our findings are similar to those of our previous studies and many other studies in terms of etiological characteristics.[15–17] Previous studies have shown an association between a high TBSA and increased mortality.[18] The total mortality rate in our study was 0.9%. Previous studies have reported a total mortality rate of 10.5% and 60% in the patient group with a TBSA of >40%.[18] Our patients with a TBSA of >40% had 28

a mortality rate of 57.9%, which was in agreement with the results of these previous studies.

Some studies have reported silver sulfadiazine as the most frequently used product for burn treatment.[19,20] We also used silver sulfadiazine for the treatment of burn injuries in our clinic. We observed that net dressings containing chlorhexidine were quite effective in treating the injury of patients with second degree superficial burns, and we recommend the use of this product in patients with second degree superficial burns. We frequently use hydrotherapy in our clinic, particularly in patients with large superficial burn areas and deep burns. We found hydrotherapy to be an effective method for scar elimination. We also observed that the use of creams for chemical debridement was useful in patients when needed.

A total 306 patients (11.3%) underwent surgical treatment at our center: graft operations were the most frequently used surgical treatment (137 cases). We used graft operation mostly for patients who had experienced flash burns, electrical burns, and burns because of falling into tandours.

Debridement operations were the second most common treatment performed at our clinic. We used debridement operations particularly for cases of flash, electrical, and tandour burns because these accidents led to deep burns. Some of our patients underwent repetitive debridement, whereas others underwent a single debridement treatment.

Burn trauma disrupts the integrity of the skin and therefore, microorganisms can easily penetrate the skin and cause infections. Prophylactic antibiotic treatment is routinely usedin our clinic, and we use this treatment in patients with ≥30% TBSA and in patients with additional problems, such as diabetes mellitus and immune sufficiency. P. aeruginosa was the microorganism most commonly cultured from the burn injuries in our patients. Patients with positive cultures were evaluated by an infectious disease specialist and treated appropriately.

One study reported the presence of S. aureus, Pseudomonas sp., and Klebsiella sp. as the most common organisms growing in injury cultures.[21] Another study conducted by Akçay et al. in our region reported Pseudomonas sp. (85%) and Enterobacter aerogenes (12%) as the most commonly cultured microorganisms.[22] The results of our study are similar to previous findings.

The socioeconomic status of most (64.3%) of the patients in our study was represented by a monthly income of <USD 400. Families in the rural parts of our region have many children. However, because majority of these families do not have a good socioeconomic status, they are unable to take care of their children; therefore, burn accidents due to the cultural reasons mentioned (heating, use of tandirs, or milk boilers, etc.) are frequent. In contrast, families with a better socioeconomic status have fewer children and they do not typically live in the rural areas; thus, they experience burn accidents less frequently as they are not exposed to the leadUlus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Albayrak et al. A retrospective analysis of 2713 hospitalized burn patients in a burns center in Turkey

ing factors for burns. Another study also reported that burn accidents tended to occur in the regions with a lower socioeconomic level.[23] The length of hospital stays is related to extensive TBSA, deep burn injury, etiological agents leading to burns, and the patient’s age.[24] In our study, the lengths of hospital stays were longer for adults than for pediatric patients, which reflects the higher TBSA of adult patients than that of pediatric patients. Another factor affecting the length of hospital stays was the patient’s own request for early discharge without recovery. When patients were asked their reasons for wanting a discharge, they stated that they had to take care of their children or parents at their homes. We also determined that long separations from spouses was another factor that led to requests for early discharge by the patients. Some studies have reported lengths of hospital stay as 13.7–19.5 days, which agree with the lengths of hospital stays determined in our study.[25–27] In summary, the lower socioeconomic level in this region in the northeastern area of Turkey leads to many burn accidents. Our view is that removal of tandirs and replacement with high ovens, restriction of cheese and butter production under primitive circumstances, encouraging cheese and butter production via dairy farm systems, and raising people’s awareness through training programs could greatly reduce the number of the burn accidents occurring in this region.

Conflict of interest: None declared.

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Albayrak et al. A retrospective analysis of 2713 hospitalized burn patients in a burns center in Turkey

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Türkiye’deki bir yanık merkezinde yatarak tedavi gören 2713 hastanın geriye dönük analizi Dr. Yavuz Albayrak,1 Dr. Ayetullah Temiz,1 Dr. Ayşe Albayrak,2 Dr. Rıfat Peksöz,1 Dr. Fatih Albayrak,3 Dr. Yusuf Tanrıkulu4 Erzurum Bölge Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Erzurum Atatürk Üniversitesi Tıp Fakültesi, Enfeksiyon Hastalıkları ve Klinik Mikrobiyoloji Anabilim Dalı, Erzurum Atatürk Üniversitesi Tıp Fakültesi, İç Hastalıkları Anabilim Dalı, Erzurum 4 KTO Karatay Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Konya 1 2 3

AMAÇ: Yanık travması, etkilenen hastalar üzerinde fiziksel, fizyolojik ve ekonomik yansımaları olan ciddi sağlık problemidir. Bu çalışma, Türkiye’nin kuzeydoğusunda bulunan ve yaklaşık dört milyon kişilik bir nüfusa hitap eden, referans bir yanık tedavi merkezinin sekiz yılı aşkın sürede takip ettiği hastaların epidemiyolojik ve demografik özelliklerini sunmayı amaçlamaktadır.

GEREÇ VE YÖNTEM: Hastaların tıbbi dosyalarından, hastaların demografik özellikleri, yanık kaynağı, yanık mahalli, yanık yüzey alanı (YYA), yapılan cerrahi tedavi, hastanede kalış süresi ve mortalite oranları analiz edildi.

BULGULAR: En sık yanık sebebi sıcak sıvılara bağlı haşlanma yanıkları (2013 olgu, %74.2) idi. Yanık merkezimizin bulunduğu bölgenin iklim koşullarına bağlı olarak donma yanığı 16 (%0.6) olguda gözlemlendi. Yanık yüzey alanına göre hastalar gruplandırıldığında; hastaların %88.7’si %0–15, %8.0’i %15–30 ve %3.3’ü ise %30’dan fazla YYA’ya sahipti. En fazla izlenen mikroorganizma Pseudomonas aeruginosa idi. Yedisi çocuk olmak üzere toplam 24 (%0.9) hasta (8 erkek, 16 kadın) öldü.

TARTIŞMA: Tandırların kaldırılması ve yerine yüksekte kurulu olan fırınların oluşturulması, peynir ve tereyağı üretiminin daha gelişmiş şartlarda yapılması ve toplumun yanık konuları hakkında bilgilendirilmesi ile, bu bölgedeki yanık olguları büyük oranda azaltılabilir.

Anahtar sözcükler: Donma yanığı; haşlanma; yanık travması.

Ulus Travma Acil Cerrahi Derg 2018;24(1):25–30

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doi: 10.5505/tjtes.2017.82342

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

ORIG I N A L A R T IC L E

Characteristics of pediatric and adult cases with open globe injury and factors affecting visual outcomes: A retrospective analysis of 294 cases from Turkey Işıl Kutlutürk Karagöz, M.D.,1 Esin Söğütlü Sarı, M.D.,2 Anıl Kubaloğlu, M.D.,3 Ahmet Elbay, M.D.,4 Ümit Çallı, M.D.,1 David P Pinero, M.D.,5 Yusuf Özertürk, M.D.,6 Titap Yazıcıoğlu, M.D.6 1

Department of Ophthalmology, Ümraniye Training and Research Hospital, İstanbul-Turkey

2

Department of Ophthalmology, Balıkesir University Faculty of Medicine, Balıkesir-Turkey

3

Department of Ophthalmology, Etiler Dünya Eye Hospital, İstanbul-Turkey

4

Department of Ophthalmology, Bezmialem Vakıf University Faculty of Medicine, İstanbul-Turkey

5

Department of Optics, Pharmacology and Anatomy, University of Alicante, Alicante-Spain

6

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

ABSTRACT BACKGROUND: This study aimed to evaluate 1-year follow-up results of cases that were diagnosed with open globe injury (OGI), to compare trauma-related characteristics between pediatric and adult cases, and to determine risk factors for a poor final visual acuity.

METHODS: This study enrolled 294 cases that met the OGI definition and were followed up for at least 1 year. Demographic and clinical features regarding ocular trauma were recorded. The cases were divided into two groups according to age: pediatric (≤16 years) and adult (>16 years) groups.

RESULTS: Children were exposed to accidents that led to OGI mostly at home, whereas adults were exposed to such accidents mostly in the office. Penetrating injuries were more common in children than in adults, and injuries most commonly occurred owing to spiky objects. Zone I injuries were most frequent in both children and adults. The frequency of high-grade injuries increased with age.

Foreign body injuries and multiple surgeries were more common in adults than in children. There was no difference between the two age groups based on ocular trauma score (OTS) and visual acuity. OTS predicted the need for multiple surgeries. In the adult group, age, multiple surgeries, and initial visual acuity were significant risk factors for the final visual acuity that was achieved.

CONCLUSION: OGI causes and risk factors for poor final visual outcomes differ in adults and children. The knowledge of these differences is crucial for taking adequate preventive measures and decreasing morbidity.

Keywords: Eye injuries; penetrating eye injuries; trauma.

INTRODUCTION The annual incidence of hospital admissions because of ocular trauma ranges between 8 and 15 per 100 000 individuals, and >10% of these patients develop vision loss.[1,2] Approximately 1.6 million people are estimated to have vision loss, 2.3 million people have bilateral visual impairment, and 19

million people have unilateral visual impairment owing to ocular trauma worldwide. Accidents leading to ocular trauma peak in the childhood and at geriatric age.[1] The majority (up to 90%) of these accidents are preventable.[2,3] The detection and definition of the causes and characteristics of trauma enables clinicians to take the most adequate preventive measures. However, causes of ocular trauma and types

Cite this article as: Kutlutürk Karagöz I, Söğütlü Sarı E, Kubaloğlu A, Elbay A, Çallı Ü, Pinero DP, et al. Characteristics of pediatric and adult cases with open globe injury and factors affecting visual outcomes: A retrospective analysis of 294 cases from Turkey. Ulus Travma Acil Cerrahi Derg 2018;24:31-8 Address for correspondence: Işıl Kutlutürk Karagöz, M.D. Ümraniye Eğitim ve Araştırma Hastanesi, Göz Hastalıkları Kliniği, İstanbul, Turkey.

Tel: +90 216 - 632 18 18 E-mail: slkutluturk@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(1):31–38 DOI: 10.5505/tjtes.2017.03607 Submitted: 08.11.2016 Accepted: 12.05.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Kutlutürk Karagöz et al. Characteristics of pediatric and adult cases with open globe injury and factors affecting visual outcomes

of injury may differ in time because of the implementation of preventive strategies, changes in working practices, and life style changes.[1] For all this, descriptive epidemiological studies on ocular trauma and its management in different regions of the world are necessary.

Open globe injury (OGI) is defined as a full-thickness injury of the sclera and cornea, which threatens vision and may result in blindness.[4,5] Compared with closed eye injuries, open injuries have poorer prognosis.[6–8] OGIs, which represent a substantial proportion of ocular traumas, accounts for a substantial proportion of ocular trauma-related hospital expenditure (>60%) and supposes a significant financial burden.[9] The estimation of final visual acuity just after OGI is important for both patients and physicians who deal with its treatment. Thus, the precise definition of factors that influence the final visual acuity and knowing the characteristics of trauma according to geographical regions and characteristics of a population would be beneficial. This study aimed to evaluate 1-year follow-up results of cases diagnosed with OGI at our hospital, to compare trauma-related characteristics between pediatric and adult cases, and to assess risk factors that influence final visual acuity.

MATERIALS AND METHODS Patients Computerized data of cases with ocular trauma who were admitted to the Emergency Ophthalmology Clinic of Dr. Lütfü Kırdar Kartal Training and Research Hospital between January 2000 and December 2011 were retrospectively evaluated. IN this study, 294 patients aged between 1 and 85 years and who met the OGI definition and were followed up for at least 1 year were included.

Parameters Evaluated Patient data regarding age, sex, time between injury and hospital admission, date of injury, follow-up duration, place of injury, types of objects that caused injury, presence of foreign body, type of trauma, location (zone), severity (grade), sites of trauma in the globe such as eyelid, primary surgery, additional surgery (multiple surgery), additional surgical procedures (keratoplasty, anterior chamber wash out, pupiloplasty, lens aspiration, phacoemulsification, anterior vitrectomy, scleral fixation, intravitreal injection, or vitreoretinal surgery), initial and final visual acuity, and ocular trauma score (OTS) of each patient were recorded.

Ocular traumas of patients included in the study were defined as penetration, perforation, intraocular foreign body (IOFB), or rupture according to the Birmingham Eye Trauma Terminology and Ocular Trauma Classification (OTC) group guidelines.[10] The term “penetration” was used for patients 32

with a single laceration detected on the eye wall, the term “perforation” was used for patients with two full-thickness lacerations (entrance and exit) caused by the same agent, and the term “rupture” was used for patients with full-thickness injuries in the eye wall caused by a blunt object. Patients with a foreign body in the eye were considered as IOFB. Localization of injury was defined according to the OTC group guidelines: injuries only limited to the cornea were considered as zone I, those in the area covering the corneoscleral limbus to a 5-mm point posterior on the sclera were considered as zone II, and those extending their full thickness into the sclera at >5 mm posterior to the corneoscleral limbus were considered as zone III. The severity of a trauma was categorized into the following four grades according to Eagling criteria: grade 1 involving the cornea and anterior sclera with and without prolapse of the iris, grade 2 involving concurrent anterior segment and lens injury, grade 3 involving posterior segment injury and vitreous loss, and grade 4 involving extensive anterior and posterior injuries.[11] The OTS score for each patient was calculated based on initial visual acuity, rupture, endophthalmitis, perforating injury, retinal detachment, and afferent pupillary defect parameters.[12] All decimal visual acuity values recorded in the medical history of each patient were converted into the logMAR scale for statistical analyses. Three different groups of patients were defined according to the logMAR visual acuity obtained: ≤0.3, 0.3–1.0, and >1.0. A visual acuity of >1.0 was considered to be poor, whereas that of ≤0.3 was considered to be good. Besides a subdivision of the sample according to the level of vision, two additional groups were defined according to age: pediatric group comprising patients aged ≤16 years and adult group comprising patients aged >16 years.

All cases underwent a primary repair of OGI in the shortest time after admission (first 24 h). Patients with a corneal trauma and lamellar laceration without spontaneous leakage were followed up after fitting a therapeutic contact lens and prescribing topical antibiotic therapy. For cases that required a surgical procedure for repairing an injury, topical antibiotherapy was administered until surgery. In these cases, systemic antibiotherapy was not prescribed, only receiving intrachamber antibiotherapy intraoperatively and a subconjunctival injection of a combination of antibiotic and steroid postoperatively. Intravitreal antibiotherapy was administered to cases that were suspected of endophthalmitis, detected during the postoperative follow-up. For these cases, topical treatment was continued for at least 1 month after the surgery, and they underwent detailed ophthalmological examination at regular intervals. Additional surgeries were performed if required during the follow-up.

Statistical Analysis Data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA) version 15.00 software.

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Kutlutürk Karagöz et al. Characteristics of pediatric and adult cases with open globe injury and factors affecting visual outcomes

In addition to descriptive statistics (mean, standard deviation, and frequencies), crosstab table and chi-square test were used to assess the significance of differences in percentages among the groups. For quantitative variables, two group comparisons were performed using Student’s t-test for unpaired data that were normally distributed (checked with Kolmogorov– Smirnov test), whereas Mann–Whitney test was used for data that were not normally distributed. Moreover, the predicting factors for the final visual acuity were identified using logistic regression analysis. For all cases, the level of significance was considered to be p values of <0.05.

RESULTS Of 294 study participants, 118 (40.2%) were included in the pediatric group (mean age, 7.67±4.15 years) and 176 subjects (59.8%) were included in the adult group (mean age, 36.85±15.00 years). The majority of accidents occurred at home, and most patients were admitted to the hospital within the first 24 h. The general characteristics of the pediatric and adult groups are presented in Table 1.

Differences were detected between the pediatric and adult groups in terms of sex, place of accident, type of trauma, and Table 1. General characteristics of cases with ocular trauma

Pediatric Adult group group (n=118) (n=176)

n % n %

p

Sex

Male

69

58.5

151

85.8

Female

49

41.5

25

14.2

64

36.4

<.001

Place of accident

Home

95

80.5

<.001

Office/school

7 5.9 69 39.2

16

Street/traffic accident

13.6

43

24.4

Type of trauma a

Rupture

26 22.2 60 34.3 .027

Penetrating

91 77.8 115 65.7

Cause of trauma

Spiky objects

41

34.7

43

24.4

Glass

19 16.1 11 6.8

Stone

13 11.0 14 8.0

Metal

8 6.8 27 15.3

Wood

8 6.8 21 11.9

Assault

7 5.9 12 6.8

Traffic accident

Other

5

4.2

21

11.9

17 14.4 26 14.8

Two perforating-type traumas were not included in the analysis.

a

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

.005

cause of trauma. The ratio of male:female patient was significantly higher in the adult group than in the pediatric group.

In the pediatric group, home was the most common place of accident, whereas in the adult group, office was the most common place of accidents. Penetrating injuries were more prevalent in the pediatric group than in the adult group. Regarding the cause of trauma, Sharp pointed objects, glass, and stones were the most frequent causes of trauma in the pediatric group, whereas sharp pointed objects, metal, wood, and traffic accidents were the most common causes of trauma in the adult group. Final visual acuity was >1.0 after an injury caused by wood in all pediatric cases and was >1.0 after traffic accidents in one of the highest percentage of adult cases (66.7%). Although visual acuity was observed to be more frequently better than 1.0 logMAR after traumas accompanied by foreign body in both adult and pediatric groups (74.1% and 66.7% in adults and children, respectively), the presence of foreign body did not have any significant effect on postoperative visual acuity (p>0.05). Trauma-related characteristics are summarized in Table 2.

Zone I traumas were most frequent in both the groups, although differences among the age groups in the distribution of traumas according to zones did not reach statistical significance. Grade 2, 3, and 4 traumas were more frequent in the adult group than in the pediatric group, whereas the frequency of grade 1 injury was higher in the pediatric group than in the adult group. The presence of foreign body was significantly more frequent in the adult group than in the pediatric group. Regarding the surgical management of cases, the requirement of multiple surgical procedures was more frequent in the adult group than in the pediatric group. Cornea involvement was the most common site of trauma in both the groups, followed by iris involvement and lens injury. Eyelid involvement, traumatic cataract development, traumatic injury of lens, intravitreal hemorrhage, and retinal injury were more common in the adult group than in the pediatric group.

There were no differences between the groups with regard to distribution of cases according to OTS. The characteristics of trauma according to OTS in the pediatric and adult groups are shown in Tables 3 and 4, respectively. Although an increase was observed in penetrating injuries in the adult group as OTS progressed to 5 (i.e., improved), a decrease was determined in rupture injuries. In contrast, the distribution of types of trauma as a function of OTS was found to be more similar in the pediatric group. The frequency of multiple surgery increased in the adult group as OTS worsened (i.e., progressed to 1) (p<0.001). Likewise, the frequency of multiple surgeries was higher in the pediatric group as OTS progressed to 1 (rate was the highest for OTS of 2). In the adult group, the frequency of the presence of foreign body increased as OTS progressed to 4 (p=0.003). In the pediatric group, no difference was found between different values of OTS in terms of the presence of foreign body. Both initial and final visual acuity worsened as OTS worsened (progressed to 1) in both the groups.

33

KutlutĂźrk KaragĂśz et al. Characteristics of pediatric and adult cases with open globe injury and factors affecting visual outcomes

Table 2. Trauma-related characteristics of the cases

Pediatric group Adult group (n=118) (n=176)

n % n %

p

Distribution according to the zones

Zone I

83

70.3

120

69.0

.692

Zone II

21 17.8 37 21.3

Zone III

14 11.9 17 9.8

Distribution according to the grades

Grade 1

75 64.1 81 46.3 .025

Grade 2

19 16.2 42 23.9

Grade 3

19 16.2 37 21.0

5

4.2

16

9.1

6

5.1

27

15.3

Grade 4

Presence of foreign body

.006

Surgerya

Primary

86 73.5 94 54.7 .001

Multiple

31 26.5 78 45.3

Ocular trauma scores

1

40 33.9 61 34.7 .839

2

45 38.1 64 36.4

3

26 22.0 38 21.6

4

7

5

0 0.0 2 1.1

5.9

11

6.3

Involved site

Cornea involvement

106 89.8 160 90.9 .757

Iris involvement

66 55.9 79 44.9 .063

Lens injury

33 28.0 78 44.3 .005

31

Presence of hyphema

55

31.3

.358

30 25.4 46 26.1 .891

Sclera involvement

29 24.6 45 25.6 .848

28

Development of traumatic cataract

23.7

69

39.2

.006

Limbal involvement

24 20.3 48 27.3 .175

Vitreous involvement

21 17.8 36 20.5 .572

Presence of iridodialysis

14

11.9

28

15.9

.331

Presence of intravitreal hemorrhage

9

7.6

31

17.6

.014

Retinal injury

8

6.8

32

18.2

.005

Eye-lid involvement

5

4.2

24

13.6

.008

Optic disc involvement

5

4.2

13

7.4

.270

a

289 cases that underwent surgery.

The surgical procedures performed are summarized in Table 5. The frequency of vitreoretinal surgery was higher in the adult group than in the pediatric group. The frequencies of other procedures were found to be similar in both the groups.

Logistic regression analysis was performed to determine the factors that had an influence on the final visual acuity achieved 34

26.3

Conjunctiva involvement

in the adult group. A prediction model was created including, as potential influencing factors, age, sex, eyelid, cornea, conjunctiva, sclera, limbal, iris, optic disc involvement, presence of hyphema and iridodialysis, development of traumatic cataract, lens injury, presence of intravitreal hemorrhage, retinal injury, presence of foreign body, initial visual acuity, OTS, zone, grade, and surgery, and requirement or not of multiple surgery. Age Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Kutlutürk Karagöz et al. Characteristics of pediatric and adult cases with open globe injury and factors affecting visual outcomes

Table 3. Characteristics of trauma according to ocular trauma scores in the pediatric group

Ocular trauma scores

p

1 2 3 4 n % n % n % n %

Type of trauma

Rupture

11 28.2 11 24.4 4 15.4 0 0.0 .303

Penetrating

28 71.8 34 75.6 22 84.6 7 100.0

Presence of foreign body

0

0.0

2

4.4

3

11.5

1

14.3

.130

Surgery

Primary

30 75.0 27 60.0 22 88.0 7 100.0 .024

Multiple

10 25.0 18 40.0 3 12.0 0 0.0

Initial logMAR visual acuity

≤0.3

1 2.5 0 0.0 0 0.0 5 71.4 <.001

0.3–1.0

0 0.0 1 2.2 5 19.2 0 0.0

>1.0

39 97.5 44 97.8 21 80.8 2 28.6

Final (1 year follow-up) logMAR visual acuity

≤0.3

6 15.0 5 11.1 7 26.9 5 71.4 <.001

0.3–1.0

1 2.5 10 22.2 7 26.9 0 0.0

>1.0

33 82.5 30 66.7 12 46.2 2 28.6

logMar: Logarithm of the minimum angle of resolution.

Table 4. Characteristics of trauma according to ocular trauma scores in the adult group

Ocular trauma scores

p

1 2 3 4 5 n % n % n % n % n %

Type of trauma

Rupture

29 47.5 19 30.2 8 21.1 2 18.2 2 100.0 .010

Penetrating

32 52.5 44 69.8 30 78.9 9 81.8 0 0.0

Presence of foreign body

5

8.2

10

15.6

6

15.8

6

54.5

0

0.0

.003

Surgery Primary

25 41.0 29 45.3 30 81.1 8 100.0 2 100.0 <.001

Multiple

36 59.0 35 54.7 7 18.9 0 0.0 0 0.0

Initial logMAR visual acuity

≤0.3

0 0.0 0 0.0 0 0.0 9 81.8 2 100.0 <.001

0.3–1.0

0 0.0

>1.0

61 100.0 64 100.0 19 50.0 0 0.0 0 0.0

0 0.0 19 50.0 2 18.2 0 0.0

Final (1 year follow-up) logMAR visual acuity ≤0.3

0 0.0 9 14.1 12 31.6 11 100.0 2 100.0 <.001

0.3–1.0

8 13.1 17 26.6 17 44.7 0 0.0 0 0.0

>1.0

53 86.9 38 59.4 9 23.7 0 0.0 0 0.0

logMar: Logarithm of the minimum angle of resolution.

(p=0.003; OR=1.067; 95% CI=1.023–1.113), multiple surgery (p=0.015; OR=6.443; 95% CI=1.427–29.083), and initial visUlus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

ual acuity (p=0.009; OR=6.735; 95% CI=1.611–28.157) were risk factors, whereas eyelid involvement (p=0.005; OR=0.010; 35

Kutlutürk Karagöz et al. Characteristics of pediatric and adult cases with open globe injury and factors affecting visual outcomes

quent in males, with the male:female ratios of 1.4:1 and 6:1 in the pediatric and adult groups, respectively.

Table 5. Surgical procedures

Pediatric Adult p group group (n=118) (n=176)

n % n %

Penetrating keratoplasty 15 12.7 27 15.3 .528 Anterior chamber lavage

17

14.4

33

18.8

.331

Pupiloplasty

12

10.2

13

7.4

.402

Lens aspiration

17 14.4 39 22.2 .097

Phacoemulsification

10 8.5 17 9.7 .730

Anterior vitrectomy

15 12.7 28 15.9 .447

Scleral fixation

5 4.2 8 4.5 .900

Intravitreal injection

2 1.7 3 1.7 .995

Vitreoretinal surgery

3

2.5

16

9.1

.025

Table 6. Initial and final logMAR visual acuity in the pediatric and adult groups

Pediatric Adult p group group (n=118) (n=176)

n % n %

Initial logMAR visual acuity ≤0.3 0.3–1.0 >1.0

6 5.1 11 6.3 .116 6 5.1 21 11.9 106 89.8 144 81.8

Final (1 year follow-up) logMAR visual acuity ≤0.3

23 19.5 34 19.3 .183

0.3–1.0

18 15.3 42 23.9

>1.0

77 65.3 100 56.8

logMar: Logarithm of the minimum angle of resolution.

95% CI=0.000–0.247) was a protecting factor. In the pediatric group, a model was created using the same influencing factors as those in the adult group. Age (p=0.008; OR=0.826; 95% CI=0.718–0.950) was significant as a protecting factor, although no parameter was determined to be a risk factor.

DISCUSSION Besides ocular trauma characteristics, including causes, place, mechanism of action, severity, and localization, it is necessary to determine the factors that influence the posttreatment visual acuity to define and initiate the most adequate preventive actions. Many epidemiological studies have reported that ocular trauma is more common among males than among females.[13–19] In our sample, ocular trauma was also more fre36

Accidents leading to ocular trauma occurred in office and home among adult cases (39.2% and 36.4%, respectively), and the frequency in children of home accidents leading to ocular trauma was 80.5% and school accidents was 5.9% (p<0.001).

A study in Qatar evaluated 106 children aged <16 years who were admitted to a hospital after ocular injury and reported that 40.6% of traumas were OGI and that 42.5% of traumas occurred at home.[16] In addition, similar results were reported by studies in the literature.[19–21] A Chinese study comprising overall age groups reported that the majority of ocular traumas were work related and resulted in substantial loss of vision.[22] According to our outcomes and the results of all these studies, it appears recommendable to take measures at home to protect children from danger, as well as at work, by wearing safety goggles to prevent accidents leading to ocular trauma. Occupational accidents that cause ocular trauma in adults can be substantially prevented by education given within the scope of occupational health and safety and by encouraging the use of eye-protecting devices.[23] Different causes of ocular trauma have been reported, such as stone, wooden and metallic objects, household goods, entertainment objects, and firearm/penetrating/sharp objects.

[15,20–24] In the present study, the most frequent causes of ocular trauma were sharp pointed objects (34.7%), glass (16.1%), and stone (11.0%) in the pediatric group and sharp pointed objects (24.4%), metal (15.3%), wood (11.9%), and traffic accident (11.9%) in the adult group. Final visual acuity was more frequently >1.0 logMAR in the pediatric group when injured by wood (100%), whereas it was the highest in the adult group when injured after traffic accidents (66.7%). Although zone I traumas were more frequent in both the pediatric and adult groups (70.3% and 69%, respectively), no difference was determined between the groups in terms of distribution of traumas according to zones.

The rate of serious injuries increases with age.[25] In Italy, a 12-year retrospective evaluation of children aged <14 years revealed that hospitalization was required in 3% of overall ocular traumas.[18] In Greece, the rate of hospitalization owing to ocular trauma in all the age groups in a 9-year period was 7%.[14] In the present study, although the frequency of grade 1 injury was higher in the pediatric group than in the adult group, that of grade 2, 3, 4 injuries was higher in the adult group than in the pediatric group. This confirmed the hypothesis that the grade increases with age. The presence of foreign body was also more common in the adult group than in the pediatric group (15.3% vs. 5.1%; p=0.006). In in the adult group, the most common cause of injury was metal (40.7%), whereas in the pediatric group, the most common cause was sharp pointed objects (33.3%). Initial visual acuity was most frequently >1.0 logMAR in traumas accompanied by foreign body in both the groups (74.1% and 66.7% in the adult Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Kutlutürk Karagöz et al. Characteristics of pediatric and adult cases with open globe injury and factors affecting visual outcomes

and pediatric groups, respectively). However, the presence of foreign body did not have an effect on postoperative visual acuity (p>0.05). This result contradicts that of many studies in the literature. This may be because of the small number of patients with IOFB in the study group.[26] Many studies have reported that the cornea and sclera are the most commonly involved areas in open injuries.[8,13,15,16,24,27–29] Likewise, in the present study, cornea involvement owing to trauma was the most prevalent in both the groups, followed by iris involvement and lens injury. Eyelid involvement, traumatic cataract development, traumatic injury of the lens, intravitreal hemorrhage, and retinal injury were more commonly found in the adult group than in the pediatric group. In addition, eyelid involvement (p=0.005; OR=0.010; 95% CI=0.000–0.247) was a protecting factor. This protective effect may depend on the eyelid blinking activity that prevents globe penetration during trauma. Although studies in the literature have different findings related to eyelid involvement percentage, no clear results have shown the potential risk or protective effect of eyelid involvement, except a study from Israel. In Israel, 118 eyes (116 patients) with OGI were evaluated in a 10-year period, and eyelid injuries were associated with poor visual outcomes.

[29] Despite differences in terms of the severity of trauma and the level of involvement of ocular structures, no difference was found between both the groups in terms of distribution of cases according to OTS. The fact that initial visual acuity is an important component in OTS calculation and the presence of foreign body is not included in such calculation may be factors that account for this finding. In the present study, OTS predicted the final visual acuity, and this prognosis became poorer as OTS worsened in both the pediatric and adult groups.

In our sample, primary surgery was performed in 61.2% of cases, and multiple surgeries were required in 37.1% of overall cases. The frequency of multiple surgeries was higher in the adult group than in the pediatric group (26.5% vs. 45.3%; p=0.001). In addition, the rate of multiple surgeries increased in adults as OTS worsened (p<0.001) and this similarly occurred in children, although the frequency of multiple surgery was higher in cases with OTS of 2 (p=0.024). According to this, OTS worsening predicts the potential requirement of multiple surgeries.

No significant difference was observed between the pediatric and adult groups in terms of the distribution of final visual acuity. According to all these outcomes and similar to adults, the final visual acuity was poor in our sample of children, although the severity of trauma and the need for multiple surgeries were lower in children than in adults.

Defining risk factors for a poor final visual outcome after ocular trauma is crucial to provide the most adequate information and counseling to patients with these types of traumas.

Most studies in the literature reported that an age of <5 years or an increased age, eyelid injury, injuries with retrolimbal inUlus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

volvement, wound length of >5 mm, globe rupture, vitreous hemorrhage, retinal detachment, and relative afferent pupillary defect were risk factors for a final best-corrected visual acuity.[7,8,17,29–34] In our study, the risk factor analysis revealed that there was no significant parameter that affected final visual acuity in children, although age was the only protective factor. In adults, age, additional surgical procedure, and initial visual acuity were significant as risk factors.

In conclusion, OGI is more prevalent among males than among females. In children, majority of accidents leading to OGI occur at home, whereas in adults, majority of accidents occur in office. Penetrating injuries, most of them owing to sharp pointed objects, are more common in children than in adults. Foreign body injuries and multiple surgeries are more common in adults than children, with an increase in the frequency of high-grade injuries with age. OTS can be used to predict the requirement of multiple surgeries. In adults, age, multiple surgeries, and initial visual acuity are significant risk factors for the final visual acuity. To determine the causes and risk factors for OGI, a condition that can result in a serious loss of vision, it is crucial for taking adequate preventive measures and for decreasing morbidity. Education on preventing occupational risks should also include the causes of OGI and the preventive measures to avoid them.

Conflict of interest: None declared.

REFERENCES 1. MacEwen CJ. Ocular injuries. J R Coll Surg Edinb 1999;44:317–23.

2. Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. Surv Ophthalmol 2013;58:476–85.

3. Easterbrook M. Prevention of ocular trauma. Can J Ophthalmol 2009;44:501–3.

4. Kuhn F, Morris R, Witherspoon CD. Birmingham Eye Trauma Terminology (BETT): terminology and classification of mechanical eye injuries. Ophthalmol Clin North Am 2002;15:139–43.

5. Schmidt GW, Broman AT, Hindman HB, Grant MP. Vision survival after open globe injury predicted by classification and regression tree analysis. Ophthalmology 2008;115:202–9.

6. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after their management in the tribal areas of Western India: a historical cohort study. Graefes Arch Clin Exp Ophthalmol 2008;246:191–7.

7. Smith AR, O’Hagan SB, Gole GA. Epidemiology of open- and closedglobe trauma presenting to Cairns Base Hospital, Queensland. Clin Exp Ophthalmol 2006;34:252–9.

8. Soliman MM, Macky TA. Pattern of ocular trauma in Egypt. Graefes Arch Clin Exp Ophthalmol 2008;246:205–12.

9. Cao H, Li L, Zhang M, Li H. Epidemiology of pediatric ocular trauma in the Chaoshan Region, China, 2001-2010. PLoS One 2013;8:e60844.

10. 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.

11. Eagling EM. Perforating injuries of the eye. Br J Ophthalmol 1976;60:732-6.

37

Kutlutürk Karagöz et al. Characteristics of pediatric and adult cases with open globe injury and factors affecting visual outcomes 12. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmol Clin North Am 2002;15:163–5.

13. Oum BS, Lee JS, Han YS. Clinical features of ocular trauma in emergency department. Korean J Ophthalmol 2004;18:70–8.

14. Mela EK, Dvorak GJ, Mantzouranis GA, Giakoumis AP, Blatsios G, Andrikopoulos GK, et al. Ocular trauma in a Greek population: review of 899 cases resulting in hospitalization. Ophthalmic Epidemiol 2005;12:185–90.

15. Soylu M, Sizmaz S, Cayli S. Eye injury (ocular trauma) in southern Turkey: epidemiology, ocular survival, and visual outcome. Int Ophthalmol 2010;30:143–8.

16. Al-Mahdi HS, Bener A, Hashim SP. Clinical pattern of pediatric ocular trauma in fast developing country. Int Emerg Nurs 2011;19:186–91.

17. Cao H, Li L, Zhang M. Epidemiology of patients hospitalized for ocular trauma in the Chaoshan region of China, 2001-2010. PLoS One 2012;7:e48377.

18. Malagola R, Arrico L, Migliorini R, D’Ambrosio EM, Grenga R. Ocular traumatology in children. A retrospective study. G Chir 2012;33:423–8.

19. Sharifzadeh M, Rahmanikhah E, Nakhaee N. Pattern of pediatric eye injuries in Tehran, Iran. Int Ophthalmol 2013;33:255–9.

20. Cariello AJ, Moraes NS, Mitne S, Oita CS, Fontes BM, Melo LA Jr. Epidemiological findings of ocular trauma in childhood. Arq Bras Oftalmol 2007;70:271–5.

21. Serrano JC, Chalela P, Arias JD. Epidemiology of childhood ocular trauma in a northeastern Colombian region. Arch Ophthalmol 2003;121:1439–45.

22. 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.

23. Soong TK, Koh A, Subrayan V, Loo AV. Ocular trauma injuries: a 1-year surveillance study in the University of Malaya Medical Centre, Malaysia.

2008. Graefes Arch Clin Exp Ophthalmol 2011;249:1755–60.

24. Mansouri M, Faghihi H, Hajizadeh F, Rasoulinejad SA, Rajabi MT, Tabatabaey 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.

25. Saeed A, Khan I, Dunne O, Stack J, Beatty S. Ocular injury requiring hospitalisation in the south east of Ireland: 2001-2007. Injury 2010;41:86–91.

26. Chiquet C, Zech JC, Denis P, Adeleine P, Trepsat C. Intraocular foreign bodies. Factors influencing final visual outcome. Acta Ophthalmol Scand 1999;77:321–5.

27. Oner A, Kekec Z, Karakucuk S, Ikizceli I, Sözüer EM. Ocular trauma in Turkey: a 2-year prospective study. Adv Ther 2006;23:274–83.

28. Fea A, Bosone A, Rolle T, Grignolo FM. Eye injuries in an Italian urban population: report of 10,620 cases admitted to an eye emergency department in Torino. Graefes Arch Clin Exp Ophthalmol 2008;246:175–9.

29. Knyazer B, Bilenko N, Levy J, Lifshitz T, Belfair N, Klemperer I, et al.

Open globe eye injury characteristics and prognostic factors in southern Israel: a retrospective epidemiologic review of 10 years experience. Isr Med Assoc J 2013;15:158–62.

30. Bunting H, Stephens D, Mireskandari K. Prediction of visual outcomes after open globe injury in children: a 17-year Canadian experience. J AAPOS 2013;17:43–8.

31. Han SB, Yu HG. Visual outcome after open globe injury and its predictive factors in Korea. J Trauma 2010;69:E66–72.

32. Cillino S, Casuccio A, Di Pace F, Pillitteri F, Cillino G. A five-year retrospective study of the epidemiological characteristics and visual outcomes of patients hospitalized for ocular trauma in a Mediterranean area. BMC Ophthalmol 2008;8:6.

33. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK, Katz J. The epidemiology of ocular trauma in rural Nepal. Br J Ophthalmol 2004;88:456–60.

34. Tok O, Tok L, Ozkaya D, Eraslan E, Ornek F, Bardak Y. Epidemiological characteristics and visual outcome after open globe injuries in children. J AAPOS 2011;15:556–61.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Açık göz yaralanmalarının çocuk ve erişkin yaş gruplarındaki karakteristikleri ve görsel prognozu etkileyen risk faktörleri: Türkiye’den 294 olgunun geriye dönük analizi Dr. Işıl Kutlutürk Karagöz,1 Dr. Esin Söğütlü Sarı,2 Dr. Anıl Kubaloğlu,3 Dr. Ahmet Elbay,4 Dr. Ümit Çallı,1 Dr. David P Pinero,5 Dr. Yusuf Özertürk,6 Dr. Titap Yazıcıoğlu6 Ümraniye Eğitim ve Araştırma Hastanesi, Göz Hastalıkları Kliniği, İstanbul Balıkesir Üniversitesi Tıp Fakültesi, Göz Hastalıkları Anabilim Dalı, Balıkesir 3 Etiler Dünya Göz Hatanesi, Göz Hastalıkları Kliniği, İstanbul 4 Bezmialem Vakıf Üniversitesi Tıp Fakültesi, Göz Hastalıkları Anabilim Dalı, İstanbul 5 Alicante Üniversitesi, Optik, Farmakoloji ve Anatomi Anabilim Dalı, Alicante, İspanya 6 Kartal Dr. Lütfi Kırdar Eğitim ve Araştırma Hastanesi, Göz Hastalıkları Kliniği, İstanbul 1 2

AMAÇ: Açık göz yaralanması (AGY) olgularının karakteristiklerini ve kötü görsel prognoz için risk faktörlerini çocuk ve erişkin yaş gruplarında incelemek.

GEREÇ VE YÖNTEM: En az bir yılık takibi olan 294 AGY olgusu çalışmaya alındı. Göz travması ile ilgili demografik ve klinik özellikler kaydedildi.

Olgular yaşlarına göre çocuk (≤16 yıl) ve erişkin (>16 yıl) olmak üzere iki gruba ayrıldı.

BULGULAR: Açık göz yaralanmasına neden olan kazalara çocukların çoğunlukla ev ortamında maruz kaldığı görülürken erişkinlerin iş ortamlarında maruz kaldığı görüldü. Penetran göz yaralanmalarının çocuklarda daha sık olduğu ve sıklıkla sivri uçlu cisimlerle oluştuğu saptandı. Her iki grupta da Zon 1 yaralanmaların daha sık olduğu görüldü. Yüksek evre yaralanmaların sıklığının yaş ile birlikte arttığı saptandı. Yabancı cisim yaralanmaları ve birden fazla ameliyat gerekliliği erişkin grupta daha fazlaydı. Yaş grupları arasında oküler travma skoru (OTS) ve görme keskinliği açısından fark yoktu. OTS, birden fazla ameliyat ihtiyacı ile ilişkili bulundu. Erişkin yaş grubunda, yaş, birden fazla ameliyat olmak ve başlangıç görme keskinliği sonuç görme keskinliği için önemli risk faktörleri olarak bulundu.

TARTIŞMA: Hem AGY nedenleri hem de kötü görsel prognoz için risk faktörleri, erişkin ve çocuk yaş gruplarında farklılıklar göstermektedir. Bu farklılıkların bilinmesi önleyici tedbirlerin alınmasında ve morbiditenin azaltılması konusunda önemli olabilir.

Anahtar sözcükler: Göz yaralanmaları; penetran göz yaralanmaları; travma.

Ulus Travma Acil Cerrahi Derg 2018;24(1):31–38

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doi: 10.5505/tjtes.2017.03607

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

ORIG I N A L A R T IC L E

Health results of a coup attempt: evaluation of all patients admitted to hospitals in Istanbul due to injuries sustained during the July 15, 2016 coup attempt İsmail Tayfur, M.D.,1 Mustafa Ahmet Afacan, M.D.,1 Mehmet Özgür Erdoğan, M.D.,1 Şahin Çolak, M.D.,1 Özgür Söğüt, M.D.,2 Burcu Genç Yavuz, M.D.,2 Korkut Bozan, M.D.3 1

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

2

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

3

Department of Emergency Medicine, Göztepe Medical Park Private Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: A coup attempt against the government took place in Turkey on July 15, 2016. This attempt caused serious injuries and deaths in the country. In this study, the data of patients referred to all hospitals in Istanbul during the attempt were evaluated, and differences between natural disasters, other terrorist actions, and coup attempts were analyzed.

METHODS: In total, 1104 patients were injured in the abovementioned coup attempt. In this study, the demographic and health information of 882 coup victims who were admitted to all hospitals (state and private) in Istanbul on July 15 and 16, 2016 and registered at the Crisis Center of Istanbul Provincial Health Directorate was analyzed.

RESULTS: Of the 882 patients evaluated, 97.27% were male and 2.73% were female. The mean age of the patients was 34.12 years.

Most (82.43%) patients were admitted to state hospitals, and 17.57% were admitted to private hospitals. The total mortality rate due to the abovementioned coup attempt was 10.4% (9.76% in state hospitals and 13.54% in private hospitals). Of the 882 patients evaluated, 65.07% had gunshot injuries, 11.11% had been assaulted, 7.70% had experienced tank/motor vehicle accidents, 5.44% had other penetrating injuries, 5.32% had soft-tissue trauma, 2.83% had experienced falls (including falls from heights), 0.33% had psychiatric disorders, and 2.15% were admitted for other reasons.

CONCLUSION: The patterns of injury and mortality resulting from the July 15, 2016 coup attempt differed from those resulting from natural disasters and terrorist acts and were similar to those encountered during wars: the victims were predominantly male, similar to those in wars. Following a coup attempt, an increase in the number of patients with post-traumatic stress disorder can be expected. Further studies focusing on the incidence of this disorder due to the abovementioned coup attempt in Turkey are needed.

Hospital disaster plans need to include information and plans related to terrorist acts, such as coup attempts.

Keywords: Coup; disaster; injury; July 15 2016.

INTRODUCTION Disaster is defined as the catastrophic disruption of existing functions, with human, economic, and environmental impacts that the community cannot absorb using its own resources alone. Disasters have natural and human origins. Human-in-

duced disasters can occur as a result of people’s direct or indirect actions;[1] the two most important types of such disasters are war and terrorism. Terrorism is defined as the attempt to achieve a political or ideological goal through the use of violence or threat of violence.[2]

Cite this article as: Tayfur İ, Afacan MA, Erdoğan MÖ, Çolak Ş, Söğüt Ö, Genç Yavuz B, et al. Health results of a coup attempt: evaluation of all patients admitted to hospitals in Istanbul due to injuries sustained during the July 15, 2016 coup attempt. Ulus Travma Acil Cerrahi Derg 2018;24:39-42 Address for correspondence: İsmail Tayfur, M.D. Sağlık Bilimleri Üniversitesi, Haydarpaşa Numune Sağlık Uygulama ve Araştırma Merkezi, Acil Tıp Kliniği, İstanbul, Turkey.

Tel: +90 216 - 542 32 32 E-mail: ismailtayfur@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(1):39–42 DOI: 10.5505/tjtes.2017.57296 Submitted: 08.11.2016 Accepted: 30.03.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Tayfur et al. Health results of July 15, 2016 coup attempt, in Istanbul, Turkey

The government of Turkey described the coup attempt in that country, which took place on July 15, 2016, as a terrorist act.[3] Coup attempts that are considered to be terrorist acts are major social events that have become common in underdeveloped and developing countries, particularly since the 1980s.[4] In political terms, “coup” refers to the seizure of government or forceful change of the political regime. Coup attempts by the army are defined as military and those by civilians or civil parties are defined as civilian. Military coup attempts are usually undertaken by a military force. Civilian coup attempts are usually undertaken by a parliament or other groups in the effort to defend a nation’s rights.[5] The official records of the Republic of Turkey document previous coup attempts undertaken on May 27, 1960 and September 12, 1980 and memorandums on March 12, 1971, February 28, 1997, and April 27, 2007.[6] During the 20th century, most military coup attempts have occurred in developing countries, such as Argentina, Chile, Burma, Greece, and Turkey.[4] During almost all of these attempts, majority the of people killed or injured were civilians.[7,8] On July 15 and 16, 2016, a group of soldiers unsuccessfully attempted a coup in Turkey. In many provinces of Turkey, people protested against the coup and showed resistance.

During these protests, the soldiers involved in the coup attempt committed violent acts against civilians; 248 people were killed and 2,193 were injured.[9] In Istanbul, 99 people were killed and 1,104 were injured.

Coup attempts are often discussed in terms of their social and political effects, but they also have many negative effects on public health. These effects may include death, injury, permanent disability, and short- and long-term psychological disorders due to trauma. The effects of coup attempts on public health have not been investigated adequately. Evaluation of these effects will contribute useful data for future generations.

attempt were evaluated to obtain complete data of hospitalized patients. The data were analyzed using SPSS software (ver. 17.0; SPSS Inc., Chicago. IL, USA). Values are given as means and percentages. Categorical variables were analyzed using the chi-squared test.

RESULTS According to data from the Crisis Center of Istanbul Provincial Health Directorate, 882 patients were admitted to state and private emergency services in the Istanbul Province on July 15 and 16, 2016. Of these, 858 (97.27%) were male and 24 (2.73%) were female. The mean age of the patients was 34.12 years (range: 7–76 years).

Most (727/882, 82.43%) patients were admitted to state hospitals and 155 (17.57%) were admitted to private hospitals.

In total, 160 (18.14%) patients were referred to level 2 hospitals, 481 (54.53%) were referred to level 3 education and research hospitals, and 241 (27.32%) were referred to level 3 university hospitals.

Of the 882 patients, 574 (65.07%) had gunshot injuries, 98 (11.11%) had been assaulted, 68 (7.70%) had experienced motor vehicle accidents, 48 (5.44%) had other penetrating injuries, 47 (5.32%) had soft-tissue trauma, 25 (2.83%) had experienced falls (including falls from heights), 3 (0.33%) had psychiatric disorders, and 19 (2.15%) were admitted for other reasons (Fig. 1).

In total, 511 patients were hospitalized at the admitting services; 33 were admitted to intensive care units, 53 were transferred to tertiary hospitals, and 285 were discharged on July 15 and 16, 2016. Due to discharges, the number of hospitalized patients decreased from 568 on July 17, 2016 to 346 on July 18, 2016, 275 on July 19, 2016, 254 on July 20, 2016, and 227 on July 21, 2016 (Fig. 2).

Number of patients 65.07%

In this study, data on deaths and injuries that occurred in Istanbul during the July 15, 2016 coup attempt were evaluated from a medical point of view.

MATERIALS AND METHODS The Istanbul Provincial Health Directorate approved the study protocol on October 31, 2016 and granted use of their data. Injury and death information from the onset of the coup attempt, transferred from all public and private hospitals in the province of Istanbul to the Crisis Center of Istanbul Provincial Health Directorate on July 15 and 16, 2016, was evaluated. Patients’ age, sex, and injury type were recorded on standard forms. Records from the days following the coup 40

11.11%

7.70%

5.44%

GI Assault T/MVA PI (n=574) (n=98) (n=68) (n=48)

5.32%

2.83%

STT Fall (n=47) (n=25)

0.33%

PD (n=3)

2.15%

Other (n=19)

Figure 1. The type of injuries (%) observed in the July 15, 2016 coup attempt (GI: Gunshot injuries; T/MVA: Tank/motor vehicle accidents; PI: Penetrating injuries; STT: Soft-tissue trauma; PD: Psychiatric disorders).

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Tayfur et al. Health results of July 15, 2016 coup attempt, in Istanbul, Turkey

600

Patients hospitalized

500 400 300 200 100 0

July 17

July 18

July 19

July 20

July 21

Figure 2. Number of patients hospitalized within the first 5 days after the July 15, 2016 coup attempt.

In total, 92 patients died in hospitals on July 15, 2016; 21 patients died in private hospitals, 6 patients each died in state and university hospitals, and 59 patients died in tertiary hospitals. The total mortality rate due to the July 15, 2016 coup attempt was 10.4% (9.76% in public hospitals and 13.54% in private hospitals).

DISCUSSION Natural disasters, such as earthquakes, affect people of all ages and both sexes in similar proportions. The patient profile associated with the July 15, 2016 coup attempt differed from that associated with natural disasters, such as earthquakes and floods, in Turkey. The patient population associated with the Van earthquake had a female:male ratio of approximately 1:1;[10] in contrast, 97.28% of those injured in the abovementioned coup attempt were young males, probably because the people struggling against the coup were predominantly from that group. The types of injury and mortality related to the July 15, 2016 coup attempt that were recorded at hospitals also differed from those related to natural disasters or terrorist acts. These injuries were similar to those encountered during war and, similar to warfare, predominantly affected males.

healthcare institutions in Istanbul within a 20-h period. When architectural plans for new hospitals are made, the inclusion of large mass gathering areas for use in similar situations would be helpful.

Of the 260 people injured during the Boston Marathon events on April 15, 2013, only three (1.15%) victims died.

[15] Emergency medicine specialists and surgeons in Boston have linked this low mortality rate to the well-coordinated emergency system, presence of five emergency services near the explosion site, equitable distribution of patients requiring critical care among hospitals, and competence of skilled hospital personnel. The death:injury ratio resulting from the July 15, 2016 coup attempt was higher than that resulting from the Boston Marathon events. Healthcare institutions were prepared for possible events during the marathon, and the terrorist activity occurred during the day. The abovementioned coup attempt was an unexpected and unforeseeable event that occurred at night; thus, the staff available may have been inadequate compared with that available during the day. These deficiencies related to the features of the coup attempt may have contributed to the higher mortality rate.

The civilian mortality rate during the Bosnian War was 3.9%.

The mortality rate among our study population was 10%.

Lower civilian death:injury ratios under war conditions may be related to better preparation of hospitals for possible events, the presence of medical personnel in military units, and the effectiveness of emergency patient transport systems.

[16]

During the events that began in Egypt on June 30, 2013, with political tensions leading to a military coup on July 3, 2013, 3,533 people died and 11,520 people were injured.[7] More than 9,000 people have died and more than 20,000 have been injured during the ongoing events following the April 2014 coup in Ukraine, according to the records obtained from the United Nations.[8] The total mortality rates were 30.66% for the Egyptian coup, approximately 45% for the Ukrainian coup, and 10.4% for the Turkey coup attempt on July 15, 2016.

Most (82.43%) of the patients injured in the abovementioned coup attempt were referred to state hospitals, and 17.57% were referred to private hospitals. The total mortality rate was 10.4% (9.76% in public hospitals and 13.54% in private hospitals). Hospitals were able to meet the demand despite the adverse conditions of the crisis and the urgent need for many medical services within a very short time period. During the coup attempt, the mortality rate increased due to the closure of main roads and destruction of ambulances by gunfire.[11â&#x20AC;&#x201C;14] The provision of medical supplies to healthcare facilities was also difficult for the same reasons.

The night-time occurrence of the July 15, 2016 coup attempt in Turkey made management more difficult. Hospitals operate with the minimum number of staff required outside of regular working hours. Under these conditions, the hospitals had to admit and care for trauma patients in a manner that exceeded their capacities shortly after the sudden and unforeseen coup attempt. The mortality rate of the population exposed to life-threatening injuries on July 15, 2016 was lower than that of the population exposed in the coups in Egypt and Ukraine.

Hospitals and emergency medical services command system used hospital disaster and emergency action plans that had been prepared in advance, which may have affected the mortality rate.

In the abovementioned coup attempt, approximately 900 injured patients were admitted to the emergency services of

In our study population, 0.34% of the patients admitted to emergency services on the first day of the coup attempt had

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Tayfur et al. Health results of July 15, 2016 coup attempt, in Istanbul, Turkey

anxiety or other psychiatric disorders. In this population, traumatic injuries were examined according to the preliminary plan, but an increase in the number of patients with post-traumatic stress disorder following the coup attempt could have been anticipated. Further studies focusing on the incidence of this disorder related to the July 15, 2016 coup attempt are needed.

Conclusion The patterns of injury and mortality resulting from the July 15, 2016 coup attempt differed from those resulting from natural disasters and terrorist acts and were similar to those resulting from war: the victims were predominantly male, similar to that observed in war. Hospital disaster plans need to include information and plans related to terrorist acts, such as coup attempts. Following a coup attempt, an increase in the number of patients with post-traumatic stress disorder can be expected. Further studies focusing on the incidence of this disorder related to the abovementioned coup attempt in Turkey are needed.

Conflict of interest: None declared.

REFERENCES 1. Quarantelli EL. Where We Have Been and Where We Might Go, What is a Disaster?: A Dozen Perspectives on the Question. 1th ed. London: Routledge; 1998. p. 146–59.

2. The Definition of Terrorism. A Report by Lord Carlile of Berriew Q.C. Independent Reviewer of Terrorism Legislation. March 2017. Available

at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/228856/7052.pdf. Accessed June 1, 2017.

3. http://aa.com.tr/tr/gunun-basliklari/cumhurbaskani-erdogan-15-temmuz-yeni-nesil-bir-teror-eylemidir/657197. Accessed Feb 8, 2017.

4. https://tr.wikipedia.org/wiki/Askeri_darbe. Accessed Feb 21, 2017.

5. https://eksisozluk.com/sivil-darbe-ile-askeri-darbe-arasindakifark--2030437. Accessed Feb 21, 2017.

6. https://tr.wikipedia.org/wiki/Türkiye’de_askeri_müdahaleler. Accessed Feb 21, 2017.

7. http://aa.com.tr/tr/dunya/misirdaki-katliamin-bilancosu-3-bin-533olu/225113. Accessed Jan 26, 2017.

8. http://www.presstv.ir/Detail/2016/06/17/470910/Russia-PutinUkraine-coup-detat. Accessed Jan 26, 2017.

9. http://www.mfa.gov.tr/no_-27_-26-ocak-2017_-yunanistan-tarafindan-iadesi-reddedilen-sekiz-darbe-girisimcisi-hk_.tr.mfa. Accessed Jan 27, 2017.

10. Dursun R, Görmeli CA, Görmeli G. Evaluation of the patients in Van Training and Research Hospital following the 2011 Van earthquake in Turkey. Ulus Travma Acil Cerrahi Derg 2012;18:260–4.

11. http://www.cnnturk.com/turkiye/jandarma-bogazici-ve-fatih-sultanmehmet-koprulerini-kapatti. Accessed Jan 25, 2017.

12. http://www.sabah.com.tr/yasam/2016/08/14/ates-altinda-can-kurtaran-melekler. Accessed Jan 25, 2017.

13. http://www.trthaber.com/videolar/hainler-ambulansa-bile-atesetti-29978.html. Accessed Jan 25, 2017.

14. https://www.youtube.com/watch?v=9ftRU3u8pSA. Accessed Jan 25, 2017.

15. Landman A, Teich JM, Pruitt P, Moore SE, Theriault J, Dorisca E, et al.

The Boston Marathon Bombings Mass Casualty Incident: One Emergency Department’s Information Systems Challenges and Opportunities.

Ann Emerg Med 2015;66:51–9.

16. Hebrang A, Henigsberg N, Golem AZ, Vidjak V, Brnić Z, Hrabac P. Care of military and civilian casualties during the war in Croatia. Acta Med Croatica 2006;60:301–7.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Darbe girişiminin sağlık bilançosu: 15 Temmuz darbe girişimine bağlı yaralanmalar nedeni ile İstanbul’daki hastanelere başvuran tüm hastaların değerlendirilmesi Dr. İsmail Tayfur,1 Dr. Mustafa Ahmet Afacan,1 Dr. Mehmet Özgür Erdoğan,1 Dr. Şahin Çolak,1 Dr. Özgür Söğüt,2 Dr. Burcu Genç Yavuz,2 Dr. Korkut Bozan3 1 2 3

Sağlık Bilimleri Üniversitesi, Haydarpaşa Numune Sağlık Uygulama ve Araştırma Merkezi, Acil Tıp Kliniği, İstanbul Sağlık Bilimleri Üniversitesi, Haseki Sağlık Uygulama ve Araştırma Merkezi, Acil Tıp Kliniği, İstanbul Özel Göztepe Medical Park Hastanesi, Acil Servis, İstanbul

AMAÇ: 15 Temmuz 2016 tarihinde Türkiye’de sivil halk ile askerin karşı karşıya geldiği bir darbe girişimi gerçekleşmiştir. Bu darbe girişimi ülkede ciddi yaralanma ve ölümlere neden olmuştur. Bu çalışmada, darbe girişimi esnasında İstanbul ilindeki tüm hastanelere başvuran hastalar, sağlık açısından değerlendirilmiş, olayın doğal afetlerden ve diğer terörist eylemlerden farkları analiz edilmiştir.

GEREÇ VE YÖNTEM: Darbe girişimindeki olaylar nedeniyle mağdur olan 1104 hasta mevcuttur. Bu çalışmada, 15–16 Temmuz 2016 tarihleri arasında İstanbul’daki tüm hastanelere (kamu ve özel) başvuran ve İstanbul İl Sağlık Müdürlüğü Kriz Merkezi’nde kayıt altına alınan 882 darbe mağduru yaralının demografik ve sağlık bilgileri analiz edilmiştir.

BULGULAR: Değerlendirmeye alınan 882 hastanın %97.27’si erkek, %2.73’ü kadındır. Hastaların yaş ortalamaları 34.12’dir. Hastaların %82.43’ü kamu hastanelerine, %17.57’si ise özel hastanelere başvurmuştur. Toplam ölüm oranı %10.4 olarak bulunurken, kamu hastanelerinde %9.76, özel hastanelerde ise %13.54 olarak bulunmuştur. Hastaların %65.07’si ateşli silah yaralanması, %11.11’i darp, %7.7’si tank veya motorlu taşıt yaralanması, %5.44’ü delici kesici alet yaralanması, %5.32’si yumuşak doku travması, %2.83’ü düşme ve yüksekten düşme, %2.15’i diğer nedenlerle, üç hasta da psikiyatrik bozukluklar nedeni ile hastanelere başvurmuştur.

TARTIŞMA: 15 Temmuz darbe girişimindeki hastanelere başvuran hastaların yaralanma ve ölüm nedenleri, doğal afetler ya da terörist eylemlerden farklıdır. Darbe girişimindeki yaralanmalar savaşlarda karşılaşılabilecek nedenlerle gerçekleşmiştir. Gene mağdurların savaşlardaki gibi erkek cinsiyet ağırlıklı olduğu görülmüştür. Bu çalışmada ilk 48 saat içinde olan fiziksel yaralanmalar ve sonuçları incelenmiş olup, post travmatik stres bozukluğu açısından uzun dönem çalışmalar yapılabilir. Ayrıca, Hastane Afet Planları içerisinde darbe gibi çok az görülen toplumsal olaylarla ilgili çalışmalar da yer almalıdır.

Anahtar sözcükler: 15 Temmuz; afet; darbe; yaralanma.

Ulus Travma Acil Cerrahi Derg 2018;24(1):39–42

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doi: 10.5505/tjtes.2017.57296

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

ORIG I N A L A R T IC L E

Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects Osman Akdağ, M.D.,1 Gökçe Yıldıran, M.D.,1 Mustafa Sütçü, M.D.,2 Mehtap Karameşe, M.D.1 1

Department of Plastic, Reconstructive and Aesthetic Surgery, Selçuk University Faculty of Medicine, Konya-Turkey

2

Department of Plastic, Reconstructive and Aesthetic Surgery, Medipol University Faculty of Medicine, İstanbul-Turkey

ABSTRACT BACKGROUND: Our objective was to compare the outcomes of dorsal hand defect reconstruction using a posterior interosseous artery flap (PIAF) and a reverse adipofascial radial forearm flap (RARFF).

METHODS: From 2008 to 2013, 23 patients who underwent hand soft tissue defect reconstruction with PIAF (11 patients) and RARFF (12 patients) were included in this retrospective study. Reconstruction methods were compared in terms of functionality with disability of the arm, shoulder, and hand (DASH) score and range of motion (ROM) and aesthetically with scar assessment. Operation times, length of hospital stay, and donor site problems were compared.

RESULTS: We found no statistically significant differences between PIAF and RARFF in terms of ROM, DASH score, and length of hospital stay. Statistically significant differences were found in operation time, scar assessment, and donor site problems between PIAF and RARFF patients.

CONCLUSION: RARFF showed better results than PIAF in dorsal hand defects, but in RARFF, the major arteries of the hand are sacrificed.

Keywords: Hand soft tissue defect; posterior interosseous artery flap; reverse adipofascial radial forearm flap; reverse radial forearm flap.

INTRODUCTION Hand injuries can occur to anyone, resulting in defect of the soft tissue as well as exposition of the tendons, cartilage, bone, nerves, and joints. Appropriate skin coverage protects the hand’s vital structures through which hand functioning is maintained.[1] Optimal soft tissue reconstruction should be easy to perform and should provide the patient with good hand functioning. Although several types of flaps are available for reconstructing dorsal hand defects, posterior interosseous artery flap (PIAF) and reverse adipofascial radial forearm flap (RARFF) techniques are frequently used because of including reliable and pliable tissue.[2] These one-step reconstruction procedures require only one operative field, and the surgeon is able to work with a thin flap that can be conveniently dissected; both techniques result in a high survival rate.[3,4]

RARFF is a modification of the classic reverse radial forearm flap that only uses the adipofascial component of the flap; in this procedure, the skin graft is applied over the flap, and then the donor site is successfully treated, resulting in effective reconstruction of the hand soft tissue defect with strong blood supply. We have been performing RARFF instead of traditional reverse radial forearm flap for hand soft tissue defect in our clinic since 2008, and RARFF provides thin, pliable tissue and causes fewer donors site morbidities than the classic reverse radial forearm flap or PIAF. PIAF has been widely used in the reconstruction of hand soft tissue defects because it is thin and pliable and the flap conforms to the texture of the hand.[5] The choice of flap for hand soft tissue defect reconstruction remains contentious and is often based on the surgeon’s pref-

Cite this article as: Akdağ O, Yıldıran G, Sütçü M, Karameşe M. Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects. Ulus Travma Acil Cerrahi Derg 2018;24:43-8 Address for correspondence: Osman Akdağ, M.D. Selçuk Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Konya, Turkey.

Tel: +90 332 - 606 05 05 E-mail: oakdag@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(1):43–48 DOI: 10.5505/tjtes.2017.41196 Submitted: 12.03.2017 Accepted: 17.04.2017 Online: 00.00.0000 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Akdağ et al. Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects

erences, the vascularity of the hand, the recipient site, and the patient’s characteristics.[2] Comparative clinical studies may show long term result about proper flap chose and may be used to guide surgeons in making their choice about which type of flap to use.

In this retrospective study, we analyzed and compared the technical details, outcomes, advantages, and disadvantages of using PIAF and RARFF in 23 patients who underwent dorsal hand defect reconstruction.

MATERIALS AND METHODS Patients A total of 23 patients (males/females: 15/8) with dorsal hand defects who underwent reconstruction with PIAF or RARFF between January 2008 and December 2013 were retrospectively analyzed. Written informed consent was obtained from each patient prior to surgery. The protocols used in this study were approved by the Selcuk University, Medical Faculty Research Ethics Committee.

The cases of all patients were treated as emergencies. The demographic features of the patients are shown in Table 1. All patients had skin defects with exposure of vital hand structures, such as tendons, bones, and joints. To ensure the accuracy and objectivity of the study, only patients with a soft tissue defect on the dorsal side of the hand were chosen.

Patients with bone fracture or nerve, tendon, or joint injury were excluded because the presence of these conditions might affect the functional results. In this study, patients who were treated with PIAF comprised the PIAF group and those who were treated with RARFF comprised the RARFF group.

Surgical Techniques PIAF PIAF was designed according to the size of the defect between the radial and ulnar bones on the dorsal side of the mid-forearm. A line was drawn from the lateral epicondyle to the distal radioulnar joint. Flap dissection was continued radial to the ulnar joint and distal to the proximal direction.

The posterior interosseous artery arises from the common interosseous artery or the ulnar artery and travels along

the intramuscular septum between the extensor digiti minimi and the extensor carpi ulnaris muscles.[6] To ensure adequate hand coverage, a reverse pattern flap is chosen, and the anastomosis between the anterior interosseous and the posterior interosseous arteries (PIOA) must be preserved.

PIOA runs deep alongside the posterior interosseous nerve.

The nerve should be preserved during the dissection. The proximal PIOA is clamped before it is ligated to check the vascular supply to the flap. After ligation of PIOA, the flap is passed through a wide subcutaneous tunnel to cover the hand defects (Fig. 1).

RARFF The flap was designed between the radial and ulnar bones on the volar side of the mid-forearm. After examining the skin, a “lazy-S”-shaped incision was made and the flap was separated from the underlying adipofascial tissue. The size of RARFF was based on the size of the hand defect. The adipofascial flap borders, which included the forearm fascia, were cautiously cut, and the connections between the radial arteries were protected. The radial artery and the concomitant veins were dissected and ligated in the proximal forearm. The flap dissection progressed from the proximal area to the distal area.

The pivot point was located 1–2 cm above the radial styloid.[7] RARFF was transposed to the defect through a subcutaneous tunnel and then sutured. A skin graft was applied over the flap. The forearm skin that was left at the donor site was then directly sutured (Fig. 2).

Evaluation Criteria The mean follow up period for all patients was 1 year (range, 1–5 years). The viability and dehiscence of the two flaps and the graft survival were recorded. All patients were evaluated with objective (functional) and subjective (aesthetic) criteria.

The results of the reconstruction methods were reviewed, and hand functionality was evaluated using i) the disability of the arm, shoulder, and hand (DASH) score and ii) range of motion (ROM) for the metacarpophalangeal joint (MCPJ), proximal interphalangeal joint (PIPJ), and distal interphalangeal joint (DIPJ). The DASH score comprised 30 questions, and the score ranged from 30 points, for no limitation, to 150 points, for maximum limitation.[8] Data were transformed using the following formula: {[(sum of n responses / n) − 1] ×

Table 1. Demographic properties of patients, flap size, and donor site coverage

Number of patients Age (years) Sex Flap dimension Donor site coverage

Posterior interosseous artery flap

Reverse adipofascial radial forearm flap

11

12

30.9 (SD 14.5)

38.6 (SD 12.9)

Male/female: 6/5

Male/female: 9/3

2249.5 (SD 628.1) mm2

2713.6 (SD 479.7) mm2

Skin graft

Primary closure

SD: Standard deviation.

44

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(a)

(b)

(c)

(d)

Figure 1. (a) Hand defect and flap design. (b) PIAF elevation. (c) Flap setting before subcutaneous tunneling. (d) View at 12 months postoperatively.

(a)

(b)

(c)

(d)

Figure 2. (a) Hand defect. (b) Adipofascial flap design. (c) Intraoperative view. (d) View at 12 months postoperatively.

25}; this made it easy for comparison with other measures on a 0–100 scale.

ROM for each patient was compared with the normal ROM value for MCPJ, PIPJ, and DIPJ.[9] The outcomes were aesthetically reviewed with scar assessment measured as being excellent, good, normal, fair, and poor. This assessment was subjective.

The PIAF and RARFF flap techniques were compared in terms of operation time, length of hospital stay, and donor site problems. Donor site problems were identified as cold intolerance, numbness, and pain. These were evaluated as being either present in the patient or non-existent.

Statistical Analysis The Mann–Whitney U test and the chi-square test were used to analyze the statistical significance of the results. Continuous data were expressed as mean and standard deviation (SD).

RESULTS Between January 2008 and December 2013, 23 patients with dorsal hand defects were treated in our clinic. The defects resulted from trauma in nine patients, infection in four, resection of tumors in six, extravasation in two, and burn in two.

The hands of 11 patients (male/female: 6/5) were reconstructed with PIAF and the hands of 12 patients (male/female: 9/3) were reconstructed with RARFF. The mean age of

the patients were 30.9 (SD, 14.5) years and 38.6 (SD, 12.9) years in the PIAF and RARFF groups, respectively. The mean sizes of the flaps were 2249.5 (SD, 628.1) mm2 and 2713.6 (SD, 479.7) mm2 in the PIAF and RARFF groups, respectively (Table 1).

The RARFF donor sites were primarily closed, whereas the PIAF donor sites were covered with skin grafts. All the flaps in the RARFF group survived. In the PIAF group, two PIAF flaps underwent venous congestion, which only caused dehiscence of the sutures in one patient and partial flap necrosis in one patient. Both the partial necrosis and dehiscence healed with excision and primary suture. In the PIAF group, the donor sites covered with a graft successfully healed with no subsequent problems. The same result occurred in the RARFF donor sites that were primarily sutured. No paralysis of the posterior interosseous nerve was observed in any of the patients in the PIAF group.

There were no statistically significant differences between the PIAF and RARFF groups in terms of ROM of MCPJ, PIPJ, and DIPJ (p>0.05). The DASH scores of all the patients were similar, and no limitation in function of the upper extremity (p>0.05) was observed (Table 2).

The patients treated with RARFF expressed their satisfaction about the operation. In the RARFF group, eight (66.7%) of the 12 patients assessed the scar on their hand as excellent, four (33.3%) assessed it as good, and all 12 (100%) rated their donor site as excellent. Among the 11 patients treated with PIAF, seven (63.6%) assessed the scar on their hand as excel-

Table 2. Functional results of PIAF and RARFF

ROM (degree of angle)

DASH score

MCPJ

PIPJ

DIPJ

0 point

1 point

Posterior interosseous artery flap

89.82 (SD 0.4)

97.27 (SD 3.4)

76.82 (SD 4.04)

54.5%

45.5%

reverse adipofascial radial forearm flap

89.58 (SD 0.6)

95 (SD 4.2)

75 (SD 4.7)

75%

25%

PIAF: Posterior interosseous artery flap; RARFF: Reverse adipofascial radial forearm flap; ROM: Range of motion; DASH: Disability of the arm, shoulder and hand; MCPJ: Metacarpophalangeal joint; SD: Standard deviation; PIPJ: Proximal interphalangeal joint; DIPJ: Distal interphalangeal joint.

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Akdağ et al. Posterior interosseous flap versus reverse adipofascial radial forearm flap for soft tissue reconstruction of dorsal hand defects

Table 3. Results of scar assessments of recipient and donor sites

Recipient area (Excellent/ good/normal/ fair/poor)

Donor area (Excellent/ good/normal/ fair/poor)

Posterior interosseous artery flap (11 patients)

Excellent: 7; Good: 4

Fair: 8; Poor: 3

reverse adipofascial radial forearm flap (12 patients)

Excellent: 8; Good: 4

Excellent: 12

Table 4. Comparison of operation time, length of hospital stay, venous congestion, and donor site morbidities between the two techniques Reconstruction option

Operation time (minute)

Hospitalization time (day)

Venous congestion (n)

PIAF RARFF

Donor site morbidities (n) Cold intolerance

Numbness

161.8 (SD 15.3)

5.7 (SD 0.6)

2

3

9

118.3 (SD 5.7)

5.6 (SD 0.7)

0

0

0

PIAF: Posterior interosseous artery flap; RARFF: Reverse adipofascial radial forearm flap; SD: Standard deviation.

lent and four (36.4%) assessed it as good, but eight (72.7%) rated their donor site as fair and three (27.3%) rated it as poor. The differences between the donor site and scar assessment for these two groups was statistically significant (p=0.001; Table 3).

The mean operation time was 118.3 (SD, 5.7) min in the RARFF group and 161.8 (SD, 15.3) min in the PIAF group. A statistically significant difference was found between the two groups for this variable (p=0.001; Table 4).

The mean length of hospital stay for patients treated with PIAF was 5.7 (SD, 0.6) days and that for patients treated with RARFF was 5.6 (SD, 0.7) days; there were no statistically significant differences between the groups (p>0.05).

Three (27.3%) of the 11 patients who underwent PIAF identified cold intolerance as a donor site problem and nine (81.8%) identified numbness. None of the patients complained of pain. None of the patients in the RARFF group complained of donor site problems (Table 4).

decreases immobilization and risk of contracture.[10] Although it is known that free flaps offer excellent reconstruction for hand defects, local flap reconstruction techniques, including PIAF and RARFF, provide simple, quick, one-step reconstruction with similar tissue. Distant flaps, including the groin and inferior hypogastric flaps, have some drawbacks, such as requiring multistage operations necessitating prolonged immobilization, which may increase morbidity and lengthen hospital stay.[11] Liu et al.[2] reported their experience of reconstructing hand defects with the use of reverse forearm flap that does not contain the radial or ulnar artery.

As shown in the functional outcome of this study, both PIAF and RARFF ensure that patients have the possibility of being able to use their hands in daily activities as soon as possible.

In our study, we found that RARFF could be used for broader therapeutic indications than PIAF because there is no functional difference between the two techniques and RARFF has better aesthetic results for dorsum of hand if compared to PIAF and causes less donor site morbidity. On the other hand, PIAF may be more preferable to RARFF considering the arterial pattern. Because PIAF is a perforator flap and RARFF sacrifices the major arteries of the hand.

RARFF provides thin, pliable tissue and less donor site morbidity than the classic reverse radial forearm flap or PIAF. With RARFF, the skin graft is applied over the flap using only adipofascial tissue, thereby avoiding donor site morbidity. It should be noted that after radial forearm flap procedure, elevating a fascial flap will be harder for future procedures such as tenolysis or nerve reconstruction. Although RARFF has a strong blood supply, one of its major drawbacks is that a major artery is sacrificed, which compromises the viability of the hand and the radial forearm perforator flap, which preserves the radial artery. This flap doesn’t need to sacrifice the radial artery and covers moderate-sized hand and wrist defects.[7,8]RARFF gives excellent aesthetic and functional results (Tables 2, 3, and 4).

As a technique, RARFF is easier to perform than PIAF. Moreover, the elevation of RARFF is faster than that of PIAF.

Hand soft tissue defects must be reconstructed with thin, pliable, hairless skin. A single-step reconstruction procedure

PIAF is a perforator flap used to cover hand defects that provides tissue quality, texture, and similar hand color. PIAF’s ma-

DISCUSSION

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jor advantage is that it does not require division or sacrifice of a major artery of the hand.[12]

and achieves better donor site results, both aesthetically and functionally.

The technically demanding dissection time of PIAF is mentioned as a drawback, and in this study, it can be seen that the operation time was different between the two groups.

Close proximity of the posterior interosseous artery to the nerve requires fastidious dissection. Injury of the posterior interosseous nerve results in motor deficits in hand function.

To avoid nerve and pedicle injury, direct visualization of the posterior interosseous nerve and the pedicle is crucial. Such a demanding dissection prolongs the operation time. In our results, the operation times in the PIAF group were longer than those of the RARFF group. The difficulty in dissection and the longer operation time have been reflected in the literature and mentioned as drawbacks of the PIAF technique.

[13] RARFF provides fast and effective results for patients who are at a risk for sustained anesthesia and those for whom free flap cannot be performed.

The limitation of this study is that it was impossible to close all the PIA F donor defects primarily. Coban et al.[17] showed that if donor site of posterior interosseous artery flap is closed with V-Y advancement flaps, donor site morbidity will reduce, and this method will create a much more acceptable aesthetic scar. Further prospective studies will improve the comparison of RARFF and “adipofascial” posterior interosseous flap.

Sonderegger et al.[18] who used PIAF as adipofascial flap for radioulnar synostosis and skin was never taken with the PIAF. This retrospective study evaluated the long-term results of RARFF and PIAF using the objective and subjective criteria.

This kind of studies will be guidance for surgeons to choose between the RARFF and PIAF techniques.

Although the operation time for PIAF is longer than that for RARFF, the length of hospital stay did not differ between the two groups in our study.

Another drawback related to PIAF is venous congestion, which is the major cause of partial or total flap necrosis.[14,15] In our study, we observed venous congestion due to tension exerted on the flap in two patients of the PIAF group (18.18%) that caused suture dehiscence and partial necrosis.

Incorporating a longer skin paddle over the pedicle might prevent venous congestion. Although we were able to address this problem with excision and primary saturation, there are many reports in the literature that resulted in total flap necrosis. The authors concluded that if the PIAF skin paddle extends up to the distal third of the forearm, the risk of venous congestion may decrease. In addition, compression or kinking of the vascular pedicle must be prevented.[14–16] The eligibility of the flap depends on the results of the primary defect and donor site morbidity. In this study, no differences in the functional results were found between the PIAF and RARFF groups. The DASH scores and ROM values of both flaps were found to be similar.

Patients are mainly worried about defects related to hand reconstruction in the early postoperative period, but over time, their concern shifts to the donor site or to the aesthetic appearance of their hand. In our series, the aesthetic results for the RARFF group were better than those for the PIAF group (Table 3). In addition to the aesthetic results, donor site problems identified by patients in the PIAF group were worse than those identified by patients in the RARFF group (Table 4). Donor site problems, such as numbness and cold intolerance, depend on the graft application. RARFF is an improved method from the traditional reverse radial forearm flap Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

In conclusion, when considering the appropriate reconstruction for hand soft tissue defects, surgeons can consider RARFF as an option because it is fast and has a reliable blood supply, but it involves the sacrifice of a major blood vessel of the hand. PIAF obviates the need for the latter, but requires more time and effort for a meticulous dissection. On the other hand it has poor donor site morbidityin terms of aesthetic appearance.

Conflict of interest: None declared.

REFERENCES 1. Karamese M, Akatekin A, Abac M, Koplay TG, Tosun Z. Fingertip Reconstruction With Reverse Adipofascial Homodigital Flap. Ann Plast Surg 2015;75:158–62.

2. Liu DX, Wang H, Li XD, Du SX. Three kinds of forearm flaps for hand skin defects: experience of 65 cases. Arch Orthop Trauma Surg 2011;131:675–80.

3. Acharya AM, Bhat AK, Bhaskaranand K. The reverse posterior interosseous artery flap: technical considerations in raising an easier and more reliable flap. J Hand Surg Am 2012;37:575–82.

4. Kaufman MR, Jones NF. The reverse radial forearm flap for soft tissue reconstruction of the wrist and hand. Tech Hand Up Extrem Surg 2005;9:47–51.

5. Keskin M, Beydes T, Tosun Z, Savaci N. Close range gun shot injuries of the hand with the “mole gun”. J Trauma 2009;67:139–42.

6. Appleton SE, Morris SF. Anatomy and physiology of perforator flaps of the upper limb. Hand Clin 2014;30:123–35.

7. Yang D, Morris SF, Tang M, Geddes CR. Reversed forearm island flap supplied by the septocutaneous perforator of the radial artery: anatomical basis and clinical applications. Plast Reconstr Surg 2003;112:1012–6.

8. Fang QG, Shi S, Zhang X, Li ZN, Liu FY, Sun CF. Upper extremity morbidity after radial forearm flap harvest: a prospective study. J Int Med Res 2014;42:231–5.

9. Bain GI, Polites N, Higgs BG, Heptinstall RJ, McGrath AM. The functional range of motion of the finger joints. J Hand Surg Eur Vol 2015;40:406–11.

10. Jones NF, Jarrahy R, Kaufman MR. Pedicled and free radial forearm flaps for reconstruction of the elbow, wrist, and hand. Plast Reconstr Surg

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11. Gong X, Lu LJ. Reconstruction of severe contracture of the first web space using the reverse posterior interosseous artery flap. J Trauma 2011;71:1745–9.

15. Akinci M, Ay S, Kamiloglu S, Erçetin O. The reverse posterior interosseous flap: A solution for flap necrosis based on a review of 87 cases.

J Plast Reconstr Aesthet Surg 2006;59:148–52.

12. Tan O. Reverse posterior interosseous flap in childhood: a reliable alternative for complex hand defects. Ann Plast Surg 2008;60:618–22.

16. Angrigiani C, Grilli D, Dominikow D, Zancolli EA. Posterior interosseous reverse forearm flap: experience with 80 consecutive cases.

Plast Reconstr Surg 1993;92:285–93.

13. Neuwirth M, Hubmer M, Koch H. The posterior interosseous artery flap: clinical results with special emphasis on donor site morbidity. J Plast Reconstr Aesthet Surg 2013;66:623–8.

17. Coban YK, Gumus N, Cetinus E. Triangular design and V-Y closure of donor site of posterior interosseous artery flap. Plast Reconstr Surg 2004;114:264.

14. Lu LJ, Gong X, Lu XM, Wang KL. The reverse posterior interosseous flap and its composite flap: experience with 201 flaps. J Plast Reconstr Aesthet Surg 2007;60:876–82.

18. Sonderegger J, Gidwani S, Ross M. Preventing recurrence of radioulnar synostosis with pedicled adipofascial flaps. J Hand Surg Eur Vol 2012;37:244–50.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Dorsal el defektlerinin yumuşak doku onarımı için posterior interosseöz arter flebi ile ters akımlı adipofasyal radyal ön kol flebinin kıyaslanması Dr. Osman Akdağ,1 Dr. Gökçe Yıldıran,1 Dr. Mustafa Sütçü,2 Dr. Mehtap Karameşe1 1 2

Selçuk Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Konya Medipol Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İstanbul

AMAÇ: Bu çalışmadaki amacımız el dorsumundaki defektlerin posteriyor interosseöz arter flebi (PİA) ve ters akımlı adipofasyal radial önkol (RRÖF) ile onarım sonuçlarını kıyaslamaktır.

GEREÇ VE YÖNTEM: Geriye dönük olarak dizayn edilen bu çalışmaya 2008–2013 yılları arasında, PİA ile (11 hasta) ve RRÖF ile (12 hasta) el dorsumundaki yumuşak doku defektleri onarılan 23 hasta dahil edildi. Onarım yöntemleri fonksiyonel olarak kol, omuz ve el sorunları anketi (DASH) skoru, eklem hareket açıklığı (ROM) ile; estetik olarak skarın görünümü ile değerlendirildi. Ameliyat süreleri, hastanede kalış süreleri ve donör alan problemleri kıyaslandı.

BULGULAR: Posteriyor interosseöz arter flebi ve RRÖF arasında ROM ve DASH skorları ve hastanede kalış süresi açısından istatistiksel açıdan fark saptanmadı. Ameliyat süreleri, skar değerlendirmesi ve donör alan problemleri açısından ise istatistiksel açıdan fark saptandı.

TARTIŞMA: Dorsal el defektlerinde RRÖF sonuçları PİA’dan daha iyidir, ne varki RRÖF elin ana bir arterini sakrifiye etmektedir.

Anahtar sözcükler: El yumuşak doku defekti; posterior interooseöz flep; ters akımlı adipofasyal radial ön kolflebi; ters akımlı radial ön kolflebi.

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doi: 10.5505/tjtes.2017.41196

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ORIG I N A L A R T IC L E

Clinical features, diagnosis, and treatment of traumatic pulmonary pseudocysts Seray Hazer, M.D.,1 Umut Perçem Orhan Söylemez, M.D.2 1

Department of Thoracic Surgery, Ataturk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara-Turkey

2

Department of Radiology, Bingol State Hospital, Bingol-Turkey

ABSTRACT BACKGROUND: Traumatic pulmonary pseudocysts (TPP) are rare complications of blunt chest trauma. The aim of this study is to increase the understanding of this rare entity with imaging and clinical parameters for preventing complications and determining the correct treatment approach by observing 15 cases.

METHODS: We retrospectively reviewed the medical data and thoracic computed tomography scans of 185 patients who underwent examinations in our department after chest trauma between July 2014 and December 2015.

RESULTS: Fifteen patients had TPPs, and their clinical features and imaging findings were evaluated. Their average age was 26.33 (range, 1–89) years. The cause of TPP was traffic accident in 13 patients and falling from a height in two. Tube thoracostomy was required in five patients. None of the patients required thoracotomy, and 66% of them recovered without any complications. Five patients died because of serious concomitant injuries.

CONCLUSION: Sudden shearing force across the pulmonary parenchyma results in an area of pulmonary contusion and airtransfer from the airway to the contused area, which in turn leads to pneumatocele formation. Conservative treatment is recommended for these patients, but complications can occur because of cyst rupture. Patients should be closely monitored and be made aware of the risk of life-threatening complications.

Keywords: Blunt chest trauma; computed tomography; pneumatocele; traumatic pulmonary pseudocyst.

INTRODUCTION Lung parenchymal injury caused by blunt chest trauma is frequently accompanied by pulmonary contusion and intrapulmonary hemorrhage; however, the occurrence of traumatic pulmonary pseudocyst (TPP) is uncommon.[1] The compliance of the osteochondral thoracic cage can allow the transmission of compressive force to the lung parenchyma in young individuals. Small lacerations occur with rapid compression and decompression of the parenchyma, and the retraction of the surrounding elastic lung tissue results in the formation of small cavities that fill with air or fluid.[2] TPP occurs in 2.9% of pulmonary parenchymal injuries and 0.34% of all chest traumas.[3] The appearance of TPP on chest X-ray depends on the size and location of the lesion, severity of pulmonary con-

tusion, and position of the patient (recumbent or upright).

Thoracic computed tomography (CT) provides detection and evaluation of TPP with 100% sensitivity.[1] This study aimed to elucidate concomitant injuries, most common localization, treatment strategies, and prognosis of TPP and define radiological appearance of TPP on CT. Radiologic and clinical features of 15 patients admitted to our emergency department with TPP after blunt chest trauma were retrospectively evaluated.

MATERIALS AND METHODS We reviewed the data of 185 patients who underwent thoracic CT examinations in our department after chest trauma

Cite this article as: Hazer S, Söylemez UPO. Clinical features, diagnosis, and treatment of traumatic pulmonary pseudocysts.

Ulus Travma Acil Cerrahi Derg 2018;24:49-55 Address for correspondence: Seray Hazer, M.D. Atatürk Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi, Göğüs Cerrahisi Kliniği, Ankara, Turkey.

Tel: +90 312 - 567 70 00 E-mail: drserayhazer@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(1):49–55 DOI: 10.5505/tjtes.2017.56023 Submitted: 18.06.2016 Accepted: 15.05.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Hazer et al. Clinical features, diagnosis, and treatment of traumatic pulmonary pseudocysts

between July 2014 and December 2015. TPPs were detected in 15 patients (8.1%). Patients with pseudocysts that developed after penetrating trauma were excluded from our study.

The CT scan field extended from the level of the thoracic inlet down to the posterior costophrenic sulci. The scanning parameters were 100 mAs, 120 kV, 3-mm slice thickness, and 0.8631 pitch. All images were viewed in mediastinal, pulmonary, and bone window settings and evaluated by a radiologist. The number, shape (circular, oval, and lobulated), location (segment), air-fluid levels within the lesions (intracavitary fluid), and other pulmonary and extrapulmonary injuries were recorded (Table 1, 2). Size measurements were obtained for craniocaudal and transverse diameters (Fig. 1).

Cavitary lesions that surrounded by parenchymal contusion were determined in different shapes (circular, oval, and lobulated ). The other reasons of cavitary lesions were excluded, and the lesions that rapidly changed pattern or resolved in the follow-up examinations without a specific treatment were diagnosed as TPP. The indication for tube insertion was determined by the presence of ≥10% pneumothorax or hemothorax in a hemithorax or presence of symptoms

of cardiac or pulmonary insufficiency. Patients with serious abdominal injuries underwent abdominal exploration. When large air leaks, mediastinal emphysema, or lobular atelectasis were detected, bronchoscopy was performed. Patients were admitted to the intensive care unit if life-threatening complications occurred. Chest X-rays were obtained daily during the hospitalization period, and patients were followed up with first-week, first-month, and third-month control chest X-rays.

The resolution time of pseudocysts was analyzed using the Kaplan–Meier curve, and deceased patients were excluded for this analyze. The log-rank test was used to compare recovery curves. The effects of size of TPP and intracavitary fluid on resolution time were analyzed using the Cox regression method.

RESULTS TPP was detected in 15patients (13 males, 2 females) after blunt chest trauma. Their average age was 26.33 (range, 1–89) years. The cause of TPP was traffic accidents in 13

Table 1. Extrathoracic injuries in patients with traumatic pulmonary pseudocyst Patient

Brain injury

Abdominal injury

Bone fracture

1

Subarachnoid hemorrhage

–

Lumbar vertebrae, scapula, and

pelvic bone fractures

2

–

Spleen laceration

Pelvic bone fracture

3

Subarachnoid hemorrhage

Retroperitoneal hematoma

Humerus, thoracic, and lumbar vertebrae fractures

4

–

–

Thoracal vertebrae fracture

5

Cerebral contusion, and subdural

–

Metacarpal, cervical, and

hemorrhage

thoracal

vertebrae fractures

6

Subarachnoid hemorrhage, and

Clavicular fracture

cerebral contusion

Spleen and pancreatic contusions

7

Femoral diaphysis fracture

8 –

–

–

Liver, kidney, and spleen laceration, and

–

9

–

renal and retroperitoneal hematomas

10

Scalp hematoma

Adrenal hematoma

Scapula and pelvic bone fractures

11

Subarachnoid and intraventricular

–

–

hemorrhages, calvarial, and maxillofacial

fractures, and pneumocephalus Retroperitoneal hematoma

–

12

Subarachnoid hemorrhage, and

calvarial fractures

13

–

–

Lumbar vertebrae fracture

14

–

Liver contusion, and right adrenal hemorrhage

Lumbar vertebrae fracture

15

–

–

Scapula fracture

50

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Hazer et al. Clinical features, diagnosis, and treatment of traumatic pulmonary pseudocysts

Table 2. Characteristics of traumatic pulmonary pseudocyst Patient

Number of cysts

Size of the biggest cyst (mm)

Location

Shape

1

11

2

5

11x12

Left lower lobe

Circular

7x8

Left upper lobe (4), Right lower lobe (1)

Circular

3 4

2

31x32

Right lower lobe

Lobulated

1

24x36

Right lower lobe

Oval

5 6

9

9x15

Left upper lobe (8), Right upper lobe (1)

Circular and oval

2

19x21

Left upper lobe

Circular

7

2

10x11

Left upper lobe

Circular

8

6

21x23

Right upper lobe (2), Left lower lobe (4)

Circular and lobulated

9

8

16x21

Right upper lobe (2), Right lower lobe (6)

Oval

10

2

9x15

Left lower lobe

Oval

11

7

14x18

Right upper lobe (3), Right lower lobe (4)

Oval and lobulated

12

4

17x18

Right upper lobe

Circular

13

2

6x12

Left upper lobe

Oval

14

4

13x27

Right upper lobe

Oval and lobulated

15

1

16x18

Right upper lobe

Lobulated

patients and falling from a height in two. The most common clinical symptoms were chest pain, dyspnea, and cough. Rib fractures were identified in 11 patients (Fig. 2), intracavitary fluid in eight (Fig. 3), hemopneumothorax in seven, and pneumothorax in four (Fig. 4). A chest tube was inserted in five patients, and none required thoracotomy (Table 3). TPPs were located in the left upper lobe in 5 patients, right upper lobe in six, and left lower lobe in three. Intracavitary fluid was observed in eight patients. The pseudocysts were classified as circular in seven patients, lobulated in five, and oval in seven.

Pseudocysts of both circular, oval and lobulated shapes were observed in four patients (Table 2). The size of the biggest Figure 2. Three oval-shaped cystic lesions seen in the right upper lobe (arrows). Air-fluid level can be seen in the cysts consistent with intracavitary fluid. Patchy hyperdense contusion areas surraund the cysts . Rib fracture can also be seen (curved arrow).

Figure 1. The cystic cavitary circular-shaped lesion in the right upper lobe posterior segment. Size measurement is shown (14Ă&#x2014; 17.7 mm). There is a hyperdense rim in the cystâ&#x20AC;&#x2122;s periphery due to contusion. Thin pneumothoraxis seen anteriorly (black arrow).

Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Figure 3. Oval-shaped hyperdense lesions seen in the right upper lobe posterior segment. The cysts are filled with blood (arrows).

Subcutaneous emphysema is seen (curved arrows).Contusion areas can be seen in both lung parenchymas.

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Hazer et al. Clinical features, diagnosis, and treatment of traumatic pulmonary pseudocysts (a)

Figure 4. Oval-shaped pseudocyst in the left lower lobe (black arrow). Intracavitary hemorrhage is seen in the cyst as air-fluid level.

Pneumothorax was seen on the left side (white arrow).

(b)

cyst measured was 36 mm and that of the smallest cyst was 6 mm (Table 2).

Radiological and clinical findings revealed other organ injuries in addition to lung injuries in 13 patients. Other radiological findings included bone fractures [scapula, clavicle, femoral diaphysis, pelvis, calvarium, maxillofacial, metacarpal, humerus, and vertebrae (cervical, thoracic and lumbar)]; lacerations of the liver, spleen, and kidneys; retroperitoneal, calvarial, adrenal, and subdural hematomas; subarachnoid and intraventricular hemorrhage; pneumocephalus; splenic and liver contusions; and perisplenic fluid (Table 1). Five patients died because of severe concomitant brain and abdominal injuries.

Ten patients recovered without any complications, and their pseudocysts resolved completely. An 18-year-old male patient required mechanical ventilation because of cranial injury.

Pneumonia occurred during follow-up in the intensive care

Figure 5. (a) Multiple circular-shaped pseudocysts in the left upper lobe anterior segment (thick black arrow). Smaller pseudocysts can also be seen in the left lung (thin black arrow). Hemothorax is seen (curved arrow). (b) 7 days after trauma consolidation, air bronchograms occurred in the patient (arrow). The clinical symptoms were consistent with pneumonia.

Table 3. Characteristics such as patient age, gender, etiology of trauma, thoracic posttraumatic findings, and chest tube insertion Patient Age Gender Trauma Pneumothorax Hemothorax

Sternum Rib Intracavitary fracture fracture fluid

Chest tube insertion

1

23

Female

Fall from height

+

+

–

+

+

+

2

6

Male

Traffic accident

+

–

–

+

–

–

3

28

Male

Traffic accident

–

+

–

+

+

–

4

30

Male

Traffic accident

–

–

+

–

–

–

5 22 Male Traffic accident +

+ + + + +

6 23 Male Traffic accident +

– – – – +

7

25

Male

Traffic accident

–

–

–

+

–

–

8

21

Male

Traffic accident

+

–

–

+

+

–

9

16

Male

Traffic accident

+

+

–

+

+

+

10

18

Male

Traffic accident

+

+

–

+

+

–

11

1

Female

Fall from height

+

–

–

–

–

–

12

89

Male

Traffic accident

+

+

–

+

+

+

13 26 Male Traffic accident –

– – – – –

14

41

Male

Traffic accident

+

+

–

+

+

–

15

26

Male

Traffic accident

+

+

+

+

–

–

52

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Hazer et al. Clinical features, diagnosis, and treatment of traumatic pulmonary pseudocysts

Resolutiontime Censored

1.0

Visible pseudocyst

0.8

0.6

0.4

0.2

0.0 .00

20.00

40.00

60.00 Time

80.00

100.00 120.00

Figure 6.Table shows the resolution time of the pseudocysts. The mean resolution time was 45.53 days, and the median resolution time was 56.0 days. (Visible Pseudocysts = percentage of patients, resolution time = days).

unit and antibiotic treatment was initiated (Fig. 5).

The mean resolution time was 45.53 days (24.3â&#x20AC;&#x201C;66.8 days, 95% confidence interval for mean), and the median resolution time was 56.0 days (Fig. 6). There was no correlation between cyst size and resolution time. Correlation between intracavitary fluid and resolution time was determined. Pseudocysts without fluid were resolved earlier (median, 56 days) than pseudocysts with fluid (median, 74 days; p=0.04).

infants, single or multiple well-demarcated cystic air collections can develop as a complication of mechanical ventilation.

[6] Some studies have explained that the reason for the higher frequency of TPPs in younger age groups is that the chest walls of younger patients are more compliant and permit greater transmission of impact to the lungs.[6] In our series, most of the patients (86%) were in the younger age group (â&#x2030;¤30 years), but the other two cases were 41 and 89 years old.

TPPs can be detected on chest X-rays as thin-walled cavities filled with air or with air-fluid levels if hemorrhage occurs.

They are mostly seen on chest X-rays as circular, oval, or lobulated cavitary lesions immediately adjacent to or within an area of contusion. The most characteristic feature of TPPs is that they change in size, shape, and nature within days. All patients had lung contusions, and in one patient, a control CT examination showed intracystic fluid (Fig. 7). TPPs were located in the left upper lobe (33%), right upper lobe (33%), left lower lobe (13%), and in both right upper and left lower lobes (7%). Rib fractures (73%), intracavitary fluid (53%), hemopneumothorax (46%), and pneumothorax (25%) were detected on the first radiological examination.

Thoracic CT is a sensitive method for the early detection of TPP and allows differential diagnosis of the lesion. A diagnosis of TPP can be confidently made in patients who develop the (a)

DISCUSSION In our study, TPPs were detected in 8.1% of patients with blunt chest traumas, and this rate was higher than that reported in the literature. Sudden shearing force across the pulmonary parenchyma leads to an area of pulmonary contusion and airtransfer from the airway to the contused area, which in turn results in pneumatocele formation. TPP is defined as an air-filled cavitary lesion without epithelial lining developing in the pulmonary parenchyma after blunt chest trauma. TPPs result from pulmonary parenchymal laceration as the initial event followed by normal elastic recoil of the surrounding lung with air trapping in the remaining cavity.[4] The moreelastic chest walls of young patients permit greater transmission of kinetic energy to the lung parenchyma; therefore, TPP is more common in pediatric and young adult patients. Because of rapid compression and decompression, lacerations occur and the cavities fill with air or blood.[5] TPP can develop after either blunt, penetrating, or barotrauma, and there is no significant difference between the proportions of patients with TPP with these trauma types. Particularly in Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

(b)

Figure 7. (a) Oval-shaped pseudocyst in the left upper lobe (arrow). (b) In the third day of trauma, control CT showed that the cyst filled with hemorrhage and seem as hyperdense parenchymal lesion (arrow).

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Hazer et al. Clinical features, diagnosis, and treatment of traumatic pulmonary pseudocysts

characteristic cystic lesion shortly after chest trauma occurs.

TPP is not always apparent in the first 48 h on chest X-rays.

Chest X-ray on the day of injury has a diagnostic yield of 33%–50% because of the lesions being too small and/or obscured by pulmonary contusion opacities.[6] In most cases, TPP is detectable on chest X-ray after a few days because by this time, the lung contusions have resolved to some degree or the TPPs have developed fully. Routine use of CT in cases of chest trauma will help in identifying lesions that are undetectable on chest X-rays. In addition, other cavitary pulmonary lesions, such as lung abscess, cavitary tuberculosis, mycosis, cancer, hematoma, bronchial cyst, and pulmonary sequestration, can easily be ruled out.[7] In cases of suspicion of bronchial or tracheal injury after blunt trauma, flexible bronchoscopy should be performed.

The most frequent clinical symptoms of TPP are tachypnea, cough, pain, and hemoptysis occurring within 12–36 h after trauma.[8] In our study, 60% of patients had chest pain, 40% had dyspnea, and 30% had cough.The 1-year-old female who was admitted because of a fall from a height was unconscious.

Chest tube was inserted in five patients. The indication for tube insertion was determined by the presence of ≥10% pneumothorax or hemothorax in a hemithorax. There was no enlargement of pseudocyst or progression of intracavitary fluid; therefore, none of patients required surgery due to pseudocyst.

None of the patients required thoracic exploration. Conservative treatment is considered to be a better choice for patients with TPP and includes follow-up; however, the occasional use of antibiotics to guard against secondary infection is controversial.[9] Although antibiotic prophylaxis is not routinely recommended, early antibiotic treatment is necessary if there is persistent fever, leukocytosis, radiographic features, intubation, mechanical ventilation, or other signs of an increased risk of infection.[1] We used prophylactic antibiotics for all patients, nevertheless pneumonia occurred in one patient who was intubated in the intensive care unit. Complications such as cardiopulmonary compression caused by progressive enlargement of a pseudocyst, superinfection, pneumothorax, hemothorax, and hemoptysis due to TPP rupture may occur.

Clinical deterioration has been shown to respond very successfully to radiographically guided percutaneous drainage. If drainage and coagulation are successfully restored and bleeding is controlled with minimally invasive approaches, surgical procedures may be prevented. Repeated bronchoscopies with airway toilet and kinetic therapy/postural drainage are alternative treatment initiatives during the early phase.[10] Kinetic therapy and postural drainage, even used prophylactically in multiple trauma patients whose injuries and pattern predispose to acute respiratory distress syndrome, have been shown to improve oxygenation in patients with impaired pulmonary function.[11,12] Double-lumen endotracheal intubation and embolization may be considered if bleeding originates from one lobe only. Surgery is rarely needed and is typically reserved for 54

cases in which percutaneous drainage is not feasible or not successful. Surgical management has traditionally taken the form of either tube insertion or thoracotomy with lobectomy.

[9] In our study, only 33% of patients required tube insertion and none underwent thoracotomy.

Chon’s study showed significant differences in resolution times between cysts <2 cm and those >2 cm, as well as between blood-filled pseudocysts and uncomplicated pseudocysts. The complete resolution time ranged between 9 and 305 days.[10] Some studies determined that TPP complications developed between 1 and 9 days (especially within 5 days) after trauma; therefore, close follow-up is necessary for the first 5 days for possible complications.[6] In our series, pneumothorax occurred in two patients on the second day. There was no correlation between cyst size and resolution time.

Correlation between intracavitary fluid and resolution time was determined. Pseudocysts without fluid were resolved earlier (median, 56 days) than pseudocysts with fluid (median, 74 days). Number of cysts and presence of intracavitary hemorrhage did not affect the complication rates.

After blunt chest trauma, TPP can occur rarely and usually resolves within 1–4 (average, 1.8) months.[7] Atelectatic areas or fibrous scars can persist when the pseudocyst doesnot entirely resolve. Thoracic CT is superior to chest X-ray for identifying cysts within contusions. The correct diagnosis of TPP with radiological imaging can help the physician prevent complications and avoid unnecessary interventions. Typically, the prognosis is good for TPP and its unusual complications.

TPPs are seen after high-energy trauma, so the radiologist and physician must be aware of other systemic injuries. Chest X-ray is usually sufficient for follow-up in most patients with TPP, but in complicated cases, CT is the best choice for complications such as hemorrhage, infection, abscess formation, and rupture.

In our patients, most of the lesions were located in a subpleural parenchyma near the chest wall where rib fractured and swelling of soft tissue or subcutaneous emphysema was observed. In our series, 12 lesions (22.6%) had an irregular shape, which was different from all TPPs that have a round or oval shape as reported in the literature. Five lesions with irregularly shaped images were confirmed in this study by coronal planar reformation images. The mean size of the lesions in our patients was 1.8 cm, which was smaller than that reported in the literature (average, 2–10 cm). All irregular lesions were >2 cm in size in our study. The sizes of TPPs with irregular shape (mean, 3.5 cm) were significantly larger than those with oval shape (mean, 1.5 cm). This could be related to the presence of disrupted interlobular septum in the irregularly shaped lesions.

In conclusion, the incidence of TPPs in our study is higher than that reported in previous studies. CT can accurately demonstrate the characteristics of the lesions and complicaUlus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Hazer et al. Clinical features, diagnosis, and treatment of traumatic pulmonary pseudocysts

tions. Irregularly shaped cavities were significantly larger than those with an oval shape, and air-filled pseudocysts resolved more quickly than those containing fluid. Patients with TPP with pneumothorax, hemothorax, or both can be treated with drainage and/or surgical hemostasis instead of TPP resection. Patients with TPP without these complications may recover without treatment. TPP does not require follow-up CT scan or intervention in the absence of complications.

Conflict of interest: None declared.

REFERENCES 1. Zheng Z, Pan Y, Guo F, Pan T, Li J. Traumatic pulmonary pseudocyst: a rare but noteworthy entity. Am Surg 2011;77:1098–100.

2. Tsitouridis I, Tsinoglou K, Tsandiridis C, Papastergiou C, Bintoudi A. Traumatic pulmonary pseudocysts: CT findings. J Thorac Imaging 2007;22:247–51.

3. Kocer B, Gulbahar G, Gunal N, Dural K, Sakinci U. Traumatic pulmonary pseuodocysts: two case reports. J Med Case Rep 2007;1:112.

4. Melloni G, Cremona G, Ciriaco P, Pansera M, Carretta A, Negri G, et al.

Diagnosis and treatment of traumatic pulmonary pseudocysts. J Trauma 2003;54:737–43.

5. Koç I. Traumatic pulmonary pseudocyst: A case report. J Clin Exp Invest

2014;5:304–6.

6. Ulutas H, Celik MR, Ozgel M, Soysal O, Kuzucu A. Pulmonary pseudocyst secondary to blunt or penetrating chest trauma: clinical course and diagnostic issues. Eur J Trauma Emerg Surg 2015;41:181–8.

7. Shin MS, Ho KJ. Computed tomography evaluation of posttraumatic pulmonary pseudocysts. Clin Imaging 1993;17:189–92.

8. Van Hoorebeke E, Jorens PG, Wojciechowski M, Salgado R, Desager K, Van Schil P, et al. An unusual case of traumatic pneumatocele in a nine-year-old girl: a bronchial tear with clear bronchial laceration. Pediatr Pulmonol 2009;44:826–8.

9. Jackson CC, Bettolli M, De Carli C, Rubin S, Sweeney B. Thoracoscopic treatment of a neonatal traumatic pneumatocele. J Laparoendosc Adv Surg Tech A 2008;18:170–3.

10. Chon SH, Lee CB, Kim H, Chung WS, Kim YH. Diagnosis and prognosis of traumatic pulmonary psuedocysts: a review of 12 cases. Eur J Cardiothorac Surg 2006;29:819–23.

11. Steinhausen E, Bouillon B, Yücel N, Tjardes T, Rixen D, Paffrath T, et al. Nonoperative management of post-traumatic pulmonary pseudocyst after severe thoracic trauma and hemorrhage by coagulation management, kinetic therapy, and control of secondary infection: a case report. J Trauma 2007;63:1391–4.

12. Staudinger T, Kofler J, Müllner M, Locker GJ, Laczika K, Knapp S, et al. Comparison of prone positioning and continuous rotation of patients with adult respiratory distress syndrome: results of a pilot study. Crit Care Med 2001;29:51–6.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Travmatik pulmoner psödokistlerde klinik özellikler, tanı ve tedavi yöntemleri Dr. Seray Hazer,1 Dr. Umut Perçem Orhan Söylemez2 1 2

Atatürk Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi, Göğüs Cerrahisi Kliniği, Ankara Bingöl Devlet Hastanesi, Radyoloji Kliniği, Bingöl

AMAÇ: Travmatik pulmoner psödokistler künt göğüs travmalarının nadir komplikasyonlarıdır. Çalışmamızın amacı, bu nadir durumun komplikasyonlarından kaçınmak ve doğru tedavi yaklaşımını tespit etmek üzere 15 olgunun radyolojik ve klinik parametrelerle değerlendirilmesidir.

GEREÇ VE YÖNTEM: Temmuz 2014–Aralık 2015 tarihleri arasında kliniğimizde toraks travması nedeniyle takip edilen 185 hastanın bilgileri ve radyolojik görüntüleri geriye dönük olarak değerlendirildi.

BULGULAR: Travmatik pulmoner psödokist tespit edilen 15 hastanın klinik özellikleri ve görüntüleme bulguları değerlendirildi. Ortalama yaş 26.33’dü (1–89 yaş). On üç olguda etiyolojide trafik kazası sorumlu iken iki olguda yüksekten düşme sonrası gelişmişti. Beş olguda tüp torakostomi uygulandı. Olguların %66’sı komplikasyonsuz iyileşti ve hiçbir olguda torakotomi gereksinimi olmadı. Beş olgu, eşlik eden toraks dışı ciddi yaralanmaya bağlı olarak kaybedildi.

TARTIŞMA: Pnömotosel formasyonu akciğer parankiminde meydana gelen ani makaslama gücü etkisiyle parankimde kontüzyon gelişmesi ve kontüzyon alanından ani hava çıkışıyla oluşmaktadır. Bu hastalarda önerilen tedavi yaklaşımı konservatif olmakla birlikte kist rüptürüne bağlı komplikasyonlar gelişebilir. Hastalar yakın takip edilmelidirler ve hayatı tehdit eden komplikasyonlar açısından dikkatli olunmalıdır.

Anahtar sözcükler: Bilgisayarlı tomografi; künt göğüs travması; pnömotosel; travmatik pulmoner psödokist.

Ulus Travma Acil Cerrahi Derg 2018;24(1):49–55

doi: 10.5505/tjtes.2017.56023

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ORIG I N A L A R T IC L E

Analyses of combat-related injuries to the maxillofacial and cervical regions and experiences in an operational field hospital Mehmet Burak Aşık, M.D.,1 Sinan Akay, M.D.,2 Sami Eksert, M.D.3 1

Department of Otolaryngology and Head& Neck Surgery, Gülhane Training and Research Hospital, Ankara-Turkey

2

Department of Radiology, Dr. Aşkım Tüfekçi State Hospital, Adana-Turkey

3

Department of Anesthesiology and Reanimation, Gülhane Research and Training Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: With the changing conditions of war, maxillofacial injuries are observed more frequently. Particularly in urban areas, high-energy explosive devices (HEEDs), such as improvised explosive devices, are often used alongside long-barreled weapons (LBWs). It is important to use trauma scoring systems and a multidisciplinary approach for medically and accurately responding to the trauma patient in a timely manner. This study aimed to compare the Military Combat Injury Scale (MCIS) and Military Functional Incapacity Scale (MFIS) between injuries sustained by LBWs or HEEDs and to share experiences of an operational field hospital.

METHODS: Medical data of 84 patients admitted to an operational field hospital with maxillofacial and cervical injuries sustained

by LBWs and HEEDs between July 27, 2015, and July 22, 2016 were reviewed. MCIS and MFIS scores were calculated for all patients; records of the qualifying patients were studied for the Glasgow Coma Scale (GCS) scores and injury sites. The patients were divided into two groups according to the device/weapon causing the injury: injuries sustained by LBWs in group I and those sustained by HEEDs in group II. RESULTS: All patients were males, with a mean age of 28.75 (range 20–58) years. The average GCS score was 13.4, but it was lower than 15 in 16 (19%) of the patients. There was no statistically significant difference in MCIS scores between the LBW and HEED groups (p=0.206). In addition, there was no statistically significant difference in MFIS scores between the LBW and HEED groups (p=0.238).

CONCLUSION: Maxillofacial and cervical region injuries are increasing in modern conflicts that are usually located in urban areas.

Injuries sustained by HEEDs as well as those sustained by LBWs in the maxillofacial area are morbid and mortal. Rapid and comprehensive intervention is life-saving and helping the patient to further trauma treatment.

Keywords: High-energy explosive device; maxillofacial trauma; trauma; trauma scoring system.

INTRODUCTION Maxillofacial and cervical injuries are common in both civilian and military trauma settings. The importance of having specialized surgeons to deal with the head, face, and neck was observed during the First World War.[1] More recently, Dobson et al.[2] noted that head and neck injuries are more common during terrorist attacks than during conventional modern warfare. Recent literature from the contemporary

theaters of conflict in Iraq and Afghanistan has reported an increase in maxillofacial injuries, ranging from 26% to 36%.[3,4] This increase may be influenced by the use of modern combat body armor and nature of asymmetrical warfare in urban areas. According to Kosashvili et al.,[5] even with modern body armor, the maxillofacial and cervical region has the highest rate of penetrating wounds from shrapnel, creating a vulnerable anatomical area. Overall, the incidence of penetrating head and neck trauma has been increasing in modern combat.

Cite this article as: Aşık MB, Akay S, Eksert S. Analyses of combat-related injuries to the maxillofacial and cervical regions and experiences in an operational field hospital. Ulus Travma Acil Cerrahi Derg 2018;24:56-60 Address for correspondence: Mehmet Burak Aşık, M.D. Gülhane Eğitim ve Araştırma Hastanesi, KBB ve Baş-Boyun Cerrahisi Kliniği, Ankara, Turkey.

Tel: +90 312 - 304 57 10 E-mail: burock312@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(1):56–60 DOI: 10.5505/tjtes.2017.75333 Submitted: 17.03.2017 Accepted: 12.05.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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The body armor currently employed effectively protects the chest and abdomen, but leaves the face and neck exposed, resulting in a shift toward increased head and neck injuries.[5,6] Major causes of facial combat injuries include blasts, high-velocity/high-energy missiles, and low-velocity missiles. Blasts caused by high-energy explosive devices (HEEDs) [improvised explosive devices (IEDs), projectile missiles, etc.] often contain metal fragments, with hundreds of metal pellets.

[2,6] Those combatants who are closest to the explosion are exposed to morbid and mortal injuries.[6] Moreover, longbarreled weapon (LBW) injuries to the face and neck often create major resuscitation and surgical problems. In the case of an injury sustained by LBW to the face, early operative management of the injured soft and skeletal tissues of the face is related to less morbidity and mortality.[7]

Table 1. Components of the Military-spesific Combat Injury Scale (MCIS) MCIS Injury Severity Score

Description

1 Minor 2 Moderate 3 Serious 4 Severe 5

Likely Lethal

Table 2. Components of the Military Functional Incapacity Scale Associated MCIS Score MFIS Score Description

Early evacuation of the injured patient to an operational field hospital to undergo a multidisciplinary approach for trauma is a vital part of the treatment for patients who have suffered from ballistic trauma. The main areas in which disputes do exist are the surgical timing, necessity of surgery, and trauma evaluation.

1

1

Able to continue mission

2

2

Able to contribute to

This study aimed to compare the Military Combat Injury Scale (MCIS) and Military Functional Incapacity Scale (MFIS) severity scores of maxillofacial and cervical injuries due to LBWs and HEEDs in a combat area. In addition, injury patterns and demographic data of the patients admitted to the emergency department of an operational field hospital were reviewed.

MCIS: Military Combat Injury Scale; MFIS: Military Functional Incapacity Scale.

MATERIALS AND METHODS Review board approval was obtained for this retrospective study. Medical data of 84 patients admitted to an operational field hospital with maxillofacial and cervical injuries from LBWs and HEEDs between July 27, 2015, and July 22, 2016, were reviewed. Cases were gathered during military operations against terrorist groups in the southeastern part of Turkey, and all patients were soldiers or police officers. MCIS and MFIS scores were calculated for all patients, and records of the qualifying patients were studied for the Glasgow Coma Scale (GCS) scores and injury sites. The patients were divided into two groups according to the device/weapon causing the injury: injuries caused by LBWs in group I and those caused by HEEDs in group II. The injury sites were sorted by and defined anatomically as the upper third of the face, middle third of the face, lower third of the face, and cervical region. The extent of the injury was graded according to MCIS as follows: 1 = minor, 2 = moderate, 3 = serious, 4 = severe, and 5 = likely lethal.[8] In this study, the patients were also evaluated according to MFIS as follows: 1 = able to continue mission, 2 = able to contribute to sustaining the mission, 3 = lost to mission, and 4 = lost to military.[8] MCIS and MFIS scores are shown in Table 1 and 2.

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sustaining mission

3–4

3

Lost to mission

4–5

4

Lost to military

Statistical Analysis Gathered data were analyzed using SPSS 15.0 software for Windows (IBM, Chicago, Illinois, USA). Variables were investigated using visual methods (histograms and probability plots) and analytical methods (Kolmogorov–Smirnov and Shapiro–Wilk’s tests) to determine whether or not they were distributed normally. The descriptive analyses were presented using the mean±standard deviation for normally distributed variables. The Student’s t-test was used to compare these parameters between MCIS severity scores and MFIS scores of patients who have suffered from trauma due to HEED and LBW. A p-value of <0.05 was considered to show a statistically significant result.

RESULTS Severity Scores Eighty-four patients were included in this study. All patients were males, with a mean age of 28.75 (range, 20–58) years.

The average GCS score was 13.4, but it was lower than 15 in 16 (19%) of the patients. The mean MCIS score was 1.91, the median was 2, and there was no statistically significant difference between the LBW and HEED groups (p=0.206) (Table 3). The mean MFIS score was 1.85, the median was 1, and there was no statistically significant difference between the LBW and HEED groups (p=0.238) (Table 3).

Injury Pattern Of the patients with injuries isolated only to the face, 40% (n=20) were injuries sustained by HEEDs and 73% (n=25) 57

Aşık et al. Analyses of combat-related injuries to the maxillofacial and cervical regions and experiences in an operational field hospital

were those sustained by LBWs in a total of 45 patients. In injuries sustained by HEEDs, the most commonly associated cervicofacial region was the middle third of the face, which was injured in 23/50 patients (46%), whereas the upper third of the face was affected in 13/50 HEED patients (26%). In injuries sustained by LBWs, the most commonly associated cervicofacial region was the cervical region, which was injured in 14/34 patients (41%). The least frequently fractured bony complex in the patients in the HEED group was the mandibula (eight cases) (16%), whereas the upper 1/3 and the middle 1/3 parts of the face (six cases for each) (17%) were the least commonly fractured bony complexes of the cervicofacial region in the LBW group. Table 4 shows the injury site and causation totals.

Figure 1. Maxillomandibular fracture. Image of bleeding control, soft tissue repair, and tracheotomy.

Surgical Workload Seventy-nine of the patients with cervicofacial injuries sustained by HEEDs or LBWs survived (94%). The mean and median MCIS severity scores of the decedents (n=5) with multiple injury sites, particularly the thorax and head, were both 4. In the decedents, the mean Abbreviated Injury Scale (AIS) score was 4.6 (3, 4, 6, 6, and 4 for the five patients, respectively), with one patient among these in whom the MCIS score was 2 and the AIS score was 3. Two of the decedents were injured by LBWs and three were injured by HEEDs. The mean AIS score of the survivors was 1.3 (median 1), with one unexpected survivor with an AIS score of 5.

Maxillofacial or cervical surgeries were required in 39% (n=33) of the 84 patients with cervicofacial injuries at the operational field hospital. Sixteen of these 33 patients required surgical interventions under general anesthesia for primarily Table 3. Distribution of cases according to their Militaryspecific Combat Injury Scale and Military-specific Functional Injury Scale

Number of cases

MCIS

MFIS

Mean±SD Mean±SD

LBW

34

2.08±1.16 2.01±1.01

HEED

50

1.80±0.90 1.76±0.82

Total

84

1.91±1.02 1.85±0.91

MCIS: Military-spesific Combat Injury Scale; MFIS: Military Functional Incapacity Scale; LBW: Long barreled weapon; HEED: High-energy explosive device; SD: Standard deviation.

Figure 2. Image of the intrabuccal region sharpnel. Excision of the shrapnel from the face and primary soft tissue repair was performed.

bleeding control, soft tissue repair, airway security, and maxillofacial reconstruction (Fig. 1). Surgeries were performed in 17 patients for minimal bleeding control, excision of shrapnel from the face, and debridement or primary soft tissue repair of cervicofacial wounds (Fig. 2). Of these, only 12 required additional reconstructive surgery and were evacuated to an advanced hospital for further treatment.

Thirty-seven patients (46% of the survivors) with minor injuries were discharged from the field hospital and returned to military duty. Thirty patients were discharged for a period of rest because of other medical problems. Hospitalization was necessary in 83% (n=70) of the patients, with 17% (n=12) of the hospitalized patients requiring stays in the intensive care unit.

DISCUSSION Although AIS is the most commonly used trauma scoring system by injury researchers, MCIS and MFIS, which were described by Lawnick et al.[8] in 2013, are currently and increas-

Table 4. Distribution of maxillofacial injuries according to the injury pattern and their localization

Upper 1/3 of face

Middle 1/3 of face

Lower 1/3 of face

Cervical

Total

Long barreled weapon

6

6

8

14

34

High-energy explosive device

13

23

8

6

50

Total

19

29

16

22 84

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ingly used for classifying and defining military-related injuries.

[9] Lawnick et al.[8] noted that MCIS showed superior performance compared with AIS because its source was rooted in combat injury databases. In addition, Wordsworth et al.[10] concluded that AIS cannot predict the need for reconstructive surgery for combat-related maxillofacial injuries. The development of MCIS and MFIS included five combat body regions, injury severity along a five-point scale, injury descriptions for a spectrum of combat-related injuries, and injury description codes.[8] Moreover, MFIS was based on military functional capacity in a process relevant to MCIS. Despite this previous research, there remains a controversy with regard to which is the best trauma scoring scale.

In the present study, it was concluded that the combat-related maxillofacial and cervical HEED injury severity scores were as high as the LBW injury severity scores. There was no statistically significant difference between the HEED and LBW groups with regard to MCIS scores (p=0.206).

Wordsworth et al.[10] concluded that the maxillofacial region is commonly injured during blasts. Similarly, in this study on modern conflicts, which occur in narrow places and near urban areas, maxillofacial and cervical injuries are commonly observed because of the use of HEEDs like IEDs. Therefore, maxillofacial and cervical injuries sustained by HEEDs are as important as injuries sustained by LBWs. In addition, there was no significant difference between injuries sustained by HEED and those sustained by LBWs with regard to MFIS scores (p=0.238). Injuries sustained by both HEEDs and by LBWs decreased functional capacities of the combatants in the combat area. Moreover, there were few publications evaluating trauma scoring and comparing maxillofacial and cervical injuries sustained by HEEDs and LBWs in the literature.

The results of this study showed that more than half of the injuries sustained to the cervicofacial region from a blast or penetrating injuries were relatively minor and managed by a single procedure in the field hospital. We also found that in the patients with trauma sustained by HEEDs, the maxilla was the most frequently fractured bony complex. However, the cervical region was the most injured region of the face and neck in injuries sustained by LBWs. This difference could be explained by the ballistic rules and the use of a ballistic guard apparatus. In HEED explosions, the upper and lower thirds of the face are protected with a ballistic helmet and a reflexive maneuver of the neck to avoid the blast. Therefore, the blast eruption and materials directly affect the middle third of the face. Similarly, Levin et al.[11] reported that most battlefield injuries in their study (44%) also involved the maxilla. Moreover, Breeze et al.[12] and Feldt et al.[13] found that the maxilla sustained the most injuries in their studies on >15,000 patients who had suffered from trauma. When an injury is sustained by an LBW (gunshot), there is no time to react with an avoidance maneuver and no guard apparatus for the neck. Therefore, the overall mortality rate was 6% (n=5), and our findings suggested that mortality was assoUlus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

ciated with systemic or complex injuries. In our study, no deaths occurred from isolated cervicofacial combat-related injuries. Similar to our results, Norris et al.[14] found that systemic injuries, rather than isolated facial injuries, affected the mortality rate.

Much of the literature suggests that early intervention is necessary for patients who have suffered from maxillofacial and cervical trauma.[6,10,12,14–16] Similarly, we suggest that primary life-saving procedures should be performed in the operational field hospital along with a multidisciplinary evaluation of the patient and surgical procedures for hemorrhage, splint stabilization, or rigid fixation of the facial bony framework; closure of the primary soft tissue; and securing the airway. The standard ABCs of trauma care should apply to the patients with maxillofacial and cervical injuries, and the primary goal of treatment for maxillofacial injuries is early conservative repair, with an emphasis on symmetrical and functional facial contours.[17] Overall, an airway assessment is the first priority in the management of maxillofacial and cervical trauma.[14,18] Common indications for a surgical airway intervention are massive or minimal hemorrhage, glottic edema (as observed with inhalation injuries), and maxillofacial skeletal trauma.

[16] A facial laceration repair with a soft tissue approximation was the most common head and neck procedure in our operational field hospital. Based on Brennan’s[15] study on 298 patients from the Iraq and Afghanistan conflicts, we suggest that the soft tissue can be closed immediately after extensive irrigation and conservative debridement. When the patient is hemodynamically stabilized, multidisciplinary evaluation of the patient who has suffered from trauma should be performed and comprehensive treatment plan should be made.[16] The limitations of this study included the lack of ability to confirm the information with the radiological and operative records of patients who have suffered from maxillofacial and cervical trauma, and the effective categorization of the injuries via trauma coding systems. Data analyzed for this study showed that a few of primary records of the patients were insufficient for the forensic and medical evaluations. Moreover, there was a lack of complete data on the post-injury complications and comprehensive treatment of these patients.

Conclusion The maxillofacial and cervical regions are the most commonly injured sites in modern conflicts, which are usually located in urban areas. Blast injuries due to IEDs, which are a form of injury sustained by HEEDs, are currently seen quite often in these conflicts. Because of the huge blast effects of these injuries, trauma scoring systems should be used for further evaluation of the patients to predict the extent of reconstructive surgery that may be required for functional and esthetic morbidity of combat-related injuries to the maxillofacial region. Early and accurate medical and surgical interventions in maxillofacial and cervical injuries secondary to HEEDs or 59

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LBWs may lower the rates of morbidity and subsequent disfigurement, and preserve the esthetic architecture, making future reconstruction possible.

Trauma Acute Care Surg 2013;75:573–81.

9. Champion HR, Holcomb JB, Lawnick MM, Kelliher T, Spott MA, Galarneau MR, et al. Improved characterization of combat injury. J Trauma 2010;68:1139–50.

10. Wordsworth M, Thomas R, Breeze J, Evriviades D, Baden J, Hettiaratchy S. The surgical management of facial trauma in British soldiers during combat operations in Afghanistan. Injury 2017;48:70–74.

Conflict of interest: None declared.

REFERENCES 1. Tong D, Beirne R. Combat body armor and injuries to the head, face, and neck region: a systematic review. Mil Med 2013;178:421–6.

2. Dobson JE, Newell MJ, Shepherd JP. Trends in maxillofacial injuries in war-time (1914-1986). Br J Oral Maxillofac Surg 1989;27:441–50.

3. Owens BD, Kragh JF Jr, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. J Trauma 2008;64:295–9.

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

5. Kosashvili Y, Hiss J, Davidovic N, Lin G, Kalmovic B, Melamed E, et al. Influence of personal armor on distribution of entry wounds: lessons learned from urban-setting warfare fatalities. J Trauma 2005;58:1236– 40.

6. Salinas NL, Brennan J, Gibbons MD. Massive facial trauma following improvised explosive device blasts in Operation Iraqi Freedom. Otolaryngol Head Neck Surg 2011;144:703–7.

7. Glapa M, Kourie JF, Doll D, Degiannis E. Early management of gunshot injuries to the face in civilian practice. World J Surg 2007;31:2104–10.

8. Lawnick MM, Champion HR, Gennarelli T, Galarneau MR, D’Souza E, Vickers RR, et al. Combat injury coding: a review and reconfiguration. J

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

12. Breeze J, Gibbons AJ, Hunt NC, Monaghan AM, Gibb I, Hepper A, et al. Mandibular fractures in British military personnel secondary to blast trauma sustained in Iraq and Afghanistan. Br J Oral Maxillofac Surg 2011;49:607–11.

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

14. Norris O, Mehra P, Salama A. Maxillofacial Gunshot Injuries at an Urban Level I Trauma Center-10-Year Analysis. J Oral Maxillofac Surg 2015;73:1532–9.

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

16. Keller MW, Han PP, Galarneau MR, Brigger MT. Airway management in severe combat maxillofacial trauma. Otolaryngol Head Neck Surg 2015;153:532–7.

17. Cunningham LL, Haug RH, Ford J. Firearm injuries to the maxillofacial region: an overview of current thoughts regarding demographics, pathophysiology, and management. J Oral Maxillofac Surg 2003;61:932–42.

18. McLean JN, Moore CE, Yellin SA. Gunshot wounds to the face-acute management. Facial Plast Surg 2005;21:191–8.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Maksillofasiyal ve servikal bölgelerde savaşa bağlı yaralanmaların analizi ve operasyonel saha hastanesindeki deneyimler Dr. Mehmet Burak Aşık,1 Dr. Sinan Akay,2 Dr. Sami Eksert3 1 2 3

Gülhane Eğitim ve Araştırma Hastanesi, KBB ve Baş-Boyun Cerrahisi Kliniği, Ankara Dr. Aşkım Tüfekçi Devlet Hastanesi, Radyoloji Kliniği, Adana Gülhane Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Ankara

AMAÇ: Savaşın değişen şartları ile maksillofasiyal yaralanmalar daha sık görülmeye başlandı. Özellikle kentsel alanlarda, el yapımı patlayıcı gibi yüksek enerjili patlayıcı cihazlar, uzun namlulu silahların yanında sıklıkla kullanılmaktadır. Travma hastasına zamanında tıbbi ve doğru tepki verebilmek için travma puanlama sistemleri ve çok disiplinli yaklaşım kullanılması önemlidir. Bu çalışmada, uzun namlulu silahlar ya da yüksek enerjili patlayıcı cihazlar tarafından oluşan yaralanmalar arasında Askeri Yaralanma Ölçeği (MCIS) ve Askeri İşlevsellik Arızası Ölçeği (MFIS) karşılaştırıldı ve operasyonel saha hastanesinin deneyimleri paylaşıldı.

GEREÇ VE YÖNTEM: 27 Temmuz 2015 ile 22 Temmuz 2016 tarihleri arasında uzun namlulu silah (LBW) ve yüksek enerjili patlayıcılardan (HEED) kaynaklı maksillofasiyal ve servikal yaralanmaları sebebi ile operasyon hastanesine başvuran 84 hastanın tıbbi verileri gözden geçirildi. Tüm hastalar için MCIS ve MFIS skorları hesaplandı ve nitelikli hastaların kayıtları Glasgow Koma Ölçeği (GKS) skorları ve hasar alanları için değerlendirildi. Hastalar yaralanmaya neden olan cihaza/silaha göre iki gruba ayrıldı: I. grup LBW ve II. gruptaki HEED olarak belirlendi.

BULGULAR: Hastaların tümü erkekti ve yaş ortalaması 28.75 idi (20–58). Ortalama GKS skoru 13.4 iken, 16 hastada (%19) 15’ten düşüktü. LBW ve HEED grupları arasında MCIS skorlarında istatistiksel olarak anlamlı farklılık yoktu (p=0.206). Ek olarak LBW ve HEED grupları arasında MFIS skorlarında istatistiksel olarak anlamlı farklılık yoktu (p=0.238).

TARTIŞMA: Maksillofasiyal ve servikal bölge yaralanmaları, çoğunlukla kentsel alanlarda bulunan modern çatışmalara daha çok girmeye başlamıştır.

Yüksek enerjili patlayıcı cihazların yol açtığı yaralanmalar, maksillofasiyal alanda uzun namlulu silahların neden olduğu yaralanmalar kadar morbid ve ölümcüldür. Hızlı ve kapsamlı müdahale, hayat kurtarıcıdır ve hastanın ileri travma tedavisine yardımcı olur.

Anahtar sözcükler: Maksillofasyal travma; travma; travma skorlama sistemi; yüksek enerjili patlayıcılar.

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ORIG I N A L A R T IC L E

Operative and non-operative management of children with abdominal gunshot injuries Mehmet Şerif Arslan, M.D.,1 Hikmet Zeytun, M.D.,1 Serkan Arslan, M.D.,1 Erol Basuguy, M.D.,1 Mehmet Hanifi Okur, M.D.,1 Bahattin Aydoğdu, M.D.,1 Cemil Göya, M.D.,2 İbrahim Uygun, M.D.,1 Selçuk Otçu, M.D.1 1

Department of Pediatric Surgery, Dicle University Faculty of Medicine, Diyarbakır-Turkey

2

Department of Radiology, Dicle University Faculty of Medicine, Diyarbakır-Turkey

ABSTRACT BACKGROUND: Non-operative management (NOM) is a standard treatment method for solid organ injuries worldwide. There is no consensus on the management of gunshot wounds (GSW) because of the higher frequency of hollow viscus injuries (HVI) and the unpredictable depth of tissue damage produced by kinetic energy transfer during retardation of the bullet. Here we aimed to reevaluate indications for surgery and NOM based on our pediatric patients with abdominal GSW. METHODS: We performed a retrospective analysis of patients evaluated and treated for abdominal GSW at University of Dicle between January 2010 and October 2016. Patients with hemodynamic instability, signs of peritonitis on serial abdominal examination, and free air in the abdomen underwent laparotomy; these were included in group I (n=17). Patients managed non-operatively were included in group II (n=13).

RESULTS: Our statistical analysis showed significantly lower Hb levels and systolic blood pressure levels (p<0.001) and higher pulse rate, higher mean injury severity score, and longer length of stay at intensive care unit in patients in group I than in those in group II (p<0.001). We further detected colon perforation (n=10) and small bowel perforation (n=7) in patients in group I; liver laceration (n=4), splenic injury (n=1), and renal injury (n=3) but no solid organ injury or HVI (n=5) were detected in patients in group II. CONCLUSION: The major drawback of NOM is the difficulty in diagnosing HVI in abdominal GSW, which may delay treatment. We suggest that patients with solid organ damage who are hemodynamically stable and exhibit no signs of peritonitis upon serial abdominal exam may be treated with NOM. Keywords: Children; gunshot injuries; hollow viscus injuries; non-operative management.

INTRODUCTION The incidence of penetrating trauma due to firearms has significantly increased worldwide.[1,2] Injuries due to firearms are the second leading cause of pediatric trauma deaths in the United States.[3] Although non-operative management (NOM) is a standard treatment method for solid organ injuries after blunt trauma, there is no consensus on its utility in managing penetrating gunshot wounds (GSW). Laparotomy is generally preferred among surgeons in cases of GSW because of

the possibility of organ damage resulting from unpredictable kinetic energy transfer during passage and retardation of the bullet, which results in a higher frequency of hollow viscus injuries (HVI) and more difficulty in accurately diagnosing HVI, and thus there is a greater potential for treatment delays more than blunt trauma.[4,5] In the present study, we aimed to re-evaluate indications for surgery in pediatric patients with GSW and to determine the effectiveness of non-operative treatment of solid organ damage after exclusion of HVI, using NOM criteria.

Cite this article as: Arslan MŞ, Zeytun H, Arslan S, Basuguy E, Okur MH, Aydoğdu B, et al. Operative and non-operative management of children with abdominal gunshot injuries. Ulus Travma Acil Cerrahi Derg 2018;24:61-5 Address for correspondence: Mehmet Serif Arslan, M.D. Dicle Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Diyarbakır, Turkey.

Tel: +90 412 - 248 80 01 E-mail: md.msarslan@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(1):61–65 DOI: 10.5505/tjtes.2017.15359 Submitted: 26.12.2016 Accepted: 28.04.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Arslan et al. Operative and non-operative management of children with abdominal gunshot injuries

MATERIALS AND METHODS We performed a retrospective analysis of patients evaluated and treated for GSW at Dicle University Emergency Department between January 2010 and October 2016. The study was approved by the Dicle University Ethics Committee.

Patients included in the study were aged <17 years with abdominal GSW, where the bullet track was directly intra-abdominal and/or where the bullet track was observed to be adjacent to the intra-abdominal area, but high-density fluid was noted in the pelvis. Patients with head and extremity injuries were excluded from the study. After initial evaluation at the emergency department, all patients underwent computed tomography (CT). CT images were interpreted by a radiology specialist according to the following criteria for abdominal evaluation: 1) free air in the abdomen and/or retroperitoneum, 2) free fluid in the pelvis without solid organ injury, 3) bullet track injuries, 4) intraperitoneal contamination, and 5) bowel wall thickening. Immediate laparotomy was planned for all patients who fit at least two of the above criteria with ongoing hemodynamic instability and peritonitis (Fig. 1, 2).

The patients were divided into two groups. Patients with hemodynamic instability, signs of peritonitis on serial abdominal examination, and free air in the abdomen were included in group I and underwent emergent laparotomy. Stable patients without the above-mentioned signs were included in group

II and managed non-operatively (Fig. 3). Patients were analyzed by age, sex, hemoglobin (Hb) levels at admission, blood pressure, pulse rate, cause of injury, mean injury severity score (ISS), length of stay in the intensive care unit (ICU), and mortality and morbidity criteria. Data were statistically analyzed using Statistical Package for the Social Sciences (SPSS) (Windows 10.0, SPSS Inc., Chicago, IL) to determine significant factors affecting NOM. For comparisons of incidences for univariate analyses, Chi-square or Fisher’s exact test were used, whereas the independent t-test or Mann–Whitney U test was used to compare the values. p-value < 0.05 was considered to be statistically significant.

RESULTS We studied medical records of 302 patients who were initially admitted to the emergency department with GSW. After retrospective analysis, 30 patients (10.1%) were included in our study based on their relevance to our criteria. The mean age of our patients was 10.4±3.8 (4–16) years. Twenty-three (76.6%) were males and 7 (23.3%) were females. Seventeen (56.6%) of the 30 patients were operable and included in group I (Table 1). Thirteen (43.3%) patients were managed

by NOM and included in group II. The mean time from admission to surgery was 6.4±12.5 (1–48) h. Colon perforation was found in 10 (58.8%) of the 17 patients in group I and segmental resection was performed. Seven (70%) of these 10 patients also underwent colostomy for intraperitoneal contamination or other problems. Two of these seven patients who had undergone colostomy also underwent splenectomy and nephrectomy because of grade 4–5 lacerations of the spleen and kidney. Colon perforations were primarily repaired in three (30%) of these 10 patients.

Diagnostic laparoscopy was planned 48 h after injury for one patient in the NOM group II. This patient was included in Gunshot wounds (GSW)

Figure 1. Coronal CT of a 15-year-old male in group I.

Peritonitis (+) Hemodynamic instability and/or HVI (+)

Peritonitis (–) Hemodynamic stability and/or HVI (–)

Peritonitis during serial abdominal exam (+)

Diagnostic laparoscopy

Surgery

HVI (+)

HVI (–)

NOM

Figure 2. Axial CT of a 17-year-old female in group I.

62

Figure 3. Flow diagram of the characteristics of the patients.

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Arslan et al. Operative and non-operative management of children with abdominal gunshot injuries (a)

Table 1. Image and examination findings of cases of group I Group I (n=17)

n

(b)

%

The computerized tomography images criteria for evaluation Free air in the abdomen and/or retroperitoneum

11

64.7

Free fluid in the pelvis without solid organ injury

10

58.8

Bullet track injuries

13

76.4

Intraperitoneal contamination

12

70.5

Bowel wall thickening

9

52.9

Hemodynamic instability

10

58.8

Peritonitis

17

100

Figure 4. (a, b) A 7-year-old female with ileal microperforation.

Serial abdominal examination

group I after developing signs of peritonitis (Fig. 4a, b). A microperforation was detected in the ileum during laparoscopy.

This patient underwent laparotomy, and the microperforation was primarily repaired after exclusion of additional pathologies. Small bowel perforation was found in 7 (41.2%) of 17 patients in group I and were primarily repaired. None of the cases required ileostomy.

In addition to the pathologies observed mentioned above, we also detected small bowel evisceration (n=2), bladder perforation (n=3), femoral vessel injury (n=2), vaginal injury (n=1), and eye injury (n=2). Postoperative sepsis with multiple organ failure developed in one patient. During further exploration in this patient, anastomotic leaks were detected, which were repaired primarily, and the colostomy was revised. Another patient exhibiting multiple organ failure required massive transfusion and then died (mean transfusion requirement was 8 units).

The 13 hemodynamically stable patients in group II did not show any signs of HVI during radiological imaging and

were managed non-operatively. Liver laceration (grade I–III), splenic injury (grade II), and renal injury (grade II-III) was detected in four (30.7%), one (7.6%), and three (23%) patients, respectively. No solid organ injury or HVI was found in the remaining five (38.4%) patients. In the five patients where no solid organ injury was found, the bullet track was adjacent to the intra-abdominal area and there was high-density fluid in the pelvis, similar to that observed in the patient in whom an ileum perforation was discovered 48 h later. Because patients in group II were hemodynamically stable, no morbidity or mortality was observed.

Statistical analysis demonstrated significantly lower Hb levels and systolic blood pressure levels in patients in group I than in those in group II (p*=0.01 and p*=0.00, respectively). However, the pulse rate, mean ISS, and length of ICU stay were significantly higher in patients in group I than in those in group II (p*=0.00, p*=0.00, and p*=0.00, respectively). Differences between the two groups with respect to the need for blood transfusions and the length of follow-up were not statistically significant (p=0.88 and p=0.11, respectively) (Table 2).

DISCUSSION Many studies have demonstrated that NOM is safe for patients with solid organ injuries caused by blunt abdominal

Table 2. Demographic data of all patients with gunshot wounds

Group I (Surgery, n=17)

Group II (NOM, n=13)

p

11.1±3.7 (range 4–16)

9.6±3.9 (range 4–16)

=0.297

12/5

11/2

=0.510

8.7±1.3 (range 6.43–12.1)

11±1.7 (range 8.6–13.8)

*

83.8±7.8 (range 70–95)

105±6.9 (range 90–115)

*

126±17.6 (range 95–148)

96±9.9 (range 78–110)

*

19 (range 5–38)

5.6 (range 2–17)

*

Hospitalization period at ICU (days), (Mean±SD)

5.6±1.8 (range 2–8)

2.3±0.9 day (range 1–4)

*

Hospitalization period (days), (Mean±SD)

3.7±2.3 (range 0–10)

2.7±2.5 (range 1–10)

=088

1.8±1.4 (0–4)

0.5±0.7 (0–2)

=011

1 (5.8)

0

Patient age (year), (Mean±SD) Gender (Male/Female) Hemoglobin, (Mean±SD) Systolic blood pressure (mmHg), (Mean±SD) Pulse rate (min), (Mean±SD) Injury Severity Score, (Mean±SD)

Blood transfusion (IU), (Mean±SD) Mortality, n (%)

=0.01 =0.00 =.000 =0.00 =0.00

NOM: Nonoperative management; SD: Standard deviation.

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Arslan et al. Operative and non-operative management of children with abdominal gunshot injuries

trauma.[6,7] Until recently, emergency laparotomy was the standard treatment for abdominal GSW.[5] However, there are an increasing number of studies demonstrating the importance of NOM of GSW.[8] Retrospective and prospective studies in adults report that the success rate of NOM in cases of anterior abdominal GSW is 30%.[9] Moreover, a previous study conducted at our center demonstrated that 10 of 30 (33.3%) patients with penetrating abdominal injuries including GSW were successfully treated with NOM.[4] The success rate of NOM in patients with GSW depends on which solid organ was damaged.[10] Renz et al.[11] reported successful NOM in 13 patients with liver injury due to GSW. Similarly, Demetriades et al.[12] used NOM in 11 patients (7% of the liver injuries in the study) with liver injury caused by GSW. Another study by Demetriades et al.[5] reported that 28.4% of penetrating liver injuries, 3.5% of splenic injuries, and 14.9% of renal injuries were managed non-operatively.

Furthermore, Bozdag et al.[13] published their 10 case series with thoracoabdominal GSW which were managed non-operatively, of which five were grade I-II liver injury. Despite many studies demonstrating successful NOM of GSW in adults, few studies have been conducted among pediatric patients.[4] In their multi-centric study, Dicker et al.[14] operated on 106 (80%) of 132 patients aged <19 years with penetrating liver injury (100 GSW and 32 stab wounds) because of the increased incidence of further organ damage alongside liver injury. On the other hand, the success rate of NOM was as high as 95% for kidneys which is a retroperitoneal organ with a rich blood supply.[15] In a previous study from our institution, the success rate of NOM was 89%, even in high-grade renal traumas.[16] There are few studies on the safety of NOM in the case of splenic injury. In a study with 225 patients with penetrating splenic injury, only 24 (10.6%) of them could be managed non-operatively.[17] In another study conducted

by Böyük et al.,[18] only 3 (7.5%) of 40 patients treated with NOM had splenic injuries. The most likely reason for the higher rate of operative management in splenic injury is the higher incidence of co-HVI and diaphragmatic perforation.[19] In our study, we were only able to successfully use NOM in one of the three patients with splenic injury; the other two patients underwent splenectomy.

In addition, in our study, the incidence of HVI was considerably higher wit GSW than with blunt and stab trauma.

Because GSW entail high kinetic energy which causes more extensive damage that cannot be predicted by imaging modalities, surgeons tend to manage them operatively.[20] Although CT is a commonly used and reliable imaging technique for diagnosing solid organ damage after penetrating injuries, its reliability in diagnosing HVIs is not determined.[21,22] For this reason, it is imperative to monitor hemodynamic parameters and perform serial abdominal examinations during follow-up of patients treated with NOM. If a patient develops symptoms of peritonitis or unexplained abdominal symptoms, diagnostic laparoscopy should be performed. In the liter64

ature, studies encouraging the use of NOM of penetrating abdominal trauma reported that patients undergoing surgery following delayed diagnosis of HVI did not develop any serious complications, even after an interval of 24–56 h from the time of injury to surgery.[23,24] A multi-institutional study which supported NOM investigated blunt intestinal trauma in children aged <15 years. In this study, 214 patients with HVI were divided into four groups according to the time elapsed from the time of injury to surgery (<6, 6–12, 12–24, and >24 h). Data did not demonstrate any significant difference in the development of complications or the length of stay at the hospital among the patient groups.[25] The success rate of NOM is higher for liver and renal injuries than for splenic injuries. Therefore, minimally invasive techniques, such as laparoscopic vascular embolization or splenography, may be preferentially performed over NOM in patients with splenic injury.[26] Despite diagnostic difficulties, using diagnostic CT to facilitate the decision to operate in cases of GSW is quite safe in patients with hemodynamic instability and signs of peritonitis upon serial abdomen examination. GSW causes surrounding organ damage by dispersing kinetic energy throughout the track of the bullet. In cases where the decision is made to perform NOM, following up closely with serial abdominal examinations is extremely important if the bullet track does not pass intra-abdominally. In our study, one patient who was managed non-operatively exhibited peritonitis upon serial abdominal examination and required surgery. Even though the bullet track was extraperitoneal, the patient exhibited small bowel perforation. Therefore, monitoring even patients with extraperitoneal bullet tracks for signs of HVI is very important. During the follow-up of patients undergoing NOM, adequate observation, serial abdominal examinations and diagnostic laparoscopy are preferable methods for selecting patients who are surgical candidates, avoiding the repeated exposure to ionizing radiation entailed in repeat CT.

Conclusion NOM is becoming an accepted noninvasive treatment modality for abdominal GSW in the pediatric population, and its popularity is increasing worldwide. The major drawback is the difficulty in diagnosing HVI in abdominal GSW, which usually delays the treatment. Patients with solid organ damage, who are hemodynamically stable, who exhibit no signs of peritonitis upon serial abdominal exam, and have no radiologic signs of HVI on CT may be treated with NOM. Nevertheless, more multi-centric prospective research studies are needed in this area.

Acknowledgments The writers wish to thank Eda Bozdemir and Mariah Ozkir for their assistance in language editing of this paper.

Conflict of interest: None declared.

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Arslan et al. Operative and non-operative management of children with abdominal gunshot injuries

REFERENCES 1. Bodalal Z, Mansor S. Gunshot injuries in Benghazi-Libya in 2011: the Libyan conflict and beyond. Surgeon 2013;11:258–63.

2. Tasigiorgos S, Economopoulos KP, Winfield RD, Sakran JV. Firearm injury in the United States: An overview of an evolving public health problem. J Am Coll Surg 2015;221:1005–14.

3. Veenstra M, Patel V, Donoghue L, Langenburg S. Trends in pediatric firearm-related injuries over the past 10 years at an urban pediatric hospital. J Pediatr Surg 2015;50:1184–7.

4. Cigdem MK, Onen A, Siga M, Otcu S. Selective nonoperative management of penetrating abdominal injuries in children. J Trauma 2009;67:1284–6.

5. Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, et al. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg 2006;244:620–8.

6. Stylianos S. Outcomes from pediatric solid organ injury: role of standardized care guidelines. Curr Opin Pediatr 2005;17:402–6.

7. Arslan S, Guzel M, Turan C, Doğanay S, Kopru M. Management and treatment of splenic trauma in children. Ann Ital Chir 2015;86:30–4.

8. Singh N, Hardcastle TC. Selective non operative management of gunshot wounds to the abdomen: a collective review. Int Emerg Nurs 2015;23:22–31.

9. Demetriades D, Velmahos G, Cornwell E 3rd, Berne TV, Cober S, Bhasin PS, et al. Selective nonoperative management of gunshot wounds of the anterior abdomen. Arch Surg 1997;132:178–83.

10. DuBose J, Inaba K, Teixeira PG, Pepe A, Dunham MB, McKenney M. Selective non-operative management of solid organ injury following abdominal gunshot wounds. Injury 2007;38:1084–90.

11. Renz BM, Feliciano DV. Gunshot wounds to the liver. A prospective study of selective nonoperative management. J Med Assoc Ga 1995;84:275–7.

12. Demetriades D, Gomez H, Chahwan S, Charalambides K, Velmahos G, Murray J, et al. Gunshot injuries to the liver: the role of selective nonoperative management. J Am Coll Surg 1999;188:343–8.

13. Bozdag Z, Turkoglu A, Gumus M, Gumus H, Boyuk A, Kuzu H, et al.

Non-Operative Management of Thoracoabdominal Gunshot Injury: Thirteen Unusual Cases. J Curr Surg 2015;4;199–203.

14. Dicker RA, Sartorelli KH, McBrids WJ, Vane DW. Penetrating hepatic trauma in children: operating room or not? J Pediatr Surg 1996;31:1189–91.

15. Nance ML, Lutz N, Carr MC, Canning DA, Stafford PW. Blunt renal injuries in children can be managed nonoperatively: outcome in a consecutive series of patients. J Trauma 2004;57:474–8.

16. Okur MH, Arslan S, Aydogdu B, Arslan MS, Goya C, Zeytun H, et al.

Management of high-grade renal injury in children. Eur J Trauma Emerg Surg 2017;43:99–104.

17. Berg RJ, Inaba K, Okoye O, Pasley J, Teixeira PG, Esparza M, et al.

The contemporary management of penetrating splenic injury. Injury 2014;45:1394–400.

18. Böyük A, Gümüş M, Önder A, Kapan M, Aliosmanoğlu I, Taşkesen F, et al. Splenic injuries: factors affecting the outcome of non-operative management. Eur J Trauma Emerg Surg 2012;38:269–74.

19. Okur MH, Uygun I, Arslan MS, Aydogdu B, Turkoglu A, Goya C, et al.

Traumatic diaphragmatic rupture in children. J Pediatr Surg 2014;49:420–3.

20. Dokucu AI, Otçu S, Oztürk H, Onen A, Ozer M, Bükte Y, et al. Characteristics of penetrating abdominal firearm injuries in children. Eur J Pediatr Surg 2000;10:242–7.

21. Mohamed G, Reyes HM, Fantus R, Ramilo J, Radhakrishnan J. Computed tomography in the assessment of pediatric abdominal trauma.

Arch Surg 1986;121:703–7.

22. Sivit CJ, Eichelberger MR, Taylor GA. CT in children with rupture of the bowel caused by blunt trauma: diagnostic efficacy and comparison with hypoperfusion complex. AJR Am J Roentgenol 1994;163:1195–8.

23. Bensard DD, Beaver BL, Besner GE, Cooney DR. Small bowel injury in children after blunt abdominal trauma: is diagnostic delay important? J Trauma 1996;41:476–83.

24. Niederee MJ, Byrnes MC, Helmer SD, Smith RS. Delay in diagnosis of hollow viscus injuries: effect on outcome. Am Surg 2003;69:293–8.

25. Letton RW, Worrell V; APSA Committee on Trauma Blunt Intestinal Injury Study Group. Delay in diagnosis and treatment of blunt intestinal injury does not adversely affect prognosis in the pediatric trauma patient.

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26. Davoodi P, Budde C, Minshall CT. Laparoscopic repair of penetrating splenic injury. J Laparoendosc Adv Surg Tech A 2009;19:795–8.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Batın ateşli silah yaralanması olan çocuklarda cerrahi ve cerrahi olmayan yaklaşımımız Dr. Mehmet Şerif Arslan,1 Dr. Hikmet Zeytun,1 Dr. Serkan Arslan,1 Dr. Erol Basuguy,1 Dr. Mehmet Hanifi Okur,1 Dr. Bahattin Aydoğdu,1 Dr. Cemil Göya,2 Dr. İbrahim Uygun,1 Dr. Selçuk Otçu1 1 2

Dicle Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Diyarbakır Dicle Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Diyarbakır

AMAÇ: Solid organ yaralanmalarında, bütün dünyada standart tedavi yöntemi “nonoperative management”dır (NOM). Kurşun, trakt boyunca yaydığı yüksek enerjiden dolayı oluşturmuş olduğu doku hasarının derinliği öngörülememekte ve içi boş ogan (İBO) yaralanma sıklığı yüksek olduğundan ateşli silah yaralanması (ASY) ile ilgili bir konsensüs bulunmamaktadır. Bu çalışmada, karın bölgesinde ASY olan hastaların cerrahi ve NOM kriterlerini ortaya koymayı amaçladık.

GEREÇ VE YÖNTEM: Ocak 2010–Nisan 2016 tarihleri arasında karnında ASY olan hastalar geriye dönük olarak analiz edildi. Hemodinamik instabilitesi olan, seri karın muayenelerinde peritonit bulgusu devam eden, karında serbest havası olan grup 1 (n=17) operasyona alındı. NOM ile tedavi edilen olgular ise grup 2 (n=13) idi.

BULGULAR: Grup 1 ile grup 2’yi karşılaştırdığımızda; grup 1’de hemoglobin (Hb) seviyesi ve sistolik kan basıncı istatistiksel olarak düşük iken (p<0.001), yoğun bakımda kalış süresi ve ortalama yaralanma şiddet skoru (ISS) ise istatistiksel olarak yüksek idi (p<0.001). Ayrıca Grup 1’deki olguların 10’unda kolon perforasyonu, yedisinde ise ince bağırsak perforasyonu saptadık. Grup 2’deki olgularımızın dördünde karaciğer yaralanması, birinde dalak, üçünde ise renal yaralanma var iken, beşinde ise parankimatoz organ yaralanması ve İBO saptamadık.

TARTIŞMA: Karında ASY’lerindeki problem İBO yaralanması tanısındaki zorluklara bağlı olarak tedavinin gecikmesidir. Hemodinamik olarak stabil ve seri karın muayenelerinde peritonit bulgusu olmayan parankimatoz organ yaralanmaları NOM olarak tedavi edilebilinir.

Anahtar sözcükler: Ateşli silah yaralanması; çocuklar; içi boş organ yaralanması; non-operatif takip.

Ulus Travma Acil Cerrahi Derg 2018;24(1):61–65

doi: 10.5505/tjtes.2017.15359

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ORIG I N A L A R T IC L E

Fundus-first technique and partial cholecystectomy for difficult laparoscopic cholecystectomies İsmail Cem Sormaz, M.D.,1 Yiğit Soytaş, M.D.,1 Ali Fuat Kaan Gök, M.D.,1 İlker Özgür, M.D.,2 Levent Avtan, M.D.1 1

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

2

Department of General Surgery, Acıbadem University Acıbadem International Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: This study aims to evaluate the impact of conversion from retrograde dissection to fundus-first technique (FF) or laparoscopic partial cholecystectomy (LPC) on complication rates, operation time, and duration of hospitalization.

METHODS: The medical records of 210 consecutive patients who underwent laparoscopic cholecystectomy between January 2010 and December 2014 were retrospectively evaluated. All laparoscopic cholecystectomies were initiated with retrograde dissection (RD). In cases of difficulty in dissection of critical view of safety , the operation strategy was first converted to FF and then to LPC when FF was considered insufficient for safe cholecystectomy.

RESULTS: Of the 210 cases, LC was initiated and completed with RD in 197 cases. FF was implemented in 13 cases due to difficulties in dissection. In the FF group, laparoscopic total cholecystectomy was successfully accomplished in seven patients, and LPC was performed in the remaining six cases. Three postoperative complications occurred in the RD group and two in the LPC group. No major intraoperative complications or perioperative mortality occurred in any patients.

CONCLUSION: In elective, noncomplicated cases, the safe posterior window (critical view of safety) principle should be implemented. However, in complicated cases where anatomic uncertainties are dominant, the performance of FF technique or LPC may decrease conversion rates to open surgery and contribute to accomplishing the laparoscopic intervention safely.

Keywords: Anterograde dissection; difficult cholecystectomy; fundus-first; laparoscopy; partial cholecystectomy; retrograde dissection.

INTRODUCTION Laparoscopic cholecystectomy (LC) was first introduced by Eric Muhe through a direct-view laparoscope without any camera monitor imaging system in 1985.[1] In the mid-1990s, Kato et al.[2] reported that the gallbladder could be successfully separated from the cystic bed via dissection of the Calot’s triangle.

Since then, the retrograde approach has become widely used by surgeons throughout the world, and LC became the standard treatment for gallstone disease and acute cholecystitis.

In the setting of difficult dissection of Calot’s triangle during LC, the risk of severe complications and the rate of conver-

sion to open surgery increases. Although conversion to open surgery is not considered as a failure, it is clear that it eliminates the advantages of laparoscopy and lengthens the time of recovery and does not always provide a better view of the anatomy.[3] In the era of minimally invasive surgeries, junior surgeons, in particular, do not have enough experience with the open approach. This may lead to more serious bile duct injuries, such as transsection or resection of the common bile duct (CBD).[4] The fundus-first (FF) technique (dome down, antegrade dissection) and laparoscopic partial cholecystectomy (LPC) decreases the rate of major complications and conversion rate

Cite this article as: Sormaz İC, Soytaş Y, Gök AFK, Özgür İ, Avtan L. Fundus-first technique and partial cholecystectomy for difficult laparoscopic cholecystectomies. Ulus Travma Acil Cerrahi Derg 2018;24:66-70 Address for correspondence: İsmail Cem Sormaz, M.D. İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Çapa, Şehremini, 34093 İstanbul, Turkey.

Tel: +90 212 - 414 20 00 / 31180 E-mail: icsormaz@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(1):66-70 DOI: 10.5505/tjtes.2017.26795 Submitted: 23.06.2017 Accepted: 14.09.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Sormaz et al. Fundus-first technique and partial cholecystectomy for difficult laparoscopic cholecystectomies

in cases with difficult dissection of the cystic duct and cystic artery.[5,6] This study aims to evaluate the effects of conversion from RD to FF or LPC on complication and conversion rates to open surgery in cases of difficult laparoscopic cholecystectomies.

MATERIALS AND METHODS The medical records of 240 consecutive patients who underwent LC for cholelithiasis and cholecystopathy between January 2010 and December 2014 in a tertiary reference center were retrospectively evaluated. All laparoscopic cholecystectomies were initiated with a retrograde dissection (RD). In cases of difficulty in dissection or inability in clearly identifying the cystic pedicle components, the operation was continued using the FF approach. Patients who underwent LC in addition to other abdominal operations and/or underwent primary open surgery due to additional medical conditions were excluded from the study. Urgent conversions (hemorrhage or suspicious of malignancy) to open surgery were also excluded. The patients who underwent LC with RD or FF technique were defined as the RD or FF groups, respectively.

Demographic data, indications for surgery, intraoperative findings, and the rate of complications were analyzed in these two patient groups.

All procedures performed in the study involving human participants were in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written and informed consent was obtained from each patient before surgery. Ethics committee approval was not required because the study had a retrospective design.

Surgical Technique A 30-degree telescope and a high-definition camera monitor were used as standard in all cases, and the operations were performed with four ports. Antibiotics (ampicillin/sulbactam 1000 mg) were prophylactically administered at the induction of anesthesia. After hanging the gallbladder fundus in the cephalic direction with the grasper, the dissection was started from the Calot’s triangle. In accordance with the “critical view of safety” method,[7] the underlying fatty tissue and fibrous tissue were dissected by first opening the serosa on the posterior face of Calot’s triangle and then on the anterior face.

Near the infundibulum, the cystic duct and cystic artery were separated in such a way that it allowed the appearance of only these two structures. The cystic artery and biliary duct were then clipped at the proximal and distal ends and were divided.

The gallbladder was separated from the liver bed with a RD using a hook, spatula, or scissors connected to an electrocautery device. After ensuring hemostasis of the liver bed, the gallbladder was removed from the abdomen through the port, where a 10-mm clip gun was used.

In cases where the Calot’s triangle could not be identified Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

clearly enough with the RD method, the FF technique was used as an early step of the operation. In the anterograde approach, the dissection continued from the fundus up to the infundibulum. The gallbladder was dissected from the liver bed using an electrocautery device. For retracting the liver, a part of the peritoneum was left on the liver bed for holding and hanging the liver. In cases where the cystic artery and biliary duct were safely identified, these structures were divided after clipping. However, if access to the Calot’s triangle could not be safely achieved due to fibrosis or inflammation, LPC was performed by excising a part of the gallbladder and its content from a safe margin. All stones and debris were carefully removed, and suction/irrigation was repeated until all stones and debris were removed. The infundibular stump was closed with approximation of the surrounding tissues, or it was left open in case there was no suitable tissue for approximation. In cases where the posterior wall of the gallbladder was difficult to separate from the liver bed and the bladder pedicle components were not accessible, the posterior wall of the bladder was partially left in situ and a partial cholecystectomy was performed. The mucosa of the remaining posterior wall was cauterized. A drain was placed in the subhepatic region in all patients who underwent cholecystectomy by the FF technique or LPC.

Statistical Analysis Statistical analysis was performed using SPSS version 16.0 (SPSS, Chicago, IL, USA). Continuous variables were calculated as mean±SD, and compared using the Mann–Whitney U test. P<0.05 was considered statistically significant

RESULTS Of the 240 patients who underwent cholecystectomy, 30 patients were excluded who underwent LC simultaneously with another abdominal operation during the same session or had primary open surgery due to additional medical conditions (n=27), were converted to open surgery due to hemorrhage from the liver bed (n=2), or were intraoperatively suspected of having gallbladder malignancy (n=1). Therefore, 210 patients were included in this study.

All 210 dissections were initiated with RD. A total of 197 operations (93.8%) were completed with RD and 13 (6.2%) with the FF technique. Of the 13 patients who underwent the FF technique, LPC was performed in six.

The mean age of the two groups was similar in the RD and FF groups; however, the male ratio was higher in the FF group.

The mean duration of operation was significantly shorter in the RD group than in FF group (46.12±5.98 vs. 87.00±34.25, p<0.001). The mean duration of hospitalization was also significantly lower in the RD group than in the FF group (1.28±0.56 vs. 2.76±2.48, p<0.001) (Table 1).

In the FF group, the main reason for converting from RD to 67

Sormaz et al. Fundus-first technique and partial cholecystectomy for difficult laparoscopic cholecystectomies

Table 1. Patient and operative characteristics for retrograde dissection and fundus-first groups

Retrograde dissection group

Fundus-first technique group

Age, years (range)

44.29±13.36 (18–72)

42.38±6.27 (36–58)

0.36

Sex (female/male)

150/47

7/6

<0.05

46.12±5.97 (30–65)

87.00±34.25 (55–145)

<0.001

1.28±0.56 (1–3)

2.76±2.48 (2–11)

<0.001

Duration of surgery, min (range) Duration of hospitalization, days (range)

p

FF was the inability for safe surgical dissection at the Calot’s triangle due to dense fibrotic tissue in 11 patients who had either chronic (n=8) or acute (n=3) cholecystitis. In the remaining two patients in the FF group, FF was preferred because of intraoperative suspicion of anatomic variation at the Calot’s triangle. In the FF group, laparoscopic total cholecystectomy was successfully achieved in seven patients, whereas LPC was performed in the remaining six patients. Of these six patients, safe dissection at the Calot’s triangle could not be achieved because of unclear anatomy due to chronic cholecystitis in four patients and suspicion of anatomic variations in two. In the six patients who underwent LPC, the infundibular stump of the gallbladder was oversewn using a 3/0 PDS in four. In the remaining two patients with LPC, the gallbladder stump could not be sewn because the surrounding tissues were fragile and no bile leakage was observed intraoperatively. In one case, the liver was very friable and vulnerable to bleeding; therefore, the posterior wall of the gallbladder was partially left in situ and the mucosa was cauterized. In the RD group, intraoperative gallbladder perforation during surgical manipulation occurred in 10 (4.8%) patients.

an obese woman aged 35 years who developed port-site infection postoperatively. Incisional hernia at the port site occurred in this patient and primary repair of the hernia was performed 3 months after the operation.

In the whole group, postoperative complications occurred in five (2.4%) patients. The complication rates were significantly higher in the FF group than in the RD group [15.4% (2/13) vs.

1.5% (3/197), p<0.001].

DISCUSSION

Postoperative complications were observed in three (1.4%) patients in the RD group. The first patient, a woman aged 31 years, developed extrahepatic bile duct obstruction postoperatively. No calculi or obstructions were detected in the choledochus on magnetic resonance cholangiopancreatography (MRCP), which was performed twice. The patient underwent diagnostic endoscopic retrograde cholangiopancreatography (ERCP), and a stone was removed from the distal choledochus. The patient was discharged after ERCP without any problems. The second patient, a man aged 55 years with diabetes, underwent LC 6 days after an acute cholecystitis attack. The patient was discharged on the 1st postoperative day after drain removal. He was readmitted to the emergency room with abdominal pain and fever 7 days after LC. Abdominal ultrasonography revealed an infected hematoma at the subhepatic region. Percutaneous abscess drainage and antibiotic therapy were applied and the patient was discharged 1 week later without any symptoms. The third patient was 68

Postoperative complications occurred in two patients in the FF group. The first patient, aged 44 years, developed biliary fistula after the operation. This patient had undergone LPC and the infundibular stump had not been oversewn due to the fragility of the surrounding tissues. The fistula persisted with a flow of 300 cc/day for 7 days. MRCP showed leakage from the gallbladder stump. He underwent endoscopic papillotomy and stent application, which resulted in complete recovery of the fistula, and the patient was discharged following drain removal 11 days after surgery. The second patient, a woman aged 42 years, presented with jaundice 2 years after the operation. MRCP revealed extrahepatic bile duct obstruction due to a retained stone at the distal choledochus. Endoscopic papillotomy was performed and the stone was successfully removed. No major intraoperative complications or perioperative mortality occurred in all patients.

Laparoscopic cholecystectomy is the gold standard treatment for symptomatic cholelithiasis[8–11] and protecting vascular and biliary structures is essential during LC. LC can be difficult, even for experienced surgeons, when severe fibrosis and sclerosis at the Calot’s triangle prohibit safe surgical dissection. In such cases, most surgeons consider conversion from laparoscopic to open surgery. It is generally accepted that conversion to open surgery during cholecystectomy should not be considered as failure and it can be performed for the safety of the operation when needed. However, conversion to open surgery loses the advantages of laparoscopic surgery such as the magnification offered by camera, better exploration than subcostal incision, and faster and more comfortable postoperative recovery. In cases of difficulty in dissection and inability in determining the biliary duct and/or cystic artery, the option of FF and LPC should be considered before conversion.

The conversion rates to open surgery during LC range between 1% and 24%.[12–15] The conversion rate can be as high as 44% during LC in patients with acute gangrenous cholecystitis.[16] The use of FF and LPC techniques during difficult cases can avoid conversion to open surgery. In the study of MahUlus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Sormaz et al. Fundus-first technique and partial cholecystectomy for difficult laparoscopic cholecystectomies

mud et al.,[17] the conversion rate to open surgery decreased from 5.2% to 1.2% with the use of FF technique. Gupta et al.[18] reported that the use of FF technique decreased the conversion rate from 18.8% to 2.1% in patients with chronic cholecystitis. In a recent review, it was reported that partial cholecystectomy and the FF technique resulted in decreased rate of complications[19] On the other hand, the FF technique can be hazardous in cases with thickened and shortened cystic plate due to inflamed gall bladder, and vasculobiliary injuries can occur because of the proximity of the right portal pedicle and bile duct in such patients.[20] The FF technique might pose some technical difficulties during LC. Retracting the liver can be difficult during cholecystectomy when using the FF technique. Therefore, we preferred to leave a part of peritoneum on the liver bed for retraction to overcome this problem. The other limitation of the FF technique is the blood staining of the operative field in case of bleeding. The flow direction of the bleeding is to the opposite site of dissection direction in RD, whereas blood flows directly to the dissection field in the FF technique. Attentive hemostasis is crucial to avoid blood staining of the dissection field. In our study, the use of FF technique instead of RD was decided during the early stages of the operations, when RD was considered to be insufficient for safe dissection in difficult cases. The FF technique was used in 6.2% of our patients, and 2.8% of the patients underwent LPC. Partial cholecystectomy might be considered as another surgical option for cholecystectomy during laparoscopy before deciding to proceed with open cholecystectomy. In a systematic review and meta-analysis, it was reported that partial cholecystectomy resulted in lower rates of common bile duct injury, but more frequent postoperative minor complications in difficult cholecystectomies.[6] Kulen et al.[21] analyzed the data of 80 patients with cholelithiasis who underwent LPC (n=40) and conversion cholecystectomy (n=40). The authors reported that no patients in the LPC group suffered from late complications; however, the rate of late complications was 32.5% in the conversion cholecystectomy group. Subhepatic collection, biliary fistula, and residual bile duct stones constituted the most frequent complications after LPC.[6,21] Palliative or minimally invasive techniques such as percutaneous drainage and ERCP are the most efficient treatments for such complications following LPC.[22] The incidence of postoperative ERCP after LPC was reported as 4.1%, and the most common indications for ERCP after LPC were retained stones (59%) and bile leakage (31.5%).[6] In our study, postoperative ERCP was performed in two of the six patients who underwent LPC. The indications for ERCP were postoperative biliary leakage and retained bile duct stone in these patients.

Both patients did well after appropriate endoscopic intervention with no further morbidity. The complication rate in the patients who underwent LPC was high (33%) in our study, which was probably due to the relatively small number of such patients. It is well-known that the rate of wound infection, Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

bile leaks, CBD injury, and cardiopulmonary complications is lower in LPC than in open surgery.[22] Also, the median duration of hospitalization in open surgery is 3–10 days;[23–26] our median duration of hospitalization was 3.25 days (2–11 days).

The use of RD or FF technique might affect the duration of surgery. In our study, the duration of operation was longer in the FF group than in the RD group. Neri et al.,[5] reported that the mean duration of surgery was 70 min and 90 min with the use of FF and RD technique, respectively. However, in their series, the FF technique was not used as an alternative method before converting to open surgery instead the dissections initially began with the “fundus-first” method, which was different from our study. Contrary to our findings, the authors found that the operation duration was longer in the RD group than in the FF group. We used the FF technique in difficult cases when RD was considered unsafe for further dissection during surgery; therefore, the operative time was found to be longer in the FF group in our patients.

This study has some limitations. This was a retrospective study with small sample size, and follow-up evaluation was lacking in most of the cases without complication.

The general approach in difficult cholecystectomy is performing LPC or conversion to open approach. In our study, we performed the FF technique before proceeding with LPC. We accomplished successful cholecystectomy in more than 50% (7/13) of the operations using the FF approach and avoided the potential complications of LPC in these patients. In the remaining patients (6/13), LPC was performed with an acceptable rate of minor complications.

Conclusion The protection of the main vascular and biliary tract structures is essential to perform a safe LC. Risk factors can be predictive for difficult cholecystectomy and surgeons with inadequate experience should be aware of potential complications. In the event of difficult cholecystectomies, safer options such as the FF technique and LPC should be determined by the experience of surgeon in complex biliary surgery before converting to open surgery. It should be kept in mind that difficult cases in LC may be aggravating even in case of open surgery. Nevertheless, it should be considered that conversion to open surgery is not a complication. In cases where the exploration cannot be performed safely, or in cases such as hemorrhage where open surgery is considered safer, one should not hesitate to convert to open cholecystectomy. The desire to complete the operation must not prevent finishing the procedure safely.

Conflict of interest: None declared.

REFERENCES 1. Reynolds W Jr. The first laparoscopic cholecystectomy. JSLS 2001;5:89–

69

Sormaz et al. Fundus-first technique and partial cholecystectomy for difficult laparoscopic cholecystectomies 94.

2. Kato K, Kasai S, Matsuda M, Onodera K, Kato J, Imai M, et al. A new technique for laparoscopic cholecystectomy-retrograde laparoscopic cholecystectomy: an analysis of 81 cases. Endoscopy 1996;28:356–9.

3. Henneman D, da Costa DW, Vrouenraets BC, van Wagensveld BA, Lagarde SM. Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review. Surg Endosc 2013;27:351–8.

4. Wolf AS, Nijsse BA, Sokal SM, Chang Y, Berger DL. Surgical outcomes of open cholecystectomy in the laparoscopic era. Am J Surg 2009;197:781–4.

5. Neri V, Ambrosi A, Fersini A, Tartaglia N, Valentino TP. Antegrade dissection in laparoscopic cholecystectomy. JSLS 2007;11:225–8.

6. Elshaer M, Gravante G, Thomas K, Sorge R, Al-Hamali S, Ebdewi H. Subtotal cholecystectomy for “difficult gallbladders”: systematic review and meta-analysis. JAMA Surg 2015;150:159–68.

7. Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 2010;211:132–8.

8. Johansson M, Thune A, Nelvin L, Lundell L. Randomized clinical trial of day-care versus overnight-stay laparoscopic cholecystectomy. Br J Surg 2006;93:40–5.

9. Perissat J. Laparoscopic cholecystectomy: the European experience. Am J Surg 1993;165:444–9.

10. Scott TR, Zucker KA, Bailey RW. Laparoscopic cholecystectomy: a review of 12,397 patients. Surg Laparosc Endosc 1992;2:191–8.

11. Berggren U, Gordh T, Grama D, Haglund U, Rastad J, Arvidsson D. Laparoscopic versus open cholecystectomy: hospitalization, sick leave, analgesia and trauma responses. Br J Surg 1994;81:1362–5.

12. Araujo-Teixeira JP, Rocha-Reis J, Costa-Cabral A, Barros H, Saraiva AC, Araujo-Teixeira AM. Laparoscopy or laparotomy in acute cholecystitis (200 cases). Comparison of the results and factors predictive of conversion. Chirurgie 1999;124:529–35.

13. Lo CM, Fan ST, Liu CL, Lai EC, Wong J. Early decision for conversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis.

Am J Surg 1997;173:513–7.

14. Mattioli FP, Cagnazzo A, Razzetta F, Bianchi C, Varaldo E, Campagna A, et al. Laparoscopic cholecystectomy. An analysis of the reasons for a

conversion to conventional surgery in an elective surgery department.

Minerva Chir 1999;54:471–6.

15. Parra Blanco JA, Bueno López J, Madrazo Leal C, Fariñas Alvarez C, Torre Carrasco F, Fariñas MC. Laparoscopic cholecystectomy: analysis of risk factors for predicting conversion to open cholecystectomy. Rev Esp Enferm Dig 1999;91:359–64.

16. Koperna T, Kisser M, Schulz F. Laparoscopic versus open treatment of patients with acute cholecystitis. Hepatogastroenterology 1999;46:753– 7.

17. Mahmud S, Masaud M, Canna K, Nassar AH. Fundus-first laparoscopic cholecystectomy. Surg Endosc 2002;16:581-4.

18. Gupta A, Agarwal PN, Kant R, Malik V. Evaluation of fundus-first laparoscopic cholecystectomy. JSLS 2004;8:255–8.

19. Hussain A. Difficult laparoscopic cholecystectomy: current evidence and strategies of management. Surg Laparosc Endosc Percutan Tech 2011;21:211–7.

20. Strasberg SM, Gouma DJ. ‘Extreme’ vasculobiliary injuries: association with fundus-down cholecystectomy in severely inflamed gallbladders.

HPB (Oxford) 2012;14:1–8.

21. Kulen F, Tihan D, Duman U, Bayam E, Zaim G. Laparoscopic partial cholecystectomy: A safe and effective alternative surgical technique in “difficult cholecystectomies”. Ulus Cerrahi Derg 2016;32:185–90.

22. Philips JA, Lawes DA, Cook AJ, Arulampalam TH, Zaborsky A, Menzies D, et al. The use of laparoscopic subtotal cholecystectomy for complicated cholelithiasis. Surg Endosc 2008;22:1697–700.

23. Schirmer BD, Edge SB, Dix J, Hyser MJ, Hanks JB, Jones RS. Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis. Ann Surg 1991;213:665–76.

24. Rattner DW, Ferguson C, Warshaw AL. Factors associated with successful laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 1993;217:233–6.

25. Schäfer M, Krähenbühl L, Büchler MW. Predictive factors for the type of surgery in acute cholecystitis. Am J Surg 2001;182:291–7.

26. Livingston EH, Rege RV. A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg 2004;188:205–11.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Zor kolesistektomiler için teknik çözümler: Fundus-first tekniği ve parsiyel kolesistektomi Dr. İsmail Cem Sormaz,1 Dr. Yiğit Soytaş,1 Dr. Ali Fuat Kaan Gök,1 Dr. İlker Özgür,2 Dr. Levent Avtan1 1 2

İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul Acıbadem Üniversitesi Acıbadem International Hospital, Genel Cerahi Anabilim Dalı, İstanbul

AMAÇ: Bu çalışmanın amacı, retrograd diseksiyondan (RD) fundus-first (FF) tekniğine ya da laporoskopik parsiyel kolesistektomiye (LPK) geçişin komplikasyonlar, ameliyat süresi ve hastanede kalış süresi üzerine etkisini değerlendirmektir.

GEREÇ VE YÖNTEM: Ocak 2010–Aralık 2014 tarihleri arasında laparoskopik kolesistektomi (LK) yapılan 210 hastanın tıbbi kayıtları geriye dönük olarak incelendi. Tüm LK’lere RD yöntemiyle başlanıldı. Güvenlik penceresinin diseksiyonunda zorluk yaşanması durumunda operasyon ilk olarak FF tekniğine geçildi. Fundus-first tekniğinin de güvenli bir kolesistektomi için yetersiz kaldığı durumlarda ise LPK tercih edildi.

BULGULAR: Laparoskopik kolesistektomi ile başlanan 210 olgunun 197’si RD ile sonlandırıldı. On üç olguda diseksiyon sırasındaki zorluklar nedeniyle FF tekniği uygulandı. Fundus-first grubunda yedi olguda laparoskopik total kolesistektomi başarıyla gerçekleştirildi, geri kalan altı hastada LPK uygulandı.

Ameliyat sonrası RD grubunda üç komplikasyon, LPK grubunda iki komplikasyon saptandı. Tüm olgular değerlendirildiğinde majör intraoperatif komplikasyon ve peroperatif mortalite görülmedi.

TARTIŞMA: Elektif ve komplikasyonsuz olgularda güvenli posteriyor pencere (güvenlik penceresi) prensibi uygulanmalıdır. Ancak anatomik belirsizliklerin ön planda olduğu komplike olgularda RD tekniğinde ısrarcı olmamak ve FF ya da LPK tekniklerinden birini tercih etmek açık cerrahiye dönme oranlarını azaltır ve güvenli bir laporoskopik müdahale yapılmasını sağlar.

Anahtar sözcükler: Antegrad diseksiyon; fundus-first; laparoskopi; parsiyel kolesistektomi; retrograde diseksiyon; zor kolesistektomi.

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doi: 10.5505/tjtes.2017.26795

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CAS E SERI ES

Endoscopic diagnosis and treatment of biliary obstruction due to acute cholangitis and acute pancreatitis secondary to Fasciola hepatica infection Kemal Dolay, M.D.,1 Mustafa Hasbahçeci, M.D.,2 Engin Hatipoğlu, M.D.,3 Fatma Ümit Malya, M.D.,1 Adem Akçakaya, M.D.1 1

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

2

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

3

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

ABSTRACT In the differential diagnosis of biliary obstruction with unknown etiology, biliary fascioliasis should be considered in endemic and nonendemic regions. After diagnostic evaluation, endoscopic retrograde cholangiopancreatography (ERCP) was performed for etiological evaluation and/or treatment of biliary obstruction in five patients with a mean age of 55.8 years. Endoscopic sphincterotomy and cholangiogram revealed linear filling defects in the biliary system. Fasciola hepatica parasites were extracted using balloon and basket catheters in two and three patients, respectively. No morbidity or mortality was observed. F. hepatica infection should be considered as a differential diagnosis of biliary obstruction with unknown etiology in endemic and non-endemic regions. ERCP can be the standard diagnostic and/or therapeutic procedure in cases of biliary obstruction due to fascioliasis. Due to slippery and gel-like characteristics of the parasite, use of a basket catheter in semi-opened position may be required in case of unsuccessful extraction using a balloon catheter.

Keywords: Biliary tract; endoscopic retrograde cholangiopancreatography; Fasciola hepatica.

INTRODUCTION Fasciola hepatica is a well-known helminth parasite,which has important economic and public health consequences, especially in subtropical regions and temperate climates.[1] In the hepatic phase, young flukes first migrate to the liver parenchyma. After 6–7 weeks, they enter into the bile ducts of definitive hosts and become sexually mature. In the biliary phase, adult flukes can remain asymptomatic for many years.

Besides the fact that biliary complications are more common in tropical countries, biliary fascioliasis causing biliary obstruction, cholangitis, or pancreatitis should be considered as a differential diagnosis of biliary obstruction with unknown etiology in endemic regions.[2–4] For such cases, endoscopic retrograde cholangiopancreatography (ERCP) can be the

standard diagnostic and/or therapeutic procedure in which the leaf-like nematode is detected and extracted from the biliary system.[2] For the parasites located in the main bile ducts and presenting as complicated biliary obstruction, certain maneuvers and instruments can be used, including balloon catheters, biopsy forceps, and snare or basket catheters.[5] However, due to the slippery, gel-like structure of Fasciola, extraction using balloon catheter cannot be successful in all the cases; in such cases, it may be logical to use a basket catheter in a semiopened position for extraction.

We aimed to present the technical details of biliary fascioliasis diagnosed during ERCP performed for the etiological eval-

Cite this article as: Dolay K, Hasbahçeci M, Hatipoğlu E, Malya FÜ, Akçakaya A. Endoscopic diagnosis and treatment of biliary obstruction due to acute cholangitis and acute pancreatitis secondary to Fasciola hepatica infection. Ulus Travma Acil Cerrahi Derg 2018;24:71-3 Address for correspondence: Kemal Dolay, M.D. Bezmialem Vakıf Üniv. Tıp Fakültesi Hastanesi, Genel Cerrahi Anabilim Dalı, Vatan Caddesi, Fatih, İstanbul, Turkey.

Tel: +90 212 - 453 17 00 E-mail: dolayk@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(1):71–73 DOI: 10.5505/tjtes.2017.89490 Submitted: 24.01.2017 Accepted: 13.09.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Dolay et al. Endoscopic treatment of life-threatining biliary fasciolasis

uation and/or endoscopic treatment of biliary obstruction in five patients.

CASE SERIES Patients There were five patients who were diagnosed with biliary fascioliasis during ERCP which was performed for biliary obstruction due to a presumptive diagnosis of acute cholangitis (n=3) and acute pancreatitis (n=2) between January 2000 and January 2016. The mean age of the patients was 55.8 (range, 34â&#x20AC;&#x201C;60) years, with a female to male ratio of 4:1. There was no history of travelling to high-endemic regions for fascioliasis in these patients. Institutional review board approval was obtained. The study was performed according to the Declaration of Helsinki. Informed consent was not obtained from patients due to the retrospective design of this case series.

As an initial step, all patients underwent hepatobiliary ultrasound; three patients then underwent magnetic resonance cholangiopancreatography. Laboratory and ultrasonographic findings indicated obstructive jaundice probably caused due to choledocholithiasis in two patients, and magnetic resonance imaging indicated filling defects in the biliary system in the remaining three patients; therefore, all the patients underwent ERCP (Fig. 1).

Figure 2. Endoscopic view of Fasciola hepatica. (a)

(b)

Figure 3. (a) Use of a basket catheter in semi-opened position. (b) Endoscopic extraction of Fasciola hepatica using a basket catheter.

Technique Standard sphincterotome and/or precut sphincterotomy with a needle knife papillotome were performed to cannulate the naive papilla after achieving an en face position. Cholangiogram revealed linear filling defects in the distal common bile duct and main hepatic duct in three and two patients, respectively. After sufficient endoscopic sphincterotomy, balloon catheter was used to extract the live parasites in two patients (Fig. 2). However, basket catheter in a semi-opened position was necessitated in three patients due to the slippery and gel-like structure of the parasite (Fig. 3a, 3b). There were one and two live F. hepatica parasites (Fig. 4) in three Figure 4. Live Fasciola hepatica parasite in vitro.

Figure 1. Magnetic resonance cholangiopancreatography of a patient showing a hypointense filling defect (white arrow) at the distal common bile duct which mimics a gallstone.

72

and one patients, respectively. In one patient, the extracted parasite was thought to be dead due to the absence of any movement. No morbidity or mortality was observed. After the procedure, a single dose of triclabendazole (10 mg/kg; Egaten 250; Novartis, Switzerland) was prescribed to all the patients. After the intervention, clinical findings were completely resolved and biochemical abnormalities normalized within an average of ten days.

DISCUSSION In non-endemic areas for F. hepatica, the underlying pathologies for patients with obstructive jaundice usually include choledocholithiasis or biliary malignancy.[2,6] However, biliary Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

Dolay et al. Endoscopic treatment of life-threatining biliary fasciolasis

obstruction caused by F. hepatica may also lead to the misdiagnosis of cholangiocarcinoma or choledocholithiasis. Furthermore, in endemic countries for F. hepatica, an accurate diagnosis in the presence of obstructive jaundice cannot be reached using conventional imaging techniques because these parasites rarely cause biliary obstruction.[5] Because of the technical limitations, images obtained using conventional imaging techniques are of lesser significance than those obtained using ERCP. The detection of filling defects in the biliary system has been the first radiological finding without a specified pathology. Even at the beginning of biliary evaluation during ERCP, it has been reported that the first impression is bile duct stones or sludge.[6] Therefore, such parasites should be considered while evaluating patients with obstructive jaundice, particularly in endemic areas of the world.

For all the patients included in this case series, hepatobiliary ultrasound was performed as an initial step. Although magnetic resonance cholangiopancreatography following ultrasound was planned at the secondary level, ERCP was directly performed following ultrasound in two patients due to the presence of laboratory findings that suggested biliary obstruction associated with acute cholangitis and ultrasonographic findings that suggested choledocholithiasis. Therefore, ERCP was used for both diagnostic and therapeutic purposes for treating mechanical biliary obstruction in two patients. Additionally, ERCP can be regarded as the gold standard for diagnostic and therapeutic purposes in such patients when the diagnosis is confirmed.

For the endoscopic treatment of biliary fascioliasis, endoscopic sphincterotomy is the first step for the extraction of the parasite. Extraction of the parasite is mostly achieved using a balloon catheter.[2,5,7,8] However, the slippery and gel-like structure of the parasite may cause difficulty in extracting the parasites via a balloon catheter, as observed in two of our

cases. For such patients, a basket catheter in a semi-opened position can be used for the extraction of the parasites.[6,9] In conclusion, biliary fascioliasis may have variable clinical presentations, and ERCP plays a crucial role both in diagnosis and treatment. Additionally, a semi-opened basket catheter may increase the success of extraction of live Fasciola parasites from the bile duct.

Conflict of interest: None declared.

REFERENCES 1. Moazeni M, Ahmadi A. Controversial aspects of the life cycle of Fasciola hepatica. Exp Parasitol 2016;169:81–9.

2. Ha JS, Choi HJ, Moon JH, Lee YN, Tae JW, Choi MH, et al. Endoscopic Extraction of Biliary Fascioliasis Diagnosed Using Intraductal Ultrasonography in a Patient with Acute Cholangitis. Clin Endosc 2015;48:579–82.

3. Haseeb AN, El-Shazly AM, Arafa MA, Morsy AT. Clinical, laboratory and ultrasonography features of proven human fascioliasis. J Egypt Soc Parasitol 2003;33:397–412.

4. Hawramy TA, Saeed KA, Qaradaghy SH, Karboli TA, Nore BF, Bayati NH. Sporadic incidence of Fascioliasis detected during hepatobiliary procedures: a study of 18 patients from Sulaimaniyah governorate. BMC Res Notes 2012;5:691.

5. Ezzat RF, Karboli TA, Kasnazani KA, Hamawandi AM. Endoscopic management of biliary fascioliasis: a case report. J Med Case Rep 2010;4:83.

6. Niknam R, Kazemi MH, Mahmoudi L Pharm D. Three Living Fasciola Hepatica in the Biliary Tract of a Woman. Iran J Med Sci 2015;40:465–8.

7. Bektaş M, Dökmeci A, Cinar K, Halici I, Oztas E, Karayalcin S, et al. Endoscopic management of biliary parasitic diseases. Dig Dis Sci 2010;55:1472–8.

8. Boşnak VK, Karaoğlan İ, Sahin HH, Namiduru M, Pehlivan M, Okan V, et al. Evaluation of patients diagnosed with fascioliasis: A six-year experience at a university hospital in Turkey. J Infect Dev Ctries 2016;10:389–94.

9. Wang M, Pleskow DK. Fasciola hepatica. Endoscopy 2013;45 Suppl 2 UCTN:E207–8.

OLGU SERİSİ - ÖZET

Fasciola hepatica’ya ikincil akut kolanjit ve akut pankreatitin yol açtığı biliyer obstrüksiyonun endoskopik tanı ve tedavisi Dr. Kemal Dolay,1 Dr. Mustafa Hasbahçeci,2 Dr. Engin Hatipoğlu,3 Dr. Fatma Ümit Malya,1 Dr. Adem Akçakaya1 1 2 3

Bezmialem Vakıf Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul Medical Park Fatih Hastanesi, Genel Cerrahi Kliniği, İstanbul İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul

Biliyer Fasciola hepatica enfestasyonu, endemik ve non-endemik bölgelerde etiyolojisi bilinmeyen biliyer tıkanıklığın ayırıcı tanısında olası bir sebep olarak düşünülmelidir. Tanısal değerlendirme sonrası safra yollarında obstrüksiyon saptanan ortalama yaşları 55.8 yıl olan beş hastaya etiyolojik değerlendirme ve/veya endoskopik tedavi için endoskopik retrograd kolanjiyopankreatografi uygulandı. Endoskopik sfinkterotomi ve kolanjiyogram, biliyer sistemde safra dolum defektlerini gösterdi. Balon ve sepet kateteri kullanılarak sırasıyla iki ve üç hastada Fasciola hepatica parazitleri çıkartıldı.

Morbidite veya mortalite görülmedi. Fiziksel ve laboratuvar bulgular 10 gün içinde kademeli azalarak normalleşti. Fasciola hepatica, endemik ve nonendemik bölgelerde etiyolojisi bilinmeyen safra yolu tıkanıklığı ayırıcı tanısında öncelikle düşünülmelidir. Fasciola hepatica’ya bağlı safra yolu tıkanıklığı olgularında endoskopik retrograd kolanjiyopankreatografi standart tanı ve/veya tedavi yöntemidir. Parazitin kaygan ve jel benzeri yapısından dolayı, balon kateterin yetersiz kaldığı durumlarda, yarı-açık pozisyonda sepet kateterin kullanılması gerekebilir.

Anahtar sözcükler: Biliyer sistem; endoskopik retrograd kolanjiyopankreatografi; Fasciola hepatica.

Ulus Travma Acil Cerrahi Derg 2018;24(1):71–73

doi: 10.5505/tjtes.2017.89490

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Pediatric dural venous sinus thrombosis following closed head injury: an easily overlooked diagnosis with devastating consequences Joe M Das, MCh., Rashmi Sapkota, Binjura Shrestha Department of Neurosurgery, College of Medical Sciences - Teaching Hospital, Bharatpur-10, Chitwan-Nepal

ABSTRACT Dural venous sinus thrombosis (DVST) is an uncommon finding after traumatic brain injury. The diagnosis can often be initially missed, particularly if not associated with an overlying fracture. Pediatric DVST following closed head injury and without an overlying fracture is very rare, with only 20 cases reported in the literature to date. Here we present the case of a 19-month-old boy who presented with a history of trivial fall and an episode of fever. On presentation, the pediatric Glasgow Coma Scale (pGCS) score was E3V4M6, and initial brain computed tomography (CT) was normal. He was initially conservatively managed. However, subsequent CT, taken following an episode of seizure, revealed right tentorial subarachnoid hemorrhage and falx hematoma. Conservative management was continued till he started developing recurrent seizures with a decrease in pGCS scores. Repeat CT revealed sinus thrombosis that involved the posterior aspect of the superior sagittal sinus with a massive brain edema.The coagulation profile was normal, and no fracture overlying the sinus was observed. Although he underwent emergency bifrontal decompressive craniotomy, he did not recover.This study emphasizes on the importance of not missing the diagnosis of sinus thrombosis and the devastating consequences that can occur if it is overlooked.

Keywords: Child; closed head injuries; cranial venous sinus thrombosis; decompressive craniectomy; early post-traumatic seizures.

INTRODUCTION Although dural venous sinus thrombosis (DVST) is observed in 4% of patients following penetrating head injury, it is rare following closed head injury.[1] In closed head injuries, DVST is usually associated with a fracture overlying the sinus. The occurrence of DVST without an overlying fracture is quite unique, particularly in the pediatric population, with only 20 cases reported in the literature to date.[2,3] Management guidelines are not clearly defined for such cases because of the rarity of the condition. Thus, if not carefully considered, the diagnosis of DVST can often be missed.

CASE REPORT A 19-month-old boy who was born at full-term via normal de-

livery and had normal developmental mile stones presented to our emergency room (ER) following a 4-h history of fall from one stair height. He was referred from a secondary care hospital, where he had an episode of fever. There was no history of loss of consciousness, vomiting, seizures, nasal bleed, earache, or ear discharge. He did not have any previous illness or hospital admissions. On reaching the ER, his pediatric Glasgow Coma Scale (pGCS) score (Table 1) was E3V4M6, and his pupils were bilaterally equal and reacted to light. There was no asymmetry of limb movements. He did not have any external injury, and no features of chest or abdominal injury was observed. He underwent brain computed tomography (CT) at the previous hospital, which was reported as normal. Hence, he was managed by the Department of Pediatrics and was examined to rule out infective causes of fever and altered sensorium. Almost 15 h after the trauma, he started

Cite this article as: Das JM, Sapkota R, Shrestha B. Pediatric dural venous sinus thrombosis following closed head injury: an easily overlooked diagnosis with devastating consequences. Ulus Travma Acil Cerrahi Derg 2018;24:74-7 Address for correspondence: Joe M Das, MCh. Adres bilgisi: Dept. of Neurosurgery, College of Medical Sciences, Teaching Hospital, P.O. Box: 23, Bharatpur-10 Chitwan, Nepal.

Tel: +9779802998899 E-mail: drjoemdas@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(1):74â&#x20AC;&#x201C;77 DOI: 10.5505/tjtes.2017.22823 Submitted: 04.06.2017 Accepted: 01.11.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Table 1. Pediatric Glasgow Coma Scale (pGCS) score[10]

>1 year

<1 year

Eye opening

4

Spontaneously

Spontaneously

3

To verbal command

To shout

2

To pain

To pain

1

No response

No response

Best motor response

6

Obeys

Spontaneous movements

5

Localizes pain

Localizes pain

4 Flexion-withdrawal

Flexion-withdrawal

3

Abnormal flexion

Abnormal flexion

2

Abnormal extension

Abnormal extension

1

No response

No response

>5 years

2–5 years

0–23 months

Best verbal response

5

Oriented and converses

Appropriate words and phrases

Coos and smiles appropriately

4

Disoriented and converses

Inappropriate words

Cries

3

Inappropriate words

Cries and/or screams

Inappropriate crying and/or screaming

2

Incomprehensible sounds

Grunts

Grunts

1

No response

No response

No response

developing generalized tonic–clonic seizures, refractory to phenytoin. Hence, he was transferred to the Neurosurgery Intensive Care Unit. Repeat brain CT (Fig. 1) revealed rightsided tentorial subarachnoid hemorrhage (SAH) and falx hematoma. Parenteral sodium valproate was initiated, and his seizures were controlled. On the next day, his pGCS score was E2V3M6, and breast feeding was initiated. He was active

till the third post-trauma day, when he developed another episode of right-sided focal seizures. Midazolam was initiated as an add-on anticonvulsant, following which the seizures were controlled. Repeat plain brain CT (Fig. 2a) revealed a massive cerebral edema with diffuse hypoxic injury. Contrastenhanced CT brain (Fig. 2b) showed a sinus thrombosis that involved the posterior aspect of the superior sagittal sinus. (a)

(b)

Figure 1. Non-contrast axial computed tomography (CT) of the brain showing right-sided tentorial subarachnoid hemorrhage and falx hematoma.

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Figure 2. (a) Non-contrast axial CT of the brain showing diffuse brain edema and effacement of ventricles. (b) Contrast-enhanced axial CT of the brain showing the thrombosed superior sagittal sinus.

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Das et al. Pediatric dural venous sinus thrombosis following closed head injury

Posttraumatic DVST is a rare condition that is associated with high morbidity and mortality. The sinus thrombosis is often missed in plain brain CT images. However, careful study of non-contrast-enhanced CT images may often reveal hyperdensity of the sinus,[6] as in this case, although we initially missed it. The diagnosis is quite often revealed on retrospection and careful analysis of the situation.[7] This needs to be confirmed with contrast -enhanced CT or MRI. We propose that DVST should be suspected in a patient with a head injury when one or more of the following red flag signs are observed.

Figure 3. Retrospective analysis of initial non-contrast CT of the brain showing hyperdense superior sagittal sinus.

We could not wait for magnetic resonance imaging (MRI) of the brain. His platelet count, prothrombin time–International Normalized Ratio, bleeding time, and clotting time were all normal. He underwent emergency bifrontal decompressive craniotomy with falx duraplasty. The brain was full and pulsatile. The patient was postoperatively ventilated. However, before we could perform postoperative CT, he suffered a cardiac arrest at 6 h after the surgery and he could not be resuscitated. On subsequent retrospective analysis of the second CT (Fig. 3) in the console, we noticed that the superior sagittal sinus was completely thrombosed. Usually in CT images, the top-most axial cuts are not included; hence, the diagnosis can be missed because the superior sagittal sinus may sometimes be clearly observed in such cuts only.

DISCUSSION Although the exact incidence of DVST following head injury remains unknown, it is believed to occur in up to 4% of patients with penetrating head injuries. DVST is rare following closed head injuries, particularly injuries that are mild. The exact cause of sinus thrombosis after a closed head injury is unknown. However, the following factors may be responsible.[4] 1. Injury to the wall of the dural sinus 2. Inward extension of the thrombosis from injured emissary veins 3. Intramural hemorrhage with subsequent injury to the lining endothelium DVST is rare in children, with an incidence of 0.07 in 100,000.

Antithrombin defects, protein C and S defects, and factor V gene defect (associated with activated protein C resistance) are common predisposing factors for DVST in the pediatric population. Polycythemia and congenital heart diseases can also predispose to DVST.[5] 76

1. Persistent focal seizures refractory to usual anticonvulsants 2. Brain CT showing features of tentorial and falx SAH 3. GCS that does not improve in a patient with tentorial or falx SAH 4. Fever occurs within 12 h of head injury 5. Persistent giddiness or vomiting[8] 6. Late deterioration in a patient’s clinical condition[9] This study underscores the importance of interpreting brain CT in patients with traumatic head injury, particularly those with the red flag signs as mentioned above. DVST, if left alone, can lead to morbidity and mortality owing to an increased intracranial pressure secondary to venous infarct.

Conflict of interest: None declared.

REFERENCES 1. Muthukumar N. Uncommon cause of sinus thrombosis following closed mild head injury in a child. Childs Nerv Syst 2005;21:86–8.

2. Beer-Furlan A, de Almeida CC, Noleto G, Paiva W, Ferreira AA, Teixeira MJ. Dural sinus and internal jugular vein thrombosis complicating a blunt head injury in a pediatric patient. Childs Nerv Syst 2013;29:1231–4.

3. Wilcher J, Pannell M. Dural Sinus (Cerebral Venous) Thrombosis in a Pediatric Trauma Patient: A Rare Complication After Closed Head Injury. Pediatr Emerg Care 2016;32:872–4.

4. Ochagavia AR, Boque MC, Torre C, Alonso S, Sirvent JJ. Dural venous sinus thrombosis due to cranial trauma. Lancet 1996;347:1564.

5. Reith W. The Brain. In: Vogl TJ, Reith W, Rummery EJ, editors. Diagnostic and Interventional Radiology. 1st ed. Berlin: Springer; 2016. p.

131–2.

6. Rao KC, Knipp HC, Wagner EJ. Computed tomographic findings in cerebral sinus and venous thrombosis. Radiology 1981;140:391–8.

7. Khursheed N, Altaf R, Furqan N, Wani A, Jain A, Ali Y. Post-traumatic sagittal sinus thrombosis: case report. Ulus Travma Acil Cerrahi Derg 2013;19:69–72.

8. Yuen HW, Gan BK, Seow WT, Tan HK. Dural sinus thrombosis after minor head injury in a child. Ann Acad Med Singapore 2005;34:639–41.

9. Dobbs TD, Barber ZE, Squier WL, Green AL. Cerebral venous sinus thrombosis complicating traumatic head injury. J Clin Neurosci 2012;19:1058–9.

10. Campbell JE. Trauma scoring in the prehospital setting. In: International Trauma Life Support – For Prehospital Care Providers. 1st ed. India: Dorling Kindersley; 2009. p. 382.

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OLGU SUNUMU - ÖZET

Kapalı kafa travması sonrası pediyatrik dural venöz sinüs trombozu: Kötü sonuçları olan ve kolayca atlanan bir tanı Dr. Joe M Das, Rashmi Sapkota, Binjura Shrestha Tıp Bilimleri Koleji, Sinir Cerrahisi Anabilim Dalı, Eğitim Hastanesi, Bharatpur-10, Chitwan-Nepal

Travmatik beyin yaralanması sonrası dural venöz sinüs trombozu (DVST) sık görülmeyen bir bulgudur. Başlangıçta tanı özellikle üstünde bir kırık yoksa sıklıkla atlanabilir. Üstünde kırık olmayan pediyatrik DVST çok ender olup literatürde bu tarihe kadar yalnızca 20 olgu bildirilmiştir. Burada önemsiz bir düşme ve bir febril epizot öyküsü olan 19 aylık bir erkek çocuğu sunuyoruz. Bize geldiğinde Glasgow Koma Skalası skoru (pGKS) E3V4M6 olduğu gibi beynin bilgisayarlı tomografi (BT) taraması normaldi. Başlangıçta konservatif tedavi edildi. Ancak bir nöbet sonrası çekilen müteakip BT taraması tentoriyumda subaraknoid kanama ve falks hematomunu gösterdi. pGKS’de düşüşle birlikte yinelenen nöbetleri gelişmeye başlayana kadar konservatif tedaviye devam edildi. Yinelenen BT taraması masif beyin ödemiyle birlikte süperiyor sagital sinüsün arka yüzünü etkileyen sinüs trombozunu açığa çıkardı. Koagülasyon profili normaldi ve sinüsün üzerinde kırık yoktu. Acil bifrontal dekompressif kraniyektomi uygulanmasına rağmen hasta kurtarılamadı. Bu olgu sunumu, sinüs tanısını atlamamanın ve atlandığı takdirde yıkıcı sonuçlara yol açabilen bu patolojinin önemini vurgulamaktadır.

Anahtar sözcükler: Çocuk; dekompressif kraniyektomi; erken posttravmatik nöbetler; kapalı kafa travması; kraniyal venöz sinüs trombozu.

Ulus Travma Acil Cerrahi Derg 2018;24(1):74–77 doi: 10.5505/tjtes.2017.22823

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Extension of a coronary intramural hematoma after blunt chest trauma Maeng Real Park, M.D., Mun Ki Min, M.D., Ji Ho Ryu, M.D., Dae Sub Lee, M.D., Kang Ho Lee, M.D. Department of Emergency Medicine, Pusan National University Yangsan Hospital, Korea Yangsan-South Korea

ABSTRACT Coronary artery dissection and intramural hematoma after blunt chest trauma are rare, but life-threatening, complications. Coronary intramural hematoma extension is even rarer. A 31-year-old man was transferred to our hospital for worsening left chest pain during while he was admitted at a nearby hospital due to blunt chest trauma. Bedside echocardiography showed akinesis of the left ventricular apex and anterior wall as well as hypokinesis of the mid-to-basal anteroseptal wall and mid-to-basal lateral and posterior walls of the left ventricle. Computed tomography coronary angiography revealed intramural hematoma in the left main (LM) coronary and proximal left anterior descending (LAD) arteries. Percutaneous coronary intervention, with bare metal stent implantation from the LM coronary artery to the proximal LAD artery, was performed to treat the occlusion caused by the hematoma. After stenting, the hematoma that compressed the LM coronary artery shifted the left circumflex (LCX) artery, and the intramural hematoma developed and extended to the LCX artery. To resolve this occlusion, a drug-eluting stent was successfully implanted in the LCX artery. The patient was discharged without complications. At 2-month follow-up, he remained asymptomatic, with no recurrence of cardiovascular symptoms. Delayed chest pain after trauma should be suspected during coronary dissection, and on treatment, care must be taken to extend the hematoma.

Keywords: Chest trauma; coronary artery dissection; coronary intramural hematoma.

INTRODUCTION Coronary artery dissection and intramural hematoma after blunt chest trauma are rare, but life-threatening, complications.[1â&#x20AC;&#x201C;4] Coronary intramural hematoma extension is even rarer. These injures may cause an acute myocardial infarction, and patients may report angina-like pain. We report a case of development and extension of an intramural hematoma toward the left circumflex (LCX) artery during percutaneous coronary intervention (PCI) to treat intramural hematoma in the left main (LM) coronary and proximal left anterior descending (LAD) arteries after blunt chest trauma.

CASE REPORT A 31-year-old man, with no medical history, was transferred

to our hospital for worsening left chest pain. He had been admitted at a nearby hospital due to trauma following a motorcycle accident 10 days before admission to our hospital. No fractures or internal organ injuries were found on initial examinations [chest computed tomography (CT), brain CT, Xray, laboratory examination] performed at the first hospital.

At the time of transfer, his vital signs were as follows: blood pressure, 120/78 mmHg; pulse rate, 72 beats/min; respiratory rate, 20 breaths/min; and saturation, 99%. A 12-lead ECG showed ST depression in lead I, lead II, aVF, V2, V3, V4, V5, and V6, and ST elevation in aVR (Fig. 1). Bedside echocardiography showed akinesis of the left ventricular apex and anterior wall as well as hypokinesis of the mid-to-basal anteroseptal wall and mid-to-basal lateral and posterior walls

Cite this article as: Park MR, Min MK, Ryu JH, Lee DS, Lee KH. Extension of a coronary intramural hematoma after blunt chest trauma. Ulus Travma Acil Cerrahi Derg 2018;24:78-81 Address for correspondence: Mun Ki Min, M.D. Geumo-ro 20, Mulgeum-eup, Yangsan, Gyeongnam, 626-770, Korea Yangsan-South Korea.

Tel: 082-55-360-1467 E-mail: broadman@hanmail.net Ulus Travma Acil Cerrahi Derg 2018;24(1):78â&#x20AC;&#x201C;81 DOI: 10.5505/tjtes.2017.72393 Submitted: 25.05.2017 Accepted: 10.11.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Figure 1. Electrocardiogram shows ST depression in lead I, lead II, aVF, V2, V3, V4, V5, and V6, and ST elevation in aVR.

of the left ventricle, with preserved left ventricular ejection fraction of 56%. Serum levels of troponin I, creatine kinase, and MB isoenzymes were 0.24 ng/ml, 337 U/L, and 7.6 ng/ml, respectively. CT coronary angiography revealed intramural hematoma in the LM coronary and proximal LAD arteries.

There was no evidence of aortic dissection or pulmonary thromboembolism (Fig. 2). Urgent coronary angiography revealed nearly total occlusion of the LM coronary artery, with a thrombolysis in myocardial infarction distal flow score of 2 due to intramural hematoma. PCI with bare metal stent (Liberte 4.5×20 mm) implantation from the LM coronary artery to the proximal LAD artery was performed (Fig. 3a–c) to treat the occlusion caused by hematoma. After stenting, the hematoma compressing the LM coronary artery shifted the LCX artery, and the intramural hematoma developed and extended to the LCX artery. This intramural hematoma was diagnosed by intravascular ultrasound (IVUS). To resolve this occlusion, a drug-eluting stent (Synergy 4.0×16 mm) was successfully implanted in the LCX artery (Fig. 3d–f). The patient was discharged without complications. At 2-month follow-up, he remained asymptomatic, with no recurrence of cardiovascular symptoms.

DISCUSSION

Figure 2. Computed tomography angiography revealed an intramural hematoma from the left main coronary artery to the left anterior descending artery.

Cardiac injuries after blunt chest trauma are common (5%– 15%).[5] Autopsy studies have revealed that the incidence of coronary artery injuries secondary to blunt chest trauma is approximately 2%.[6] Coronary artery injuries resulting in myocardial infarction and ischemia are extremely rare after blunt chest trauma.[7–9] The LAD artery is the most commonly af-

(a)

(b)

(c)

(d)

(e)

(f)

Figure 3. (a) The left main coronary and left anterior descending arteries compressed by the intramural hematoma; (b) Intravascular ultrasound (IVUS) confirmation of the diagnosis; (c) Stenting; (d, e) After stenting, the hematoma shifted the left circumflex (LCX) artery, and (f) the intramural hematoma developed and extended to the LCX artery.

The hematoma was confirmed by IVUS. White arrow indicates artery that the intramural hematoma compressed.

White asterisk indicates the hematoma identified by IVUS.

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fected vessel (71.4%), followed by the right coronary (19%), LM coronary (6.4%), and LCX (3.2%) arteries.[10] Significant delays (up to seven days) between blunt chest trauma and coronary artery dissection have been reported.

[11] High awareness of intramural hematomas or dissections is required when performing PCI, because a hematoma may appear as diffuse coronary luminal narrowing.

In the present case, the patient reported chest pain seven days after trauma, and CT angiography revealed a coronary intramural hematoma. Hypokinesis and akinesis shown by echocardiography indicated cardiac ischemia or infarction.

This was a case of an intramural hematoma in the LM coronary and LAD arteries after blunt chest trauma and extension of the hematoma to the LCX artery. The hematoma was successfully detected by IVUS and treated with multiple stents.

A few cases of coronary artery dissection and extension of an intramural hematoma after PCI have been reported;[12,13] however, to our knowledge, this is the first case of extension of an intramural hematoma after blunt chest trauma.

Although the mechanism and cause of the extension of an intramural hematoma are not known, vessels facilitating the extension of a hematoma are typically relatively healthy, thereby allowing propagation of blood within the media, without being impeded by calcific or fibrotic plaque.[14] A previous study reported that previous thrombolytic therapy affected hematoma extension after PCI.[12] In the present case, it was thought that microvascular damage of the blood vessels might have affected the hematoma.

Although there is no clear consensus regarding the management of a multivessel intramural hematoma, the key principal of re-establishing coronary flow in the setting of ongoing ischemia, as with any acute coronary syndrome, still applies.[15]

Conclusion Coronary artery dissection and intramural hematoma after blunt chest trauma are rare, but life-threatening, complications. Coronary intramural hematoma extension is even rarer. Delayed chest pain after trauma should be suspected during coronary dissection, and on PCI, care must be taken to extent the hematoma.

Conflict of interest: None declared.

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REFERENCES 1. Colombo F, Zuffi A, Lupi A. Left main dissection complicating blunt chest trauma: case report and review of literature. Cardiovasc Revasc Med 2014;15:354–6.

2. da Silva AC, de Paula JE, Mozer GW, Toledo LF, Soares RL, Albertal M. Simultaneous dissection and intramural hematoma of left anterior descending and circumflex coronary arteries after blunt chest trauma. Int J Cardiol 2012;155:e34–6.

3. Voyce SJ, Ball SP, Gore JM, Shine WJ, Weiner BH. Angiographically documented thrombotic coronary artery occlusion secondary to mild nonpenetrating thoracic trauma. Cathet Cardiovasc Diagn 1991;24:179–81.

4. Kohli S, Saperia GM, Waksmonski CA, Pezzella S, Singh JB. Coronary artery dissection secondary to blunt chest trauma. Cathet Cardiovasc Diagn 1988;15:179–83.

5. Atalar E, Açil T, Aytemir K, Ozer N, Ovünç K, Aksöyek S, et al. Acute anterior myocardial infarction following a mild nonpenetrating chest trauma-a case report. Angiology 2001;52:279–82.

6. Prêtre R, Chilcott M. Blunt trauma to the heart and great vessels. N Engl J Med 1997;336:626–32.

7. Wilczynska-Golonka M, Rostoff P, Siniarski A, Skrzypek A, Gackowski A, Konduracka E, et al. Trauma-induced acute myocardial infarction due to delayed dissection of the left anterior descending coronary artery. Am J Emerg Med 2017;35:939.e1–2.

8. Zeng C, Hu W, Zhu N, Zhao X, Xu J, Ye S, et al. Right coronary artery dissection and aneurysm presented as acute inferior myocardial infarction from an automobile airbag trauma. Am J Emerg Med 2015;33:1537. e5–7.

9. Sasaki T, Temmoku J, Inukai T, Sugiyama T, Inokuchi R, Shinohara K. Acute myocardial infarction after trauma: potency of percutaneous coronary intervention with transcatheter arterial embolization. Am J Emerg Med 2016;34:1186.e1–3.

10. Christensen MD, Nielsen PE, Sleight P. Prior blunt chest trauma may be a cause of single vessel coronary disease; hypothesis and review. Int J Cardiol 2006;108:1–5.

11. Poyet R, Capilla E, Kerebel S, Brocq FX, Pons F, Jego C, et al. Acute myocardial infarction and coronary artery dissection following rugby-related blunt chest trauma in France. J Emerg Trauma Shock 2015;8:110–1.

12. El-Mawardy M, Abdel-Wahab M, Richardt G. Extension of a coronary intramural hematoma as a complication of early percutaneous coronary intervention after thrombolytic therapy. Case Rep Med 2013;2013:218389.

13. Hirose M, Kobayashi Y, Kreps EM, Stone GW, Moussa I, Leon MB, et al.

Luminal narrowing due to intramural hematoma shift from left anterior descending coronary artery to left circumflex artery. Catheter Cardiovasc Interv 2004;62:461–5.

14. Maehara A, Mintz GS, Bui AB, Castagna MT, Walter OR, Pappas C, et al. Incidence, morphology, angiographic findings, and outcomes of intramural hematomas after percutaneous coronary interventions: an intravascular ultrasound study. Circulation 2002;105:2037–42.

15. Haden G, Polenta S, Jelnin V, Soffer D, Hecht H. Images in cardiology: postpartum intramural hematoma-evaluation by computed tomographic angiography. J Clin Hypertens (Greenwich) 2009;11:656.

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OLGU SUNUMU - ÖZET

Künt göğüs travması sonrası koroner intramüral hematomun yayılması Dr. Maeng Real Park, Dr. Mun Ki Min, Dr. Ji Ho Ryu, Dr. Dae Sub Lee, Dr. Kang Ho Lee Pusan Ulusal Üniversitesi, Yangsan Hastanesi, Acil Tıp Kliniği, Yangsan, Güney Kore

Künt göğüs travması sonrası koroner arter diseksiyonu ve intramüral hematom seyrek görülen, ancak yaşamı tehdit edici bir komplikasyondur. Koroner intramüral hematomun yayılması ise çok daha seyrek görülür. Otuz bir yaşındaki erkek yakındaki bir hastaneye künt göğüs travması nedeniyle kabulü sırasında kötüleşen sol göğüs ağrısı nedeniyle hastanemize sevk edildi. Hasta başı ekokardiyografisinde sol ventriküler apeks ve ön duvarda akinezi, sol ventrikül anteroseptal duvar ve arka duvarlarının orta-alt bölümlerinde hipokinezi görüldü. Bilgisayarlı tomografi koroner anjiyografi sol ana koroner arter ve proksimal sol ön inen arterde intramüral hematomun varlığını gösterdi. Hematomun neden olduğu tıkanıklığı açmak için sol ana koroner arterden proksimal sol sirkumfleks (LCX) artere perkütan koroner girişim (PKG) ile çıplak metal stent implante edildi. Stentlemeden sonra sol ana koroner arteri baskılayan hematom LCX artere doğru yer değiştirdi. Yine intramüral hematom gelişti ve LCX’e uzandı. Bu tıkanıklığı çözmek için bir ilaç salan stent başarıyla LCX arter içine implante edildi. Hasta komplikasyonsuz taburcu edildi. İzlemin ikinci ayında hasta semptomsuzdu ve hastada kardiyovasküler semptomlar nüksetmemişti. Travma sonrası geç dönemde oluşan göğüs ağrısı koroner arter diseksiyonundan kuşkulandırmalı ve hematomun genişlemesine karşı dikkatli olunmalıdır.

Anahtar sözcükler: Göğüs travması; intramüral hematom; koroner arter diseksiyonu.

Ulus Travma Acil Cerrahi Derg 2018;24(1):78–81

doi: 10.5505/tjtes.2017.72393

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Neurological recovery after traumatic Cauda Equina syndrome due to glass fragments: An unusual case Mehmet Şenoğlu, M.D., Ali Karadağ, M.D., Çağlar Türk, M.D., Füsun Demirçivi Özer, M.D. Department of Neurosurgery, Health Sciences University, Tepecik Research and Training Hospital, İzmir-Turkey

ABSTRACT Penetrating spinal injuries with foreign bodies are exceedingly rare. To date, pathological problems due to glass fragments in the spinal canal have rarely been reported. In this report, the case presenting with a back laceration, leg pain, and leg weakness was found to have glass frag-ments in the spinal canal at the L2-L3 level by lumbar computed tomography and magnetic resonance imaging. After L2 total laminectomy and retrieval of the glass fragments, the dura was re-paired. The patient was discharged from the hospital after complete neurological recovery. In cases of spinal canal injuries due to foreign bodies, early operative decompression of the neural elements is the treatment of choice. Patients with Cauda Equina syndrome due to glass fragments have a good prognosis for functional recovery.

Keywords: Cauda Equina injury; cerebrospinal fluid leak, foreign body; operative; outcomes.

INTRODUCTION Direct injuries of Cauda Equina fibers from foreign bodies are exceedingly rare.[1] Penetrating injuries of the spine most commonly occur because of sharp objects or gunshot wounds.

Penetrating spinal injuries secondary to glass are very rare; to date, only a few cases have been reported in English medical literature.[1] We report a case of Cauda Equina syndrome as a result of penetrating trauma due to glass, after the patient fell on a glass table.

CASE REPORT A 26-year-old female fell backward on a glass table, which shattered. Glass shards penetrated her back, and she was brought to our emergency room. She was complaining of right leg pain and weakness. On physical examination, an arterial blood pressure of 120/75 mmHg, a pulse rate of 80/ min, a respiratory rate of 20 breaths/min, and an axillary temperature of 36.2°C. She had a Glasgow Coma Scale of 15.

Physical examination revealed a linear, 4-cm laceration in the left paraspinal lumbar area with minimal external bleeding.

There were small pieces of glass fragments on the skin surface. Neurological examination demonstrated right lower extremity paresis and hypoesthesia. By Lovett scoring,[2] motor strength was 2/5 for plantar flexion and 2/5 for dorsiflexion of the right ankle. The plantar response babinski reflex was detected bilaterally normal. Rectal sphincter muscle tone was normal. Urogenital examination result was normal. Other physical findings were also normal. Routine laboratory test results were all normal.

Computed tomography (CT) showed a hyperdense object compatible with a glass fragment entering the spinal canal between the spinous processes of L2 and L3 on sagittal images (Fig. 1). In the spinal canal, under the L2 lamina, several small hyperdense objects were seen, along with hypodense areas (air). On axial slices, a fragment of glass that had entered the spinal canal from the left was seen. The spinal canal at L2-L3 was narrowed by a radio-opaque foreign body, which entered from the left and pressed on the cauda fibers. In the left paraspinal muscle area, tissue density was increased because of subcutaneous edema and hematoma. A small amount of

Cite this article as: Şenoğlu M, Karadağ A, Türk Ç, Demirçivi Özer F. Neurological recovery after traumatic Cauda Equina syndrome due to glass fragments: An unusual case. Ulus Travma Acil Cerrahi Derg 2018;24:82-4 Address for correspondence: Mehmet Şenoğlu, M.D. Sağlık Bilimleri Üniversitesi Tepecik Eğitim ve Araştırma Hastanesi, Nöroşirürji Kliniği, İzmir, Turkey.

Tel: +90 232 - 469 69 69 E-mail: mehmetsenoglu@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(1):82–84 DOI: 10.5505/tjtes.2017.40583 Submitted: 19.05.2017 Accepted: 21.08.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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gas was seen in the spinal canal (Fig. 1a). On magnetic resonance imaging (MRI) at the L2-L3 level, in the right paraspinal subcutaneous and muscle tissues, a rod-shaped object of low-signal intensity was seen extending into the spinal canal to the L2-L3 level (Fig. 1b). Several hours after presenting to the emergency department, the patient was taken to the operating room. The spinal column and vertebral arches were exposed through a posterior incision from L2 to L3. The wound was explored. Two glass fragments were removed from the paravertebral muscles, and then an L2 total laminectomy was performed. After the dura was opened, two small glass fragments and a 30×20-mm glass fragment, which was compressing the Cauda Equina, were removed (Fig. 1c). No intraoperative complications occurred, and after duraplasty, no signs of cerebrospinal liquid leak were observed. Postoperatively, the patient noticed that her leg pain had resolved while still in the recovery room. Within 24 hour postoperatively, neurological recovery was complete, with 5/5 plantar flexion and 5/5 dorsiflexion strength of the right ankle. At 2 days postoperatively, she was ambulating without support.

Postoperative lumbar CT showed no foreign bodies in the spinal canal (Fig. 1d).

DISCUSSION Spinal injuries are most commonly due to falls, motor vehicles, and sports-related accidents.[1,3] Penetrating injuries of the spinal canal are relatively rare compared to those caused by blunt trauma. Most are caused by bullets and knives; spinal injuries by glass fragments are extremely rare.[1,3,4] Anamnesis, physical examination, and imaging techniques must be done for the right treatment option prior to the

(a)

(b)

removal of the embedded object. If the foreign body is made of lead or copper, systemic toxicity may develop. In such cases, surgery is indicated even if neurological symptoms are absent. Urgent surgery to remove sharp foreign bodies in the spinal canal is indicated to prevent neurological deterioration, independent of the level of injury.[3,4] Besides direct damage to nerves, other risks of foreign bodies in the spinal canal are cerebrospinal fluid fistula and infection. During closure of the dura, removal of hematoma, bone fragments, and foreign bodies is important to lower the risk of infectious complications.[4,5] Neurological deficits related to direct injury are usually evident immediately after the trauma. Severe initial neurological deficits rarely improve after decompressive surgery.

Delayed deficits may occur because of infection, granuloma formation, iron encrustation, or direct contact of the glass fragments with neural tissue.[3,5] Both plain radiographs and CT are fast and effective imaging modalities for demonstrating metallic and glass foreign bodies. CT can also show the trajectory of the injury.[4,5] MRI can also provide precise data about the location of glass fragments.[5] In our case, CT scan demonstrated the glass fragment adjacent to lamina, and then the MRI showed that the glass fragment was located intradurally.

After spinal cord injuries, a variety of motor, sensory, and autonomic function loss below the level of lesion may occur.[1,3] In our patient, only a unilateral partial motor deficit was present. The prognosis for functional recovery is good in patients with Brown–Sequard or Cauda Equina syndrome.

(d)

(c)

Figure 1. (a) Sagittal CT at L2–L3. A glass fragment from the broken table is seen intruding into the spinal canal. (b) T2-weighted sagittal MRI images show a hypointense object in the spinal canal. (c) Glass fragments from the broken table after removal from the spinal canal. (d) Postoperative lumbar CT. No foreign bodies are seen in the spinal canal (CT: Computed tomography; L: Lumbar; MRI: Magnetic resonance imaging).

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Şenoğlu et al. Neurological recovery after traumatic Cauda Equina syndrome due to glass fragments [1] Good functional recovery is related to rapid, aggressive decompressive surgery of the Cauda Equina region.[4,5] Wide surgical exposure enables safe removal of intradural foreign bodies under direct visualization after the lamina is partially or totally removed.[3] Failure to remove a retained foreign body from within the spinal canal may result in cerebrospinal fluid leak, osteomyelitis, meningitis, migration of the foreign body, and/or progressive neurological deficits.[4]

In summary, rapid imaging and aggressive operative management in cases of penetrating traumas to the spinal cord may improve the chances for rapid improvement and optimal long-term neurological outcome.

Conflict of interest: None declared.

REFERENCES 1. Baghai P, Sheptak PE. Penetrating spinal injury by a glass fragment: case report and review. Neurosurgery 1982;11:419–22.

2. Dyck PJ, Boes CJ, Mulder D, Millikan C, Windebank AJ, Dyck PJ, et al.

History of standard scoring, notation, and summation of neuromuscular signs. A current survey and recommendation. J Peripher Nerv Syst 2005;10:158–73.

3. Opel DJ, Lundin DA, Stevenson KL, Klein EJ. Glass foreign body in the spinal canal of a child: case report and review of the literature. Pediatr Emerg Care 2004;20:468–72.

4. Oertel MF, Kreitschmann-Andermahr I, Ryang YM, Gilsbach JM, Korinth MC. The awak-ened intraspinal glass shard. Acta Neurochir (Wien) 2009;151:99–101.

5. Akcakaya MO, Aras Y, Yorukoglu AG, Ovalioglu C, Sencer A. Cervical intradural glass fragment: a rare cause of neuropathic pain. Turk Neurosurg 2012;22:667–70.

OLGU SUNUMU - ÖZET

Cam parçacıkları nedeniyle oluşan travma kaynaklı Cauda Equina sendromunda tam nörolojik iyileşme: Olağandışı olgu Dr. Mehmet Şenoğlu, Dr. Ali Karadağ, Dr. Çağlar Türk, Dr. Füsun Demirçivi Özer Sağlık Bilimleri Üniversitesi Tepecik Eğitim ve Araştırma Hastanesi, Nöroşirürji Kliniği, İzmir

Yabancı cisimlerle omurilik yaralanmaları oldukça nadirdir. Bununla beraber patolojik problemlere neden olan spinal kanalın içindeki cam parçacıkları çok nadir raporlanmıştır. Bu raporda, lomber manyetik rezonans görüntüleme ve bilgisayarlı tomografi kullanılarak sırtta laserasyon, bacakta ağrı ve güç kaybı ile gelen ve L2-L3 seviyesinde cam parçacıkları mevcut hasta sunuldu. L2 total laminektomi ve cam parçacıklarının tamamen çıkartılması sonrası dura tamir edildi. Takiplerde tam nörolojik iyileşme saptanan hasta taburcu edildi. Bu cam fragmanlarıyla olan spinal yaralanmalarda nöral elemanların erken operatif dekompresyonu seçeneklerden biridir. Cam parçacıklarıyla ilişkili Cauda Equine sendromlu hasta, fonksiyonel olarak iyi bir prognoza kavuşmuştur.

Anahtar sözcükler: Beyin omurilik sıvısı sızıntısı; Cauda Equina yaralanması; operatif; sonuçlar; yabancı cisim.

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CAS E R EP O RT

An unexpected long-term complication of genital burn in a child: Secondary cryptorchidism Mustafa Öksüz, M.D.,1 Hasan Deliağa, M.D.,2 Adem Topkara, M.D.,3 Ömer Faruk Koçak, M.D.4 1

Department of Plastic, Reconstructive and Aesthetic Surgery, Servergazi State Hospital, Denizli-Turkey

2

Department of Pediatric Surgery, Servergazi State Hospital, Denizli-Turkey

3

Department of Plastic, Reconstructive and Aesthetic Surgery, Pamukkale University Faculty of Medicine, Denizli-Turkey

4

Department of Plastic, Reconstructive and Aesthetic Surgery, Yüzüncü Yıl University Faculty of Medicine, Van-Turkey

ABSTRACT Genital and perineal burns are rare and challenging injuries with serious long-term complications. Involvement of the testes is a sign of severity. There is limited knowledge in the literature about the management of complications and testes involvement in genital and perineal burns. In this report, we present the case of an 8-year-old boy with secondary cryptorchidism due to burn contracture who was treated by increasing the scrotal volume by Z-plasties, skin graft, and orchidopexy.

Keywords: Burn scar; cryptorchidism; genital burn; perineal burn; skin graft.

INTRODUCTION Genital and perineal burns generally accompany extensive burns.[1–3] They are seldom detected as isolated injuries.[1–3] General causes of genital and perineal burns are hot liquids and flames both in children and adults.[1–4] Testes involvement is extremely rare and is a sign of high morbidity and even mortality.[2] The leading long-term complication is burn scar contracture in genital and perineal burns.[4,5] The main problematic issue is to manage it and is still an unsettled question.

CASE REPORT An 8-year-old boy was admitted to our hospital because of genital and perineal burn contractures. He had a scald burn injury 3 years ago and was treated by grafting the burned areas. There were constrictive bands passing from the perineum to the groin. The right hemiscrotum was fused with the right thigh. The right testis was not in the scrotum and

palpated in the groin entrapped under the constrictive bands.

It was stated by the parents that the right testis was located in the scrotum prior to injury. The left testis was normal. The range of motion of the right leg was limited, especially during abduction (Fig. 1a).

The constrictive bands were released, and groin exploration was performed. The scar tissue did not extend through the inguinal canal. The testis was dissected and prepared for orchidopexy procedure. There was no sign of persistent processus vaginalis or a hernia sac (Fig. 1b). The scrotum was separated from the thigh and was expanded with multiple Z-plasties. The orchidopexy procedure was completed after gaining enough volume into the scrotum for the testis. The skin defects of the thigh and groin were covered by splitthickness skin grafts (Fig. 1c).

The postoperative period was uneventful, and 1 year postoperatively, the results were satisfactory (Fig. 1d).

Cite this article as: Öksüz M, Deliağa H, Topkara A, Koçak ÖF. An unexpected long-term complication of genital burn in a child: Secondary cryptorchidism. Ulus Travma Acil Cerrahi Derg 2018;24:85-7 Address for correspondence: Mustafa Öksüz, M.D. Adres bilgisi: Servergazi Devlet Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Kliniği, 20000 Denizli, Turkey Tel: +90 258 - 361 32 32 E-mail: drmustafaoksuz@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(1):85–87 DOI: 10.5505/tjtes.2017.93027 Submitted: 14.04.2016 Accepted: 07.09.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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(a)

(b)

(c)

(d)

Figure 1. (a) The range of motion of the right leg was limited especially in abduction, and the right hemiscrotum was fused with the right thigh. (b) Image after the right testis is prepared for orchidopexy procedure. There was no sign of a hernia sac or a patent processus vaginalis. (c) The skin defect of the thigh and the groin are covered by split-thickness skin grafts, and the orchidopexy procedure is completed. (d) One year postoperatively, the right hemiscrotum is free from the thigh and the cosmetic result is satisfactory.

DISCUSSION Genital and perineal burns are rare injuries because of the secure and protected anatomic location provided by the thighs and abdomen.[1–3] They generally accompany extensive burns and are seldom detected solely.[1–3] Despite this protection, the reported occurrence is 8.3% in children1 and 1.7% in adults;[4] among these, the occurrence of isolated cases is 0.6%–4%.[1,2] Scalds are the primary cause followed by flames, contact, and electrical burns.[1,2,4] The most frequent complication of genital and perineal burns is scar contracture, which causes movement disorders, cosmetic problems, and testes entrapment.[2,4–7] Children are more prone to contracture formation because of growth process6. Contracture release and coverage of the defect even with skin grafts or local skin flaps is the preferred treatment.[8–10] The reported postoperative results are generally satisfactory and complication-free.

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The preferred surgical procedures for contracture release in genital and perineal regions are triangular plasty transposition or advancement flaps of local tissue such as Z-plasty.[6,9] A musculocutaneous flap is not advised because of possible harm to spermatogenesis due to increase in temperature of testes caused by the flap.[10] We performed multiple Z-plasties to release the scrotal contracture and increase the volume of the scrotum in order to prevent re-ascent or compartment syndrome.

Testes involvement in genital and perineal burns is extremely rare because of the mobility provided by the cremasteric reflex and thick cover provided by the scrotal skin, dartos muscle, and tunica albuginea, as well as the protection provided by the anatomic location.[2,7,8] It is stated that testes involvement is directly correlated with increased morbidity and even mortality in genital and perineal burns.[2] This is probably because testicular involvement is almost always associated with the most severe burns.[2] Ulus Travma Acil Cerrahi Derg, January 2018, Vol. 24, No. 1

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There are four pediatric testes burns reported in two established studies about testes burns in children.[2,7] Three of these cases were diagnosed early and treated with orchiectomy in two patients and orchidopexy in one.[2] The fourth case was a long-term complication caused by constrictive bands restricting the testes above the scrotum; the scrotal skin was preserved. Bilateral orchidopexy was the choice of treatment after the release of the constrictive bands.[7] The burned scrotum in our patient did not allow us to directly perform orchidopexy because of limited volume of the scrotum; therefore, we had to carry out Z-plasty to expand the scrotum before establishing orchidopexy.

Acquired undescended testes demonstrate the same germ cell maldevelopment that is observed in congenital cryptorchidism because of the increased heat of the testis. The increased heat of the effected testis causes germ cell apoptosis by direct and indirect mechanisms and defective germ cell maturation by heat shock proteins, reactive oxygen species, and Sertoli cell damage. There is also evidence that the risk of testicular malignancy in cryptorchidism is increased by fourto eight-fold. Irrespective of the underlying reason of cryptorchidism, in order to prevent permanent damage to the effected testes, suitable surgical procedures should be performed to protect the testes from germ cell maldevelopment and possible malignancy.[11–13]

Conclusion Although the long-term functional and cosmetic outcome of burns to the genitals and perineum in children is a challenging problem, there is lack of information in the medical literature to constitute a treatment algorithm.

There is no single perfect genital and perineal skin reconstruction technique defined for burn contractures. The diversity of techniques to reconstruct genital and perineal contracture reflects the challenge and complexity of these defects.

The choice of suitable reconstruction modality depends on the surgeon’s preference to achieve best reconstructive results with acceptable morbidity.

Although testes burn is a very rare entity, it is a sign of severity when included. Careful examination of the testes should be performed in all children with genital and perineal burns to ensure not missing an entrapped testis as a long-term complication. Orchidopexy should be performed to prevent germ cell maldevelopment and malignancy.

Conflict of interest: None declared.

REFERENCES 1. Klaassen Z, Go PH, Mansour EH, Marano MA, Petrone SJ, Houng AP, et al. Pediatric genital burns: a 15-year retrospective analysis of outcomes at a level 1 burn center. J Pediatr Surg 2011;46:1532–8.

2. Angel C, Shu T, French D, Orihuela E, Lukefahr J, Herndon DN. Genital and perineal burns in children: 10 years of experience at a major burn center. J Pediatr Surg 2002;37:99–103.

3. Abel NJ, Klaassen Z, Mansour EH, Marano MA, Petrone SJ, Houng AP, et al. Clinical outcome analysis of male and female genital burn injuries: a 15-year experience at a level-1 burn center. Int J Urol 2012;19:351–8.

4. Harpole BG, Wibbenmeyer LA, Erickson BA. Genital burns in the national burn repository: incidence, etiology, and impact on morbidity and mortality. Urology 2014;83:298–302.

5. Alghanem AA, McCauley RL, Robson MC, Rutan RL, Herndon DN. Management of pediatric perineal and genital burns: twenty-year review.

J Burn Care Rehabil 1990;11:308–11.

6. Grishkevich VM. Burned perineum reconstruction: a new approach. J Burn Care Res 2009;30:620–4.

7. Kara IG, Sarioğlu A. Cryptorchidism as a result of burn injury. Burns 1999;25:663–5.

8. Agarwal P. Scrotal Reconstruction: Our Experience. Journal of Surgery Pakistan (International) 2012;17:32–5.

9. Huang T. Management of perineal burn complications in children. Burns 2007;33S:S23–4.

10. Huang T. Management of burn injuries of the perineum. In: Herndon D, editor. Total Burn Care. 3rd ed. Elsevier; 2007. p. 749–58.

11. Barthold JS, González R. The epidemiology of congenital cryptorchidism, testicular ascent and orchiopexy. J Urol 2003;170:2396–401.

12. Ong C, Hasthorpe S, Hutson JM. Germ cell development in the descended and cryptorchid testis and the effects of hormonal manipulation.

Pediatr Surg Int 2005;21:240–54.

13. Setchell BP. The Parkes Lecture. Heat and the testis. J Reprod Fertil 1998;114:179–94.

OLGU SUNUMU - ÖZET

Yanık skarına bağlı gelişen sekonder kriptorşidizm olgusu Dr. Mustafa Öksüz,1 Dr. Hasan Deliağa,2 Dr. Adem Topkara,3 Dr. Ömer Faruk Koçak4 Servergazi Devlet Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Kliniği, Denizli Servergazi Devlet Hastanesi, Çocuk Cerrahisi Kliniği, Denizli Pamukkale Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Kliniği, Denizli 4 Yüzüncü Yıl Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Kliniği, Van 1 2 3

Genital ve perianal yanıklar ciddi ve zorlu uzun dönem komplikasyonları ile ortaya çıkabilmektedir. Literatüründe herhangi bir bildirilmiş yanık sekeli olarak oluşan kriptorşitizm olgusuyla karşılaşmadık. Kriptorşitizminde yanıkların rolünü göstermek için, sekiz yaşında yaygın perineal ve inguinal yanıkları sonucu kriptorşitizm olan çocuk bildirilmiştir. Azalan skrotal volüm skarlı doku üzerine z-plasti, deri grefti ve inmemiş testis onarımı ile gerçekleştirildi.

Anahtar sözcükler: Deri grefti; genital yanık; kriptorşidizm; perianal yanık; yanık skarı.

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