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Cilt - Volume 17

Sayı - Number 5

Eylül - September 2011

TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

www.tjtes.org Index Medicus, Medline, EMBASE/Excerpta Medica, Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜB‹TAK-ULAKB‹M Türk Tıp Dizini’nde yer almaktadır. Indexed in Index Medicus, Medline, EMBASE/Excerpta Medica and Science Citation Index-Expanded (SCI-E), Index Copernicus and the Turkish Medical Index of TÜB‹TAK-ULAKB‹M.

ISSN 1306 - 696x


ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA AND EMERGENCY SURGERY Editör (Editor) Recep Güloğlu Yardımcı Editörler (Associate Editors) Kaya Sarıbeyoğlu Hakan Yanar Ahmet Nuray Turhan Geçmiş Dönem Editörleri (Former Editors) Ömer Türel Cemalettin Ertekin Korhan Taviloğlu

ULUSAL BİLİMSEL DANIŞMA KURULU (NATIONAL EDITORIAL BOARD) Fatih Ağalar Yılmaz Akgün Levhi Akın Alper Akınoğlu Mehmet Ali Akkuş Murat Aksoy Şeref Aktaş Ali Akyüz Ömer Alabaz Cem Alhan Nevzat Alkan Edit Altınlı Acar Aren Cumhur Arıcı Oktar Asoğlu Mehmet Aşık Ali Atan Bülent Atilla Levent Avtan Yunus Aydın Erşan Aygün Mois Bahar Akın Eraslan Balcı Emre Balık Umut Barbaros Semih Baskan M Murad Başar Mehmet Bayramiçli Ahmet Bekar Orhan Bilge Mustafa Bozbuğa Başar Cander Nuh Zafer Cantürk Münacettin Ceviz Banu Coşar Figen Coşkun İrfan Coşkun Nahit Çakar Adnan Çalık Fehmi Çelebi Gürhan Çelik Oğuz Çetinkale M. Ercan Çetinus Sebahattin Çobanoğlu Ahmet Çoker Cemil Dalay Fatih Dikici Yalım Dikmen Osman Nuri Dilek Levent Döşemeci Murat Servan Döşoğlu Kemal Durak Koray Dural Engin Dursun Mehmet Eliçevik İmdat Elmas Ufuk Emekli

İstanbul Çanakkale İstanbul Adana Ankara İstanbul İstanbul İstanbul Adana İstanbul İstanbul İstanbul İstanbul Antalya İstanbul İstanbul Ankara Ankara İstanbul İstanbul İstanbul İstanbul Elazığ İstanbul İstanbul Ankara Kırıkkale İstanbul Bursa İstanbul Edirne Konya Kocaeli Erzurum İstanbul Ankara Edirne İstanbul Trabzon Erzurum İstanbul İstanbul İstanbul Edirne İzmir Adana İstanbul İstanbul Sakarya Antalya Düzce Bursa Ankara Ankara İstanbul İstanbul İstanbul

Haluk Emir Yeşim Erbil Şevval Eren Hayri Erkol Metin Ertem Mehmet Eryılmaz Figen Esen Tarık Esen İrfan Esenkaya Ozlem Evren Kemer Nurperi Gazioğlu Fatih Ata Genç Alper Gökçe Niyazi Görmüş Feryal Gün Ömer Günal Nurullah Günay Haldun Gündoğdu Mahir Günşen Emin Gürleyik Hakan Güven Tufan Hiçdönmez Gökhan İçöz İbrahim İkizceli Murat İmer Haluk İnce Fuat İpekçi Ferda Şöhret Kahveci Selin Kapan Murat Kara Hasan Eşref Karabulut Ekrem Kaya Mehmet Yaşar Kaynar Mete Nur Kesim Yusuf Alper Kılıç Hakan Kınık Talat Kırış Haluk Kiper Hikmet Koçak M Hakan Korkmaz Güniz Meyancı Köksal Cüneyt Köksoy İsmail Kuran Necmi Kurt Mehmet Kurtoğlu Nezihi Küçükarslan İsmail Mihmanlı Mehmet Mihmanlı Köksal Öner Durkaya Ören Hüseyin Öz Hüseyin Özbey Faruk Özcan Perihan Ergin Özcan Akın Özden Cemal Özçelik İlgin Özden

İstanbul İstanbul Diyarbakır Bolu İstanbul Ankara İstanbul İstanbul Malatya Ankara İstanbul İstanbul Tekirdağ Konya İstanbul Düzce Kayseri Ankara Adana Bolu İstanbul Edirne İzmir İstanbul İstanbul İstanbul İzmir Bursa İstanbul Ankara İstanbul Bursa İstanbul Samsun Ankara Ankara İstanbul Eskişehir Erzurum Ankara İstanbul Ankara İstanbul İstanbul İstanbul Ankara İstanbul Sakarya İstanbul Erzurum İstanbul İstanbul İstanbul İstanbul Denizli Diyarbakır İstanbul

Mehmet Özdoğan Şükrü Özer Halil Özgüç Ahmet Özkara Mahir Özmen Vahit Özmen Volkan Öztuna Niyazi Özüçelik Süleyman Özyalçın Emine Özyuvacı Salih Pekmezci İzzet Rozanes Kazım Sarı Ali Savaş İskender Sayek Tülay Özkan Seyhan Gürsel Soybir Yunus Söylet Erdoğan Sözüer Mustafa Şahin Cüneyt Şar Mert Şentürk Feridun Şirin İbrahim Taçyıldız Gül Köknel Talu Ertan Tatlıcıoğlu Gonca Tekant Cihangir Tetik Bülent Tırnaksız Mustafa Tireli Alper Toker Rıfat Tokyay Salih Topçu Turgut Tufan Fatih Tunca Akif Turna Zafer Nahit Utkan Ali Uzunköy Erol Erden Ünlüer Özgür Yağmur Müslime Yalaz Serhat Yalçın Sümer Yamaner Mustafa Yandı Nihat Yavuz Muharrem Yazıcı Cumhur Yeğen Ebru Yeşildağ Hüseyin Yetik Cuma Yıldırım Bedrettin Yıldızeli Sezai Yılmaz Kaya Yorgancı Coşkun Yorulmaz Tayfun Yücel

Ankara Konya Bursa İstanbul Ankara İstanbul Mersin İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul Ankara Ankara İstanbul İstanbul İstanbul Kayseri Tokat İstanbul İstanbul İstanbul Diyarbakır İstanbul Ankara İstanbul İstanbul Ankara Manisa İstanbul İstanbul Kocaeli Ankara İstanbul İstanbul Kocaeli Urfa Balıkesir Adana İstanbul İstanbul İstanbul Trabzon İstanbul Ankara İstanbul Tekirdağ İstanbul Gaziantep İstanbul Malatya Ankara İstanbul Sakarya


ULUSLARARASI BİLİMSEL DANIŞMA KURULU INTERNATIONAL EDITORIAL BOARD

Juan Asensio Zsolt Balogh Ken Boffard Fausto Catena Howard Champion Elias Degiannis Demetrios Demetriades Timothy Fabian Rafi Gürünlüoğlu Clem W. Imrie Kenji Inaba Rao Ivatury Yoram Kluger Rifat Latifi Sten Lennquist Ari Leppaniemi Valerie Malka Ingo Marzi Kenneth L. Mattox Carlos Mesquita

Miami, USA New Castle, Australia Johannesburg, S. Africa Bologna, Italy Washington DC, USA Johannesburg, S. Africa Los Angeles, USA Memphis, USA Denver, USA Glasgow, Scotland Los Angeles, USA Richmond, USA Haifa, Israel Tucson, USA Malmö, Sweden Helsinki, Finland Sydney, Australia Frankfurt, Germany Houston, USA Coimbra, Portugal

Ernest E Moore Pradeep Navsaria Andrew Nicol Hans J Oestern Andrew Peitzman Basil A Pruitt Peter Rhee Pol Rommens William Schwabb Michael Stein Spiros Stergiopoulos Michael Sugrue Otmar Trentz Donald Trunkey Fernando Turegano Selman Uranues Vilmos Vecsei George Velmahos Eric J Voiglio Mauro Zago

Denver, USA Cape Town, S. Africa Cape Town, S. Africa Celle, Germany Pittsburgh, USA San Antonio, USA Tucson, USA Mainz, Germany Philadelphia, USA Petach-Tikva, Israel Athens, Greece Liverpool, Australia Zurich, Switzerland Oregon, USA Madrid, Spain Graz, Austria Vienna, Austria Boston, USA Lyon, France Milan, Italy

REDAKSİYON (REDACTION) Erman Aytaç

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

Başkan (President) Başkan Yardımcısı (Vice President) Genel Sekreter (Secretary General) Sayman (Treasurer) Yönetim Kurulu Üyeleri (Members)

Recep Güloğlu Kaya Sarıbeyoğlu Ahmet Nuray Turhan Hakan Yanar M. Mahir Özmen Ediz Altınlı Gürhan Çelik

İLETİŞİM (CORRESPONDENCE)

Ulusal Travma ve Acil Cerrahi Derneği İstanbul Üniversitesi İstanbul Tıp Fakültesi Genel Cerrahi Anabilim Dalı, Travma ve Acil Cerrahi Servisi, 34390 Çapa, İstanbul

Tel: +90 212 - 588 62 46 - 531 12 46 Faks (Fax): +90 212 - 533 18 82 e-posta (e-mail): travma@travma.org.tr Web: www.travma.org.tr

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

Ulusal Travma ve Acil Cerrahi Derneği adına Sahibi (Owner) Yazı İşleri Müdürü (Editorial Director) Yayın Koordinatörü (Managing Editor) Amblem Yazışma adresi (Correspondence address) Tel Faks (Fax)

Recep Güloğlu Recep Güloğlu M. Mahir Özmen Metin Ertem Ulusal Travma ve Acil Cerrahi Dergisi Sekreterliği Deniz Abdal Mah., Köprülü Mehmet Paşa Sok., Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul +90 212 - 531 12 46 - 531 09 39 +90 212 - 533 18 82

Abonelik: 2011 yılı abone bedeli (Ulusal Travma ve Acil Cerrahi Derneği’ne bağış olarak) 75.- YTL’dir. Hesap No: Türkiye İş Bankası, İstanbul Tıp Fakültesi Şubesi 1200 - 3141069 no’lu hesabına yatırılıp makbuz dernek adresine posta veya faks yolu ile iletilmelidir. Annual subscription rates: 75.- (USD) p-ISSN 1306-696x • e-ISSN 1307-7945 • Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır. (Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus and Turkish Medical Index) • Yayıncı (Publisher): KARE Yayıncılık (KARE Publishing) • Tasarım (Design): Ali Cangül • İngilizce Editörü (Linguistic Editor): Corinne Can • İstatistik (Statistician): Empiar • Online Dergi & Web (Online Manuscript & Web Management): LookUs • Baskı (Press): Yıldırım Matbaacılık • Basım tarihi (Press date): Eylül (September) 2011 • Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur. (This publication is printed on paper that meets the international standard ISO 9706: 1994).


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, 2001 yılından itibaren Index Medicus ve Medline’da, 2005 yılından itibaren Excerpta Medica / EMBASE indekslerinde, 2007 yılından itibaren Science Citation Index-Expanded (SCI-E) ile Journal Citation Reports / Science Edition uluslararası indekslerinde ve 2008 yılından itibaren Index Copernicus indeksinde yer almaktadır. 2001-2006 yılları arasındaki 5 yıllık dönemde SCI-E kapsamındaki dergilerdeki İmpakt faktörümüz 0,5 olmuştur. Dergide araştırma yazılarına öncelik verilmekte, bu nedenle derleme veya olgu sunumu türündeki yazılarda seçim ölçütleri daha dar tutulmaktadır. PUBMED’de dergi “Ulus Travma Acil Cerrahi Derg” kısaltması ile yer almaktadır. Dergiye yazı teslimi, çalışmanın daha önce yayınlanmadığı (özet ya da bir sunu, inceleme, ya da tezin bir parçası şeklinde yayınlanması 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 Türkçe ve İngilizce yazılmış makaleler yayınlanabilir. 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. 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 190-210 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 kişiler-

den izin alınmalı ve izin belgesi dergi editörlüğüne ayrıca açıklamasıyla birlikte gönderilmelidir. Hastaların görüntülendiği fotoğraflara, hastanın ve/veya velisinin imzaladığı bir izin belgesi eşlik etmeli veya fotoğrafta hastanın yüzü tanınmayacak şekilde kapatılmış olmalıdır. Renkli resim ve şekillerin basımı için karar hakemler ve editöre aittir. Yazarlar renkli baskının hazırlık aşamasındaki tutarını ödemeyi kabul etmelidirler. Kaynaklar: Metin içindeki kullanım sırasına göre düzenlenmelidir. 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.


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. 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 2008 in Index Copernicus. For the five-year term of 2001-2006, our impact factor in SCI-E indexed journals is 0.5. It is cited as ‘Ulus Travma Acil Cerrahi Derg’ in PUBMED. Submission of a manuscript by electronic means implies: that the work has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis); that it is not under consideration for publication elsewhere; and that its publication in the Turkish Journal of Trauma and Emergency Surgery is approved by all co-authors. The author(s) transfer(s) the copyright to the Turkish 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 may be submitted in Turkish or in English. All submissions are initially reviewed by the editor, and then are sent to reviewers. All manuscripts are subject to editing and, if necessary, will be returned to the authors for answered responses to outstanding questions or for 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. 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” section, called “Upload Your Files”.

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ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY C‹LT - VOL. 17

SAYI - NUMBER 5

EYLÜL - SEPTEMBER 2011

İçindekiler - Contents Deneysel Çalışma - Experimental Studies 377-382 Prevention of adhesion to prosthetic mesh: comparison of oxidized generated cellulose, polyethylene glycol and hylan G-F 20 Prostetik yamaya karşı adezyonun önlenmesi: Okside rejenere selüloz, polietilen glikol ve hylan G-F 20’nin karşılaştırılması Altınlı E, Sümer A, Köksal N, Onur E, Senger S, Eroğlu E, Çelik A, Gümrükçü G 383-389 Beneficial effects of alpha lipoic acid on cerulein-induced experimental acute pancreatitis in rats Sıçanlarda seruleinle deneysel olarak oluşturulan akut pankreatitte alfa lipoik asitin faydalı etkileri Bulut NE, Özkan E, Ekinci O, Dulundu E, Topaloğlu Ü, Şehirli AÖ, Ercan F, Şener G

Klinik Çalışma - Original Articles 390-395 The value of CRP, IL-6, leptin, cortisol, and peritoneal caspase-3 monitoring in the operative strategy of secondary peritonitis Sekonder peritonitte planlı abdominal onarımın sonlandırılma kararında C reaktif protein, interlökin 6, leptin, kortizol ve kaspaz 3 değerlerinin etkisi Pehlivanlı F, Ağalar F, Ağalar C, Saygun O, Daphan C, Aydınuraz K, Büyükkoçak U, Çağlayan O, Dom S, Şahiner T 396-400 Scoring systems in the diagnosis of acute appendicitis in the elderly Yaşlılarda akut apandisit tanısında skorlama sistemleri Konan A, Hayran M, Kılıç YA, Karakoç D, Kaynaroğlu V 401-406 Factors affecting morbidity in penetrating rectal injuries: a civilian experience Penetran rektal yaralanmalarda morbiditeye etkili faktörler: Sivil deneyim Gümüş M, Kapan M, Önder A, Böyük A, Girgin S, Taçyıldız İ 407-412 The use of Ender nail in intertrochanteric fractures supported with external fixation İntertrokanterik kırıklarda Ender çivilerinin eksternal fiksatörle desteklenmesi Ertürk C, Çağman B, Altay MA, Işıkan UE 413-418 Characteristics of open globe injuries in geriatric patients Geriatrik hastalarda açık göz küresi yaralanmalarının özellikleri Tök L, Yalçın Tök Ö, Özkaya D, Eraslan E, Sönmez Y, Örnek F, Bardak Y 419-422 Hot milk burns in children: a crucial issue among 764 scaldings Çocuklarda sıcak süt yanıkları: 764 haşlanma yanığında önemli bir sorun Yastı AÇ, Koç O, Şenel E, Kabalak AA 423-429 Cardiac and great vessel injuries after chest trauma: our 10-year experience Göğüs travması sonrasında gelişen kalp ve büyük damar yaralanmaları: 10 yıllık deneyimimiz Onan B, Demirhan R, Öz K, Onan İS 430-434 Still an unknown topic: child abuse and “shaken baby syndrome” Hala bilinmeyen bir konu: Çocuk istismarı ve “Sarsılmış Bebek Sendromu” Balcı E, Gün İ, Mutlu Şarlı Ş, Akpınar F, Yağmur F, Öztürk A, Günay O

Cilt - Vol. 17 Sayı - No. 5

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ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY C‹LT - VOL. 17

SAYI - NUMBER 5

EYLÜL - SEPTEMBER 2011

İçindekiler - Contents 435-439 Delayed presentation of posttraumatic diaphragmatic hernia Geç bulgu veren travmatik diyafram hernileri Okan İ, Baş G, Ziyade S, Alimoğlu O, Eryılmaz R, Güzey D, Zilan A 440-444 10-year evaluation of train accidents Tren kazalarının 10 yıllık değerlendirilmesi Akkaş M, Ay D, Metin Aksu N, Günalp M 445-449 Kadınların başına gelen ev kazaları ve ilk yardım bilgi düzeyleri Domestic accidents involving women and first aid knowledge Serinken M, Türkçüer İ, Karcıoğlu Ö, Akkaya S, Uyanık E 450-454 Karın içi ateşli silah yaralanmalarında komplikasyon oranlarını etkileyen faktörler The affecting factors on the complication ratio in abdominal gunshot wounds Taş H, Mesci A, Eryılmaz M, Zeybek N, Peker Y

Olgu Sunumu - Case Reports 455-457 Masked urinary bladder injury with a bullet expulsed spontaneously during voiding Ateşli silah yaralanmasıyla oluşan gizli mesane yaralanması ve kurşunun spontan miksiyonla üretradan atılması Çalışkan M, Evren İ, Kabak İ, Atak İ, Gökcan R 458-460 Spondylolisthesis mimicking the progression of dissection in a case of chronic Stanford type B aortic dissection Kronik Tip-B aort diseksiyonlu bir olguda diseksiyonun ilerlemesini taklit eden lomber spondilolistezis Göz M, Torun MF, Mordeniz C, Aydın MS, Demirkol AH, Karabağ H 461-463 Multidetector computed tomography diagnosis of ileal and antropyloric gallstone ileus İleum ve antropilorik yerleşimli safra taşı ileusunun çok kesitli bilgisayarlı tomografi ile tanısı Altınkaya N, Koç Z, Alkan Ö, Demir Ş, Belli S 464-466 Gunshot injury to the penis in a patient with penile prosthesis: a case report Penis protezli hastanın penisinde ateşli silah yaralanması: Olgu sunumu Öztürk Mİ, İlktaç A, Koca O, Kalkan S, Kaya C, Karaman Mİ 467-469 Inflamed vermiform appendix within the sac of incarcerated left inguinal hernia Boğulmuş sol kasık fıtığı içinde inflame vermiform apendiks Turanlı S, Yüksel MU, Pirhan Y, Çetin A 470-472 Late recognized nail aspiration in a child: case report Çocukta geç farkedilen çivi aspirasyonu: Olgu sunumu Çobanoğlu U, Can M, Birincioğlu İ, Edirne Y, Melek M

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Eylül - September 2011


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):377-382

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2011.93195

Prevention of adhesion to prosthetic mesh: comparison of oxidized generated cellulose, polyethylene glycol and hylan G-F 20 Prostetik yamaya karşı adezyonun önlenmesi: Okside rejenere selüloz, polietilen glikol ve hylan G-F 20’nin karşılaştırılması Ediz ALTINLI,1 Aziz SÜMER,2 Neşet KÖKSAL,1 Ender ONUR,3 Serkan SENGER,1 Ersan EROĞLU,1 Atilla ÇELİK,1 Gülistan GÜMRÜKÇÜ4 BACKGROUND

AMAÇ

The aim of this study was to investigate the impact of oxidized generated cellulose, polyethylene glycol and hylan G-F 20 on adhesion formation, fibrosis and inflammation after repair of abdominal wall defect with polypropylene mesh in an animal model.

Bu çalışmanın amacı, hayvan modelinde karın duvarı defektlerinin polipropilen yama ile tamirinden sonra oluşan adezyon formasyonu, fibrozis ve enflamasyon üzerine okside rejenere selüloz, polietilen glikol ve hylan G-F 20’nin etkilerini araştırmaktır.

METHODS

GEREÇ VE YÖNTEM

Forty rats were divided into four groups and abdominal wall defect was established. The defect was repaired with polypropylene mesh alone (control group), polypropylene mesh and hylan G-F 20 as adhesion barrier, polypropylene mesh and oxidized generated cellulose as adhesion barrier, or polypropylene mesh and polyethylene glycol as adhesion barrier in Groups I, II, III, and IV, respectively. Rats were sacrificed on the 14th day in all groups.

Kırk sıçan dört gruba ayrıldı ve karın duvarı defekti oluşturuldu. Defektler sırası ile grup I, II, III ve IV olacak şekilde; sadece polipropilen yama (kontrol grubu), polipropilen yama ve adezyon bariyeri olarak hylan G-F 20, polipropilen yama ve adezyon bariyeri olarak okside rejenere selüloz, polipropilen yama ve adezyon bariyeri olarak polietilen glikol kullanılarak onarıldı. Sıçanlar 14. günde öldürüldü.

RESULTS

BULGULAR

A comparison of the groups in terms of macroscopic adhesion scores revealed statistically significant differences between the groups using an adhesion barrier and the control group. Severe fibroblast proliferation was seen in the control group and mild fibroblast proliferation was seen in polyethylene glycol group.

Makroskopik adezyon açısından karşılaştırıldıklarında kontrol gurubu ile adezyon bariyeri kullanan gruplar arasında istatistiksel olarak anlamlı fark bulundu. Kontrol grubunda ileri derecede fibroblast proliferasyonu ve polietilen glikol grubunda hafif fibroblast proliferasyonu görüldü.

CONCLUSION

SONUÇ

Polyethylene glycol is an effective adhesion prevention barrier. Laparoscopic surgery has become the standard method in most of the surgical field. With its laparoscopic apparatus, polyethylene glycol allows easy application on the damaged surface.

Polietilen glikol etkili bir adezyon bariyeridir. Son dönemde laparoskopik cerrrahi birçok alanda standart metot haline gelmiştir. Polietilen glikol laparoskopik düzeneği sayesinde hasarlı yüzey üzerine uygulama kolaylılığı sağlamaktadır.

Key Words: Abdominal surgery; adhesion barrier; prevention.

Anahtar Sözcükler: Karın cerrahisi; adezyon bariyeri; koruma.

Departments of 1General Surgery, 4Pathology, Haydarpaşa Numune Training and Research Hospital, Istanbul; 2Department of General Surgery, Yüzüncü Yıl University, Faculty of Medicine, Van; Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey.

Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, 1 Genel Cerrahi Kliniği, 4Patoloji Bölümü, İstanbul; 2 Yüzüncü Yıl Üniversitesi, Tıp Fakültesi, Genel Cerrahi Kliniği, Van; 3 Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul.

Correspondence (İletişim): Aziz Sümer, M.D. Yüzüncü Yıl Üniversitesi, Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Van, Turkey. Tel: +90 - 505 - 925 71 42 e-mail (e-posta): azizsümer2002@yahoo.com

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Ulus Travma Acil Cerrahi Derg

Adhesions are the fibrous bands formed between the body structures and neighboring organs. They typically form from inflammation and after surgical traumas. The adhesions arising after abdominal operations rank first among the problems with which modern surgery has to cope. Independent of the methods used, after each abdominal operation, intraabdominal adhesion formations emerge. The postoperative intraabdominal adhesion rates range between 64-97%. Following open gynecological interventions, this ratio may increase up to 97%.[1-7] The postoperative adhesions are an important problem for surgeons at reoperation owing to the increased access time into the abdominal cavity, difficulties during exploration and injuries to the adjacent organs. In 1998 in the United States, the cost of treatment for preventing formation of adhesions and complications was 1.6 billion dollars. In the U.S. alone, 400,000 adhesion-related operations per year are applied, oriented to complications formed due to adhesion. The defects constituted on the abdominal wall cannot be closed primarily. Under these conditions, the usage of prosthetic material is essential. To date, many prosthetic materials have been developed and used in the repair of incisional hernia. Multifilament polyester mesh, double filament polypropylene mesh and polytetrafluoroethylene mesh are some of these.[8-10] For preventing the formation of postoperative adhesions, the benefits of physical membranes have been shown in many experimental studies.[11-13] It is difficult to apply adhesion barriers directly on a damaged surface. The physical barriers suitable for usage especially during laparoscopic operation are limited.[14] Oxidized regenerated cellulose (Interceed®) has a beneficial effect on adhesions by forming a physical separation of adjacent peritoneal surfaces.[15] Polyethylene glycol (SprayGel®) consists of two synthetic liquid precursors that, when mixed, rapidly cross-link to form a solid, flexible, absorbable hydrogel.[16] hylan G-F 20 (Synvisc®) is a high-molecular-weight, reticulated hyaluronic acid.[17] The aim of the present study was to evaluate whether adhesions due to intraperitoneal mesh can be prevented with the use of physical barriers such as oxidized generated cellulose, polyethylene glycol and hylan G-F 20.

MATERIALS AND METHODS This study was performed in the Haydarpaşa Numune Training and Research Hospital Animal Research Laboratory and was approved by Ethical Committee of Haydarpaşa Numune Training And Research Hospital (4/15/2004, no. 10). In the study, 40 male Wistar Albino rats weighing approximately 250-300 g were used. The animals 378

were cared for according to the principles of the National Institutes of Health publication “Guide for Care and Use of Laboratory Animals,” revised 1996. Surgical Procedure Following anesthesia application of intramuscular ketamine (50 mg/kg) injection to the rats, a 2 cm midline��������������������������������������������� skin incision was done. After the skin incision, a 2x2 cm full layer defect was performed on the abdominal wall of the rats, and the defect was repaired by mesh materials 2.5 by 2.5 cm in diameter. After polypropylene mesh was fixed to the abdominal wall with 4/0 polypropylene suture unilaterally, anti-adhesive materials were placed under the mesh, respectively, and the free polypropylene mesh edges were fixed to abdominal wall with 4/0 polypropylene suture. Rats were divided into four groups of 10 rats each as follows: Group I: Polypropylene mesh only (control group) Group II: Polypropylene mesh and hylan G-F 20 as adhesion barrier Group III: Polypropylene mesh and oxidized regenerated cellulose as adhesion barrier Group IV: Polypropylene mesh and polyethylene glycol as adhesion barrier The surgical procedure was done under a semisterile condition. Different surgeons performed the first and second laparotomies. En bloc removal of mesh and adhesions with any visceral organ was done for all groups, and the samples were preserved in 10% formol solution for histopathological assessment. Evaluation of Adhesion Formation Adhesion formation was evaluated macroscopically and microscopically. Macroscopic evaluation was performed according to the scoring system suggested by Mazuji et al.[18] (Table 1) (Fig. 1). Histopathologic Evaluation An independent pathologist performed the histopathologic evaluation. Five-micron thick sections from the tissues embedded into paraffin were obtained. Sections were stained with hematoxylin-eosin (H&E) and evaluated under light microscope with respect to fibrosis and inflammation (Table 2 and Fig. 2).[19] Table 1. Adhesion severity scoring scale (Majuzi et al.) Score Evaluation

0 1 2 3 4

No adhesion Filmy adhesions easily separable with blunt dissection Mild to moderate adhesions with freely dissectible plane Moderate to dense adhesion with difficult dissection Non-dissectible plane Eylül - September 2011


Prevention of adhesion to prosthetic mesh

(a)

(b)

Fig. 1. (a) Macroscopic view of adhesions with score 0. (b) Macroscopic view of adhesions with score 4.

(a)

(b)

Fig. 2. (a) Histopathologic view in the control group: Adhesions between liver and polypropylene mesh pore due to fibrosis (H-E x 400). (b) Histopathologic view in polyethylene glycol group: Mild inflammation is seen around the mesh pore (H-E x 40).

Statistical Analysis SPSS (Statistical Package for the Social Sciences) for Windows 11.0 program was used for statistical analysis. The difference between the groups for each type was reviewed by chi-square test. The relation between groups was investigated by employing the Spearman correlation analysis.

RESULTS The standardized surgical procedures and the administration of the protocols were well tolerated by the animals. None of the animals died postoperatively. Rats were sacrificed on the 14th day in all groups with high-dose ether anesthesia.

Bilateral comparison of the groups in terms of macroscopic adhesion scores demonstrated statistically significant differences between the groups with an adhesion barrier and the control group (p<0.004, p<0.01, p<0.0001), respectively. It was found that the polyethylene glycol group was the most distinct group from the other groups in terms of macroscopic adhesion. The distribution of the groups with respect to adhesion scores is shown in Table 3. Bilateral comparison of the groups in terms of the inflammation scores revealed statistically significant differences between the group using polyethylene glycol and the control group (p<0.0001). No statisti-

Table 2. Histopathologic evaluation performed according to fibrosis grading scale and inflammation grading scale (Hooker et al.) Score

Fibrosis grading scale

Inflammation grading scale

None Minimal, loose Moderate Florid, dense

None Giant cells, occasional lymphocytes, and plasma cells Giant cells, plasma cells, eosinophils, neutrophils Many inflammatory cells, microabscesses

0 1 2 3

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Table 3. Comparison of the groups in terms of macroscopic adhesion severity score Adhesion severity score

Groups

Control (n=10)

Hylan G-F 20 (n=10)

Oxidized Regenerated Cellulose (n=10)

Polyethylene glycol

0 1 2 3 4 Total

– – – 3 (30%) 7 (70%) 10

– 1 (10%) 5 (50%) 4 (40%) – 10

– – 4 (40%) 5 (50%) 1 (10%) 10

3 (30%) 5 (50%) 2 (20%) – – 10

(n=10)

Table 4. Comparison of the groups in terms of inflammation score Inflammation score

Groups

Control (n=10)

Hylan G-F 20 (n=10)

Oxidized Regenerated Cellulose (n=10)

Polyethylene glycol

0 1 2 3 Total

– – 6 (60%) 4 (40%) 10

– 3 (30%) 6 (60%) 1 (10%) 10

– 3 (30%) 6 (60%) 1 (10%) 10

– 8 (80%) 2 (20%) – 10

(n=10)

Table 5. Comparison of the groups in terms of fibrosis score Fibrosis score

Groups

Control (n=10)

Hylan G-F 20 (n=10)

Oxidized Regenerated Cellulose (n=10)

Polyethylene glycol

0 1 2 3 Total

– – 5 (50%) 5 (50%) 10

– 3 (30%) 5 (50%) 2 (20%) 10

– 2 (20%) 7 (70%) 1 (10%) 10

– 8 (80%) 2 (20%) – 10

cal difference was found between the other adhesion barriers and the control group. The distribution of the groups as per the inflammation scores is shown in Table 4. Bilateral comparison of the groups in terms of the fibrosis score showed a statistically significant difference between the polyethylene glycol group and control group (p<0.001). No statistical difference was found between the other adhesion barriers and the control group. The distribution between groups is shown in Table 5.

DISCUSSION Adhesion formation after abdominopelvic procedures has an impact upon patient morbidity, success of subsequent surgical procedures and costs to the health care system in general. In the current approach, 380

(n=10)

in order to prevent adhesions, peritoneal damage should be reduced during the operation, inflammatory response should be reduced, coagulation formation should be prevented, and fibrinolysis has to be stimulated. An ideal physical membrane barrier should not affect wound healing or stimulate fibrosis formation and should be effective in the presence of blood and foreign material.[14] Despite the development of minimally invasive techniques in many procedures and the ultimate decrease in trauma during operations, the technique alone does not effectively eliminate adhesion formation.[16] While using Prolene mesh, contact between the mesh and the visceral organs leads to a severe adhesion formation. In the study of Felemovicius et al.,[20] an abdominal defect of 2.5 cm was made in three groups comprised of 20 rats each, and those defects Eylül - September 2011


Prevention of adhesion to prosthetic mesh

were repaired by Prolene, Sepramesh, and Sepramesh + Seprafilm, respectively. Adhesion signs were observed by electron microscopy in all 20 rats who received Prolene mesh. Similarly, we determined Grade 3 and 4 adhesions in 10 out of 10 rats in our control group. There was a statistically significant difference between the Prolene group and polyethylene glycol and hylan G-F 20 groups with regard to macroscopic adhesion grades. To our knowledge, there is no study focusing on the usage of hylan G-F 20 as an adhesion barrier in intraabdominal adhesions in the current literature. In our study, hylan G-F 20 was used as an adhesion barrier by laying it underneath the polypropylene mesh. According to the statistical analysis, adhesion grade was 2 in one (10%), 3 in five (50%) and 4 in four (40%) subjects in the hylan G-F 20 group. In terms of macroscopic adhesion grade, there was a statistically significant difference between the hylan G-F 20 and Prolene groups. The TC-7 (oxidized regenerated cellulose) barrier has been shown to provide significant reductions in the severity, incidence and width of postoperative adhesion formation.[21,22] Reid et al.[15] conducted a prospective clinical study in which they evaluated 40 female patients with a history of adhesiolysis because of �������������������������������������������� ovarian������������������������������������� adhesions or cystectomy due to ovarian cyst. They covered both of the ovaries with TC-7, but sprayed heparin solution over one of them. The second-look laparoscopy demonstrated adhesion in 21 (52.5%) of 40 patients in the TC-7 + heparin spray group and in 26 (65%) of 40 patients in the TC-7 group, and use of heparin in conjunction with TC-7 was shown to exhibit no statistically significant difference. In our study, based on the macroscopic scores, we determined a statistically significant difference between the TC-7 and polypropylene groups. We also determined a statistically significant difference between the polyethylene glycol and TC-7 groups; the difference between TC-7 and hylan G-F 20 was not statistically significant. Polyethylene glycol is a nontoxic and nonmigrating adhesion barrier, which is used during laparoscopic and open surgical procedures due to its strong adhesive properties and easy-to-apply nature. It has an air pump and an apparatus that are particularly convenient for laparoscopic surgery. There is no risk of viral transmission via synthetic pieces and the polyethylene-based hydrogel does not carry any infection potential. Moreover, owing to its methylene blue kit, it contributes to the visualization of the damaged surface by staining it blue.[23-25] Dunn et al.[23] divided 16 rats with cecum abrasion into control and polyethylene glycol groups, while splitting 20 New Zealand rabbits with induced uterine Cilt - Vol. 17 Sayı - No. 5

horn abrasion again into control and polyethylene glycol groups. They treated the abrasion site with polyethylene glycol in the treatment groups. An abrasion between the cecum and lateral wall was determined in 7 of 8 rats in the control group and in 1 of 8 rats in the polyethylene group with cecum abrasion model. Adhesion was found to cover more than 50% of the uterine horn in 8 of 10 rabbits in the control group and in 2 of 10 rabbits in the polyethylene glycol group with uterine horn abrasion. Polyethylene glycol was observed to cause a significant reduction in the incidence of adhesion formation. Metler et al.[25] conducted a study on 64 patients by dividing them into two groups and comparing the control group (n=30) treated solely with surgery and the study group treated with surgery + polyethylene glycol. Open and laparoscopic surgeries were performed for leiomyoma or leiomyomatous uterine lesions. Laparoscopic surgery was applied on 82.4% (n=28) of the study group and 76.7% (n=23) of the control group. Mean duration for application of polyethylene glycol barrier was 3.7 minutes, and the average amount of polyethylene glycol used for each patient was 1.9 kits. Adhesion formation in the secondary laparotomies was statistically significantly lower in the study group than in the control group. In this study, polyethylene glycol, sprayed underneath the mesh during closure of the induced ventral defect with polypropylene mesh, was found to provide statistically significant reductions in macroscopic adhesion formation compared with the hylan G-F 20 and TC-7 applications. Based on the evaluations focused on macroscopic adhesions, the difference between the polyethylene glycol group and control group was found to be highly statistically significant. The highest difference was observed between the polyethylene glycol and control groups. The difference between the polyethylene glycol group and the TC-7 group in terms of macroscopic adhesion score was highly significant as well. Moreover, the difference between polyethylene glycol and hylan G-F 20 was statistically significant. Macroscopically, the polyethylene glycol group appeared to have the least amount of adhesion formation compared with the other groups, and this difference was evaluated to be statistically significant. Ozmen et al.[26] found that using sodium hyaluronate reduces the incidence and severity of abdominal adhesions following laparoscopic mesh insertion. In conclusion, although hylan G-F 20 is used for cartilage repair of the joints, it can also be used as an antiadhesive barrier after abdominal operations. Polyethylene glycol was an effective adhesion prevention barrier, and results seem to be at least comparable with those of other products. Polyethylene glycol is a reliable and easily applied adhesion barrier, and reduces 381


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adhesion formation after open and laparoscopic surgery.

REFERENCES 1. Szabo A, Haj M, Waxsman I, Eitan A. Evaluation of seprafilm and amniotic membrane as adhesion prophylaxis in mesh repair of abdominal wall hernia in rats. Eur Surg Res 2000;32:125-8. 2. Moreira H Jr, Wexner SD, Yamaguchi T, Pikarsky AJ, Choi JS, Weiss EG, et al. Use of bioresorbable membrane (sodium hyaluronate + carboxymethylcellulose) after controlled bowel injuries in a rabbit model. Dis Colon Rectum 2000;43:1827. 3. Risberg B. Adhesions: preventive strategies. Eur J Surg Suppl 1997;577:32-9. 4. Becker JM, Dayton MT, Fazio VW, Beck DE, Stryker SJ, Wexner SD, et al. Prevention of postoperative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter study. J Am Coll Surg 1996;183:297-306. 5. Menzies D, Ellis H. Intestinal obstruction from adhesions-how big is the problem? Ann R Coll Surg Engl 1990;72:60-3. 6. Ray NF, Larsen JW Jr, Stillman RJ, Jacobs RJ. Economic impact of hospitalizations for lower abdominal adhesiolysis in the United States in 1988. Surg Gynecol Obstet 1993;176:271-6. 7. Hershlag A, Diamond MP, DeCherney AH. Adhesiolysis. Clin Obstet Gynecol 1991;34:395-402. 8. Dinsmore RC, Calton WC Jr, Harvey SB, Blaney MW. Prevention of adhesions to polypropylene mesh in a traumatized bowel model. J Am Coll Surg 2000;191:131-6. 9. Oncel M, Remzi FH, Senagore AJ, Connor JT, Fazio VW. Application of Adcon-P or Seprafilm in consecutive laparotomies using a murine model. Am J Surg 2004;187:304-8. 10. Johns DA, Ferland R, Dunn R. Initial feasibility study of a sprayable hydrogel adhesion barrier system in patients undergoing laparoscopic ovarian surgery. J Am Assoc Gynecol Laparosc 2003;10:334-8. 11. Günerhan Y, Caglayan K, Sumer A, Koksal N, Altınlı E, Onur E, et al. The efficacy of carboxymetylcellulose for prevention adhesion formation after thyroid region surgery. Kafkas Uni Vet Fak Der 2009;5:785-9. 12. Rodgers KE, Johns DB, Girgis W, Campeau J, diZerega GS. Reduction of adhesion formation with hyaluronic acid after peritoneal surgery in rabbits. Fertil Steril 1997;67:553-8. 13. Wiseman DM, Gottlick-Iarkowski L, Kamp L. Effect of different barriers of oxidized regenerated cellulose (ORC) on cecal and sidewall adhesions in the presence and absence of bleeding. J Invest Surg 1999;12:141-6.

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14. Zhou J, Elson C, Lee TD. Reduction in postoperative adhesion formation and re-formation after an abdominal operation with the use of N, O - carboxymethyl chitosan. Surgery 2004;135:307-12. 15. Reid RL, Hahn PM, Spence JE, Tulandi T, Yuzpe AA, Wiseman DM. A randomized clinical trial of oxidized regenerated cellulose adhesion barrier (Interceed, TC7) alone or in combination with heparin. Fertil Steril 1997;67:23-9. 16. Mettler L, Audebert A, Lehmann-Willenbrock E, Schive K, Jacobs VR. Prospective clinical trial of SprayGel as a barrier to adhesion formation: an interim analysis. J Am Assoc Gynecol Laparosc 2003;10:339-44. 17. Kahan A, Lleu PL, Salin L. Prospective randomized study comparing the medicoeconomic benefits of Hylan GF-20 vs. conventional treatment in knee osteoarthritis. Joint Bone Spine 2003;70:276-81. 18. Mazuji MK, Kalambaheti K, Pawar B. Prevention of adhesions with polyvinylpyrrolidone. Preliminary report. Arch Surg 1964;89:1011-5. 19. Hooker GD, Taylor BM, Driman DK. Prevention of adhesion formation with use of sodium hyaluronate-based bioresorbable membrane in a rat model of ventral hernia repair with polypropylene mesh--a randomized, controlled study. Surgery 1999;125:211-6. 20. Felemovicius I, Bonsack ME, Hagerman G, Delaney JP. Prevention of adhesions to polypropylene mesh. J Am Coll Surg 2004;198:543-8. 21. Saravelos HG, Li TC. Physical barriers in adhesion prevention. J Reprod Med 1996;41:42-51. 22. Azziz R. Microsurgery alone or with INTERCEED Absorbable Adhesion Barrier for pelvic sidewall adhesion reformation. The INTERCEED (TC7) Adhesion Barrier Study Group II. Surg Gynecol Obstet 1993;177:135-9. 23. Dunn R, Lyman MD, Edelman PG, Campbell PK. Evaluation of the SprayGel adhesion barrier in the rat cecum abrasion and rabbit uterine horn adhesion models. Fertil Steril 2001;75:411-6. 24. Ferland R, Mulani D, Campbell PK. Evaluation of a sprayable polyethylene glycol adhesion barrier in a porcine efficacy model. Hum Reprod 2001;16:2718-23. 25. Mettler L, Audebert A, Lehmann-Willenbrock E, SchivePeterhansl K, Jacobs VR. A randomized, prospective, controlled, multicenter clinical trial of a sprayable, site-specific adhesion barrier system in patients undergoing myomectomy. Fertil Steril 2004;82:398-404. 26. Ozmen MM, Aslar AK, Terzi MC, Albayrak L, Berberoğlu M. Prevention of adhesions by bioresorbable tissue barrier following laparoscopic intraabdominal mesh insertion. Surg Laparosc Endosc Percutan Tech 2002;12:342-6.

Eylül - September 2011


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):383-389

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2011.99835

Beneficial effects of alpha lipoic acid on cerulein-induced experimental acute pancreatitis in rats Sıçanlarda seruleinle deneysel olarak oluşturulan akut pankreatitte alfa lipoik asitin faydalı etkileri Nuriye Esen BULUT,1 Erkan ÖZKAN,2 Osman EKİNCİ,3 Ender DULUNDU,2 Ümit TOPALOĞLU,2 Ahmet Özer ŞEHİRLİ,4 Feriha ERCAN,5 Göksel ŞENER4 BACKGROUND

AMAÇ

The present study aimed to determine the effects of alpha lipoic acid (ALA) on blood and tissue biochemical parameters, as well as tissue histopathology, in an experimental rat model of cerulein-induced acute pancreatitis (AP).

Bu çalışmada, sıçanlarda seruleinle deneysel olarak oluşturulan akut pankreatit (AP) modelinde alfa lipoik asitin (ALA) kan biyokimyasal parametreleri ve doku düzeyindeki etkileri araştırıldı.

METHODS

GEREÇ VE YÖNTEM

Three groups consisting of eight rats each were used, as follows: Group 1, controls; Group 2, cerulein-induced pancreatitis group treated with saline; and Group 3, ceruleininduced pancreatitis group treated with ALA. AP was induced by intraperitoneal administration of cerulein (20 µg/ kg) 4 times at 1-hour intervals. The animals were decapitated 12 hours after the last dose of cerulein. Blood amylase, lipase, interleukin (IL)-1ß, and tumor necrosis factor (TNF)-α levels, pancreas tissue glutathione (GSH) and malondialdehyde (MDA) levels, as well as myeloperoxidase (MPO) and Na+-K+-ATPase activity were measured. Pancreatic tissue samples were also evaluated histopathologically under a light microscope.

Her biri 8 sıçandan oluşan 3 grup oluşturuldu. Grup 1: Kontrol; Grup 2: Seruleinle pankreatit oluşturulup salin verilen grup; Grup 3: Seruleinle pankreatit oluşturulup ALA verilen grup. AP intraperitoneal olarak 20 µg/kg dozunda seruleinin 1’er saat aralıklarla 4 defa verilmesiyle oluşturuldu. Son serulein dozundan 12 saat sonra hayvanlar dekapite edildi. Kan amilaz, lipaz, interlökin (IL)-1ß, tümör nekroz faktör (TNF)-alfa düzeyleri, pankreas doku glutatyon (GSH), malondialdehid (MDA), miyeloperoksidaz (MPO) ve Na+-K+ATPase aktivitesi belirlendi. Ayrıca pankreas doku örnekleri histopatolojik olarak mikroskopta değerlendirildi.

RESULTS

While plasma amylase, lipase, IL-1ß, and TNF-α levels, and tissue MDA and MPO levels significantly increased in rats with cerulean-induced AP, tissue GSH and Na+-K+ATPase activity significantly reduced. These changes were reversed and improved with ALA treatment. CONCLUSION

BULGULAR

Seruleinle pankreatit oluşturulan grupta kan amilaz, lipaz, IL-1ß, TNF-alfa düzeyleri, doku MDA, MPO düzeyleri anlamlı derecede artarken, doku GSH ve Na+-K+-ATPase aktivitesi anlamlı derecede azaldı. ALA tedavisiyle bu değerlerde ve histopatolojide tersine değişiklikler, düzelme ve iyileşme görüldü. SONUÇ

Our findings suggest that ALA may significantly reduce morbidity and mortality by preventing organ dysfunction induced by free radicals in the pancreas.

Mevcut bulgular ALA tedavisinin, pankreasta oluşabilecek serbest radikallerin neden olduğu organ ve fonksiyon bozukluğunu önleyerek morbidite ve mortaliteyi önemli oranda azaltabileceğini düşündürmektedir.

Key Words: Acute pancreatitis; alpha lipoic acid; cerulein; cytokines; free oxygen radicals.

Anahtar Sözcükler: Akut pankreatit; alfa lipoik asit; serulein; sitokinler; serbest oksijen radikalleri.

Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul; Departments of 25th General Surgery, 3 Anesthesiology and Reanimation, Haydarpasa Numune Training and Research Hospital, Istanbul; 4Department of Pharmacology, Marmara University, Faculty of Pharmacy, Istanbul; 5Department of Histology and Embryology, Marmara University, Faculty of Medicine, Istanbul, Turkey. 1

1 Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul; Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, 2 5. Genel Cerrahi Kliniği, 3Anesteziyoloji ve Reanimasyon Kliniği, İstanbul; 4 Marmara Üniversitesi Eczacılık Fakültesi, Farmakoloji Anabilim Dalı, İstanbul; 5Marmara Üniversitesi Tıp Fakültesi, Histoloji ve Embriyoloji Anabilim Dalı, İstanbul.

Correspondence (İletişim): Erkan Özkan, M.D. Bosna Bulvarı Taşlıbayır Sok., No: 28, B Blok Kat: 3 D: 7, Üsküdar, İstanbul, Turkey. Tel: +90 - 216 - 414 45 02 / 1211 e-mail (e-posta): dr.erkan@mynet.com

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Acute pancreatitis (AP) is an inflammatory disease of the pancreas that is associated with little or no fibrosis of the gland.[1] The experimental and clinical pathophysiology of AP is poorly understood. Therefore, AP continues to be associated with significant mortality and morbidity.[2] It has recently been demonstrated that excessive formation of free oxygen radicals and changes in cytokine levels might have a role in the pathogenesis of AP. Free oxygen radicals may contribute to pancreatic acinar cell damage due to ischemia reperfusion injury through consumption of antioxidants within the tissue, and also have direct toxic effects on acinar cells.[3,4] Several cytokines are released from damaged pancreatic cells and systemic immune cells during pancreatic inflammation. Interleukin (IL)1 and tumor necrosis factor (TNF)-α are major cytokines that play a role in AP. In addition, IL-2, IL-6, IL-8, IL-10, and nitric oxide (NO) contribute to deterioration in the clinical condition. These cytokines lead to worsening of AP and systemic complications by increasing capillary permeability.[5] Alpha lipoic acid (ALA) is a strong antioxidant with anti-inflammatory effects.[6,7] In several studies, ALA has been demonstrated to inhibit free radicals that cause oxidative damage.[8,9] Cerulein is widely used in experimental models of AP.[10,11] Intraperitoneal, intravenous and subcutaneous administration of cerulein leads to edematous pancreatitis and necrotizing pancreatitis, which are characterized by edema and increased levels of serum amylase, as well as by acinar cell vacuolization and leukocyte infiltration histologically, through the stimulation of cholecystokinin receptors within the pancreatic tissue.[12,13] The aim of the present study was to determine the effects of ALA, which has anti-oxidative and antiinflammatory properties, on blood and tissue biochemical parameters as well as tissue histopathology in an experimental rat model of cerulein-induced AP.

MATERIALS AND METHODS Animals Sprague-Dawley rats of either sex (200-250 g) were maintained in a room at a constant temperature of 22±1°C with 12-hour (h) light/dark cycles and fed standard pellet chow and water ad libitum. This study was approved by the Animal Ethics Committee regulations after obtaining approval from the Animal Experimentation Ethics Committee of Haydarpasa Numune Training and Research Hospital, Experimental Research Animal Laboratory. Experimental Protocol Three groups consisting of eight animals each were used. AP was induced by intraperitoneal administration of cerulein (20 µg/kg; Sigma, St. Louis, MO, USA) 4 times at 1-h intervals. Group 1 consisted of control 384

animals. Group 2 was the cerulein-induced pancreatitis group treated with intraperitoneal isotonic sodium chloride infusion 6 h after the last dose of cerulein. Group 3 was the cerulein-induced pancreatitis group treated with 100 mg/kg intraperitoneal ALA 6 h after the last dose of cerulein; this dose of ALA was previously shown to be an effective anti-inflammatory dose. [14,15] The animals were decapitated 12 h after the last dose of cerulein. Trunk blood was collected for the assessment of amylase, lipase, TNF-α, and IL-1β. To evaluate the presence of oxidative damage in the pancreas, tissue samples were obtained and stored at -80°C for the determination of malondialdehyde (MDA) and glutathione (GSH) levels and myeloperoxidase (MPO) and Na+-K+-ATPase activities. For histological analysis, tissue samples were fixed in 10% (v/v) buffered formaldehyde, and processed for routine paraffin embedding. Tissue sections (6 µm) were stained with hematoxylin and eosin (H&E), and examined under a light microscope (Olympus-BH-2). Histological assessments were performed by an experienced histologist who was blinded to the treatment conditions. Biochemical Analysis Plasma amylase and lipase levels were determined spectrophotometrically using an automated analyzer (Olympus AU 600; Diamond Diagnostics, Holliston, MA, USA), whereas TNF-α and IL-1β were quantified in accordance with the manufacturer’s instructions and guidelines using enzyme-linked immunosorbent assay (ELISA) kits (Biosource International, Nivelles, Belgium). These particular assay kits were selected because of their high degree of sensitivity, specificity, inter- and intra-assay precision, and the small amount of plasma sample required to conduct the assay. Measurement of Pancreatic Malondialdehyde and Glutathione Levels Tissue samples were homogenized with ice-cold 150 mM KCl for the determination of MDA and GSH levels. The MDA levels were assayed for the products of lipid peroxidation by monitoring the formation of thiobarbituric acid reactive substances, as described previously.[16] Lipid peroxidation was expressed in terms of MDA equivalents using an extinction coefficient of 1.56x105 M-1 cm -1, and the results were expressed as nmol MDA/g tissue. GSH measurements were performed using a modification of the Ellman procedure.[17] Briefly, after centrifugation at 1200 xg for 10 minutes (min), 0.5 ml of supernatant was added to 2 ml of 0.3 mol/L Na2HPO4.2H2O solution. A 0.2 ml solution of dithiobisnitrobenzoate (0.4 mg/ml 1% sodium citrate) was added, and the absorbance at 412 nm was measured immediately after mixing. GSH levels were calculated using an extinction coefficient of 1.36x104 M-1 cm -1. Results were expressed as µmol GSH/g tissue. Eylül - September 2011


Beneficial effects of alpha lipoic acid on cerulein-induced experimental acute pancreatitis in rats

Measurement of Pancreatic Myeloperoxidase Activity Myeloperoxidase (MPO) is an enzyme that is found predominantly in the azurophilic granules of polymorphonuclear leukocytes (PMN). Tissue MPO activity is frequently utilized to estimate tissue PMN accumulation in inflamed tissues and correlates significantly with the number of PMN determined histochemically in tissues.[18] MPO activity was measured in tissues in a procedure similar to that documented by Hillegass et al.[19] Tissue samples were homogenized in 50 mM potassium phosphate buffer (PB, pH 6.0), and centrifuged at 41,400 xg for 10 min. The pellets were suspended in 50 mM PB containing 0.5% hexadecyltrimethylammonium bromide. After three freeze and thaw cycles with sonication between the cycles, the samples were centrifuged at 41,400 xg for 10 min. Aliquots (0.3 ml) were added to 2.3 ml of reaction mixture containing 50 mM PB, o-dianisidine and 20 mM H2O2 solution. One unit of enzyme activity was defined as the amount of MPO that caused a change in absorbance measured at 460 nm for 3 min. MPO activity was expressed as U/g tissue. Measurement of Na+- K+-ATPase Activity Measurement of Na+-K+-ATPase activity is based on the measurement of inorganic phosphate that is formed from 3 mM disodium adenosine triphosphate added to the medium during the incubation period.[20] The medium was incubated in a 37°C water bath for 5 min with a mixture of 100 mM NaCl, 5 mM KCl, 6 mM MgCl2, 0.1 mM EDTA, and 30 mM Tris HCl (pH 7.4). Following the pre-incubation period, Na2ATP, at a final concentration of 3 mM, was added to each tube, and the tubes were incubated at 37°C for 30 min. After the incubation, the tubes were placed in an ice bath, and the reaction was terminated. Subsequently, the level of inorganic phosphate was determined using a spectrophotometer (Shimadzu, Japan) at an excitation wavelength of 690 nm. The specific activity of the enzyme was expressed as Pi mg-1 protein h-1. The protein concentration of the supernatant was measured by the Lowry method.[21]

Histopathologic Evaluation of Pancreatic Damage For light microscopic analysis, samples from the pancreas were fixed in 10% buffered formalin for 48 hours, dehydrated in an ascending alcohol series, and embedded in paraffin wax. Sections, approximately 5 μm in thickness, were stained with H&E for general morphology. Histological assessments were performed with a photomicroscope (Olympus BX 51; Tokyo, Japan) by an experienced histologist who was blinded to the experimental groups. Statistical Analysis Statistical analysis was carried out using GraphPad Prism 3.0 (GraphPad Software, San Diego, CA, USA). All data are expressed as the mean±standard error of the mean (SEM). Groups of data were compared with an analysis of variance (ANOVA), followed by Tukey’s multiple comparison tests. A p value <0.05 was accepted as statistically significant.

RESULTS Plasma amylase and lipase levels were significantly higher in the saline-treated pancreatitis group compared to the control group (p<0.01). Amylase and lipase levels were significantly lower in the ALA-treated pancreatitis group compared to the saline-treated pancreatitis group (p<0.01 and p<0.001, respectively; Table 1, Fig. 1a, 1b). Tumor necrosis factor (TNF)-α and IL-1β levels were significantly higher in the saline-treated pancreatitis group compared to the control group, clearly indicating that inflammatory reactions increased within the tissue (p<0.001). The levels of these cytokines were significantly lower in the ALA-treated pancreatitis group compared to the saline-treated pancreatitis group (p<0.01; Table 1, Fig. 2a, 2b). Glutathione (GSH) is an important antioxidant that is protective against free oxygen radicals formed in several tissues as a result of pancreatitis. The level of reduced GSH in the saline-treated pancreatitis group was significantly lower compared to the control group

Table 1. Plasma amylase, lipase, tumor necrosis factor-α, and interleukin-1β levels in the sham-operated control or cerulein-induced acute pancreatitis groups treated with either saline or alpha lipoic acid Amylase (U/L) Lipase (U/L) TNF-α (pg/ml) IL-1β (pg/ml)

Cerulein-induced pancreatitis groups Controls (n=8) Mean±SEM

Saline-treated (n=8) Mean±SEM

ALA-treated (n=8) Mean±SEM

594±67.00 65.13±10.02 6.35±0.96 10.88±1.71

1182±81** 345±24.5** 45.23±8.22*** 55.47±6.24***

818±48++ 93.13±14.41+++ 15.95±2.66++ 21.35±4.29+++

ALA: Alpha lipoic acid; TNF-α: Tumor necrosis factor-α,; IL-1β: Interleukin-1β,; SEM: Standard error of the mean. **p<0.01, ***p<0.001 compared to controls; ++p<0.01, +++p<0.001 compared to saline-treated group.

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Table 2. Tissue glutathione and malondialdehyde levels and myeloperoxidase and Na+-K+-ATPase activities in the sham-operated control or cerulein-induced acute pancreatitis groups treated with either saline or ALA GSH (mmol/g) MDA (nmol/g) MPO (U/g) Na+-K+-ATPase (mmol/mg protein/h)

Cerulein-induced pancreatitis groups Controls (n=8) Mean±SEM

Saline-treated (n=8) Mean±SEM

ALA-treated (n=8) Mean±SEM

2.29±0.15 28.67±4.21 9.83±1.48

0.97±0.18*** 59.68±6.48** 28.44±4.37**

2.19±0.11+++ 30.10±3.85++ 13.66±2.43++

2.44±0.32

1.14±0.20**

2.38±0.15++

ALA: Alpha lipoic acid; GSH: Glutathione; MDA: Malondialdehyde; MPO: Myeloperoxidase; SEM: Standard error of the mean. **p<0.01, ***p<0.001 compared to controls; ++p<0.01, +++p<0.001 compared to saline-treated group.

(p<0.001). The level of reduced GSH was significantly higher in the ALA-treated pancreatitis group compared to the saline-treated group (p<0.001; Table 2, Fig. 3a). In order to assess pancreatic damage, levels of MDA, an end-product of lipid peroxidation, were measured as an indicator of oxidative injury. MDA levels in the saline-treated pancreatitis group were significantly higher compared to the control group (p<0.01). MDA levels were significantly lower in the ALA-

(a)

treated pancreatitis group than the saline-treated group (p<0.01; Table 2, Fig. 3b). Myeloperoxidase (MPO) activity was measured in tissue samples as an indicator of neutrophilic infiltration. MPO activity significantly increased in the saline-treated pancreatitis group compared to the control group (p<0.01), whereas the MPO activity was significantly lower in the ALA-treated pancreatitis group than the saline-treated group (p<0.01; Table 2, Fig. 4a).

(b)

Fig. 1. Plasma amylase and lipase levels in the sham-operated control or cerulein-induced acute pancreatitis groups treated with either saline or alpha lipoic acid (ALA). ** p<0.01, *** p<0.001 compared to controls; ++p<0.01, +++p<0.001 compared to saline-treated group.

(a)

(b)

Fig. 2. Serum tumor necrosis factor (TNF)-α and interleukin (IL)-1β levels in the sham-operated control or cerulein-induced acute pancreatitis groups treated with either saline or alpha lipoic acid (ALA). ** p<0.01, *** p<0.001 compared to controls; ++ p<0.01, +++ p<0.001 compared to saline-treated group. 386

Eylül - September 2011


Beneficial effects of alpha lipoic acid on cerulein-induced experimental acute pancreatitis in rats

(a)

(b)

Fig. 3. Tissue glutathione (GSH) and malondialdehyde (MDA) levels in the sham-operated control or cerulein-induced acute pancreatitis groups treated with either saline or alpha lipoic acid (ALA). **p<0.01, ***p<0.001 compared to controls; ++p<0.01, +++p<0.001 compared to saline-treated group.

(a)

(b)

Fig. 4. Tissue myeloperoxidase and Na+-K+-ATPase activities in the sham-operated control or cerulein-induced acute pancreatitis groups treated with either saline or alpha lipoic acid (ALA). **p<0.01 compared to controls; ++p<0.01 compared to saline-treated group.

Free oxygen radical formation leads to lipid peroxidation, which results in dysfunction in the erythrocyte membrane system and loss of activity in the membrane-enzyme systems, and thereby inactivation of Na+-K+-ATPase. In the present study, the Na+-K+-ATPase level was significantly lower in the saline-treated pancreatitis group than the control group (p<0.01), whereas it was significantly higher in the ALA-treated pancreatitis group than the saline-treated pancreatitis group (p<0.01; Table 2, Fig. 4b).

Histologic Preparation and Analysis Histopathologic scoring included assessment of edema, acinar necrosis, inflammatory cell infiltration, and hemorrhage. While regular pancreas morphology was observed in the control group, varying degrees of acinar swelling, pancreatic tissue necrosis, hemorrhage, and inflammatory cell infiltration were observed in the pancreatitis group. Histopathologic changes in the pancreas were moderately improved in the ALA-treated pancreatitis group (Fig. 5).

Fig. 5. Histopathological assessment (Hematoxylin and eosin staining, original magnification X200). (A) Control group, normal pancreatic appearance; (B) Saline-treated pancreatitis group, acinar necrosis (*) and vascular congestion (arrow) are noted; and (C) ALA-treated pancreatitis group, mild acinar necrosis (*) and vascular congestion (arrow). Cilt - Vol. 17 Say覺 - No. 5

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DISCUSSION Acute pancreatitis (AP) is a local or systemic inflammatory condition affecting surrounding tissues and organs to various degrees together with the pancreas. Several clinical forms exist, varying from edematous pancreatitis with low mortality to hemorrhagic or severe AP with high mortality.[22] Administration of cerulein in various doses and routes leads to various degrees of AP in rats.[23] The intraperitoneal administration of cerulein at a dose of 20 µg/kg, 2-4 times at 1-h intervals, leads to acute edematous pancreatitis, whereas the intraperitoneal administration of cerulein at a dose of 40-50 µg/kg, 2-4 times at 1-hour intervals, causes acute hemorrhagic necrotizing pancreatitis. Macroscopically, in rats treated with cerulein, the pancreas is enlarged and becomes edematous. The earliest histologic changes after subcutaneous and intraperitoneal cerulein administration occur in cytoplasmic vacuoles, and these vacuoles reach enormous sizes with the progression of pancreatitis. Significant interstitial inflammation and acinar cell necrosis occur within 6 hours following the administration of cerulein, reach a maximum level by the 12th hour, and often disappear within 4 days. Studies have shown that the major effect of ALA is its anti-inflammatory effect on collagen tissue and the nervous system. Another effect is protection of vessels against oxidative injury.[24] Several other pharmacologic and therapeutic effects of ALA include vasodilator, anti-carcinogenic, anti-allergic, anti-inflammatory, anti-fungal, anti-arthritic, anti-bacterial, cardioprotective, immunostimulant, and anti-viral effects.[25,26] Amylase and lipase levels are the most common parameters used for the diagnosis of AP. Amylase and lipase levels often elevate in case of AP, but not in parallel with the severity of pancreatitis.[27] In the present study, amylase and lipase levels were significantly lower in the ALA-treated cerulein-induced AP group than the saline-treated group (p<0.01 and p<0.001, respectively). Tumor necrosis factor (TNF)-α and IL-1β are the major cytokines released from macrophages. In addition to their cytotoxic effects, they also play a significant role in inflammatory reactions and regulation of inflammation.[28] Neutrophils release free oxygen radicals and several lysosomal enzymes during inflammation and following trauma. TNF-α and IL-1β are also released from activated neutrophils following stimulation.[29,30] In our study, the TNF-α and IL-1β levels were lower in the ALA-treated pancreatitis group than the saline-treated group (p<0.01). These results suggest that ALA decreases the inflammatory response by inhibiting activation and infiltration of neutrophils, which play a role in triggering tissue damage, and that ALA protects the pancreas tissue from free oxygen radical-induced damage. 388

Lipids are one of the major targets for free radical damage following pancreatitis. Free oxygen radicals initiate lipid peroxidation by removing one hydrogen atom from polyunsaturated fatty acids with the subsequent formation of hydroperoxides. As a result of these reactions, the membrane fluidity and membrane integrity of cells are impaired, leading to disintegration of cells and cell death. These subcellular structures that are released into the extracellular environment trigger several inflammatory events and further worsen the ongoing damage.[31] The MDA level was measured as an indicator of lipid peroxidation in the current study. The MDA level in the ALA-treated pancreatitis group was found to be significantly lower compared to the saline-treated group (p<0.01). MPO is an essential enzyme for normal neutrophil function and is used as an index of tissue neutrophil infiltration because its levels increase when neutrophils are stimulated by various stimulants.[32,33] We observed that ALA administration reduced the MPO levels, suggesting a protective effect against free oxygen radical-induced damage through inhibition of neutrophil infiltration and activation in the pancreatic tissues. All aerobic organisms are exposed to oxidative stress physiologically during their metabolism. GSH protects the cell from oxidative injury by reacting with free radicals and peroxides. It has been shown in several studies that tissue GSH levels are rapidly decreased during pancreatic damage.[34] In our study, the GSH level was significantly higher in the ALA-treated pancreatitis group than the saline-treated group (p<0.001). Lipid peroxidation occurs due to the formation of free oxygen radicals, which in turn leads to dysfunction in the erythrocyte membrane system and loss of activity in the membrane-enzyme systems. Consequently, Na+-K+-ATPase is inactivated. As in other transport enzymes within the erythrocyte membrane, Na+K+-ATPase enzyme is also known to depend on the presence of membrane phospholipids for its activation. [35,36] We found that the Na+-K+-ATPase activity level was significantly higher in the ALA-treated pancreatitis group compared to the saline-treated group (p<0.01). Although pancreatic tissue damage can be assessed by various parameters, we used serum TNF-α and IL-1β levels, tissue GSH and MDA levels and MPO and Na+-K+-ATPase activity in the current study. In the present study, while amylase, lipase, TNF-α, IL1β, MDA, and MPO were found to be significantly lower in the ALA-treated pancreatitis group compared to the saline-treated pancreatitis group, GSH and Na+K+-ATPase levels were significantly higher. In conclusion, our findings suggest that ALA may significantly reduce morbidity and mortality by preventing organ dysfunction induced by free radicals in the pancreas. Eylül - September 2011


Beneficial effects of alpha lipoic acid on cerulein-induced experimental acute pancreatitis in rats

REFERENCES 1. Fisher WE, Andersen DK, Bell RH Jr, Saluja AK, Brunicardi FC. Schwartz’s principles of surgery. Pancreas. Chapter 33, 9th ed., 2010. p. 1177-86. 2. Bülbüller N, Doğru O, Umaç H, Gürsu F, Akpolat N. The effects of melatonin and pentoxiphylline on L-arginine induced acute pancreatitis. Ulus Travma Acil Cerrahi Derg 2005;11:108-14. 3. Zeybek N, Gorgulu S, Yagci G, Serdar M, Simsek A, Kaymakcioglu N, et al. The effects of gingko biloba extract (EGb 761) on experimental acute pancreatitis. J Surg Res 2003;115:286-93. 4. Pooran N, Indaram A, Singh P, Bank S. Cytokines (IL-6, IL8, TNF): early and reliable predictors of severe acute pancreatitis. J Clin Gastroenterol 2003;37:263-6. 5. Gukovsky I, Gukovskaya AS, Blinman TA, Zaninovic V, Pandol SJ. Early NF-kappaB activation is associated with hormone-induced pancreatitis. Am J Physiol 1998;275:G140214. 6. Park KG, Kim MJ, Kim HS, Lee SJ, Song DK, Lee IK. Prevention and treatment of macroangiopathy: focusing on oxidative stress. Diabetes Res Clin Pract 2004;66:57-62. 7. Atmaca G. Antioxidant effects of sulfur-containing amino acids. Yonsei Med J 2004;45:776-88. 8. Park SJ, Seo SW, Choi OS, Park CS. Alpha-lipoic acid protects against cholecystokinin-induced acute pancreatitis in rats. World J Gastroenterol 2005;11:4883-5. 9. Ghibu S, Richard C, Vergely C, Zeller M, Cottin Y, Rochette L. Antioxidant properties of an endogenous thiol: Alpha-lipoic acid, useful in the prevention of cardiovascular diseases. J Cardiovasc Pharmacol 2009;54:391-8. 10. Yonetci N, Sungurtekin U, Oruc N, Yilmaz M, Sungurtekin H, Kaleli I, et al. Is procalcitonin a reliable marker for the diagnosis of infected pancreatic necrosis? ANZ J Surg 2004;74:591-5. 11. Um SH, Kwon YD, Kim CD, Lee HS, Jeen YT, Chun HJ, et al. The role of nitric oxide in experimental cerulein induced pancreatitis. J Korean Med Sci 2003;18:520-6. 12. Ozturk F, Gul M, Esrefoglu M, Ates B. The contradictory effects of nitric oxide in caerulein-induced acute pancreatitis in rats. Free Radic Res 2008;42:289-96. 13. Ding SP, Li JC, Jin C. A mouse model of severe acute pancreatitis induced with caerulein and lipopolysaccharide. World J Gastroenterol 2003;9:584-9. 14. Dulundu E, Ozel Y, Topaloglu U, Sehirli O, Ercan F, Gedik N, et al. Alpha-lipoic acid protects against hepatic ischemiareperfusion injury in rats. Pharmacology 2007;79:163-70. 15. Sehirli O, Sener E, Cetinel S, Yüksel M, Gedik N, Sener G. Alpha-lipoic acid protects against renal ischaemia-reperfusion injury in rats. Clin Exp Pharmacol Physiol 2008;35:24955. 16. Buege JA, Aust SD. Microsomal lipid peroxidation. Methods Enzymol 1978;52:302-10. 17. Beutler E. Glutathione in red blood cell metabolism. A manual of biochemical methods. New York: Grune&Stratton; 1975. p. 112-114. 18. Bradley PP, Priebat DA, Christensen RD, Rothstein G. Measurement of cutaneous inflammation: estimation of neutrophil content with an enzyme marker. J Invest Dermatol 1982;78:206-9. 19. Hillegass LM, Griswold DE, Brickson B, Albrightson-Winslow C. Assessment of myeloperoxidase activity in whole rat kidney. J Pharmacol Methods 1990;24:285-95. Cilt - Vol. 17 Sayı - No. 5

20. Reading HW, Isbir T. The role of cation-activated ATPases in transmitter release from the rat iris. Q J Exp Physiol Cogn Med Sci 1980;65:105-16. 21. Lowry OH, Rosebrough NJ, Farr AL, Randall RJ.. Protein measurement with the Folin phenol reagent. J Biol Chem 1951;193:265-75. 22. Büyükberber M, Savaş MC, Bağci C, Koruk M, Gülşen MT, Tutar E, et al. The beneficial effect of propolis on ceruleininduced experimental acute pancreatitis in rats. Turk J Gastroenterol 2009;20:122-8. 23. Baxter JN, Jenkins SA, Day DW, Roberts NB, Cowell DC, Mackie CR, et al. Effects of somatostatin and a long-acting somatostatin analogue on the prevention and treatment of experimentally induced acute pancreatitis in the rat. Br J Surg 1985;72:382-5. 24. Cadirci E, Altunkaynak BZ, Halici Z, Odabasoglu F, Uyanik MH, Gundogdu C, et al. Alpha-lipoic acid as a potential target for the treatment of lung injury caused by cecal ligation and puncture-induced sepsis model in rats. Shock 2010;33:479-84. 25. Patel BP, Hamadeh MJ. Nutritional and exercise-based interventions in the treatment of amyotrophic lateral sclerosis. Clin Nutr 2009;28:604-17. 26. Chen XS, Liu H, Ji AM, Yang YL,Yao YF. Effects of sustained release alpha lipoic acid tablet on blood lipid, on blood sugar and insulin in hyperlipidemic New Zeland rabbits. Non Fang Yi Ke Da Xue Xue Boo 2009;29:704-6. 27. Steer ML. Sabiston textbook of surgery. The biological basis of modern surgical practice. 17 th ed., 2007. 28. Steer ML. Relationship between pancreatitis and lung diseases. Respir Physiol 2001;128:13-6. 29. Bhatia M, Brady M, Shokuhi S, Christmas S, Neoptolemos JP, Slavin J. Inflammatory mediators in acute pancreatitis. J Pathol 2000;190:117-25. 30. Gultekin FA, Kerem M, Tatlicioglu E, Aricioglu A, Unsal C, Bukan N. Leptin treatment ameliorates acute lung injury in rats with cerulein-induced acute pancreatitis. World J Gastroenterol 2007;13:2932-8. 31. Eşrefoğlu M, Gül M, Ateş B, Yilmaz I. Ultrastructural clues for the protective effect of ascorbic acid and N-acetylcysteine against oxidative damage on caerulein-induced pancreatitis. Pancreatology 2006;6:477-85. 32. Akyuz C, Sehirli AO, Topaloglu U, Ogunc AV, Cetinel S, Sener G. Protective effects of proanthocyanidin on ceruleininduced acute pancreatic inflammation in rats. Gastroenterology Research 2009;2:20-28. doi:10.4021/gr2009.02.1276. 33. Yamagiwa T, Shimosegawa T, Satoh A, Kimura K, Sakai Y, Masamune A. Inosine alleviates rat caerulein pancreatitis and pancreatitis-associated lung injury. J Gastroenterol 2004;39:41-9. 34. Gül M, Eşrefoğlu M, Oztürk F, Ateş B, Otlu A. The beneficial effects of pentoxifylline on caerulein-induced acute pancreatitis in rats. Dig Dis Sci 2009;54:555-63. 35. Ozkan E, Akyüz C, Sehirli AO, Topaloğlu U, Ercan F, Sener G. Montelukast, a selective cysteinyl leukotriene receptor 1 antagonist, reduces cerulein-induced pancreatic injury in rats. Pancreas 2010;39:1041-6. 36. Magro F, Fraga S, Ribeiro T, Soares-da-Silva P. Regional intestinal adaptations in Na+,K+-ATPase in experimental colitis and the contrasting effects of interferon-gamma. Acta Physiol Scand 2005;183:191-9. 389


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):390-395

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.03443

The value of CRP, IL-6, leptin, cortisol, and peritoneal caspase-3 monitoring in the operative strategy of secondary peritonitis Sekonder peritonitte planlı abdominal onarımın sonlandırılma kararında C reaktif protein, interlökin 6, leptin, kortizol ve kaspaz 3 değerlerinin etkisi Faruk PEHLİVANLI,1 Fatih AĞALAR,1 Canan AĞALAR,2 Oral SAYGUN,1 Cağatay DAPHAN,1 Kuzey AYDINURAZ,1 Unase BÜYÜKKOÇAK,3 Osman ÇAĞLAYAN,4 Sedat DOM,1 Tayfun ŞAHİNER1 BACKGROUND

AMAÇ

We aimed to investigate the impact of C-reactive protein (CRP), interleukin (IL)-6, leptin, cortisol, and caspase-3 on the decision of terminating planned abdominal repair in secondary peritonitis.

Orta ve ciddi sekonder peritonitte planlı abdominal onarımın sonlandırılma kararında C reaktif protein (CRP), interlökin (IL) 6, leptin, kortizol ve kaspaz 3 değerlerinin etkisi araştırıldı.

METHODS

GEREÇ VE YÖNTEM

Fifteen patients with peritonitis were enrolled into the study. Serum CRP, IL-6, leptin, cortisol, and peritoneal caspase-3 activities were measured.

Orta ve ciddi sekonder peritonitli 15 hasta alındı. Serum CRP, IL-6, leptin ve kortizol düzeyleri ile periton sıvılarında kaspaz 3 ölçüldü.

RESULTS

BULGULAR

APACHE II scores at 48 hours (h) and age were significantly higher in non-survivors. A significant decrease was observed in caspase-3 activities of patients in whom ≤4 laparotomies were performed when compared with those who underwent >4 laparotomies. For patients who underwent ≤4 laparotomies, there was a significant difference in caspase-3 levels between 0 and 72 h. There was no significant difference in caspase-3 levels in non-survivors; caspase-3 levels were significantly lower in the survivors at 48 and 72 h. Changes in CRP, IL-6, leptin, and cortisol levels were not statistically significant. CONCLUSION

Mortalite gelişenlerde yaş ve 48. saat APACHE II skoru, gelişmeyenlere göre anlamlı olarak yüksek olarak bulundu. Tüm gruplarda 0. saat ve 72. saat kaspaz düzeyleri arasında anlamlı fark bulundu. Dörtten az ve fazla yıkama yapılanlar kaspaz açısından karşılaştırıldığında; az yıkama yapılanlarda kaspaz değerlerinde azalma olduğu izlendi. Dört ve daha az yıkama yapılanlarda 0. saat kaspaz ile 72. saat kaspaz değerleri arasında anlamlı farklılık bulundu. Mortalite olan grubun kaspaz 3 değerleri arasında farklılık saptanmazken, mortalite olmayan grupta kaspaz 3 48. ve 72. saat değerlerinde anlamlı bir düşüş izlendi. CRP, IL-6, leptin ve kortizol seviyelerindeki değişiklikler anlamlı bulunmadı.

CRP, IL-6, leptin, cortisol, and caspase-3 are not valuable in discriminating the number of planned operations, even though there is a significant decrease in caspase-3 “within” survivors. The discriminative value of caspase-3 for closure should be evaluated in studies in which caspase-3 is monitored for a longer duration in a large number of patients.

SONUÇ

CRP, IL-6, leptin, kortizol seviyesinin karın kapatılması kararında etkisinin olmadığı görülmüştür. Kaspaz 3 seviyelerindeki düşüş yıkama sayısını belirlemede yararlı olabilir. Karın kapamada yıkama sayısını belirlemede vekil parametre olarak kaspaz 3 seçilecekse, daha uzun sürelerdeki kaspaz aktivitesini değerlendiren çalışmalara ihtiyaç vardır.

Key Words: Caspase-3; peritonitis; planned relaparotomy; interleukin-6; cortisol.

Anahtar Sözcükler: Kaspaz 3; peritonit; planlı repalarotomi; interlökin 6; kortizol.

Departments of 1General Surgery, 2Infectious Diseases and Clinical Microbiology, 3Anesthesiology and Reanimation, 4 Biochemistry, Kirikkkale University Faculty of Medicine, Kirikkale, Turkey.

Kırıkkale Üniversitesi Tıp Fakültesi, 1Genel Cerrahi Anabilim Dalı, 2 Enfeksiyon Hastalıkları ve Klinik Mikrobiyoloji Anabilim Dalı, 3 Anesteziyoloji ve Reanimasyon Anabilim Dalı, 4Biyokimya Anabilim Dalı, Kırıkkale.

Correspondence (İletişim): Fatih Agalar, M.D. Kırıkkale Universitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, 71100 Kırıkkale, Turkey. Tel: +90 - 318 - 224 25 85 e-mail (e-posta): fatihagalar@gmail.com

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The value of CRP, IL-6, leptin, cortisol, and peritoneal caspase-3 monitoring in the operative strategy of secondary peritonitis

Among peritonitis, secondary peritonitis is the most frequently encountered intraabdominal infection, with high mortality and morbidity. Surgical source control and peritoneal toilets help peritoneal and systemic host defense mechanisms, which are the important steps in the treatment of this disease. [1-3| Today, on-demand laparotomy is accepted as the standard therapy of peritonitis, but various types of open abdominal procedures are also advocated in selected cases.[4-7] Recently, Lamme et al.[8] showed in a prospective randomized study that on-demand laparotomy is superior to planned relaparotomy in terms of hospital stay and morbidity. They found no mortality rate difference between planned relaparotomy and the on-demand group, but the morbidity rate was high and hospital stay was longer in the former. Rakic et al.[9] reached a similar conclusion in another prospective clinical study. Recently, an Amsterdam group showed the superiority of on-demand laparotomy to planned operations in terms of cost.[10] Costs were substantially lower in the on-demand group. The findings of these recent studies led us to use open abdominal approaches with more caution in the treatment of peritonitis. The increased morbidity and hospital stay may be due to the number of relaparotomies rather than the procedure itself. Since surgical trauma produces an immune depression and causes a depressed woundhealing process, a well-balanced surgical therapy should be achieved.[11-13] Thus, it is crucial to terminate the procedure by definitive closure with an optimum number of relaparotomies. Yet, there is no valid or measurable surrogate parameter in the estimation of the optimum number of planned operations. Generalization of the results to the community at large is one of the main problems of a randomized controlled study, and the problem is more evident in the case of peritonitis. Today and in the near future, various types of open abdominal approaches will probably be used by some surgeons in selected cases. Some interesting interactions between caspases and peritoneal host defenses were observed in animal models of sepsis. It was shown before that there was a marked increase in apoptosis in endotoxin-stimulated phagocytes, which was associated with a significant increase in caspase-3, -8 and -9 activities.[14] Apoptosis occurred 24 hours (h) after the onset of peritonitis in an animal model of sepsis.[15] Thus, it is logical to explore the activity of caspase-3 in the initial phase in the clinical setting. There is also a clear-cut correlation between caspase-3 levels and peritoneal mesothelial cell apoptosis.[16] With the above- mentioned literature data, monitoring of peritoneal fluid caspase levels in the treatment of peritonitis may add valid data to our clinical knowledge. Cilt - Vol. 17 Sayı - No. 5

Therefore, the aim of this prospective study was to evaluate the effects of initial three-day monitoring of plasma C-reactive protein (CRP), interleukin (IL)-6, cortisol, leptin, and peritoneal fluid caspase-3 levels on the management of planned relaparotomies and the factors affecting severity and mortality.

MATERIALS AND METHODS This prospective study was conducted in the Department of General Surgery, Kirikkale University School of Medicine. This study was approved by the Ethical Committee of Kirikkale University. Patients having secondary peritonitis and Acute Physiology and Chronic Health Evaluation (APACHE) II scores of ≥10 were included. Because APACHE II score works well in determining the severity in peritonitis, initial and second day scores were recorded in the present study.[17,18] Inclusion criteria: 1. Patients older than 16 years 2. Patients having secondary peritonitis with APACHE II score of ≥10 Exclusion criteria: 1. Patients who prefer “on-demand laparotomy” 2. Patients who will probably die within 24 h and are unresponsive to shock therapy 3. Patients with primary peritonitis 4. Patients having massive mesenteric vascular occlusions 5. Patients having pancreatitis (Due to the facts that pancreatitis has quite distinct physiopathological aspects from secondary peritonitis, and the types of the planned operations are different from those performed for secondary peritonitis) Parameters: 1. Demographic variables 2. Complete blood count, blood chemistry, APACHE II, blood CRP, IL-6, cortisol, and leptin levels 3. Peritoneal fluid caspase-3 levels Under standard anesthesia, median laparotomy was done. Source control was achieved with ostomies when possible. The peritoneal space was washed with 2-3 liters of warm saline. Standard anastomotic techniques with conventional double-layer suture methods were applied. Stapling devices were used where appropriate. If possible, the omentum was preserved during operations, because omentectomy depresses not only peritoneal defense mechanisms such as chemotactic activity of leukocytes and neutrophil phagocytosis, but also the number of free peritoneal fluid macrophages and leukocytes.[13] It also protects the bowels from foreign body so-called “Bogota bag” dur391


Ulus Travma Acil Cerrahi Derg

used (Biosource Europe, S. A. Nivelles, Belgium). Cortisol levels were assessed by electrochemiluminescence immunoassay (Roche e170 Modular Analytics, Hitachi, Japan). Caspase was assessed using Human Caspase-3 Instant ELISA (Bender Med Systems, Vienna, Austria).

Table 1. Pathologies and the outcome of patients Etiology of peritonitis

Alive Exitus Total

Small bowel perforation Colonic perforation Perforated appendicitis Anastomotic failure Retroperitoneal necrotizing fasciitis Gastric perforation Suture failure and infection after myomectomy Intestinal obstruction Total

2 3 1 2 1 1

1 0 0 2 0 0

3 3 1 4 1 1

1 0 11

0 1 4

1 1 15

Microbiological studies: Standard microbiological cultures were obtained and standard microbiologic surveillance was carried out. Antibiotic treatment: Empirical antibiotic treatment was given initially and changed if needed according to culture results. Carbapenems: Mostly meropenem (3x1 g IV), or imipenem (4x500 mg IV) was used at least 10 days. APACHE II scores of the first and second days were recorded.

ing planned relaparotomies. The Bogota bag was used for temporary closure of the abdominal cavity after the index operation. The interval between operations was one day. The procedures were terminated according to surgeon’s decision, and definitive closure was performed using heavy propylene sutures. We did not intend to definitively close the fascial planes if the length of the overall procedure exceeded 10 days. Some sort of late abdominal closure techniques were applied in those patients.

Statistical Analysis SPSS 17.0 was used for statistical analysis. Chisquare test was used for descriptive statistics, incidences and for univariate analysis of factors affecting mortality. Student’s t-test was used for analysis of parametric data, whereas Mann-Whitney U test was used for analysis of nonparametric data. Min-max was used for central dispersion measures of nonparametric tests and ±SD for parametric tests. Spearman’s correlation test was used for correlation between parameters. Friedman and Wilcoxon Signed Rank tests were applied for intraparametric changes. Values of p<0.05 were accepted as statistically significant.

During the first four laparotomies, blood samples (including index operation) for routine biochemistry, CRP, IL-6, leptin, and cortisol and peritoneal fluid samples for caspase-3 activities were obtained. Peritoneal fluid samples were obtained after the onset of laparotomy, or relaparotomy from 4 quadrants and interloop spaces. A homogenization was performed before the sample was transferred to the laboratory.

RESULTS Nine of 15 patients included in the study were male. The median age of the patients was 58 (23-79) years. Four of the patients had anastomotic failure (Table 1).

Latex immunoturbidimetric assay for CRP (Olympus AU600, Olympus Optical Co. Ltd., Japan) was done. IL-6 assays were performed using Biosource Immunoassay kit human IL-6 (Biosource International, Inc., USA). For leptin, Biosource Leptin Easia kit was

There was no growth in any cultures in 4 of 15 patients. Five patients had Escherichia coli, 3 had Pseudomonas aeruginosa, 3 had coagulase (-) Staphylococcus, 2 had Acinetobacter spp, and 7 had Candida

Table 2. The demographic variables of patients No Age Gender Mortality APACHE II (0 h) APACHE II (48 h) Hospital stay/day ICU day Number of operations 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 392

55 23 79 39 45 75 78 72 70 72 44 49 52 65 58

M F F F M M M F M F M M M F M

No No Yes No No No Yes No No Yes No No No No Yes

16 11 27 10 10 14 26 16 14 14 15 10 18 20 15

11 7 28 9 7 11 22 15 11 16 12 10 7 13 16

26 12 45 12 11 32 20 33 36 13 22 41 48 19 3

16 1 45 4 4 6 20 5 7 13 22 15 22 7 3

5 4 12 4 4 4 4 4 4 5 8 7 4 4 3 Eylül - September 2011


The value of CRP, IL-6, leptin, cortisol, and peritoneal caspase-3 monitoring in the operative strategy of secondary peritonitis

Table 3. The differences between survivors and non-survivors Parameter Age APACHE II (initial) APACHE II (48 h) Hospital stay (day) ICU stay (day) Number of operations Cortisol (initial) µg/dl Cortisol (24 h) µg/dl Cortisol (48 h) µg/dl Cortisol (72 h) µg/dl CRP (initial) mg/L CRP (24 h) mg/L CRP (48 h) mg/L CRP (72 h) mg/L IL-6 (initial) pg/ml IL-6 (24 h) pg/ml IL-6 (48 h) pg/ml IL-6 (72 h) pg/ml Leptin (initial) ng/ml Leptin (24 h) ng/ml Leptin (48 h) ng/ml Leptin (72 h) ng/ml Caspase-3 (initial) Caspase-3 (24 h) Caspase-3 (48 h) Caspase-3 (72 h) WBC (initial) mm3 WBC (24 h) mm3 WBC (48 h) mm3 WBC (72 h) mm3

Alive (n=11)

Exitus (n=4)

p

52 (23-75) 14 (10-20) 11 (7-15) 26 (11-48) 7 (1-22) 4 (4-8) 849.8 (189.3-1897) 845.9 (188.8-1616) 735 (194.6-1582) 858.9 (196.5-1654) 190.85 (23.48-199.88) 187.26 (23.04-201.11) 181.86 (23.44-200.52) 182.74 (23.69-197.4) 179.1 (22.3-18500) 145.3 (5.70-948.1) 164 (5.5-19000) 81.8 (11.9-22000) 2.99 (1.27-40.59) 2.8 (1.08-60.42) 3.76 (1.84-30) 4.92 (1.84-156.86) 47.84 (3.77-479.3) 28.76 (6.68-272.89) 18 (4.73-77.19) 12.79 (5.67-137.94) 16300 (2800-28200) 10000 (3500-20600) 10200 (4300-17600) 10500 (4500-21600)

75 (58-79) 20 (14-27) 19 (16-28) 16 (3-45) 16 (3-45) 4 (3-12) 987.3 (218.2-1342) 884 (725.6-1458) 855.5 (217-1400) 904.6 (196.5-945.7) 187.78 (34.31- 200.04) 196.41 (191.53-198.97) 165.77 (34.85-185.82) 134.64 (23.93-169.94) 303.2 (10.2-876.8) 640.65 (48.7-18500) 470.75 (51.4-1003.4) 585.00 (54.3-645.7) 4.63 (1.27-5.5) 3.18 (1.84-4.54) 2.99 (1.65-145.09) 3.95 (2.8-10.55) 28.24 (8.07-110.53) 28.15 (22.96-469.66) 31.22 (7.98-306.18) 14.15 (9.84-38.64) 7150 (5100-19100) 9950 (4100-22600) 11650 (6000-22300) 5800 (2200-16300)

0. 026 0.13 0.001 0.06 0.075 0.66 0.79 0.89 0.74 0.64 0.79 0.19 0.36 0.10 0.51 0.19 0.51 0.39 0.39 0.89 0.64 0.35 0.51 0.43 0.36 0.69 0.36 0.89 0.60 0.27

Values are expressed as median (min-max). Normal values: CRP: 0-5 mg/L, IL-6: 720-1200 pg/ml, leptin: 2.4±1.1 (females), 6.6±3 (males) ng/ml, cortisol: 19 µg/dl. WBC: White blood cell counts /mm3.

spp growth in cultures. Antifungal therapy was not administered if the culture growth was regarded as colonization.

Initial, 24, 48 and 72 h caspase-3 levels of survivors and non-survivors did not differ (Table 3). Survivors were younger and second day APACHE II scores were lower (Table 3). Total hospital stay was longer and intensive care unit (ICU) stay was shorter in survivors (Table 3). Caspase-3 levels in survivors: Initial, 24, 48. and 72 h peritoneal caspase-3 levels were 47.84 (3.77-479.3), 28.76 (6.68-272.89), 18 (4.73-77.19), 12.79 (5.67137.94), respectively. Peritoneal fluid caspase-3 levels showed a steep decline within 48 and 72 h (z=2.76, p=0.006; z=2.67, p=0.008, respectively) (Fig. 1). However, no statistically significant decrease was found among initial, 24, 48, and 72 h caspase levels in non-survivors. Cilt - Vol. 17 Sayı - No. 5

50 Median caspase-3 levels

Mechanical ventilation was needed in 7 patients. The demographic variables of patients are presented in Table 2.

60

40

Initial

30

24 h 28 h

20

72 h

10 0 Alive

Death

Fig. 1. Peritoneal caspase-3 levels within a 72-hour period in surviving patients. Caspase-3 levels in survivors: Initial, 24, 48, and 72 h peritone-

al caspase-3 levels were 47.8 (3.8-479), 28.8 (6.7-273), 18 (4.777.2), and 12.8 (5.7-138), respectively. Peritoneal fluid caspase-3 levels showed a steep decline within 48 and 72 h (z=2.76, p=0.006; z=2.67, p=0.008, respectively). However, no statistically significant decrease was found among initial, 24, 48 and 72 h caspase levels in non-survivors.

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In patients who had undergone ≤4 laparotomies, the initial and 72 h peritoneal caspase-3 levels were 33.2 (7.1-479) and 14.2 (8.85-35.2), respectively (z=2.84, p=0.004).

DISCUSSION Despite recent advances in the diagnosis and management options, mortality and morbidity in peritonitis remain high. Surgical source control is vital in the treatment of sepsis originating from the abdomen. Despite rising concerns about planned relaparotomies in the treatment of peritonitis,[8,9,19] its use in some selected cases may improve survival.[1,4,5,7] The major concern for planned relaparotomy is related with its increased morbidity and hospital stay. It is important to avoid doing unnecessary laparotomies. Because every laparotomy intent causes a further deterioration of peritoneal defense mechanisms,[3,12,13] there should be a well-balanced surgical treatment. Although speculative, one can assume that the decrease in the number of relaparotomies may cause an increase in survival rates in some groups of patients who undergo a planned relaparotomy procedure. Definitive closure of the abdominal wall is usually determined by using a very subjective criterion, the so-called “clean appearance of the abdominal cavity”. Today, the optimal number of scheduled operations that should be done before a definitive closure is not yet sufficiently understood. The authors of this present study aimed to determine a valid, helpful and measurable surrogate parameter that can be used in the decision-making process of planned relaparotomy. A significant difference was found between second day APACHE II scores and mortality. Higher second day APACHE II scores were observed in non-survivors. This finding is in accordance with the findings of a study done by Lamme et al.[8] In the present study, it was found that there was a correlation between the number of operations and hospital/ICU stay. This finding is also in accordance with the finding of Lamme et al.[8] C-reactive protein (CRP) is an acute phase reactant, and its validity in estimating the prognosis in septic patients is not well known. There are conflicting results in the literature in this regard. For example, Silvestre et al.[20] found in their study that CRP was not a good surrogate parameter for prognosis, and there was no good correlation between CRP levels and APACHE II scores. On the other hand, Prieto[21] found that CRP is an important surrogate parameter of prognosis. In the present study, CRP levels were observed for three days. In general, initial CRP levels were higher than normal, but no significant alterations were observed in 394

the consecutive days. We could not find any correlation between CRP levels and probability of mortality. While endotoxic shock due to peritonitis causes a significant increase in leptin concentrations in animal models,[22] in the clinical setting, decreased leptin levels correlate with increased mortality in patients suffering from severe secondary peritonitis.[23] In the present study, leptin levels did not correlate well with APACHE II or the number of operations. High initial levels of leptin in non-survivors did not reach a statistically significant level. Keeping in mind the small number of events (deaths), we can assume that monitoring of leptin level is useless in the decision-making process in planned laparotomy for peritonitis. In the present study, IL-6 levels were also measured, and no statistical difference was observed when patients were grouped as having high (>10) or low APACHE II score. We reached the same conclusion of other researchers, i.e. that IL-6 is not helpful in predicting mortality in peritonitis patients.[24-26] Controlling the septic source, peritoneal toilets and supportive measures such as fluid and antibiotic therapy certainly reverse the unfavorable peritoneal environment to a favorable one and restore a good recovery phase. A correlation between blood caspase levels and decrease in bacterial load in an animal model of peritonitis was shown before.[27] If a good septic source control is not achieved, an ongoing peritoneal programmed cell death occurs. Hotchkiss[28] showed that septic patients with multiple organ failure have an increased blood value of caspase-3. Most of the deaths in our study occurred as a consequence of multiple organ failure, but we did not observe any increase in intraperitoneal fluid levels of caspase-3 in non-survivors. To the best of our knowledge, this is the first clinical study to put forth the evaluation of peritoneal caspase-3 in the decision-making process of repeated laparotomies in the treatment of secondary peritonitis. Could intraperitoneal caspase-3 measurements within the initial 72-h period provide some helpful information? The definitive answer is not yet known. What was found at the end of the study was a decrease within 72 h of caspase levels in comparison with the initial level in both survivors and in those having ≤4 operations. Peritoneal fluid caspase levels seem to be altered during both the healing phase of the peritoneal inflammation and operative trauma. However, this altered peritoneal apoptotic response is not solely being regulated by endotoxin levels.[14] More research is needed on the qualitative and quantitative properties not only of mast cells but also of other peritoneal cells in clinical peritonitis. Eylül - September 2011


The value of CRP, IL-6, leptin, cortisol, and peritoneal caspase-3 monitoring in the operative strategy of secondary peritonitis

The results of the present study may have been affected by the study design and the limited number of patients included. Those shortcomings should be taken into consideration while evaluating our findings. In conclusion, second day APACHE II scores and age were found to be helpful in predicting disease severity and mortality. CRP, IL-6, leptin, cortisol, and peritoneal fluid samples for caspase-3 were not found to be helpful in discriminating the number of planned operations, even though there is a significant decrease in caspase-3 levels among surviving patients. The discriminative value of caspase-3 for abdominal closure in planned relaparotomy should be evaluated in studies in which caspase-3 levels are monitored for a longer duration in a large number of patients.

REFERENCES 1. Wittmann DH, Schein M, Condon RE. Management of secondary peritonitis. Ann Surg 1996;224:10-8. 2. Schwartz SI, Shires GT, Spencer FC, Daly JM, Fischer JE, Galloway AC. Surgical infections. Principles of Surgery. 2005. p. 78-97. 3. Agalar F, Sayek I, Agalar C, Cakmakçi M, Hayran M, Kavuklu B. Factors that may increase morbidity in a model of intra-abdominal contamination caused by gallstones lost in the peritoneal cavity. Eur J Surg 1997;163:909-14. 4. Agalar F, Eroglu E, Bulbul M, Agalar C, Tarhan OR, Sari M. Staged abdominal repair for treatment of moderate to severe secondary peritonitis. World J Surg 2005;29:240-4. 5. Wittmann DH. Staged abdominal repair: development and current practice of an advanced operative technique for suppurative peritonitis. Acta Chir Austriaca 2000;32:171-8. 6. Hadeed JG, Staman GW, Sariol HS, Kumar S, Ross SE. Delayed primary closure in damage control laparotomy: the value of the Wittmann patch. Am Surg 2007;73:10-2. 7. Wittmann DH. Operative and nonoperative therapy of intraabdominal infections. Infection 1998;26:335-41. 8. Lamme B, Boermeester MA, Belt EJ, van Till JW, Gouma DJ, Obertop H. Mortality and morbidity of planned relaparotomy versus relaparotomy on demand for secondary peritonitis. Br J Surg 2004;91:1046-54. 9. Rakić M, Popović D, Rakić M, Druzijanić N, Lojpur M, Hall BA, et al. Comparison of on-demand vs planned relaparotomy for treatment of severe intra-abdominal infections. Croat Med J 2005;46:957-63. 10. Opmeer BC, Boer KR, van Ruler O, Reitsma JB, Gooszen HG, de Graaf PW, et al. Costs of relaparotomy on-demand versus planned relaparotomy in patients with severe peritonitis: an economic evaluation within a randomized controlled trial. Crit Care 2010;14:97. 11. Agalar F, Hamaloglu E, Daphan C, Tarim A, Onur R, Renda N, et al. Effects of CO2 insufflation and laparotomy on wound healing in mice. Aust N Z J Surg 2000;70:739-42. 12. Daphan CE, Agalar F, Hascelik G, Onat D, Sayek I. Effects of laparotomy, and carbon dioxide and air pneumoperitoneum, on cellular immunity and peritoneal host defences in rats. Eur J Surg 1999;165:253-8. 13. Agalar F, Sayek I, Cakmakçi M, Hasçelik G, Abbasoglu O.

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Effect of omentectomy on peritoneal defence mechanisms in rats. Eur J Surg 1997;163:605-9. 14. Chung CS, Song GY, Moldawer LL, Chaudry IH, Ayala A. Neither Fas ligand nor endotoxin is responsible for inducible peritoneal phagocyte apoptosis during sepsis/peritonitis. J Surg Res 2000;91:147-53. 15. Kolaczkowska E, Koziol A, Plytycz B, Arnold B, Opdenakker G. Altered apoptosis of inflammatory neutrophils in MMP-9-deficient mice is due to lower expression and activity of caspase-3. Immunol Lett 2009;126:73-82. 16. Santamaría B, Benito-Martin A, Ucero AC, Aroeira LS, Reyero A, Vicent MJ, et al. A nanoconjugate Apaf-1 inhibitor protects mesothelial cells from cytokine-induced injury. PLoS One 2009;4:6634. 17. Knaus WA. APACHE 1978-2001: the development of a quality assurance system based on prognosis: milestones and personal reflections. Arch Surg 2002;137:37-41. 18. Koperna T, Schulz F. Prognosis and treatment of peritonitis. Do we need new scoring systems? Arch Surg 1996;131:1806. 19. van Ruler O, Mahler CW, Boer KR, Reuland EA, Gooszen HG, Opmeer BC, et al. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA 2007;298:865-72. 20. Silvestre J, Póvoa P, Coelho L, Almeida E, Moreira P, Fernandes A, et al. Is C-reactive protein a good prognostic marker in septic patients? Intensive Care Med 2009;35:909-13. 21. Prieto MF, Kilstein J, Bagilet D, Pezzotto SM. C-reactive protein as a marker of mortality in intensive care unit. Med Intensiva 2008;32:424-30. [Abstract] 22. Faggioni R, Feingold KR, Grunfeld C. Leptin regulation of the immune response and the immunodeficiency of malnutrition. FASEB J 2001;15:2565-71. 23. Bracho-Riquelme RL, Reyes-Romero MA, Pescador N, Flores-García AI. A leptin serum concentration less than 10 ng/ml is a predictive marker of outcome in patients with moderate to severe secondary peritonitis. Eur Surg Res 2008;41:238-44. 24. Wortel CH, van Deventer SJ, Aarden LA, Lygidakis NJ, Büller HR, Hoek FJ, et al. Interleukin-6 mediates host defense responses induced by abdominal surgery. Surgery 1993;114:564-70. 25. van Berge Henegouwen MI, van der Poll T, van Deventer SJ, Gouma DJ. Peritoneal cytokine release after elective gastrointestinal surgery and postoperative complications. Am J Surg 1998;175:311-6. 26. Riché F, Panis Y, Laisné MJ, Briard C, Cholley B, BernardPoenaru O, Graulet AM, et al. High tumor necrosis factor serum level is associated with increased survival in patients with abdominal septic shock: a prospective study in 59 patients. Surgery 1996;120:801-7. 27. Catalan MP, Esteban J, Subirá D, Egido J, Ortiz A; Grupo de Estudios Peritoneales de Madrid-FRIAT/IRSIN. Inhibition of caspases improves bacterial clearance in experimental peritonitis. Perit Dial Int 2003;23:123-6. 28. Hotchkiss RS, Swanson PE, Freeman BD, Tinsley KW, Cobb JP, Matuschak GM, et al. Apoptotic cell death in patients with sepsis, shock, and multiple organ dysfunction. Crit Care Med 1999;27:1230-51.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):396-400

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.03780

Scoring systems in the diagnosis of acute appendicitis in the elderly Yaşlılarda akut apandisit tanısında skorlama sistemleri Ali KONAN,1 Mutlu HAYRAN,2 Yusuf Alper KILIÇ,1 Derya KARAKOÇ,1 Volkan KAYNAROĞLU1

BACKGROUND

AMAÇ

Although special features of acute appendicitis in the elderly have been described in some studies, no studies evaluating the applicability of appendicitis scores exist in the literature. The aim of this study was to compare Alvarado and Lintula scores in patients older than 65 years of age.

Literatürde, yaşlılarda akut apandisitin özellikleri bazı çalışmalarda tarif edilmiştir, ancak skorlama sistemlerinin uygulanabilirliğini değerlendiren bir çalışma yoktur. Bu çalışmanın amacı 65 yaşından yaşlı hastalarda Alvarado ve Lintula skorlarını karşılaştırmaktır.

METHODS

GEREÇ VE YÖNTEM

Patients older than 65 years with appendicitis confirmed by pathology report were matched by year of admission with a group of patients admitted to the emergency department with non-specific abdominal pain. Alvarado and Lintula scores were calculated retrospectively from patient charts.

Tanısı patolojik inceleme ile kesinleşmiş 65 yaşından yaşlı hastalar, büyük acil polikliniğine başvuruları sonucunda spesifik olmayan karın ağrısı tanısı almış aynı yaş grubundaki hastalarla başvuru yılına göre sınıflandırılarak karşılaştırıldı. Alvarado ve Lintula skorları hasta dosyalarından retrospektif olarak hesaplandı.

RESULTS

BULGULAR

Both scores were observed to operate well in distinguishing between abdominal pain due to appendicitis and nonspecific abdominal pain. The Alvarado score was a better predictor compared to the Lintula score. Two parameters (absent, tingling or high-pitched bowel sounds and nausea) had similar prevalence in the control and appendicitis groups. We selected to recalculate the two scores with the exclusion of these two parameters. The two scores performed better but were more similar to each other after the modification.

Her iki skorlama metodu da apandisite bağlı karın ağrısı ve spesifik olmayan karın ayrısını ayırt etmede başarılı bulundu. Alvarado skoru, Lintula skoruna göre öngörme özelliği açısından üstündü. Kontrol ve apandisit gruplarında iki parametrenin (tınlayıcı, tiz bağırsak sesleri olması veya bağırsak seslerinin alınamaması ve bulantı) prevalansı benzerdi. İki skor, bu iki parametre olmadan tekrar hesaplandı. Düzenleme sonrası iki skorda daha iyi ve birbirlerine daha çok benzer sonuçlar verdi.

CONCLUSION

Both Alvarado and Lintula scores have a high sensitivity and specificity in the diagnosis of acute appendicitis in the geriatric age group. Their performance improves with exclusion of the two parameters “nausea” and “absent, tingling or high-pitched bowel sounds”.

Geriatrik yaş grubunda hem Alvarado hem de Lintula skorlarının akut apandisitin tanısında yüksek sensitivite ve spesifitesi vardır. Bu skorların performansları “bulantı” ve “tınlayıcı, tiz bağırsak sesleri olması veya bağırsak seslerinin alınamaması” parametreleri çıkartıldığında daha iyi hale gelmektedir.

Key Words: Acute appendicitis; Alvarado score; elderly; Lintula score.

Anahtar Sözcükler: Akut apandisit; Alvarado skoru; yaşlı; Lintula skoru.

Departments of 1General Surgery, 2Preventive Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Hacettepe Üniversitesi Tıp Fakültesi, 1Genel Cerrahi Anabilim Dalı, 2 Prevantif Onkoloji Anabilim Dalı, Ankara.

SONUÇ

Correspondence (İletişim): Ali Konan, M.D. Hacettepe Üniversitesi Tıp Fakültesi Genel Cerrahi Anabilim Dalı, Sıhhıye 06100 Ankara, Turkey. Tel: +90 - 312 - 305 43 76 e-mail (e-posta): akonan@hacettepe.edu.tr

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Scoring systems in the diagnosis of acute appendicitis in the elderly

The lifetime risk of acute appendicitis in the general population is 7%, and up to 10% of acute appendicitis occurs in the geriatric population (older than 65 years of age).[1,2] Appendicitis tends to have a more complicated course with advancing age.[3] The increased rate of perforation may be related to late admission of the patients as well as the delay in the diagnosis. Failure to diagnose appendicitis at admission is related to an increased rate of perforation.[4] Numerous diagnostic and clinical scores have been developed to increase the accuracy of diagnosis in acute appendicitis.[5-10] Although special features of acute appendicitis in the elderly have been described in some studies,[11-14] no studies evaluating the applicability of appendicitis scores exist in the literature. Described in 1986, the Alvarado score is used widely in the diagnosis of acute appendicitis. The score is based on symptoms, physical findings and laboratory data (Table 1). It has been validated in some studies and is found to be reliable, reproducible and cheap in the evaluation of adult patients with right lower quadrant pain.[15] The Lintula score was originally developed for the pediatric age group,[10] and is shown to offer some benefits compared to unaided clinical diagnosis of acute appendicitis.[16] The score consists of data taken from patient’s history and physical examination (Table 2). The aim of this study was to compare Alvarado and Lintula scores in patients older than 65 years of age.

MATERIALS AND METHODS Overall, 1728 patients were operated for acute appendicitis. Among these patients, those older than 65 years with appendicitis confirmed by pathology report were identified (n=41). This group of patients was matched by year of admission with a group of patients admitted to the emergency department with nonspecific abdominal pain (n=41). Alvarado and Lintula scores were calculated retrospectively from patient charts. The data were analyzed using the Statistical Package for Social Sciences version 15. Table 1. Alvarado scoring system Parameter Abdominal pain Anorexia Nausea and/or vomiting Muscular guarding in the right lower quadrant Temperature >37.3°C Rebound tenderness referred to right lower quadrant WBC >10000 Left shift of polymorphonuclear WBC forms >75%

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RESULTS There were 18 females and 23 males in the appendicitis group. The median age of patients was 69 (range: 65-83) years. The control group consisted of 23 females and 18 males. Receiver operating characteristics (ROC) analysis revealed that both scores were observed to operate well in distinguishing between abdominal pain due to appendicitis and non-specific abdominal pain. The Alvarado score was a better predictor (area under the curve [AUC]: 96.9%, 95% confidence interval [CI]: 94.0%-99.8%) when compared to the Lintula score (AUC: 92.8%, 95% CI: 87.4%-98.2%). Table 3 and Figure 1a show the operative characteristics for several cut-off points for both scores. For the Alvarado score, one can observe that the two cutoff points of 3 and 6 have 100% negative and positive predictive values, respectively, while maintaining an overall accuracy of more than 85%. The two values can be practically used as cut-off points to rule out or definitely diagnose appendicitis. An Alvarado score of less than 3 rules the disease out, while a score of 6 or greater is indicative of appendicitis. For the values in between, further diagnostic evaluation and/or watchful waiting is required. In this geriatric age group, we observed that the two parameters utilized in the calculation of these scores were not very informative, as they had similar prevalence in the control and appendicitis groups, respectively (33.3% vs. 40.0% for absent, tingling or high- pitched bowel sounds, and 30.8% vs. 29.3% for nausea). Therefore, we selected to recalculate the two scores excluding these two parameters. Table 3 and Figure 1b show the results of the analyses with modified scores. The AUC values improved to 97.5% (95% CI: 95.0%-100.0%) for Alvarado and 95.1% (95% CI: 90.5%-99.6) for Lintula scores. The two scores performed better but were more similar to each other after the modification. Now, it could easily be observed that Lintula scores performed closer to Alvarado scores, as both of the relatively ineffective Table 2. Lintula score

Score 1 1 1 2 1 1 1 1

Parameter Male gender Severe pain Relocation of pain Vomiting Pain in the right lower quadrant Fever (>37.5°C) Guarding Absent, tingling or high-pitched bowel sounds Rebound tenderness

Score 2 2 4 2 4 3 4 4 7 397


Ulus Travma Acil Cerrahi Derg

Table 3. Operative characteristics of several cut-off points for the Alvarado and Lintula scores Score Alvarado Lintula Alvarado (Modified) Lintula (Modified)

Cut-off point*

Sensitivity

Specificity

PPV

NPV

Accuracy

3 4 5 6 7 3 7 9 10 11 12 13 14 15 16 17 21 3 4 5 6 1 7 8 10 12 13 15 19

100.0 92.7 87.8 80.5 70.7 100.0 95.1 87.8 87.8 87.8 87.8 85.4 82.9 75.6 73.2 70.7 58.5 100.0 90.2 87.8 75.6 100.0 92.7 92.7 87.8 87.8 82.9 73.2 58.5

74.4 82.1 89.7 94.9 100.0 33.3 66.7 74.4 76.9 84.6 87.2 87.2 89.7 89.7 89.7 92.3 100.0 79.5 82.1 94.9 100.0 17.9 82.1 87.2 87.2 89.7 94.9 94.9 100.0

80.4 84.5 90.0 94.3 100.0 61.2 75.0 78.3 80.0 85.7 87.8 87.5 89.4 88.5 88.2 90.6 100.0 83.7 84.1 94.7 100.0 56.2 84.4 88.4 87.8 90.0 94.4 93.8 100.0

100.0 91.5 87.5 82.2 76.5 100.0 92.8 85.3 85.7 86.8 87.2 85.0 83.3 77.8 76.1 75.0 69.6 100.0 88.9 88.1 79.6 100.0 91.4 91.9 87.2 87.5 84.1 77.1 69.6

87.5 87.5 88.7 87.5 85.0 67.5 81.3 81.3 82.5 86.2 87.5 86.3 86.2 82.5 81.2 81.2 78.7 90.0 86.3 91.3 87.5 60.0 87.5 90.0 87.5 88.8 88.8 83.8 78.8

The modified scores exclude the scores related to the “nausea” and “absent, tingling or high-pitched bowel sounds” parameters. * Cut-off is included in positive classification; PPV: Positive predictive value; NPV: Negative predictive value.

parameters (i.e. change in bowel sounds and nausea) are included in the original scoring of Lintula (multiplied by coefficients of 4 and 2), while only the nausea parameter is used in the original scoring of Alvarado.

(a)

Alvarado scores still have two distinct cut-off points but with better predictive characteristics after the modification, which can be used to rule out (<3) or definitely diagnose (≥6) appendicitis.

(b)

Fig. 1. Receiver Operating Characteristics (ROC) curve showing the predictive values for the Alvarado (solid line) and Lintula (dashed line) scores (a) with and (b) without the modified parameters. 398

Eylül - September 2011


Scoring systems in the diagnosis of acute appendicitis in the elderly

DISCUSSION Nearly half of the patients older than 65 years who present to the emergency department have abdominal pain,[17] and acute appendicitis is the third most common cause of acute abdomen in the elderly after intestinal obstruction and biliary disease.[18] The course of acute appendicitis is relatively unfavorable in geriatric patients, and perforated appendicitis rates are higher than in younger patients. This increase in rate may be related to late presentation of the patients as well as to delay in the diagnosis. In the geriatric population, acute appendicitis is misdiagnosed in about half of the patients, and one-fourth of the patients require more than 24 hours to be diagnosed as acute appendicitis.[4] To increase the diagnostic accuracy in acute appendicitis, several scores have been developed. Although most of these scores are validated in the adult population, no study exists in the literature evaluating the geriatric population. The diagnosis of acute appendicitis in the geriatric population is challenging. The classical symptoms of acute appendicitis are defined as fever, right lower quadrant pain, anorexia, and white blood cell count >10000/mm3. In the geriatric population, less than one-third of the patients present with all four symptoms.[4] The data about specific symptoms of acute appendicitis have a wide range. For example, fever was reported to occur in 37% of the patients in one series[4] and 71% in another.[19] Similarly, the right lower quadrant pain is reported to occur in 64-91% of the patients. These variations in the reported incidence may be due to physiological changes in the structure of the appendix vermiformis with aging. In our study, we compared Alvarado and Lintula scores in a geriatric group. The appendicitis group consisted of patients with histopathologically confirmed appendicitis, and the control group was formed of patients who were admitted to the emergency department with abdominal pain and diagnosed as nonspecific abdominal pain, since no pathology was found on clinical investigations and their pain subsided under clinical observation. As the course of acute appendicitis is often atypical in the geriatric population, comparison of these two groups to detect the efficacy of Alvarado and Lintula scores is appropriate. The Alvarado score is widely used in the diagnosis of acute appendicitis. The score is calculated over 10 points, and a score higher than 6 is indicative of acute appendicitis, whereas for scores less than 4, it is unlikely that the patient has appendicitis. For scores of 4-6, follow up or imaging with computerized tomography is recommended.[20] Chan et al.,[21] in their series of 175 patients with a mean age of 30, reported the negative cut-off point to be 5. The analysis of the data gave us two cut-off points Cilt - Vol. 17 Sayı - No. 5

for the Alvarado score. None of the patients with acute appendicitis had an Alvarado score below 3, and all the patients with a score above 7 had appendicitis. This finding is compatible with that of McKay et al. [22] They found a 96.2% sensitivity and 67% specificity for scores of 3 or lower for not having appendicitis and 77% sensitivity and 100% specificity for scores of 7 or higher for having appendicitis. These findings suggest that the Alvarado score may be used in the geriatric population. The Lintula score was first developed for the pediatric age group.[10] Later, the same group validated the Lintula score in the adult population as well. They showed that the use of the Lintula score yielded a higher positive predictive value and specificity but a lower negative predictive value and sensitivity in the diagnosis of appendicitis compared with unaided diagnosis. They determined cut-off points of 15 and 21 to rule-out and diagnose appendicitis, respectively.[16] In our series, the positive predictive value for a score of 21 was 100%, with an accuracy of 78%. The cut-off limit of 15 had a positive predictive value of 88.5% and a negative predictive value of 77.8%. We found the optimal cut-off point to be 12 points, with a positive predictive value of 87.2% and a negative predictive value of 87.8%. In this geriatric group, two parameters used in the scores, i.e., “absent, tingling or high-pitched bowel sounds” and “nausea”, had similar prevalence in both the appendicitis and control groups. This finding may be related to age-related changes seen in the gastrointestinal tract. As the number and function of the myenteric enteric nervous system decrease with age, there is a decrease in the motility of the gastrointestinal system, and constipation is seen in one-fourth of the individuals over 65 years of age.[23] Therefore, these two parameters may also be found in elderly individuals without an intraabdominal pathology. The “absent, tingling or high-pitched bowel sounds” parameter has a coefficient of 4 and “nausea” has a coefficient of 2 in the original Lintula score, while nausea adds one point to the Alvarado score. After omitting these parameters, the modified Lintula score has a maximum of 26 and the modified Alvarado has a maximum of 9. With these modifications, both scores performed better (improvements in AUC from 96.9% to 97.5% and 92.8% to 95.1% for Alvarado and Lintula scores, respectively) and were closer to each other. The cut-off values for the modified Alvarado score are 3 and 6, and for Lintula score the optimal cut-off is 8. Although these data need to be validated with prospective trials, the use of these modified scores may be advisable. To diagnose appendicitis, clinicians should take into account all available historical and physical find399


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ings as well as laboratory and imaging data. There is no pathognomonic sign, symptom or laboratory test for appendicitis. Radiologic imaging studies have a high sensitivity and specificity, but routine use of these techniques not only increases the cost but is also associated with radiation and contrast exposure. Although the data presented in this study need to be validated with prospective trials, the use of these modified scores may be advisable. In conclusion, both Alvarado and Lintula scores have a high sensitivity and specificity in the diagnosis of acute appendicitis in the geriatric age group. Their performance improves with exclusion of the “nausea” and “absent, tingling or high-pitched bowel sounds” parameters.

REFERENCES 1. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990;132:910-25. 2. Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults. A prospective study. Ann Surg 1995;221:278-81. 3. Franz MG, Norman J, Fabri PJ. Increased morbidity of appendicitis with advancing age. Am Surg 1995;61:40-4. 4. Storm-Dickerson TL, Horattas MC. What have we learned over the past 20 years about appendicitis in the elderly? Am J Surg 2003;185:198-201. 5. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557-64. 6. Ohmann C, Yang Q, Franke C. Diagnostic scores for acute appendicitis. Abdominal Pain Study Group. Eur J Surg 1995;161:273-81. 7. van den Broek WT, Bijnen BB, Rijbroek B, Gouma DJ. Scoring and diagnostic laparoscopy for suspected appendicitis. Eur J Surg 2002;168:349-54. 8. Fenyö G, Lindberg G, Blind P, Enochsson L, Oberg A. Diagnostic decision support in suspected acute appendicitis: validation of a simplified scoring system. Eur J Surg 1997;163:831-8. 9. Christian F, Christian GP. A simple scoring system to reduce the negative appendicectomy rate. Ann R Coll Surg Engl

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1992;74:281-5. 10. Lintula H, Pesonen E, Kokki H, Vanamo K, Eskelinen M. A diagnostic score for children with suspected appendicitis. Langenbecks Arch Surg 2005;390:164-70. 11. Lunca S, Bouras G, Romedea NS. Acute appendicitis in the elderly patient: diagnostic problems, prognostic factors and outcomes. Rom J Gastroenterol 2004;13:299-303. 12. McCallion J, Canning GP, Knight PV, McCallion JS. Acute appendicitis in the elderly: a 5-year retrospective study. Age Ageing 1987;16:256-60. 13. Gürleyik G, Gürleyik E. Age-related clinical features in older patients with acute appendicitis. Eur J Emerg Med. 2003;10:200-3. 14. Owens BJ, Hamit HF. Appendicitis in the elderly. Ann Surg 1978;187:392-6. 15. Pouget-Baudry Y, Mucci S, Eyssartier E, Guesdon-Portes A, Lada P, Casa C, et al. The use of the Alvarado score in the management of right lower quadrant abdominal pain in the adult. J Visc Surg 2010;147:40-4. 16. Lintula H, Kokki H, Pulkkinen J, Kettunen R, Gröhn O, Eskelinen M. Diagnostic score in acute appendicitis. Validation of a diagnostic score (Lintula score) for adults with suspected appendicitis. Langenbecks Arch Surg 2010;395:495-500. 17. Yeh EL, McNamara RM. Abdominal pain. Clin Geriatr Med 2007;23:255-70. 18. Fagbohun CF, Toy EC, Baker B. The evaluation of acute abdominal pain in the elderly patient. Prim Care Update Ob/ Gyns 1999;6:181-5. 19. Rub R, Margel D, Soffer D, Kluger Y. Appendicitis in the elderly: what has changed? Isr Med Assoc J 2000;2:220-3. 20. Cağlayan K, Günerhan Y, Koç A, Uzun MA, Altınlı E, Köksal N. The role of computerized tomography in the diagnosis of acute appendicitis in patients with negative ultrasonography findings and a low Alvarado score. Ulus Travma Acil Cerrahi Derg 2010;16:445-8. 21. Chan MY, Tan C, Chiu MT, Ng YY. Alvarado score: an admission criterion in patients with right iliac fossa pain. Surgeon 2003;1:39-41. 22. McKay R, Shepherd J. The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med 2007;25:489-93. 23. Saffrey MJ. Ageing of the enteric nervous system. Mech Ageing Dev 2004;125:899-906.

Eylül - September 2011


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):401-406

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.06936

Factors affecting morbidity in penetrating rectal injuries: a civilian experience Penetran rektal yaralanmalarda morbiditeye etkili faktörler: Sivil deneyim Metehan GÜMÜŞ, Murat KAPAN, Akın ÖNDER, Abdullah BÖYÜK, Sadullah GİRGİN, İbrahim TAÇYILDIZ

BACKGROUND

AMAÇ

The principles of the treatment of rectal injuries have been determined based on the experiences gained from military injuries. While adopting these principles in civilian life, it is essential to know the characteristics of civilian rectal injuries as well as the risk factors affecting morbidity.

Rektal yaralanmaların tedavi prensipleri savaş deneyimlerine dayanmaktadır. Sivil yaralanmalarda bu prensipleri uygularken sivil rektal yaralanmaların özelliklerini ve bunun yanında morbiditeye etkili faktörleri bilmek gerekir.

METHODS

Ateşli silah ve delici-kesici aletle rektal yaralanma oluşmuş 29 hastanın özellikleri değerlendirildi. Risk faktörlerini belirlemek amacıyla hastalar morbidite olanlar ve olmayanlar şeklinde iki gruba ayrıldı (morbidite olan: Grup 1, morbidite olmayan: Grup 2) ve faktörler gruplar arasında karşılaştırıldı.

The characteristics of 29 inpatients who had been treated due to rectal injuries caused by gunshot wounds and penetrating devices were evaluated. In order to determine the risk factors, the patients were divided into two groups regarding the presence of morbidity (Group 1, with morbidity; Group 2, without morbidity) and compared. RESULTS

Severe fecal contamination, perianal or gluteal injuries, duration of trauma- treatment interval, and isolated extraperitoneal injury were significant factors that affected the development of morbidity. The length of hospital stay was significantly longer in Group 1 as compared to Group 2. CONCLUSION

Although rectal injuries are rarely encountered, they carry high morbidity and mortality. Awareness of the risk factors and planning of a patient-based treatment are essential for the success of the therapy. The rate of morbidity is substantially decreased when patients are treated in time. Thus, the awareness of both patients as well as physicians managing trauma about rectal injuries should be increased.

GEREÇ VE YÖNTEM

BULGULAR

Şiddetli fekal kontaminasyon, perianal veya gluteal yaralanma, travma tedavi intervali ve izole ekstraperitoneal yaralanma olması morbidite gelişimi üzerine etkili faktörlerdi. Hastanede kalış süresi Grup 1’de Grup 2 ile karşılaştırıldığında anlamlı derecede daha uzundu. SONUÇ

Rektal yaralanmalarla nadiren karşılaşılmasına rağmen, morbidite ve mortalite oranları yüksektir. Risk faktörlerinin bilinmesi ve hastaya göre tedavi planı yapılması tedavinin başarısı için önemlidir. Zamanında tedavi edilen hastalarda morbidite oranı önemli ölçüde azalmaktadır. Bu nedenle, doktorların yanı sıra hastaların da rektal yaralanma konusunda bilinçli olması gerekmektedir.

Key Words: Gunshot wounds; colostomy; penetrating injuries; rectal injuries; rectal repair.

Anahtar Sözcükler: Ateşli silah yaralanmaları; kolostomi; delicikesici alet yaralanmaları; rektal yaralanma; rektal onarım.

Presented at the 17th Turkish National Surgical Congress (May 26-29, 2010, Ankara, Turkey).

2010 Ulusal Cerrahi Kongresi’nde sözlü bildiri olarak sunulmuştur (26-29 Mayıs 2010, Ankara).

Department of General Surgery, Dicle University Faculty of Medicine, Diyarbakır, Turkey.

Dicle Üniversitesi Tıp Fakültesi Genel Cerrahi Anabilim Dalı, Diyarbakır.

Correspondence (İletişim): Metehan Gümüş, M.D. Dicle University, Medical Faculty, Department of General Surgery, Diyarbakır, Turkey. Tel: +90 - 412 - 248 80 01 e-mail (e-posta): metehangumus@yahoo.com

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Penetrating trauma is the most common cause of rectal injuries. In most cases, gunshot wounds account for 80%-85% of the cases. Other causes of rectal injuries include stab wounds, blunt trauma, iatrogenic injuries during surgery, foreign bodies, and sexual misadventure.[1]

tween the subgroups were analyzed by chi-square or Fisher’s exact and Mann-Whitney U tests. The correlations between variables were performed by Pearson or Spearmen’s rank correlation analyses based on the distribution of data. A value of p<0.05 was considered significant.

Although rectal injuries are rarely encountered, they are associated with high morbidity and mortality rates.[2] The principles of the treatment of rectal injuries have been determined based on the experiences gained from high-energy injuries during wartime. Since the injuries in civilian life are low-energy injuries, direct adaptation of these principles to civilian injuries has begun to be questioned. Awareness of the characteristics of civilian rectal injury cases as well as the factors affecting morbidity and mortality will contribute to improving the treatment approaches. A specific treatment method, including primary repair, diversion, presacral drainage, distal rectal washout, and antibiotherapy, or their combinations, should be determined for each patient by evaluating specific factors, including the general status of the patient and concomitant injuries, as well as local findings, such as the site and grade of rectal injury and the presence of contamination.[3]

RESULTS Of the patients, 28 (96.6%) were male and 1 (3.4%) was female. The mean age was 27.6 years (range: 1853 years) and the mean TTI was 22.8±58.2 hours. In 5 patients, the TTI was >24 hours. The mean length of hospital stay was 16.0±12.3 days (range: 5-51 days). Gunshot wounds accounted for 69.0% of the rectal injuries. Grade 3 injury existed in 58.6% of the patients. Extraperitoneal rectal injuries were present in 19 patients (65.5%). In 12 patients, 13 complications occurred. The general characteristics of the patients are summarized in Table 1.

Knowing which patients are likely candidates for morbidity in advance and close follow-up of these patients are of great importance in determining the principles of treatment. In the present study, the factors affecting morbidity in patients with rectal injury by gunshot or stab wounds in civilian life were investigated.

MATERIALS AND METHODS Twenty-nine inpatients, who had been treated between 2000 and 2009 in the General Surgery Clinic of Dicle University due to rectal injuries caused by gunshot and stab wounds, were included in the study. The demographic characteristics of the patients, as well as the trauma-treatment interval (TTI), length of hospital stay, concomitant organ injuries, Injury Severity Score (ISS), New Injury Severity Score (NISS), Revised Trauma Score (RTS), Trauma Injury Severity Score (TRISS), fecal contamination, and therapy methods were retrospectively recorded from the hospital records. In order to determine the factors affecting morbidity, the patients were divided into two groups regarding the presence of morbidity (Group 1, with morbidity; and Group 2, without morbidity), and the data of these two groups were compared. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 12.0 (SPSS, Inc., Chicago, IL, USA). Data are presented as the mean±standard deviation or n (%). One-sample Kolmogorov-Smirnov test was used to evaluate the distribution of data. The differences be402

Of the patients, 62.1% had concomitant organ injuries (Table 2). The most commonly associated injured organs were the intestine (31.0%) and bladder (27.6%). Medical therapy was administered to 1 patient and primary repair was performed on 8 patients, whereas the remaining patients received ostomies. Of the 20 patients who received ostomies, loop coTable 1. General characteristics of the patients

Cause of trauma Gunshot wound Stab wound Concomitant organ injury Present Absent Causes of morbidity Wound site infection Ano-gluteal fistula Vesicorectal fistula Necrotizing fasciitis Grade of injury I II III IV Site of injury Extraperitoneal Intraperitoneal Extra+intraperitoneal Therapy Medical Primary repair Ostomy

n 20 9 18 11 8 2 1 2 1 10 17 1 19 6 4 1 8 20

% 69.0 31.0 62.1 37.9 27.6 6.9 3.4 6.9 3.4 34.5 58.6 3.4 65.5 20.7 13.8 3.4 27.6 69.0

TTI: Trauma-treatment interval; LOHS: Length of hospital stay; SD: Standard deviation.

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Factors affecting morbidity in penetrating rectal injuries

Table 2. Concomitant injured organs in Groups 1 and 2 Organs

Group 1 (n=12) Group 2 (n=17) n (%) n (%)

Small bowel Bladder Vascular Pelvic bone Sigmoid colon Femur Urethra Others

2 (16.7) 4 (33.3) 2 (16.7) 2 (16.7) 0 (0.0) 1 (8.3) 2 (16.7) 2 (16.7)

7 (41.2) 4 (23.5) 3 (17.6) 2 (11.8) 2 (11.8) 1 (5.9) 0 (0.0) 1 (5.9)

lostomy, Hartmann’s colostomy and ileostomy were performed on 15 (75.0%), 1 (5.0%) and 4 (20.0%) patients, respectively. Morbidity was recorded in 12 patients (41.4%) (Group 1), whereas 17 patients (58.6%) had no morbidity (Group 2). No significant difference was determined between Groups 1 and 2 with respect to concomitant organ injury and the grade of injury (p=0.514 for both; Table 3). Ostomies were performed in 91.7% of the patients in Group 1 and 52.9% of the patients in Group 2 (p=0.043). The rate of patients with severe fecal contamination was significantly higher in Group 1 compared to Group 2 (75.0% vs. 35.3%, respectively; p=0.041). The rate of perianal or gluteal injuries was significantly higher in Group 1 than Group 2 (91.7%, p=0.032). No ���������������� significant����� difference was determined between the groups in terms of extraperitoneal rectal injuries (p=0.182), whereas intraperitoneal injuries were higher in Group 2 (52.9% vs. 8.3%, p=0.016; Table 3). The length of hospital stay in Group 1 was significantly longer than in Group 2 (27 days vs. 8.2 days, p<0.001; Table 4). A significant difference existed between the groups for both TTI <8 hours and ≥8 hours (p=0.038 for Groups 1 and 2). The TTI was <8 hours in 88.2% of the patients in Group 2 (Table 3). No significant difference existed between Groups 1 and 2 with respect to the mean age (<30 or ≥30 years), mean ISS (<16 or ≥16), mean RTS (<6 or ≥6), and NISS values. The mean TRISS value was 97.3±2.7 in Group 1 and 97.8±2.6 in Group 2 (Table 4). There was a significant positive correlation between the grade of injury and the number of concomitant organ injuries (r=0.430, p=0.02; Table 5). A negative correlation was determined between the number of concomitant injured organs and the TTI (r=-0.405, p=0.029) and between the NISS and TTI (r=-0.436, p=0.018; Table 5). One of the patients died of necrotizing fasciitis due to a delay in diagnosis. The mortality rate was determined to be 3.4%.

DISCUSSION The treatment of rectal injuries has four main components: 1) fecal diversion; 2) presacral drainage; 3) distal rectal washout; and 4) rectal repair, if possible.[1] Cilt - Vol. 17 Sayı - No. 5

Table 3. Comparison of the characteristics of the patients in Group 1 and Group 2

Group 1 (n=12) Group 2 (n=17) n (%) n (%)

Age (years) <30 ≥30 TTI (hours) <8 ≥8 ISS <16 ≥16 RTS <6 ≥6 Etiology GSW SW Grade I-II III-IV COI Yes No Ostomy Yes No Fecal contamination Major Minimal-Mild POG injury Yes No EP injury Yes No IP injury Yes No

p

7 (58.3) 5 (41.7)

12 (70.6) 5 (29.4)

0.432

6 (50.0) 6 (50.0)

15 (88.2) 2 (11.8)

0.038

5 (41.7) 7 (58.3)

6 (35.3) 11 (64.7)

0.514

0 (0.0) 12 (100.0)

1 (5.9) 16 (94.1)

0.586

8 (66.7) 4 (33.3)

12 (70.6) 5 (29.4)

0.568

5 (41.7) 7 (58.3)

6 (35.3) 11 (64.7)

0.514

7 (58.3) 5 (41.7)

11 (64.7) 6 (35.3)

0.514

11 (91.7) 1 (8.3)

9 (52.9) 8 (47.1)

0.043

9 (75.0) 3 (25.0)

6 (35.3) 11 (64.7)

0.041

11 (91.7) 1 (8.3)

9 (52.9) 8 (47.1)

0.032

11 (91.7) 1 (8.3)

12 (70.6) 5 (29.4)

0.182

1 (8.3) 11 (91.7)

9 (52.9) 8 (47.1)

0.016

LOHS: Length of hospital stay; TTI: Trauma-treatment interval; ISS: Injury severity score; RTS: Revised trauma score; COI: Concomitant organ injury; POG: Perianal or gluteal; EP: Extraperitoneal; IP: Intraperitoneal.

Table 4. Characteristics of the patients in Group 1 and Group 2 and their comparisons Age (year) LOHS (days) TTI (hours) ISS RTS TRISS NISS

Group 1 (n=12) Group 2 (n=17) Mean±SD Mean±SD 28.00±9.9 27.0±12.4 50.0±85.0 15.5±6.5 7.5±0.6 97.3±2.7 18.2±7.1

27.3±6.3 8.2±2.2 3.5±2.2 14.9±4.8 7.6±0.7 97.8±2.6 18.2±6.1

p 0.912 <0.001 0.103 0.744 0.679 – 0.744

LOHS: Length of hospital stay,; TTI: Trauma–treatment interval; ISS: Injury severity score; RTS: Revised trauma score; TRISS: Trauma injury severity score; NISS: New injury severity score; SD: Standard deviation.

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Table 5. The correlation coefficients between the studied variables Grade Number of COI TTI ISS RTS

Number of COI

TTI

ISS

RTS

NISS

0.430* – – – –

-0.185 -0.405* – – –

0.905** 0.613** -0.150 – –

-0.200 -0.353 0.093 -0.194 –

0.780** 0.800** -0.436* 0.851** -0.406*

*p<0.05, **p<0.001. COI: Concomitant organ injury; TTI: Trauma-treatment interval; ISS: Injury severity score; RTS: Revised trauma score; NISS: New injury severity score.

The principles of the treatment of rectal injuries have been determined based on the experiences gained from high-energy injuries during wartime. Since the injuries in civilian life are low-energy injuries, direct adaptation of these principles to civilian injuries has begun to be questioned. In a recent study, the mortality rate was reported to be 18% among 175 patients with colorectal injuries who had been treated at the 31st Combat Support Hospital during Operation Iraqi Freedom. The mortality rate among 3267 patients treated for other reasons in the same hospital was 8% during the same period of time.[4] The morbidity and mortality rates in a civilian rectal injury series have been reported to be 6%-42% and 0%-10%, respectively.[5] In a more recent study performed on 19 civilian patients with extraperitoneal rectal injuries, and 4 civilian patients with both intra- and extraperitoneal rectal injuries, Shatnawi and Bani-Hani[6] reported the morbidity and mortality rates as 47.8% and 13%, respectively. In the present study, the overall morbidity and mortality rates were 41.4% and 3.4%, respectively. The morbidity rate for those with extraperitoneal rectal injuries was 47.8%. In the present study, the fact that no mortality was determined in patients treated in time indicated the efficacy of the treatment modalities used in the management of patients with rectal injuries. Mortality occurred in only one patient in whom an extraperitoneal rectal injury had been recognized after the development of necrotizing fasciitis during the emergent operation in the orthopedics clinic. Unless rectal injuries are diagnosed and treated properly, they can lead to high-risk injuries. Rectal injuries cannot be noticed due to the anatomic localization of the area if they are not examined carefully.[6] A digital rectal examination should be performed in patients with gross rectal blood, wounds in close proximity, pelvic fractures, injuries to the genitourinary tract, and lower abdominal pain or tenderness, which suggest the possibility of a rectal injury.[6] A proctosigmoidoscopic examination should be performed in case of any suspicious findings, and sphincter tone must be checked during the examination. A negative digital rectal examination does not exclude the diagnosis of rectal injury. Therefore, further examinations should be performed in cases of suspected rectal injuries, including cystoure404

thrograms, abdominal and pelvic X-rays, water-soluble contrast studies, peritoneal lavage, and computed tomography (CT) scanning.[2] In the treatment of extraperitoneal rectal injuries, a diverting colostomy has been accepted as the standard therapy by many authors.[7-9] It has been reported that extraperitoneal rectal injuries can be safely treated with fecal diversion alone, particularly in low-velocity trauma.[10,11] Bostick et al.[7] reported that no septic complications were observed in any of the cases that underwent loop colostomies. Demirbaş et al.[12] verified the therapeutic approach consisting of a diverting colostomy (by performing a loop colostomy on all patients), distal rectal washout and presacral drainage in the treatment of ano-rectal gunshot injuries. In the present study, a loop colostomy was performed in 15 of the patients who had undergone ostomies; 1 patient underwent Hartmann’s procedure for technical reasons, and in 4 patients, the rectum was primarily repaired and an ileostomy was performed. Anterior and lateral upper two-thirds rectal wounds are intraperitoneal and should be treated similar to colon injuries. Anterior lower one-third and posterior lower two-thirds rectal injuries are extraperitoneal and can be managed by primary repair on a case-by-case basis.[2] Some authors have suggested that primary repair without diversion is feasible in selected patients. [13-15] In a study involving 30 patients with extraperitoneal rectal injuries, Levine et al.[15] suggested that primary repair without fecal diversion could be considered in patients without major associated injuries when they were treated within 8 hours of injury and had rectal injury scores (RIS) ≤2. However, the repair of extraperitoneal rectal perforations is not always technically feasible, and there is very little evidence to support the primary repair of these injuries.[11] Fecal diversion without primary repair is a safe procedure due to the anatomic considerations and technically difficult dissections. Those who advocate fecal diversion have suggested that the incidence of septic complications is less with diversion and have also shown that the incidence of stoma closure is associated with acceptable morbidity.[16] Primary repair is recommended in only one-half of the cases with extraperitoneal Eylül - September 2011


Factors affecting morbidity in penetrating rectal injuries

In the present study, the TTI was â&#x2030;Ľ8 hours in 8 patients, while it was >24 hours in 5 of these patients. Of the 5 patients, the reason for the delay was misdiagnosis in 2 patients, and ignorance and embarrassment in 3 patients. Owing to the fact that those with trans-anal rectal injuries in particular are admitted late due to social reasons, complications associated with wound infections are likely to be encountered more often. [17] Shatnawi and Bani-Hani[6] reported an association between wound infections and a treatment delay >6 hours. The duration of the TTI also increases the rate of fecal contamination. In addition to enhancing the technical capabilities, the awareness of patients and physicians about rectal injuries should be increased in an effort to shorten the TTI. In the present study, the majority of the patients without morbidity (88.2%) were in the group with a shorter TTI (<8 hours). The frequency of concomitant organ injury increased as the grade of rectal injury increased, and the TTI was shortened in those with increased concomitant organ injury. Early treatment lowers the rate of morbidity. In the present study, an increase was determined in the frequency of concomitant organ injury with an increasing grade of injury. A negative correlation was found between the increase in the frequency of concomitant organ injury and the duration of the TTI. Thus, although the likelihood of morbidity is high in patients with a high-grade injury and a high number of concomitant injured organs, we believe that early treatment leads to a decrease in the morbidity rate. Furthermore, it is suggested that intraperitoneal injury symptoms that occur in the early stages prevent the delay in diagnosis and treatment; thus, the rate of morbidity is lower in such patients due to early treatment. Intraperitoneal injuries cause an acute abdomen and lead the patients to seek care in health centers and with physicians thus enabling an early intervention. It was observed that the rate of morbidity was higher (91.7%) in the group without intraperitoneal injuries (the group with isolated extraperitoneal injuries). A limited number of symptoms in isolated extraperitoneal injuries and a delay in diagnosis particularly in occult injuries may lead to higher rates of morbidity. Cilt - Vol. 17 SayÄą - No. 5

Genitourinary tract injuries are among the most common lesions associated with rectal trauma. Injury to the bladder alone has been reported in approximately 30% of patients with rectal injuries.[7,11] Concomitant colon injuries have been reported in approximately 25% of patients with rectal injuries.[7] In their series of 17 patients with combined penetrating rectal and genitourinary tract injuries, Franko et al.[18] showed a high complication rate, including a rectovesical/urethral fistula rate of 24%. Crispen et al.[19] reported that patients sustaining combined penetrating injuries involving the rectum and bladder did not have an increased rate of immediate postoperative complications compared with isolated injuries. In the present study, there were 8 patients (27.6%) with bladder injuries. Of those, one patient had a rectovesical fistula that healed spontaneously with prolonged urethral catheter drainage. Intestinal injuries were noted in 9 patients as well (31.0%). It has been reported that the presence of shock on admission and delay in treatment have an effect on wound infections.[6] In one study, it was noted that an abdominal trauma index >16, RTS <6, blood transfusion of >10 units, and not applying rectal irrigation are effective factors in the development of pelvic abscesses.[20] Bostick et al.[7] did not report any septic complications in 28 patients, including those in whom presacral drainage was not performed (n=3). In the present study, fecal contamination, perianal or gluteal injuries, the duration of the TTI, and isolated extraperitoneal injuries were significant factors affecting the morbidity rate. The length of hospital stay was significantly longer in Group 1 compared to Group 2. 60

50 Lenght of hospital stay (days)

rectal injuries if it is possible to locate the wound.[7] The success rate of primary repair in a civilian series has been reported to be higher as compared to a military series.[4] Bostick et al.[7] performed primary repair to 32.1% of 28 extraperitoneal rectal injury cases. In the present study, primary repair or medical treatment were performed on 9 (31%) of the cases. Burch et al.[5] reported that colostomy and drainage were successful in the treatment of civilian rectal injuries, whereas additional procedures, such as diverting colostomies, rectal wound repairs and rectal irrigation had minimal effects on morbidity and mortality.

40

30

20

10

0

17

12

Group 2

Group 1

Fig. 1. The association of morbidity with the length of hospital stay. 405


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The development of morbidity prolongs the length of hospital stay in addition to its negative effects on health. Levy et al.[21] reported the length of hospital stay to be 21 days (range: 10 days to 4 months) in civilian extraperitoneal rectal injury cases. The length of hospital stay in the present study ranged from 5-51 days and was 27.0±12.4 days on average in Group 1. The length of hospital stay was significantly longer in Group 1 than in Group 2 (Fig. 1). In conclusion, a TTI >8 hours, the presence of perianal or gluteal injuries and the presence of fecal contamination were significant factors that affected the development of morbidity in penetrating rectal injuries. A positive correlation was demonstrated between the grade of injury and the number of concomitant injured organs and NISS, whereas there was a negative correlation with the TTI. It was concluded that a more severe clinical entity facilitates the early initiation of treatment and a decrease in morbidity. In order to diagnose and treat in time, the awareness of both patients and physicians about rectal injuries should be increased. Primary repair is adequate in those presenting within 8 hours with low-grade injuries but without fecal contamination, accompanying perianal defects and sphincter injuries and concomitant organ and system injuries. If the above-mentioned features do not present, ostomy should be included in the current treatment. Distal washout and presacral drainage may be applied in selected cases.

REFERENCES 1. Demetriades D, Salim A. Colon and rectal trauma and rectal foreign bodies. In: Wolff BG, Fleshman JW, Beck DE, et al., editors. The ASCRS Textbook of Colon and Rectal Surgery. New York, NY: Springer Science & Business Media; 2007. p. 322-34. 2. Cleary RK, Pomerantz RA, Lampman RM. Colon and rectal injuries. Dis Colon Rectum 2006;49:1203-22. 3. Weinberg JA, Fabian TC, Magnotti LJ, Minard G, Bee TK, Edwards N, et al. Penetrating rectal trauma: management by anatomic distinction improves outcome. J Trauma 2006;60:508-14. 4. Steele SR, Wolcott KE, Mullenix PS, Martin MJ, Sebesta JA, Azarow KS, et al. Colon and rectal injuries during Operation Iraqi Freedom: are there any changing trends in management or outcome? Dis Colon Rectum 2007;50:870-7. 5. Burch JM, Feliciano DV, Mattox KL. Colostomy and drainage for civilian rectal injuries: is that all? Ann Surg

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1989;209:600-11. 6. Shatnawi NJ, Bani-Hani KE. Management of civilian extraperitoneal rectal injuries. Asian J Surg 2006;29:11-6. 7. Bostick PJ, Johnson DA, Heard JF, Islas JT, Sims EH, Fleming AW, et al. Management of extraperitoneal rectal injuries. J Natl Med Assoc 1993;85:460-3. 8. Navsaria PH, Graham R, Nicol A. A new approach to extraperitoneal rectal injuries: laparoscopy and diverting loop sigmoid colostomy. J Trauma 2001;51:532-5. 9. Navsaria PH, Shaw JM, Zellweger R, Nicol AJ, Kahn D. Diagnostic laparoscopy and diverting sigmoid loop colostomy in the management of civilian extraperitoneal rectal gunshot injuries. Br J Surg 2004;91:460-4. 10. Velmahos GC, Gomez H, Falabella A, Demetriades D. Operative management of civilian rectal gunshot wounds: simpler is better. World J Surg 2000;24:114-8. 11. Navsaria PH, Edu S, Nicol AJ. Civilian extraperitoneal rectal gunshot wounds: surgical management made simpler. World J Surg 2007;31:1345-51. 12. Demirbaş S, Yildiz M, Uluutku AH, Kalemoğlu M, Kurt Y, Erenoğlu C, et al. Surgical treatment of ano-rectal gunshot injuries caused by low-velocity bullets. Ulus Travma Acil Cerrahi Derg 2004;10:17-21. 13. Thomas DD, Levison MA, Dykstra BJ, Bender JS. Management of rectal injuries. Dogma versus practice. Am Surg 1990;56:507-10. 14. Ivatury RR, Licata J, Gunduz Y, Rao P, Stahl WM. Management options in penetrating rectal injuries. Am Surg 1991;57:50-5. 15. Levine JH, Longo WE, Pruitt C, Mazuski JE, Shapiro MJ, Durham RM. Management of selected rectal injuries by primary repair. Am J Surg 1996;172:575-9. 16. Berne JD, Velmahos GC, Chan LS, Asensio JA, Demetriades D. The high morbidity of colostomy closure after trauma: further support for the primary repair of colon injuries. Surgery 1998;123:157-64. 17. El-Ashaal YI, Al-Olama AK, Abu-Zidan FM. Trans-anal rectal injuries. Singapore Med J 2008;49:54-6. 18. Franko ER, Ivatury RR, Schwalb DM. Combined penetrating rectal and genitourinary injuries: a challenge in management. J Trauma 1993;34:347-53. 19. Crispen PL, Kansas BT, Pieri PG, Fisher C, Gaughan JP, Pathak AS, et al. Immediate postoperative complications of combined penetrating rectal and bladder injuries. J Trauma 2007;62:325-9. 20. Gonzalez RP, Falimirski ME, Holevar MR. The role of presacral drainage in the management of penetrating rectal injuries. J Trauma 1998;45:656-61. 21. Levy RD, Strauss P, Aladgem D, Degiannis E, Boffard KD, Saadia R. Extraperitoneal rectal gunshot injuries. J Trauma 1995;38:273-7.

Eylül - September 2011


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):407-412

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.48716

The use of Ender nail in intertrochanteric fractures supported with external fixation İntertrokanterik kırıklarda Ender çivilerinin eksternal fiksatörle desteklenmesi Cemil ERTÜRK,1 Bilal ÇAĞMAN,2 Mehmet Akif ALTAY,1 Uğur Erdem IŞIKAN1

BACKGROUND

AMAÇ

Intramedullary Ender nailing in intertrochanteric fractures was very popular in the past. However, this method has fallen in favor over time, due to complications. The purpose of this study was to evaluate results with this method and possible ways to prevent these complications, including the use of unilateral fixators to support the Ender nails.

İntertrokanterik kırıklarda intramedüller Ender çivileme, geçmiş yıllarda çok yaygındı. Ancak bu yöntemin kullanımı, komplikasyonlarından dolayı zaman içerisinde azaldı. Bu çalışmanın amacı, tek yanlı eksternal fiksatörle desteklenen Ender çivileme ile bu tür komplikasyonların önlenmesi ile birlikte bu yöntemin sonuçlarını değerlendirmektir.

METHODS

GEREÇ VE YÖNTEM

This technique (Ender nailing and external fixator) was used in 39 patients (17 M/22 F, mean age: 71.4 years). The preoperative mean American Society of Anesthesiologists (ASA) score was 1.84 (range: 1-4) for all the patients. AO/ OTA classification of fractures was used. In our surgery, we used an external fixator to support the intramedullary nails. All patients were evaluated with Parker-Palmer mobility score and with the Harris hip score.

Bu teknik 39 hastada kullanıldı (17 erkek, 22 kadın; ortalama yaş 71,4 yıl). Ameliyat öncesi tüm hastaların ortalama American Society of Anesthesiologists (ASA) skoru 1,84 (dağılım, 1-4) idi. Kırıklar AO/OTA sınıflamasına göre ayrıldı. Biz ameliyatımızda eksternal fiksatörü intramedüller çivilere destek amacıyla kullandık. Son takipte, tüm hastalar Parker-Palmer mobility skoru ve Harris kalça skoru ile değerlendirildi.

RESULTS

BULGULAR

The follow-up period was 29.2 months (20-56). Two patients experienced nail migration in the knees, two patients had varus deformation with a reduction in length of 2 cm, and seven patients developed pin-track infection. The average Harris score and Parker-Palmer score of the 14 patients who presented for their last follow-up examination were 64 and 6.8, respectively.

Ortalama izlem süresi 29,2 ay (20-56) idi. İki hastada Ender çivilerinin dizden dışarı çıkması, iki hastada 2 cm kısalıkla birlikte varus deformitesi ve yedi hastada çivi dibi enfeksiyonu oluştu. Yaşamını sürdürebilen ve son takibi yapılabilen 14 hastanın ortalama Harris kalça skoru 64, Parker-Palmer skoru 6,8 idi.

CONCLUSION

SONUÇ

This method demonstrated several advantages, in that it allows the patient to put weight on the extremity after a shorter period of time and enables the fracture to heal rapidly without any serious complications.

Bu yöntemin, herhangi bir ciddi sorun görülmeksizin, kırığın kısa sürede iyileşmesini sağlaması ve ekstremitesine tam ağırlık vermesine uygun olması gibi üstünlükleri gösterilmiştir.

Key Words: Ender nails; external fixators; fracture fixation; hip fractures.

Anahtar Sözcükler: Ender çivileri; eksternal fiksatörler; kırık tespiti; kalça kırıkları.

Department of Orthopedics and Traumatology, Harran University Faculty of Medicine, Şanlıurfa; 2Department of Orthopedics and Traumatology, Av. Cengiz Gökçek State Hospital, Gaziantep, Turkey.

1 Harran Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Şanlıurfa; 2Av. Cengiz Gökçek Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Gaziantep.

Correspondence (İletişim): Cemil Ertürk, M.D. Harran Üniversitesi Tıp Fakültesi Ortopedi ve Travmatoloji Anabilim Dalı, 63300 Şanlıurfa, Turkey. Tel: +90 - 414 - 314 11 70 e-mail (e-posta): erturkc@yahoo.com

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Treatment of intertrochanteric fractures should aim to mobilize the patient quickly, to reduce mortality and hospitalization time, and to restore the patient’s functions as much as possible.[1-5] While stable intertrochanteric fractures can be treated efficiently, unstable fractures pose serious and stressful problems. In the surgical treatment of intertrochanteric fractures, endoprosthesis and external fixators are used in conjunction with methods such as rigid pinplates, sliding plate compression pins and screws, osteotomy and osteosynthesis plates, and intramedullary nails.[1-5] The advantages of Ender nails include: reduction in mortality rates, less blood loss, minimal surgical trauma, and a shorter duration of time in surgery.[6-9] Ender nails have been used in almost 12,000 cases in Europe; however, the technique has not been as popular in North America.[2] Despite their advantages, the rotational stability of Ender nails is weak. [2,10-12] In order to prevent complications that occurred in the past (������������������������������������������� including���������������������������������� the loss of initial reduction resulting from surgery, the penetration and perforation of the proximal femur by the nails, external rotation, distal nail migration, and/or reduction in femur length resulting from surgery), we attempted to counteract or minimize the insufficient rotation and axial resistance of the Ender nails by supplementing them with unilateral external fixators in the six-week period after surgery. We planned in this study to analyze the effectiveness of this combination in cases of intertrochanteric fractures.

Society of Anesthesiologists (ASA) score[13] for all the patients was 1.84 (range: 1-4). Only patients with a minimum follow-up of 12 months were included. The geometry and degree of bone comminution were graded using admission radiographs according to the Orthopedic Trauma Association’s (OTA) classification[2] from type A to C. All of the fractures were closed (Fig. 1). All of the patients were given epidural anesthesia. After attaining closed reduction with observation through a scoping device and using a traction table, firstly reduction was achieved with Ender nails, then internal fixation was reinforced with unilateral external fixators. In other words, we first performed reduction with intramedullary Ender nails to provide the alignment, and then an external fixator was added for additional stabilization. Surgical Technique In all the cases, a longitudinal incision was made 3-4 cm from the proximal adductor tubercle, and a window was opened in the bone using the awl. The number of Ender nails (Ender type intramedullary nail; Hipokrat Inc., Izmir, Turkey) varied according to the width of the patient’s femur medullary canal: 37 patients had two Ender nails inserted and 2 patients had 3 Ender nails inserted. Two or three Shanz pins were then applied to the femoral neck (Fig. 2). Unilateral external fixators (Hipofix Dynamic axial fixator;

MATERIALS AND METHODS Written informed consent was obtained from all patients, and the study was approved by the Local Ethical Committees. We proceeded by selecting a younger control group of patients with a higher life expectancy rather than an elderly group with a higher risk of deterioration. Our age indication, like that of Barrios et al.,[6] was confined to patients aged 50 years or older with usually simple fall. We used Ender nails and unilateral external fixators simultaneously in 39 patients with non-pathological closed intertrochanteric fractures who were seen in our clinic from 2003 to 2009. This group was comprised of 22 women and 17 men, ranging in age from 49 to 93 years, with a mean of 71.4 years. Of the 39 patients, 18 fractured their right and 21 their left hip. Thirty-four of the fractures were due to simple falls and 5 were due to traffic accidents. Seventeen patients (43%) had a pre-existing associated pathology, and 4 had ≥2 comorbidities. Eight of the patients had cardiovascular issues, 5 had diabetes mellitus, 4 had pulmonary issues, 3 suffered from anemia, and 1 had hemiplegic sequela. The preoperative mean American 408

Fig. 1. Right hip unstable intertrochanteric fracture. Eylül - September 2011


The use of Ender nail in intertrochanteric fractures supported with external fixation

Hipokrat Inc., Izmir, Turkey) were applied by affixing two Shanz pins to the diaphysis of the femur. Patients were able to sit up in bed the day after surgery and could walk with two crutches, with full weight exerted on the legs. After discharge, patients had to present for follow-up twice a month for up to two months. After callused tissue was seen on X-rays, patients were able to walk with a single crutch (Fig. 3). After removing the external fixator from the femur bone, intramedullary biomechanical support persisted. Fixators were removed after six weeks, either with local anesthesia or sedoanalgesia. Fracture healing was evaluated by standard radiographic projections, and union was defined as a dense callus bridging at the fracture site. Axial displacement and shortening were assessed from the radiographs. Rotational deformities and an insufficient length to measure the distance between���������������������������������������������� the medial malleolus and the anterior/superior spina iliaca were judged clinically. The Ender nails were not removed unless they caused complications. After the external fixators were removed, the condition of the patients was monitored in monthly follow-up exams. At the last follow-up, patients were evaluated according to Parker-Palmer mobility score[14] and with the Harris hip score.[15] The Parker-Palmer mortality score evaluates the patients on the basis of their ability to walk within their place of residence, their ability to walk outside, and their ability to go shopping. Each

Fig. 2. X-ray of patient six weeks later. Cilt - Vol. 17 Sayı - No. 5

activity was assigned a score on the basis of its level of difficulty: 3 points indicated that the patient had no difficulty; 2 points indicated that the patient needed a cane or other aid; 1 point indicated that the patient needed help from another person; and 0 points indicated that the activity was impossible for the patient to perform.

RESULTS The average follow-up period was 29 months (range: 20-56 months). The average hospitalization period was an average of 7 days (range: 5-18 days). The average duration of surgery was 60 minutes. None of the patients required open surgery or blood transfusions. In the six-week period following surgery, 7 of the patients (18%) developed pin-track infections. Six of these pin-track infections were surface infections that responded to oral antibiotic therapy; 1 patient developed a deep infection. In this case, the external fixators were removed without waiting for the response of the more conservative treatment because the patient had also developed an intramedullary infection in the hip. Four weeks after surgery, the external fixator was removed from this patient. No further infections were found in the patient thereafter. Thirty-three of the patients (85%) were over 60 years old. The average postoperative period was 3 days (range: 2-6 days). The average healing pe-

Fig. 3. Hip graph was seen after removal of external fixator. Ender pins in the hip were not removed, unless they caused problem. 409


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riod was 9.2 weeks (range: 8-16 weeks). There was no delayed healing or nonunion. Two of the patients developed varus deformities in the early stages. Because the Ender nails were not applied sufficiently, the fixation was inadequate, resulting in a varus slippage (5%). These were analyzed as technical errors. In these patients, shortenings of 2 cm were measured (5%). External rotation failure occurred in 1 patient. In 2 of the patients (5%), the Ender nails were removed because of irritations that developed in the knee during the follow-up period. In these patients, the external fixator had been removed previously. Ender nails were removed from the thigh when the fractures demonstrated union. After removal of the Ender nails, the patients had no complaints. The other patients had no complaints regarding their hips. Postoperative mortality was observed in 1 patient due to pulmonary embolism in the intensive care unit on the second postoperative day. Within the first 2 years, 6 of the patients (15%) died. Seven patients died after 2 years. Two patients had additional surgery (endoprosthesis). We were unable to contact 7 of the patients, but we determined that 16 of the patients were still alive. Of these, 14 presented for their last check-up; 2 were bedridden at home. None of the 14 patients who presented for their final examination had any complaints, and all had returned to their original level of function. The average Harris score and the average Parker-Palmer score of the 14 patients at the time of the most recent follow-up were 64 (range: 4482) and 6.8 (range: 5-8), respectively.

DISCUSSION We prefer Ender nails as fixation materials in our technique, as they utilize the biomechanical advantages of the nails, thereby resulting in a more rapid treatment process. Because Ender nails are flexible, their proximal tips are anatomically suited to the archshaped structure in the proximal femoral medullary cavity. We can see that this anatomical fit results in a balanced load distribution in the proximal femur; this ability is unmatched by other methods. As Ender nails perform with a three-point principle, reduction and assessment occur more often in the valgus.[16] Furthermore, it was found in Pauwellâ&#x20AC;&#x2122;s biomechanical studies of the hip that flexing momentum is highest in the subtrochanteric area, where the compound force from the femoral proximal in a healthy hip while standing or walking intersects with the long axis of the femoral shaft in this area.[17] These measures show that in platescrew systems such as the Dynamic Hip Screw (DHS), the lever of the flexing force becomes elongated, while in intramedullary nails such as Ender nails, the lever shortens. Thanks to the biomechanical advantages of the Ender nail, it is anatomically possible to carry the loads on the femoral proximal evenly along the femo410

ral medullary canal while the load on the unit area in the fractured region is minimal.[18] Despite their advantages, the rotational stability of Ender nails is weak.[10-12] Because the external rotator muscles of the hip force the hip into an external rotation motion, particularly in unstable fractures, we sought to neutralize these muscles for one to two months by adding a unilateral external fixator on neutral rotation to the hip after reduction and assessment with Ender. As the initial valgus reduction in Ender nail use is promising, we expected to stop varus thrust and reduction loss for one to two months through early loading by a few days, using an external fixator. Paley[19] and Kocaogluâ&#x20AC;&#x2122;s[20] technique combining the use of an external fixator with locked intramedullary nails in elongating long bones motivated us to choose this combination. While the aim of this technique was to comfort the patient by shortening the duration of exposure to the external fixator during elongation, in our surgery, we used the external fixator to support the intramedullary nail. While it might seem best to use only the external fixator, it should only be used in older patients with more serious conditions, given the potential complications.[5,21] Today, dynamic sliding hip nails and proximal intramedullary femoral nails (PFN and Gamma nails) are more commonly used in surgery of intertrochanteric fractures. Although there is no final consensus, DHS nails are mostly used for stable fractures while PFN and Gamma nails are mostly used for unstable fractures.[22] However, proximal intramedullary nails did not yield infallible results either; some complications and failures were reported.[3,23,24] Rigid plate screws, however, caused complications, including delayed union and non-union, wound infections and implant failure. In addition to bone fragments being devascularized, healing by callus formation is slow in the open reduction with DHS. Postoperative varus collapse, limb shortening and medial displacement of the distal fragment, as critical complications, were reported with DHS, which is one of the most widely used techniques for intertrochanteric fractures.[2,10,16] Furthermore, plate fracture secondary to failure in a bending mode may occur. Intramedullary nails have a biomechanical advantage over DHS due to the fixation device within the medullary canal. The bending moment on it is considerably less than with DHS. However, late femoral fractures at the tip of the device, such as the Gamma nail with short intramedullary stem, or through the distal locking screws have also occurred in 3% to 6% of patients. Therefore, the use of long intramedullary nails that end at the supracondylar region of the femur has been advocated. New devices, such as the Ace Trochanteric Femoral Nail and the Trochanteric Femoral Nail have been developed, but the literature on these devices EylĂźl - September 2011


The use of Ender nail in intertrochanteric fractures supported with external fixation

is limited. Additionally, the use of an intramedullary device may be precluded in severe deformities of the femoral canal or excessive anterior bowing.[3] Prosthetic replacement for hip fractures may expedite early patient mobilization and ambulation and thereby maximize the patient’s functional recovery.[25] While it is an important treatment option for displaced femoral neck fractures, primary prosthetic replacement has had limited use in acute unstable intertrochanteric fractures in elderly patients. In patients with severe osteoporosis with comminution, the prosthesis selected must replace the calcar, with provisions for greater trochanteric reattachment to restore abductor function. However, this requires a more extensive surgical procedure than does internal fixation and entails greater blood loss, longer surgical and anesthetic time, and the potential for more frequent complications, not to mention greater implant cost.[2] The external rotation deformities are certainly more commonly encountered in patients treated with Ender nailing. Although Habernek et al.[9] and Levy et al.[10] found 25% and 30% external rotation failure rates, respectively, we encountered only one case (2.6%). Habernek et al.[9] reported that 40% of patients experienced leg shortening, but in our study, only two patients (5.0%) suffered leg shortening due to varus deformity. Furthermore, Habernek et al.[9] reported that in patients with unstable fractures treated with Ender nails and cerclage wire, weight bearing was not allowed for at least six weeks postoperatively. In contrast, we did not perform any internal fixation and full weight bearing using two crutches or a walker was begun on the second postoperative day. As for the number of Ender nails, we chose to use 2-3 nails with an anteversion as opposed to the 4-5 Ender nails recommended to fill the medullary cavity completely.[18] In the Ender nail surgery performed in our previous studies, we observed that while the first two nails were sent to the femoral neck with no problem, the sending of the third, fourth, and fifth nails became more difficult. To undo perforations that may occur along the line of fracture of the femoral neck, Waddell[18] suggested that the nails be pulled back and redirected for better assessment. Unfortunately, this prolongs the operation and the duration of X-ray exposure. Moreover, the bone window in the femoral supracondylar area must naturally be opened wider. In the operations we performed using the classic method of filling the medullary cavity completely with Ender nails, we observed that in most cases, additional fissures occurred in the bone window. As a result, one may encounter unexpected complications, including the loss of stability, distal migration of the nails, or an additional supracondylar fracture due to the fissures in the femoral supracondylar region. These potential Cilt - Vol. 17 Sayı - No. 5

results contradicted our expectations of more stability. In our study, we were able to send two Ender nails to the medullary cavity more rapidly by opening a hole in the bone with an awl instead of a window, and by making a 3-4 cm mini-incision in the femoral supracondylar area. Moving along the fracture line in an intramedullary direction, the nails adapt easily to the antreversion angle because they are so few in number in the femoral neck, and because they are flexible, as Pankowich stated.[11] The two or three Ender nails sent to the medullary cavity previously while moving along the Shanz pins of the external fixator were elastic and did not fill the medulla cavity completely. Therefore, they were able to pass through the bone cortex, providing external fixation quite easily. Despite the limitations of this study, including its retrospective and noncomparative design, we believe that it can contribute to the evaluation of benefits expected from hip surgery for surgeons in trauma centers. Prospective and randomized comparative studies on hip surgery will definitely provide more conclusive data. However, these would hardly be practicable in such a complex disorder as fractures, especially because of the problems associated with adequate randomization. Therefore, further biomechanical analysis studies are necessary to confirm our findings. In our analysis, given the several advantages of the Ender nails, the method described above is more stable, successful, effective, anatomically sound, and minimally invasive. Finally, we believe that this technique is an effective one that can be applied easily and rapidly to unstable intertrochanteric fractures. Conflict of interest There is no conflict of interest applicable.

REFERENCES 1. Egol KA, Koval KJ, Zuckerman JD. Functional recovery following hip fracture in the elderly. J Orthop Trauma 1997;11:594-9. 2. Kenneth JK, Zuckerman JD. Intertrochanteric fractures. In: Bucholz RW, Heckman JD, editors. Rockwood and Green’s fractures in adults. Vol. 2, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001. p. 1634-63. 3. LaVelle DG. Fractures and dislocations of the hip. In: Canale ST, Beaty JH, editors. Campbell’s operative orthopaedics. Vol 3, 11th ed. Philadelhia: Mosby; 2008. p. 3237-308. 4. Ozkaya U, Parmaksizoğlu AS, Gül M, Kabukçuoğlu Y, Ozkazanli G, Basilgan S. Management of osteoporotic pertrochanteric fractures with external fixation in elderly patients. Acta Orthop Traumatol Turc 2008;42:246-51. 5. Atıcı T, Sahin N, Oztürk A, Yaray O. Treatment of intertrochanteric femur fractures in high-risk geriatric patients (≥65 years) with external fixation. Ulus Travma Acil Cerrahi Derg 2010;16:413-20. 6. Barrios C, Walheim G, Broström LA, Olsson E, Stark A. 411


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Walking ability after internal fixation of trochanteric hip fractures with Ender nails or sliding screw plate. A comparative study of gait. Clin Orthop Relat Res 1993;(294):187-92. 7. Berglund-Rödén M, Swierstra BA, Wingstrand H, Thorngren KG. Prospective comparison of hip fracture treatment. 856 cases followed for 4 months in The Netherlands and Sweden. Acta Orthop Scand 1994;65:287-94. 8. Eren OT, Küçükkaya M, Tezer M, Yilmaz C, Kuzgun U. Treatment of intertrochanteric fractures of the femur with Ender nails in patients over the age of 65 years. Acta Orthop Traumatol Turc 2003;37:102-6. 9. Habernek H, Wallner T, Aschauer E, Schmid L. Comparison of ender nails, dynamic hip screws, and Gamma nails in the treatment of peritrochanteric femoral fractures. Orthopedics 2000;23:121-7. 10. Levy RN, Siegel M, Sedlin ED, Siffert RS. Complications of Ender-pin fixation in basicervical, intertrochanteric, and subtrochanteric fractures of the hip. J Bone Joint Surg [Am] 1983;65:66-9. 11. Pankovich AM, Tarabishy IE. Ender nailing of intertrochanteric and subtrochanteric fractures of the femur. J Bone Joint Surg [Am] 1980;62:635-45. 12. Olerud S, Stark A, Gillström P. Malrotation following Ender nailing. Clin Orthop Relat Res 1980:139-42. 13. Ross AF, Tinker JH. Preoperative evaluation of the healthy patient. In: Rogers MC, Tinker JH, Covino BG, Longnecker DE, editors. Principles and practice of anesthesiology. St. Louis, Missouri: Mosby; 1993. p. 3-36. 14. Parker MJ, Palmer CR. A new mobility score for predicting mortality after hip fracture. J Bone Joint Surg [Br] 1993;75:797-8. 15. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An

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end-result study using a new method of result evaluation. J Bone Joint Surg [Am] 1969;51:737-55. 16. Spiegel PG, VanderSchilden J. Subtrochanteric fractures. In: Evarts CM, editor. Surgery of the musculoskeletal system. Vol. 2, 1st ed. New York: Churchill Livingstone; 1983. p. 149-85. 17. Pauwels F. Biomechanics of the normal and diseased hip. Berlin-Heidelberg-New York: Springer-Verlag; 1976. 18. Waddell JP. Subtrochanteric fractures of the femur: a review of 130 patients. J Trauma 1979;19:582-92. 19. Paley D, Herzenberg JE, Paremain G, Bhave A. Femoral lengthening over an intramedullary nail. A matched-case comparison with Ilizarov femoral lengthening. J Bone Joint Surg [Am] 1997;79:1464-80. 20. Kocaoglu M, Eralp L, Kilicoglu O, Burc H, Cakmak M. Complications encountered during lengthening over an intramedullary nail. J Bone Joint Surg [Am] 2004;86-A:2406-11. 21. Kazakos K, Lyras DN, Verettas D, Galanis V, Psillakis I, Xarchas K. External fixation of intertrochanteric fractures in elderly high-risk patients. Acta Orthop Belg 2007;73:44-8. 22. Schipper IB, Marti RK, van der Werken C. Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation. Review of literature. Injury 2004;35:142-51. 23. Williams WW, Parker BC. Complications associated with the use of the gamma nail. Injury 1992;23:291-2. 24. Ongkiehong BF, Leemans R. Proximal femoral nail failure in a subtrochanteric fracture: The importance of fracture to distal locking screw distance. Injury Extra 2007;38:445-50. 25. Altay MA, Ertürk C, Işıkan UE. Bipolar hemiarthroplasty for the treatment of femoral neck fractures and the effect of surgical approach on functional results. Eklem Hastalik Cerrahisi 2010;21:136-41.

Eylül - September 2011


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):413-418

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.67503

Characteristics of open globe injuries in geriatric patients Geriatrik hastalarda açık göz küresi yaralanmalarının özellikleri Levent TÖK,1 Özlem YALÇIN TÖK,1 Dilek ÖZKAYA,2 Elif ERASLAN,3 Yonca SÖNMEZ,4 Firdevs ÖRNEK,3 Yavuz BARDAK1

BACKGROUND

AMAÇ

We aimed to evaluate the etiological and demographic characteristics of open globe injuries in geriatric patients, to determine the factors affecting the prognosis and to discuss the differences between geriatric and young populations in light of the current literature.

Açık göz küresi yaralanması olan geriatrik hastaların demografik ve etyolojik özelliklerini değerlendirmeyi, prognozu etkileyen faktörleri tespit etmeyi ve güncel literatür eşliğinde genç nüfusla farklılıkları karşılaştırmayı amaçladık.

METHODS

Açık göz küresi yaralanması nedeniyle 1998-2009 yılları arasında tedavisi ve takibi yapılan 65 yaş üzerinde 30 hastanın dosyaları geriye dönük olarak değerlendirildi.

The medical files of 30 patients aged 65 years and older who were treated and followed up for open globe injuries between 1998 and 2009 were evaluated retrospectively. RESULTS

The mean age was 73.1 years. Sixty percent of the patients were male, with a predominance of left eye involvement. The most common type of trauma was rupture due to a blunt object. The presenting visual acuity was no light perception in 13 patients, light perception/hand movement in 15 patients and 1/200-19/200 in 2 patients. In a univariate analysis assessing the effects of demographic and clinical characteristics on final vision, the wound location, type of trauma and Ocular Trauma Score were found to be statistically significant variations. CONCLUSION

The prognosis of open globe injuries is very poor in geriatric patients. Age-related structural changes and previous history of surgeries contribute to easy development of a rupture. During the treatment process, limited recovery capacity, ocular pathology in patients and low functional capacity in this age group exert negative effects on the prognosis.

GEREÇ VE YÖNTEM

BULGULAR

Ortalama yaş 73,1 yıl idi. Hastaların %60’ı erkekti ve en fazla sol göz tutulumu vardı. En sık rastlanan travma tipi künt nesnelerle oluşan yırtılma idi. Hastaların başvuru anındaki görme keskinlikleri 13 hastada ışık hissi yokken, 15 hastada ışık hissi/el hareketleri, 2 hastada 1/20019/200 düzeyindeydi. Demografik ve klinik karakteristiklerin final görme keskinliği üzerine etkisinin değerlendirildiği tek değişkenli analizde yara yeri, travma tipi ve oküler travma skoru istatistiksel olarak anlamlı değişkenlerdi. SONUÇ

Açık göz küresi yaralanmalarının prognozu geriatrik hastalarda oldukça kötüdür. Yaşa bağlı gelişen yapısal değişiklikler, geçirilmiş cerrahiler daha kolay yırtık gelişimine neden olmaktadır. Tedavi sürecinde iyileşme kapasitesinin sınırlı olması, hastaların beraberlerinde bulunan göz patolojileri ve fonksiyonel kapasitenin bu yaş grubunda düşük olması prognozu kötü yönde etkilemektedir.

Key Words: Elderly; open globe injury; penetrating injury; rupture.

Anahtar Sözcükler: Yaşlı; açık göz küresi yaralanması; penetran yaralanma; rüptür.

Departments of 1Ophthalmology, 4Public Health, Süleyman Demirel University, Faculty of Medicine, Isparta; 2Department of Ophthalmology, Isparta State Hospital, Isparta; 3Department of Ophthalmology, Ankara Training and Research Hospital, Ankara, Turkey.

Süleyman Demirel Üniversitesi Tıp Fakültesi, 1Göz Hastalıkları Anabilim Dalı, 4Halk Sağlığı Anabilim Dalı, Isparta; 2Isparta Devlet Hastanesi, Göz Hastalıkları Kliniği, Isparta; 3Ankara Eğitim ve Araştırma Hastanesi, Göz Hastalıkları Kliniği, Ankara.

Correspondence (İletişim): Özlem Yalçın Tök, M.D. Turan Mah., Mehmet Bilginer Sitesi, C Blok, No: 9 Gökçay, Isparta, Turkey. Tel: +90 - 246 - 211 92 86 e-mail (e-posta): esattok@yahoo.com

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Open globe injury is a common cause of visual impairment and blindness. Ocular trauma is an important, worldwide and preventable public health problem.[1] The cost of ocular trauma to society is related to medical treatment as well as expenditures associated with workers’ compensation, lost days of work and production time.[2] These injuries have a global incidence rate of approximately 3.5 per 100,000 persons annually, which leads to an estimated 203,000 open globe injuries every year worldwide.[3] Patients with eye injuries are usually young, and children account for 20-50% of all ocular injuries.[4-6] Usha Vasu[7] found 81% of patients aged under 45 years. Patients aged 50 and above constituted 6.7% of the ocular trauma group in the study by Üstündağ et al. and 15.2% in the study by Soylu et al.[8,9] There are no data regarding ocular trauma in elderly patients in the current literature. The purpose of this retrospective study was to determine epidemiological and clinical characteristics and outcome of serious eye injuries in Turkish patients aged 65 years and older who presented to an emergency department of a referral ophthalmologic service.

MATERIALS AND METHODS This study was approved by the Local Ethics Committee of our institution. A review of all cases of open globe injuries who presented to the emergency unit of the Ophthalmology Department of Ankara Training and Research Hospital and Süleyman Demirel University between January 1998 and January 2009 was undertaken. The chart of each patient was reviewed to obtain data including a history of ocular injury, patient demographics (age and sex), involved eye, date of injury, anatomic location of injury, cause of injury, presenting visual acuity, and clinical signs (the presence of a relative afferent pupillary defect (RAPD), endophthalmitis, hyphema, uveal tissue and vitreous prolapse, traumatic cataract, vitreous hemorrhage, retinal detachment, intraocular foreign body, and eyelid laceration). The outcome was evaluated in terms of final best-corrected (Snellen) visual acuity, measured at the last visit. The definition and classification of ocular trauma in this study were modified from the Ocular Trauma Classification Group guidelines and Birmingham Eye Trauma Terminology.[10,11] Open globe injuries were classified into four categories as: globe ruptures, penetrating injuries, intraocular foreign body injuries, or perforating injuries. Wound location was defined as zone I if the injury was confined to the cornea including the corneoscleral limbus, as zone II if the injury was located in the corneoscleral limbus to a point 5 mm posterior into the sclera, and as zone III if the injury was located in the sclera posterior to zone II. In a study of 2500 patients by Kuhn et al.,[12] the Ocular Trauma Score (OTS) was calculated accord414

ing to the presenting findings of patients. The OTS was calculated by assigning a raw point value for the initial visual acuity (no light perception (NLP), light perception (LP)/hand motion (HM), 1/200-19/200, 20/200-20/50, and ≥20/40) and then subtracting the appropriate raw points for each diagnosis of globe rupture, endophthalmitis, perforating injury, retinal detachment, and a RAPD (Table 1). Based on the severity of the trauma, a score ranging between 0 and 100 is obtained. A low score is usually obtained after a severe trauma, which is indicative of a poor prognosis. In order to allow for an easy assessment in conformity with the OTS, presenting and final visual acuities were grouped into 5 as NLP, LP/HM, 1/200-19/200, 20/200-20/50 and ≥20/40. Statistical Analysis Data were analyzed with SPSS version 15.0 (SPSS, Inc., Chicago, IL, US). Statistical analysis of quantitative data, including descriptive statistics, parametric and non-parametric comparisons, was performed for all variables. Frequency analysis was performed using the chi-square test. Univariate chi-square analysis was performed on the variables of age, gender, cause of injury, mechanism of injury, wound location, presenting visual acuity, type of injury, OTS category, presence or absence of eyelid laceration, retinal detachment, a RAPD, endophthalmitis, vitreous prolapse, hyphema, lens damage, and uveal tissue prolapse to determine which of these was associated with visual outcome. In the univariate analysis, patients were divided into two groups as those with a final visual acuity of HM or worse and those with a final visual acuity better than HM. All P-values were two-sided, and a p-value less than 0.05 was considered statistically significant.

RESULTS A total of 30 patients with open globe injuries were enrolled in this study (18 [60%] male; 12 [40%] female). Seventeen (56.7%) left eyes and 13 (43.3%) Table 1. Calculating the Ocular Trauma Score: variables and raw points Variables Initial vision NLP LP/HM 1/200-19/200 20/200/20/50 ≥20/40 Rupture Endophthalmitis Perforating injury Retinal detachment Afferent pupillary defect

Raw points 60 70 80 90 100 -23 -17 -14 -11 -10 Eylül - September 2011


Characteristics of open globe injuries in geriatric patients

Table 2. Cause of injury Cause of injury Blunt injury with wood Branch of a tree or a plant Fall Animal Fist Glass Stone Metal Traffic accident Hammer on metal nail

n (%) 8 (26.7) 6 (20) 4 (13.4) 4 (13.4) 2 (6.7) 2 (6.7) 1 (3.3) 1 (3.3) 1 (3.3) 1 (3.3)

Table 3. Place of injury Place of injury Farm Outdoors Home Street

n (%) 19 (63.3) 5 (16.7) 5 (16.7) 1 (3.3)

right eyes were involved. The mean (±standard deviation) age of the patients was 73.06 ±5.99 years, with a range of 65-84 years. Rupture was the most common type of open globe injury, with 17 eyes (56.7%). The mechanisms of injury are shown in Table 2. Injuries were most frequently caused by a blunt object such as wood, stone or metal, during a fist assault, or by an animal while milking. Most of the traumas were caused by a large wood chip flying into the eye while chopping. 63.3% of all injuries occurred on a farm (Table 3). Of the falls, 3 patients slipped in the bathroom and hit their head/eye on the side of the washbasin or faucet, while 1 patient with hypotension fell after getting out of the bed abruptly at night, hitting the side of the bed. Thirty percent (n: 9) of open globe injuries were zone I, 36.7% (n: 11) zone II and 33.3% (n: 10) zone III. Presenting visual acuity was NLP in 13 (43.3%) patients, LP/HM in 15 (50%) patients and 1/20019/200 in 2 (6.7%) patients. We observed retinal detachment in 6 patients, the presence of a RAPD in 6, lens damage in 10, uveal tissue prolapse in 11, hyphema of varying degrees of severity in 12, vitreous hemorrhage in 9, and eyelid laceration in 3. Nine of the patients had a previous history of cataract surgery. Among these patients, rupture due to previous surgical incision was observed in 5 patients who had undergone large- incision cataract surgery, and it was found that the scar tissue extended to the sclera. No cases presented with post-traumatic endophthalmitis. Cilt - Vol. 17 Sayı - No. 5

The follow-up period ranged between 6-85 months (mean: 24.73±24.56 months), and final visual outcome was recorded at the last visit. The final visual acuity was NLP in 16 (53.3%) patients, LP/HM in 8 (26.7%), 1/200-19/200 in 5 (16.7%), and 20/20020/50 in 1 (3.3%). In the evaluation of the effects of demographic and clinical characteristics on final vision, the zone, type of trauma and OTS were found to be significant variations according to the univariate analysis (Table 4).

DISCUSSION The United States population continues to age, with 37 million people (12.4%) currently over the age of 65, and 71 million (19.7%) expected in this category by 2030. In 2005, almost 500 million (7.3%) people worldwide were 65 and older. By 2030, this is expected to increase to almost 1 billion (11.7%).[13] A majority of the estimated 40 million blind individuals around the world are in the older age groups. Data on blindness and visual impairment are obtained primarily from blindness registries and prevalence surveys in different countries throughout the world. The qualities of these data vary dramatically between countries, and comparison of the results from different studies is difficult. However, all studies indicate an increase in the prevalence of visual loss and blindness with increasing age.[14] In developing countries and Eastern countries, the most common cause of blindness is cataract and uncorrected refractive error, whereas in Western countries, the most common cause of blindness is agerelated macular degeneration among Caucasians and cataract and glaucoma among blacks.[15] Even though trauma is the most important cause of unilateral blindness in the pediatric age group, it ranks low among the elderly population. Trauma in the geriatric age group differs from that in the young age group with regard to characteristics and prognosis. In terms of gender, there is a marked predominance of males in studies including all age groups. [1,16-18] However, this predominance disappears with advancing age. In this study, the male to female ratio was close to 1:1, whereas the number of females was found to be higher than that of males in a study by Andreoli et al.[19] The predominance of males in ocular trauma among the young age group is a result of their spending more time outdoors, their employment in higher risk jobs, alcohol use, and participation in dangerous sports and hobbies, whereas the rate of risk for trauma approaches that for females with increasing age, since they eventually retire and lead a more sedentary life. We consider that the gap between genders closes with increasing age since people move to the country, and males and females work side by side in agricultural activities in our country. In this study, the 415


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Table 4. Univariate analysis of patient characteristics and final visual acuity Variables

Final visual acuity Better than HM (n=6)

Age (years) Age groups (years) 65-74 75-84 Female/ref. Male Right/ref. Left ZONE I II III Type of trauma Penetrating injury Rupture Presenting visual acuity NLP LP/HM 1/200-19/200 OTS Category “1-2” “3” Retinal detachment Relative afferent pupillary defect Lid laceration Hyphema Uveal tissue prolapse Vitreous hemorrhage Lens damage

73.83±6.85 3 (50) 3 (50) 4 (66.7) 2 (33.3) 5 (83.3) 1 (16.7) 0 6 (100) 0 1 (16.7) 4 (66.7) 1 (16.7) 2 (33.3) 4 (66.7) 0 0 0 1 (16.7) 2 (33.3) 0 3 (50.0)

NLP / HM (n=24)

p

Odds ratio (95% CI)

72.88±5.92 11 (45.8) 13 (54.2) 8 (33.3) 11 (45.8) 4 (16.7) 10 (41.7) 10 (41.7) 7 (29.2) 17 (70.8) 12 (50) 11 (45.8) 1 (4.2) 19 (79.2) 5 (20.8) 6 (25) 6 (25) 3 (12.5) 11 (45.8) 9 (37.5) 9 (37.5) 7 (29.2)

0.722 – 0.605 0.184 0.672 – 0.043 0.04 – 0.026 0.157 0.509 – 0.043 – 0.213 0.400 0.635 0.358 0.620 0.141 0.372

0.97 (0.84-1.13) 1.000a 1.143 (0.273-4.778) 0.25 (0.037-1.668) 1.692 (0.259-11.07) 1.000a 12.50 (1.09-143.44) 25.67 (1.16-568.94) 1.000a 30.33 (1.51-609.87) 12.00 (0.28-374.86) 2.75 (0.14-55.17) 1.000a 7.6 (1.068-54.092) 1.000a 6.70 (0.34-133.60) 3.67 (0.18-75.75) 2.12 (0.10-46.53) 3.333 (0.443-25.102) 0.833 (0.126-5.504) 0.714 (0.545-0.936) 3.00 (0.473-19.04)

a: Reference category; CI: Confidence interval.

farm was the most common location of trauma, which supports this hypothesis. The location of trauma was noted as farm in 47.4% of the geriatric group patients in a study performed in our country.[8] Unlike other age groups, rupture was the most common type of trauma in this study. The rate of injuries due to falls also increases in this age group. In a study by Andreoli et al.,[19] the rate of open globe injury due to falls was found to be 4% in the non-geriatric group and 65% in the geriatric group. This rate was found to be 13.4% in our study. Systemic hypertension, atherosclerotic diseases and dementia, which are common in the elderly population, also increase fall-related traumas. The prognosis is poor in fall-related traumas since blindness can develop in both eyes simultaneously. Additionally, poor final visual acuity after trauma further increases not only the risk of falls in geriatric patients but also the risk of trauma in the other eye and even the risk of multiorgan trauma. Because the most common type of trauma was rupture, presenting findings and visual acuity were very poor. Presenting visual acuity was NLP in 43.3% of 416

patients and 1/200-19/200 in only 2 patients. Wound location tends to be zone I in young patients with open globe injuries, whereas wound is localized more posteriorly in zones II and III in the geriatric age group. In this study, 70% of patients had zone II-III traumas. Additionally, previous history of surgeries also worsens the prognosis in elderly patients. It was also found in our study that the incisional scar at the site of the previous surgery was ruptured and extended to the sclera in 5 patients, and there were no intraocular lenses in 2 patients with large-incision cataract surgery. In this study, prognosis for traumas in the elderly population was found to be very poor. In the followups, a visual acuity of 1/200-19/200 or better was found in only 20% of patients. When the factors influencing final visual acuity were evaluated, remarkable differences were observed between other age groups. Previous studies of all age groups have emphasized a strong association between presenting visual acuity and final visual acuity. If the presenting visual acuity is good, so is the final visual acuity. However, in this study, no statistically significant correlation was found between Eylül - September 2011


Characteristics of open globe injuries in geriatric patients

presenting visual acuity and final visual acuity, which can be attributed in part to the small number of our patients. In this study, anatomic location of the wound, type of trauma and OTS were found to be statistically significant variations affecting the final visual acuity. After trauma to the posterior segment, prognosis was found to be poor. Zone II and zone III wound localizations increased the risk of a final visual acuity of HM or worse by 12.5- and 25.7-fold, respectively, when compared to wounds in zone I. A rupture-type injury increased a final visual acuity of HM or worse by 30fold when compared to penetrating injuries. The risk of a final visual acuity of HM or worse was increased by 7.6-fold in patients with an OTS lower than 65 compared to those with a better OTS score. In this study, the mean OTS was 50.1, whereas the median of the OTS category was found to be 2. The OTS study is heterogeneous in that it was performed in all age groups with both open- and closed-globe trauma. For this reason, the correlation between final visual acuity and the OTS is not as strong in elderly patients as in other age groups. However, it was found to be important for the determination of the prognosis and prediction of final visual acuity in terms of informing the patient and the family, particularly within the first few hours of the trauma. The rate of endophthalmitis after an open globe injury ranges between 4-12%.[20-22] In this study, it is remarkable that although most of the injuries were caused by organic materials such as a wood chip and occurred in the country, no patient presented with endophthalmitis. In the literature, there are few or no examples of intraocular object in the geriatric age group, and the most frequent mechanism of trauma is rupture, which can be explained by a more posterior location of the wound (zone II or III).[19] The enucleation rate is low despite poor final visual acuity in the geriatric age group. In our study, only three patients underwent enucleation. This can be explained by the fact that geriatric patients have lower aesthetic expectations than young patients, the risk of sympathetic ophthalmia is lower in the geriatric age group than in the young age group because of shorter life expectancy, and the presence of systemic diseases restricts the performance of additional surgical intervention. In geriatric patients, some changes occur in the function and structure of the eye with advancing age. The incidence and prevalence of diseases such as agerelated macular degeneration, glaucoma and vascular occlusive diseases increase dramatically with age. Some of these changes are condensation of the vitreous gel, changes in corneal tonicity and sensitivity, scleral rigidity, ciliary body shape and tone, and lens Cilt - Vol. 17 Say覺 - No. 5

selectivity.[23] Age-related changes of the optic nerve include a decrease in the number of axons, axonal swelling at the level of the lamina cribrosa, thickening of the lamina cribrosa, and an increase in elastic fibers. [11] Using HRF, Embleton et al.[24] found a significant negative correlation between advancing age and retinal blood volume, neuroretinal rim blood velocity and lamina cribrosa blood volume. The retinal blood supply decreases in elderly subjects, and further implies a net increase in the resistance of the vascular bed and/ or decrease in the total functional vessel diameter.[13] In addition, visual function changes include declining visual acuity and diminished visual field sensitivity. As a result of these changes, globe rigidity decreases and eye injuries can occur even after a mild trauma in the elderly population. In these patients with limited functional capacity, post-traumatic recovery cannot be achieved satisfactorily and the prognosis worsens. In conclusion, prognosis is very poor after an open globe injury in the geriatric age group. Due to agerelated ocular changes, functional capacity is limited in patients aged 65 years and older. This capacity is further decreased by pre-existing ocular diseases. Because of age-related structural changes, open globe injuries can occur even after a mild trauma. In addition, previous history of ocular surgeries, particularly largeincision cataract surgery, decreases the resistance of the globe and contributes to easy development of a rupture after a trauma. The recovery capacity is low in these patients with systemic diseases. Additionally, geriatric patients with normal fellow eye usually do not accept to undergo further surgical interventions required after primary repair and do not receive sufficient rehabilitation because of their satisfaction with the outcome. Due to these above-mentioned characteristics, the geriatric age group is different in terms of both the etiology and the clinical characteristics of the trauma. Further comprehensive studies including large series of patients are required in order to determine the prognosis in these patients.

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logical study of eye injuries in Brazilian children. Arch Ophthalmol 1988;106:781-4. 7. Vasu U, Vasnaik A, Battu RR, Kurian M, George S. Occupational open globe injuries. Indian J Ophthalmol 2001;49:43-7. 8. Üstündağ M, Orak M, Güloğlu C, Sayhan MB, Özhasenekler A. Göz yarlanması sonucu acil servise başvuran hastaların geriye dönük incelemesi. Türkiye Acil Tıp Dergisi 2007;7:647. 9. 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. 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. Kuhn F, Morris R, Witherspoon CD, Heimann K, Jeffers JB, Treister G. A standardized classification of ocular trauma. Ophthalmology 1996;103:240-3. 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. Ehrlich R, Kheradiya NS, Winston DM, Moore DB, Wirostko B, Harris A. Age-related ocular vascular changes. Graefes Arch Clin Exp Ophthalmol 2009;247:583-91. 14. Hyman L. Epidemiology of eye disease in the elderly. Eye (Lond) 1987;1:330-41. 15. Wong TY, Loon SC, Saw SM. The epidemiology of age related eye diseases in Asia. Br J Ophthalmol 2006;90:506-11.

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16. Williams DF, Mieler WF, Abrams GW, Lewis H. Results and prognostic factors in penetrating ocular injuries with retained intraocular foreign bodies. Ophthalmology 1988;95:911-6. 17. Rao LG, Ninan A, Rao KA. Descriptive study on ocular survival, visual outcome and prognostic factors in open globe injuries. Indian J Ophthalmol 2010;58:321-3. 18. Rahman I, Maino A, Devadason D, Leatherbarrow B. Open globe injuries: factors predictive of poor outcome. Eye (Lond) 2006;20:1336-41. 19. Andreoli MT, Andreoli CM. Geriatric traumatic open globe injuries. Ophthalmology 2011;118:156-9. 20. Thompson WS, Rubsamen PE, Flynn HW Jr, Schiffman J, Cousins SW. Endophthalmitis after penetrating trauma. Risk factors and visual acuity outcomes. Ophthalmology 1995;102:1696-701. 21. Reynolds DS, Flynn HW Jr. Endophthalmitis after penetrating ocular trauma. Curr Opin Ophthalmol 1997;8:32-8. 22. Tran TP, Le TM, Bui HT, Nguyen TM, Küchle M, Nguyen NX. Post-traumatic endophthalmitis after penetrating injury in Vietnam: risk factors, microbiological aspect and visual outcome. Klin Monbl Augenheilkd 2003;220:481-5. [Abstract] 23. Salvi SM, Akhtar S, Currie Z. Ageing changes in the eye. Postgrad Med J 2006;82:581-7. 24. Embleton SJ, Hosking SL, Roff Hilton EJ, Cunliffe IA. Effect of senescence on ocular blood flow in the retina, neuroretinal rim and lamina cribrosa, using scanning laser Doppler flowmetry. Eye (Lond) 2002;16:156-62.

Eylül - September 2011


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):419-422

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.95815

Hot milk burns in children: a crucial issue among 764 scaldings Çocuklarda sıcak süt yanıkları: 764 haşlanma yanığında önemli bir sorun Ahmet Çınar YASTI,1 Orhan KOÇ,2 Emrah ŞENEL,3 Afife Ayla KABALAK4

BACKGROUND

AMAÇ

Burns are among the preventable traumas encountered during childhood. Burn injuries are mostly classified as scalds, flame, electric, and chemical burns. However, each subject has some difference in the course of treatment related to the sub-etiologies. To reveal the importance of milk burns, scald burn patients were studied retrospectively.

Yanıklar çocukluk döneminde önlenebilir travmalar arasındadır. Yanık yaralanmaları çoğunlukla haşlanma, alev, elektrik ve kimyasal yanıklar olarak sınıflandırılır. Ancak her biri altta yatan etyolojiye göre tedavi sırasında farklılıklar gösterir. Bu çalışmada, haşlanma yanıklarında süt yanıklarının önemini vurgulamak için hastalar geriye dönük olarak incelendi.

METHODS

Demographics of the patients, burn etiologies, clinical presentations, and clinical courses were analyzed. There were 461 (60.4%) male and 303 (39.6%) female patients, with a 1.52 male to female ratio.

GEREÇ VE YÖNTEM

RESULTS

BULGULAR

The mean age of the group was 3.36±2.86 years. There were no difference in burn causes between males and females. The mean burned total body surface area of patients was 16.91±12.63%. Hot milk caused larger, deeper burns than the other scalds and caused more third-degree burns (p<0.001, p<0.001, p<0.05, respectively). Milk burns also resulted in longer hospital stay (days) (p<0.001). The mortality rate was also higher in milk burns than other scalds (p<0.001).

Grupların yaş ortalamaları 3,36±2,86 idi. Kadın ve erkek hastalar arasında yanık nedenleri açısından fark bulunmadı. Hastaların toplam vücut yanık alanı ortalaması %16,91±12,63 idi. Sıcak süt yanığının diğer haşlanmalardan daha geniş ve daha derin yanığa neden olduğu ve daha çok 3. derece yanıklar olduğu belirlendi (sırasıyla, p<0,001, p<0,001, p<0,05). Süt yanıkları aynı zamanda hastanede daha uzun süre kalmanın nedeniydi (p<0,001). Mortalite oranı süt yanıklarında diğer haşlanmalardan daha yüksek bulundu (p<0,001).

CONCLUSION

Hastaların (461 erkek [%60,4], 303 kadın [%39,6]; kadın erkek oranı 1,52) demografik özellikleri, yanık etyolojisi, kliniği ve klinik seyirleri değerlendirildi.

Due to the more detrimental clinical course, milk burns necessitate special consideration in clinical settings. The most important factor is to be aware that burns are deeper than they appear.

SONUÇ

Key Words: Children; scalding; milk burn.

Anahtar Sözcükler: Çocuklar; haşlanma; süt yanığı.

Departments of 1General Surgery, Burn Treatment Center, 4Anesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Ankara; 2Pediatric Surgery, Ministry of Health, Directorate General of Curative Service, Ankara; 3Department of Pediatric Surgery, Ankara Dışkapı Children Training and Research Hospital, Ankara, Turkey.

Süt yanıkları kötü klinik seyir nedeniyle özel dikkat gerektiren bir durumdur. En önemlisi ise süt yanığının görünenden daha derin olacağı gerçeğinin farkında olmaktır.

Ankara Numune Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Yanık Tedavi Merkezi, 4Anesteziyoloji ve Reanimasyon Kliniği, Ankara; 2 S.B. Tedavi Hizmetleri Genel Müdürlüğü, Pediatrik Cerrahi, Ankara; 3 Ankara Dışkapı Çocuk Hastalıkları Eğitim ve Araştırma Hastanesi, Çocuk Cerrahisi Kliniği, Ankara.

1

Correspondence (İletişim): Ahmet Çınar Yastı, M.D. Çankırı Cad., No: 67/2, Dışkapı 06030 Ankara, Turkey. Tel: +90 - 312 - 508 55 62 e-mail (e-posta): cinaryasti@gmail.com

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Even though over 90% of burns in children are preventable, this sort of trauma is still encountered worldwide. Burns carry considerable morbidity and mortality risks, and are one of the leading death causes in the pediatric population.[1] Scalding is a well-known leading burn cause among children, and children under six years of age are more prone to scalding.[2] In the literature, almost all burns regarding liquids are found under the same title, as scalding. However, in some countries, like Turkey, scalding should be subdivided. In the series considering scaldings that are sub-titled, some differences evolve in the clinical course and outcomes of the patients; however, previous reports regarding such subgroups of scalding and the number of the patients studied are limited.[3] In our study, according to our literature search, we present the largest series on scalding comparing hot water and other concentrated liquids. To evaluate the outcomes of different concentrated liquid burns in children, we prospectively followed up the burned pediatric patients.

MATERIALS AND METHODS A total of 764 patients younger than 16 years of age were hospitalized due to scalding at the Burns Units of Ankara Numune Training and Research Hospital and Ankara Dışkapı Children Training and Research Hospitals between January 1998 and January 2006. The American Burn Association hospitalization criterion was applied to all patients admitted to our department. Medical histories of the patients were questioned to reveal the etiology of the scalding. Each patient’s medical record was reviewed, and demographic features,

depth and burned total body surface area (TBSA), length of hospital stay, treatment modalities, morbidity, and mortalities were determined. Scalds were grouped as hot water, milk, soup, oil, and others (jam, marmalade, conserve, etc.). Categorical variables were evaluated by chi-square test. One-way analysis of variance was used to compare normally distributed continuous variables. After one-way analysis of variance, Tukey’s B test was used for post-hoc test. Bonferroni correction was used for multiple comparisons. Statistical analyses were carried out using the Statistical Package for the Social Sciences for Windows (version 10.0; SPSS Inc., Chicago, IL, USA). P values less than 0.05 were considered as significant.

RESULTS There were no differences in annual hospitalization numbers and male to female ratios during the study period. There were 461 (60.4%) male and 303 (39.6%) female patients. The male to female ratio was 1.52. The mean age of the group was 3.36±2.86 years (range: 0 to 16). Water was the most frequent burning agent among the study group (Table 1). Length of hospital stay was mean 12.41±10.03 days in the whole population. The mean burned TBSA of patients was 16.91±12.63%. When the burn causes were analyzed according to the width of their burned TBSA, hot milk caused larger burns (p<0.001). The hot milk group required more operative interventions than other scalds (Table 2). When the depth of the burn injury was considered, hot milk caused significantly deeper burns than the

Table 1. Patient distribution and mean ages according to the burn agent (note the high incidence of scalding with water) Etiology Water Milk Soup Oil Others

n (%)

Age (mean±SD) (years)

Range (years)

615 (80.5)* 81 (10.6) 36 (4.7) 12 (1.6) 20 (2.6)

3.44±3.04 2.62±1.34 3.56±2.77 3.04±1.28 3.65±2.20

0-16 1-8 1-13 1-5 1-8

* p<0.05; SD: Standard deviation.

Table 2. Length of hospital stay (days), burned TBSA and interventions in patients according to the scalding agent Etiology Water Milk Soup Oil Others

Length of hospital stay (days) ± SD

Burned total body surface area (%) ± SD

Number of operations [n (%)]

12.16±10.30 13.47±8.70 13.47±9.28 10.17±7.32 15.30±9.32

16.17±12.03* 25.30±14.44 11.86±9.57* 9.75±7.53* 16.00±13.58#

226 (42.7) 44 (54.3) 16 (45.7) 2 (16.7) 8 (40.0)

SD: Standard deviation; * When compared to milk p<0.001, # When compared to milk p<0.05.

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Table 3. Burn depth according to the scalding agent and compared with milk burns Depth

1st degree

Superficial 2nd degree

Deep 2nd degree

3rd degree

Etiology

n (%)

n (%)

n (%)

n (%)

n

Water Milk Soup Oil Others Total

5 (0.8) 0 0 0 0 5

87 (14.2) 11(13.6) 4 (11.1) 1 (8.3) 1 (5.0) 104 (13.6)

414 (67.3) 38 (46.9) 27 (75.0) 9 (75.0) 17 (85.0) 505 (66.0)

109 (17.7)* 32 (39.5) 5 (13.9)# 2 (16.7) 2 (10.0)§ 150 (19.7)

615 81 36 12 20 764

* When compared to milk p<0.001; # When compared to milk p=0.012; § When compared to milk p=0.009.

other scalds (Table 3) (p<0.05). In addition, hot milk caused more third-degree burns than water (p<0.001). The mean age of patients burned with hot milk was younger than of those burned with hot water (p<0.001). Medicolegal aspects of the incidents were also determined. Most of the injuries occurred accidentally (72.3%); however, data on this topic were gathered from the patient’s and/or their caretaker’s declaration on the patient charts (Table 4). The overall mortality of the study group was 10.7% (82/764) (Table 5). Mortality was due to sepsis in 42.2% and acute renal failure in 30.1% of the patients; however, there was no statistical difference between these mortality causes. The mortality rate in the hot milk group was significantly higher than in all other scalds (p<0.001). Table 4. Medicolegal aspects of the injuries regarding the burn agent Etiology

Accident n (%)

Neglect n (%)

Intent n (%)

Water Milk Soup Oil Others Total

455 (74.1) 57 (70.4) 21 (58.3) 8 (66.7) 12 (60.0) 533 (72.3)

158 (25.7) 24 (29.6) 15 (41.7) 4 (33.3) 8 (40.0) 209 (27.2)

2 (0.2) 0 0 0 0 2 (0.2)

Table 5. Mortality rates compared with milk with respect to the burn agent Etiology

n

Mortality

n (%)

615 81 36 12 20

52 (8.5) 26 (32.1)* 3 (8.3) 0 1 (5)

Water Milk Soup Oil Others * p<0.001.

Cilt - Vol. 17 Sayı - No. 5

When the hot oil and soup groups were compared with the water group, there were no statistically significant differences in the aforementioned parameters.

DISCUSSION Scalding is the most common cause of burn among the Turkish pediatric population.[4] In this age population, children generally have the capability to move about freely; however, they do not have sufficient cognition about the dangers in their immediate environment. Together with the well-known factors aggravating burn occurrence in childhood, like the socioeconomic status of the family, cultural and ethnic factors and educational status of the parents, children are put at greater risk of burn.[2] Tea is a very popular beverage among the Turkish population. Steeping tea via brewing in two pots stacked on top of each other is the traditional method of brewing tea in Turkey. Leaving the tea pot on the floor or near the edges of tables places them in easy reach of the children. Electric kettles with relatively short electric cables necessitate that they are kept far from the edges of the counter and close to the wall; however, short-cabled kettles are still not widely used in our country.[5] Most people living in the rural areas of Turkey live the traditional lifestyle, and they make dairy products such as cheese and yoghurt in their homes or backyards. In the process of preparation, milk is boiled and then left to cool to a sufficient degree for adding special fermentation culture, and consequently stored in optimum warm outdoor conditions for fermentation. As it is produced in large pots, during the production interval, it serves as a potential hazardous situation for pediatric burns. Children involuntarily bump these pots and spill them or may accidentally fall into them. Both situations result in scalding. Like other series, water was the most frequently encountered scalding agent in our series[4,6,7] followed by hot milk. All burns with hot milk were encountered among children younger than eight years of age. 421


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This is the age for starting primary school in Turkey, and is considered the age at which children are believed to have reached a sufficient level of cognitive development��������������������������������������� that secures them from the harmful effects of hot milk. The higher frequency of milk burns in the infancy period can also be correlated to parents’ tendency to feed their children with milk for its beneficial impact on healthy growth. Milk burns caused significantly larger burns in our series. As most of the hot milk burns in our patient population were due to spillage of or immersion into huge amounts of milk, they caused larger burns. According to our results, third-degree burns were encountered more frequently in milk burns. This can be explained via the oil content of the milk; however, burns were still deeper than in the oil only group, which raises the question of whether milk has a specific composition or concentration leading to deeper burns. Comprehensive animal studies can be constructed to address this topic in centers with sufficient technical support. In our series, the amount of oil that caused burn was almost always less than the amount of milk and water, and burning was always a result of spillage. Thus, oil burns were not found to be similar to milk burns in the clinical course. Milk burns required more operative interventions. This is a consequence of the deeper burns seen in this group. Nevertheless, physicians dealing with burns should be aware of the fact that milk causes deeper burns and requires frequent surgical intervention. With the aforementioned clinical presentation, milk burns appeared to have a similar hospital stay as with other burn causes; however, when mortality rates were considered, it was seen that children with milk burns would have been hospitalized for a much longer period if they had lived. To lessen the length of hospital stay and cost of the treatment, surgical intervention should be initiated as early as appropriate in the clinical course, and conservative modalities should be avoided.[8] When soup burns were considered, we saw a similar clinical course with that of water burns, which is probably related to the lower oil content of the agent. The burning due to soup was almost always a result of spillage, which caused limited burn areas as a patchy area on the skin, which we believe facilitated heat dispersion at the burned area. Most of the burns were accidental in our series; however, we had considerable neglect cases. In neglect cases, we provided information to the social services office and they initiated a process starting with an interview with the caretakers. If neglect is an ongoing issue in the family or the real etiology is intent, 422

cases may proceed to a law court to secure the children’s rights. If it is not the case, preventive measures are explained to the caretakers to avoid further injuries to the children. Even with the advanced therapy modalities in burn management, mortality remains a devastating consequence. In our scalded pediatric population, the overall mortality rate was 10.7%. Sepsis and renal insufficiency were the leading mortality causes. Both were frequent in patients referred to our clinic in the late phase of burn, reflecting the necessity and importance of early transfer to specialized burn centers. Milk burns have significantly higher mortality risk than other scalds.[3] In conclusion, scalding is the most frequent burn cause among the Turkish pediatric population. Hot milk burns should be considered as an important entity among scalds as they have a complicated clinical course and considerable mortality rates. Thus, special attention should be given to patients with milk burns. Keeping in mind that approximately 90% of burns in children are accidental according to the literature, preventive measures should be taken to protect children from scarring, in a world in which the rights of an unborn fetus are debated. Acknowledgement The authors thank Atilla Elhan, Associate Professor, Chair, Ankara University Biostatistics Department, for his contributions to the statistical evaluation of the study.

REFERENCES 1. Anlatici R, Ozerdem OR, Dalay C, Kesiktaş E, Acartürk S, Seydaoğlu G. A retrospective analysis of 1083 Turkish patients with serious burns. Part 2: burn care, survival and mortality. Burns 2002;28:239-43. 2. Foglia RP, Moushey R, Meadows L, Seigel J, Smith M. Evolving treatment in a decade of pediatric burn care. J Pediatr Surg 2004;39:957-60. 3. Light TD, Latenser BA, Heinle JA, Stolpen MS, Quinn KA, Ravindran V, et al. Demographics of pediatric burns in Vellore, India. J Burn Care Res 2009;30:50-4. 4. Lowell G, Quinlan K, Gottlieb LJ. Preventing unintentional scald burns: moving beyond tap water. Pediatrics 2008;122:799-804. 5. Sheller JL, Thuesen B. Scalds in children caused by water from electrical kettles: effect of prevention through information. Burns 1998;24:420-4. 6. Tarim A, Nursal TZ, Basaran O, Yildirim S, Türk E, Moray G, et al. Scalding in Turkish children: comparison of burns caused by hot water and hot milk. Burns 2006;32:473-6. 7. Wolf SE, Debroy M, Herndon DN. The cornerstones and directions of pediatric burn care. Pediatr Surg Int 1997;12:31220. 8. Yasti AC, Tumer AR, Atli M, Tutuncu T, Derinoz A, Kama NA. A clinical forensic scientist in the burns unit: necessity or not? A prospective clinical study. Burns 2006;32:77-82.

Eylül - September 2011


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):423-429

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.96462

Cardiac and great vessel injuries after chest trauma: our 10-year experience Göğüs travması sonrasında gelişen kalp ve büyük damar yaralanmaları: 10 yıllık deneyimimiz Burak ONAN,1 Recep DEMİRHAN,1 Kürşad ÖZ,1 İsmihan Selen ONAN2 BACKGROUND

AMAÇ

Cardiovascular injuries after trauma present with high mortality. The aim of the study was to present our experience in cardiac and great vessel injuries after chest trauma.

Göğüs travmasına bağlı kardiyovasküler yaralanmaları yüksek bir mortaliteye sahiptir. Bu çalışmanın amacı, göğüs travması sonrasında gelişen kalp ve büyük damar yaralanmalarının tedavisinde tecrübemizi sunmaktır.

METHODS

During the 10-year period, 104 patients with cardiac (n=94) and great vessel (n=10) injuries presented to our hospital. The demographic data, mechanism of injury, location of injury, other associated injuries, timing of surgical intervention, surgical approach, and clinical outcome were reviewed.

GEREÇ VE YÖNTEM

RESULTS

BULGULAR

Eighty-eight (84.6%) males presented after chest trauma. The mean age of the patients was 32.5±8.2 years (range: 12-76). Penetrating injuries (62.5%) were the most common cause of trauma. Computed tomography was performed in most cases and echocardiography was used in some stable cases. Cardiac injuries mostly included the right ventricle (58.5%). Great vessel injuries involved the subclavian vein in 6, innominate vein in 1, vena cava in 1, and descending aorta in 2 patients. Early operations after admission to the emergency were performed in 75.9% of the patients. Thoracotomy was performed in 89.5% of the patients. Operative mortality was significantly high in penetrating injuries (p=0.01).

Göğüs travması sonrasında 88 (%84,6) erkek hasta başvurdu. Tüm hastaların ortalama yaşı 32,5±8,2 yıl (dağılım 12 ile 76 yaş) idi. Penetran yaralanmalar (%62,5) en sık sebep olarak karşımıza çıktı. Bigisayarlı tomografi genel olarak uygulanırken, durumu stabil olguların bir bölümüne ekokardiyografi yapıldı. Kalp yaralanmalarında sıklıkla sağ ventrikül (%58,5) etkilendi. Büyük damar yaralanmaları subklaviyen ven (6), innominate ven (1) ve desendan aorta (2) da tespit edildi. Hastaların %75,9’una acil servise başvurduktan sonra erken dönemde ameliyat yapıldı. Torakotomi hastaların %89,5’inde uygulandı. Cerrahi mortalite penetran yaralanmalarda anlamlı derecede yüksekti (p=0,01).

CONCLUSION

Klinisyenler acil servise göğüs travması ile başvuran her hastada kalp ve damar yaralanması olasılığını düşünmelidir. Bilgisayarlı tomografi ve ekokardiyografi göğüs travmasının klinik takibinde faydalıdır. Cerrahi girişimin zamanlaması hastaların hemodinamik durumlarına bağlıdır ve multidisipliner yaklaşım hastaların prognozunu iyileştirir.

Clinicians should suspect cardiac and great vessel trauma in every patient presenting to the emergency unit after chest trauma. Computed tomography and echocardiography are beneficial in the management of chest trauma. Operative timing depends on hemodynamic status, and a multidisciplinary team approach improves the patient’s prognosis. Key Words: Cardiac injury; great vessel injury; thoracic trauma.

Department of Thoracic Surgery, Dr. Lutfi Kirdar Kartal Training and Research Hospital, Istanbul; 2Goztepe Training and Research Hospital, Istanbul, Turkey.

1

On yıllık süre içinde 104 hasta kalp (n=94) ve büyük damar (n=10) yaralanmaları ile başvurdu. Bu hastalarda demografik bilgiler, yaralanma sebepleri, yaralanma yerleri, ek yaralanmalar, cerrahi girişimin zamanlaması, cerrahi yaklaşım ve klinik sonuçlar gözden geçirildi.

SONUÇ

Anahtar Sözcükler: Kalp yaralanması; büyük damar yaralanması; göğüs travması.

1 Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, Göğüs Cerrahisi Kliniği, İstanbul; 2Göztepe Eğitim ve Araştırma Hastanesi, İstanbul.

Correspondence (İletişim): Burak Onan, M.D. Ardıçlı Mah., Ardıç Sok., Gökkuşağı 34/2, No: 26, Bahçeşehir - Esenyurt, İstanbul, Turkey. Tel: +90 - 553 - 622 38 78 e-mail (e-posta): burakonan@hotmail.com

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Thoracic trauma associated with blunt or penetrating injury is a major cause of hospitalization in the world and carries a mortality rate ranging from 15 to 77%.[1] It comprises 10-15% of all traumas, and 25% of the deaths can be directly related to thoracic trauma.[2] In chest trauma, cardiovascular injuries are the second cause of death after central nervous system injuries. Despite recent advances in diagnostic modalities and surgical techniques, cardiac and great vessel injuries are still an important predictor of the outcome following chest trauma. Our clinical experience in chest trauma, as a trauma hospital in Istanbul with a large patient population, has confirmed that these injuries almost always require an aggressive multidisciplinary approach in the emergency unit setting. Patients with cardiac injury often require immediate surgical exploration, whereas injuries to the great vessels after chest trauma may require an injury-oriented management. The purpose of this study was to present our trauma experience in cardiac and great vessel injuries, to determine the incidence of primary injuries and associated pathologies, to assess the current management strategy, and to evaluate hospital outcome at a single institution for a 10-year period.

MATERIALS AND METHODS Our hospital is a trauma center and an education hospital in Istanbul, Turkey. Because our hospital covers����������������������������������������������� a large region with an intense patient population and is located near an important motorway, the incidence of chest injury is relatively higher than at other centers in nearby areas. Between January 2000 and January 2010, 104 trauma victims presented with cardiac or great vessel injury after chest trauma. Great vessel injuries were injuries to vascular structures within the thorax that included the great arteries and veins. The demographic data, mechanism of injury, Injury Severity Score (ISS), location of injury, other associated injuries, timing of surgical repair, surgical approach, and the resultant mortalities (outcome of cardiovascular trauma) were reviewed. On diagnosis, chest X-rays and chest computed tomography (CT)

were preferred on admission. Transthoracic echocardiography (TTE) imaging was not used in unstable cases, but it was used in stable cases. For the purposes of our study, surgical interventions performed promptly in unstable patients were termed as ‘early’, while those performed in stable patients after clinical and radiological work-up were termed ‘late’. This is a descriptive study. Statistical calculations were performed using the GraphPad Prisma V.3 program for Windows (GraphPad Software, Inc., La Jolla, CA, USA). All values were expressed as mean and standard deviation. A p value less than 0.05 was considered to be significant.

RESULTS During the 10-year period, 104 patients presented to our hospital with cardiac (n=94) and great vessel (n=10) injuries after chest trauma. There were 88 male and 16 female patients, with a mean age of 32.5±8.2 years (range: 12-76). The injury mechanism was penetrating in 62.5% of patients and blunt in 37.5% of patients (Table 1). No patient was identified as having both major blunt and penetrating injuries. Stab wounds were the leading cause of penetrating injuries, whereas traffic accidents were the most common in blunt injuries. Tube thoracostomy was performed in 78 (75%) patients with pleural complications such as hemopneumothorax. Drainage was set to a mild evacuation level to avoid recurrent life-threatening massive bleeding. With respect to timing of surgical explorations, the number of early operations was significantly higher than of late operations (p=0.01, Table 2). Of all patients, 79 (75.9%) underwent an early operation. In these operations, penetrating cardiac injuries (69.6%, 55/79) were the most common cause. The most common indication of early procedures was pericardial tamponade in 61.5% of patients. Thoracotomy incision was performed in 89.5% of cases according to the localization and suggested mechanism of injuries (62.5% left anterolateral thoracotomy; 26.9% right an-

Table 1. The causes of chest trauma and distribution of cardiac and great vessel injuries Etiology

Cardiac injury Causes

Great vessel injury Artery

Vein

Penetrating injury (n=65, 62.5%) Stab wounds 54 (50.9) – 3 (2.8) Gunshot wounds 7 (6.7) – – Foreign body – – 1 (0.9) Blunt injury (n=39, 37.5%) Traffic accidents 31 (28.8) 2 (1.9) 3 (2.8) Falls 2 (1.9) – 1 (0.9) 2 8 Total 94 (90.4) 10 (9.6) * Data are presented as number of patients (percentage).

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Table 2. Distribution of patients according to the etiology of trauma and timing of surgery

Table 3. Distribution of cardiac and great vessel injuries according to the cause of chest trauma

Etiology Penetrating injury Blunt injury Total

Timing of surgery Early

Late

p

55 (52.8) 24 (23.1) 79 (75.9)

10 (9.6) 15 (14.5) 25 (24.1)

0.01 0.03 0.01

* Data are presented as number of patients (percentage).

terolateral thoracotomy). Sternotomy was performed in only 10.5% of the cases. Table 3 shows the distribution of cardiac and great vessel injuries according to the cause of chest trauma. Injury to the right ventricle was observed in 58.5% of patients, and it was common in both penetrating and blunt chest trauma. In our series, only one patient had a postmortem diagnosis of combined right ventricular injury and ventricular septal defect after a penetrating trauma. Primary suturing reinforced with Teflon pledgets or felts was used for the repair of cardiac injuries. Cardiopulmonary bypass (CPB) was not used due to the unavailability of surgical equipment and trained personnel in our hospital. Some patients were transferred to a nearby specialized cardiovascular surgery center for repair; these patients were not included in this series. Great vessel injuries included subclavian vein injury in six, innominate vein injury in one, superior vena cava injury in one, and descending aortic transection in two patients. Venous injuries were repaired by primary suturing in this series. Patients with acute aortic transection were unstable and had a widened mediastinum on chest radiographs and CT scans. Because patients’ hemodynamic instability prevented their transfer to a specialized cardiovascular surgery center, they were taken immediately to the operating room, and left anterolateral thoracotomy was performed. Aortic transections distal to the left subclavian artery were repaired by tube graft interposition (Dacron graft, no. 22) with favorable outcomes. Total aortic clamping times in these cases were 30 and 25 minutes. Additional injuries are presented in Table 4. Pulmonary lacerations, diagnosed in 12.5% of patients, were the most common injury in this series, followed by intercostal vessel injuries in 11.5% of patients. Multiple rib fractures (more than 3 ribs) and sternum fracture presented only in blunt injuries, with ratios of 9.6% and 7.6%, respectively. Internal thoracic (7.6%) and coronary artery (3.8%) injuries were detected in penetrating injuries. The other injuries included diaphragm rupture in three patients, hepatic laceration in two and ventricular septal defect associated with a penetrating injury in one. The diagnosis of ventricular septal defect was made postmortem. Cilt - Vol. 17 Sayı - No. 5

Cardiac injury (n=94) Right ventricle Right atrium Left ventricle Left atrium Right ventricle + VSD Great vein injury (n=8) Subclavian vein Innominate vein Superior vena cava Aortic injury (n=2) Descending aorta (transection)

Penetrating injury

Blunt injury

Total

35 19 9 3 1

19 5 2 1 –

54 24 11 4 1

3 – 1

3 1 –

6 1 1

2

2

VSD: Ventricular septal defect.

Table 4. Additional injuries diagnosed during surgical exploration Pulmonary laceration Intercostal vessel injury Rib fracture (>3 ribs) Sternum fracture LITA injury Coronary artery injury Left anterior descending Diagonal RITA injury Diaphragm rupture Hepatic laceration Ventricular septal defect

Penetrating Blunt injury injury 8 (7.6) 8 (7.6) – – 4 (3.8) 4 (3.8) 2 (1.9) 2 (1.9) 3 (2.8) – 2 (1.9) 1 (0.9)

Total

5 (4.8) 13 (12.5) 4 (3.8) 12 (11.5) 10 (9.6) 10 (9.6) 8 (7.6) 8 (7.6) 1 (0.9) 5 (4.8) – 4 (3.8) – 2 (1.9) – 2 (1.9) – 3 (2.8) 3 (2.8) 3 (2.8) – 2 (1.9) – 1 (0.9)

* Data are presented as number of patients (percentage). LITA: Left internal thoracic artery; RITA: Right internal thoracic artery.

The overall morbidity rate in our series was 43.2%. Atelectasia was the most common morbidity, with an incidence of 60%, followed by respiratory failure in 9.6% of patients. Two patients (4.9%) with blunt trauma had increased cardiac enzyme levels and required inotropic support in the postoperative period. They were accepted as having myocardial contusion. Only 28 cases were followed-up in the intensive care unit (ICU). Echocardiographic examination of all patients before discharge did not demonstrate pericardial collection after surgery. In this series, the mortality rate in all patients was 18.2% (Table 5). Only five patients with blunt injury were lost during the ICU stay (3 due to cranial injuries, 2 due to renal failure). Operative mortality occurred in 425


Ulus Travma Acil Cerrahi Derg

Table 5. Analysis of the patients according to type of injury, mortality, injury severity score, and hospital stay Overall mortality Operative mortality Injury Severity Score Hospital stay (days)

Penetrating injury

Blunt injury

p

Total

10 (9.6) 10 (9.6) 18.4±4.8 12.1±4.3

9 (8.6) 4 (3.8) 16.6±1.2 9.5±2.2

NS 0.01 NS NS

19 (18.2) 14 (13.4) – –

* Data are presented as number of patients (percentage) and mean values with standard deviation. A p value less than 0.05 was considered significant.

14 patients (13.4%). Four of them died after blunt injury to the liver (2 patients), right atrium (1 patient) and subclavian vein (1 patient). The other 10 patients died during operations after penetrating injury to the left ventricle (3 patients), right ventricle (2 patients), left atrium (2 patients), right ventricle and ventricular septum (1 patient), superior vena cava (1 patient), and subclavian vein (1 patient). Operative mortality of penetrating injuries was significantly higher than that of blunt injuries (p=0.01). Hospital stay and ISS score were higher in penetrating injuries. The mean hospital stay was 12.1±3.6 days (range: 5-28) (9.5 days in blunt and 12.1 days in penetrating injuries). The mean ISS was 16.6±1.2 in blunt and 18.4±4.8 in penetrating injuries.

DISCUSSION Thoracic trauma remains a major cause of hospitalization in developing countries. Blunt injuries, especially traffic accidents, are generally much more frequent than penetrating injuries in general chest trauma.[3,4] In our series, we observed that cardiac and great vessel injuries presented with an incidence of 2% within general chest trauma. The major cause of cardiac and great vessel injuries in the current series was penetrating injuries. Similarly, the ratio of associated injuries in chest trauma has been reported as up to 35% in the literature, and cardiac injuries develop in less than 2% of the victims who are able to admit to the hospital. These injuries can be highly lethal immediately after trauma and on admission of the victims. In our series, 62.5% of all cases with cardiovascular trauma had penetrating injuries, of which 87.6% were due to stab wounds. Penetrating heart traumas were generally observed in young patients with low socioeconomic status. It has been reported that cardiovascular injuries are frequently caused by penetrating chest trauma such as stab wounds and less commonly by gunshots.[3,5] Conversely, the incidence of cardiac injury after blunt chest trauma is difficult to determine, but ranges from 8% to 76%.[6] This wide range is mainly due to the variation in diagnostic criteria used and the fact that there is no gold standard test for the diagnosis. Although CT and echocardiography are both widely used modalities in the emergency unit, 426

the clinical presentation of patients and hemodynamic instability on hospital admission may affect the calculation of the exact ratio of such injuries. Greater than 90% of injuries to the great vessels occur after penetrating trauma.[7] Similarly, in our experience, great vessel injuries in penetrating trauma were mostly due to stab wounds. These injuries frequently involved the subclavian vein, followed by the superior vena cava and innominate vein. We observed that localization of the body of the sternum in the anatomic midline and the ribs on each side prevented an injury to the mediastinal great vessels including the vena cava, pulmonary artery and ascending aorta. Nevertheless, in some cases, chest wall damage after trauma, such as rib or sternum fracture, was associated with venous injuries. According to the principles of Advanced Trauma Life Support (ATLS), the management of such injuries necessitates an urgent and specific approach as a primary survey because a life-threatening massive hemorrhage may complicate the prognosis of patients. Our experience in chest trauma proved that the management is based on prompt diagnosis and treatment.[4] The management strategy for cardiac and great vessel injuries at our institution is based upon the location and type of injury, and involves a multidisciplinary team approach. Cardiovascular surgeons manage cardiovascular injuries, thoracic surgeons address associated pulmonary parenchymal lacerations, and orthopedic or general surgery consultations are made when necessary. On arrival to the emergency department, the hospital triage doctor, who was a specialist in emergency medicine, first assessed the victims and requested consultation of surgery fellows. Cardiothoracic surgeons determined the priority for admission to the emergency room or operating theater. We used an algorithm in the management of patients (Fig. 1). Based on the location and mechanism of chest injury, underlying injuries to the mediastinal structures were suggested. Patients presenting with hypotension or massive blood loss were evaluated immediately on admission. Clinically, cardiac injuries and associated pericardial tamponade presented with a variable degree of hypotension, brady/ Eylül - September 2011


Cardiac and great vessel injuries after chest trauma: our 10-year experience

Patients Unstable Operating theatre

Stable Chest X-ray CT scan

Unstable

Echocardiography

Stable

Clinical follow-up

Fig. 1. Management algorithm for cardiac and great vessel injuries after chest trauma.

tachycardia, sweating, dyspnea, and sometimes diminished cardiac sounds. Great vessel injuries mostly presented with unstable vital signs, dyspnea, hemothorax, and mediastinal enlargement. Chest X-rays were taken on admission, and chest CT imaging was performed in all stable patients. TTE was not used in unstable cases on admission, but was used in stable cases. All patients with cardiac injury had a 2-dimensional echocardiogram before hospital discharge. In our clinical practice, the trauma victims presenting with stable clinical state were managed after initial assessment and fluid replacement. All these patients were investigated with a chest roentgenogram and CT imaging to diagnose intrathoracic pathologies in detail. If mediastinal enlargement or a considerable amount of pericardial effusion was evident, TTE was performed to clarify the diagnosis and to assess myocardial performance, valve functions, and integrity of the atrioventricular septum. Burack et al.[8] noted that unstable patients with mediastinal injuries require surgery, but in stable cases, TTE and chest CT are effective screening tools. All stable patients in the current series eventually underwent surgical exploration. Our experience showed that patients with blunt injuries had a considerable time to be managed before surgery; however, those with penetrating injuries required a prompt intervention to repair the anatomical defects that might affect the outcome. We observed that 75.9% of the victims underwent early operations due to the presence of unstable hemodynamic state on admission, and most had a penetrating injury. Considering the timing of surgery, we observed that the total number of patients undergoing early operations was significantly higher in both penetrating and blunt injuries. This might show the severity of cardiovascular injuries and may be a warning for emergency staff to be aware of the necessity of surgical exploration. However, no difference was determined in ISS between patients with blunt versus penetrating injuries. Liman et al.[9] noted that mortality of chest trauma is higher if ISS is ≥16. The authors Cilt - Vol. 17 Sayı - No. 5

concluded that patients having significantly higher risk for morbidity and mortality necessitate the establishment of treatment priorities and efficient management of existing injuries. In our series, the mean ISS was 16.6±1.2 in blunt and 18.4±4.8 in penetrating injuries. Therefore, emergency staff should always keep in mind that an injury to the mediastinum can be mortal and may require prompt surgery. In general, patients with cardiac or great vessel injury triage themselves between the operative intervention or evaluation and observation. The initial presentation of the victims determines the severity of trauma and the decision to perform a prompt operation for exploration. An unstable hemodynamic state was determined by the presence of cardiac arrest or near arrest, cardiac tamponade, persistent ATLS class III shock despite fluid resuscitation,[2] chest tube output >1500 ml on insertion, >500 ml/hour for the initial hour, or >200 ml hourly for 4 hours, and massive hemothorax after chest tube drainage. In the current series of 104 patients, 75.9% presented with unstable hemodynamics and all underwent an early operation. Of these cases, 69.6% presented with penetrating chest injury. For purposes of our study, surgical interventions performed promptly in unstable patients were recorded as ‘early’, while those performed in stable patients after clinical and radiological work-up were termed ‘late’. Intercostal tube drainage is usually used as a routine preoperative procedure for chest trauma if pleural complications such as hemopneumothorax are evident. However, the use of tube thoracostomy in suspected cardiovascular injuries should be controlled and be set to a level of mild evacuation of blood. Increased evacuation may cause a life-threatening recurrent bleeding from the cardiac wound because of decompression and clot dislodging. This event is also true after operations if insidious bleeding from the laceration site continues despite surgical repair. In our experience, tube thoracostomy was performed in 75% of patients with pleural complications. Chest tubes were always placed in the operating room and before surgical incision. Drainage was set to a mild evacuation level under supervision of the surgeon to avoid life-threatening massive bleeding. Similarly, Gao et al.[10] recommended that tube drainage should be instituted for penetrating cardiac injury with hemopneumothorax immediately before the initiation of general anesthesia. Additionally, pericardial tube drainage or pericardiocentesis in the emergency unit was not performed to avoid massive bleeding and associated mortality. In patients who underwent pericardial exploration through the thoracotomy incision, pericardial window above the phrenic nerve was performed. Despite evolving advances in endoscopic surgery, cardiac and mediastinal great vessel injuries are com427


Ulus Travma Acil Cerrahi Derg

monly treated with conventional open repair techniques. Thoracotomy and sternotomy incisions are the two choices for surgical exploration. In our clinical practice, the decision regarding the type and site of surgical incision is made according to the localization and suggested mechanism of the injuries. In unstable hemodynamics, we performed mostly anterolateral thoracotomy as the first choice, and this incision was extended laterally if further exposure was needed. Conversely, sternotomy was performed in 10.5% of the cases. This incision is generally used after the diagnosis of pericardial fluid collection by echocardiography. These cases were stable clinically before surgery. Although sternotomy incision is preferred for better exposure in isolated cardiac injuries, thoracotomy incision can be useful in patients with chest trauma and associated injuries, especially in cardiac and great vessel injuries.[10,11]

tusion and concussion are also major pathologies that should be kept in mind after blunt trauma. Autopsy studies noted that the incidence of cardiac concussion ranged between 14% and 16%.[15] In such cases, contusion is usually confined to the traumatized cardiac muscle bundles that include patchy necrosis and hemorrhage causing myocardial dysfunction.

Emergency room thoracotomy is known to be a very useful tool and should be in the surgeonâ&#x20AC;&#x2122;s armamentarium as a lifesaving procedure to repair cardiovascular injuries. This intervention can be the first choice in hemodynamically unstable patients associated with blood loss into the pleural or pericardial space, but it remains a challenging procedure and may not be easily accessible to all surgeons.[12] In our hospital, an operating theater is located in the emergency unit, and thoracic surgery staff are available around the clock. Therefore, all unstable patients are transferred directly to the operating room, rather than having a surgical incision done in the emergency resuscitation room. Our approach appears to be more suitable to prevent infection and to manage patients in an optimal location.

Most injuries of the great venous structures are usually due to penetrating trauma. Blunt trauma as the cause is rare, presumably because of their distensibility and low pressure. The overall incidence of great vessel injury in penetrating trauma is approximately 5% with gunshot wounds and 2% with stab wounds.[17] In our series, both penetrating and blunt injury caused great vein injury with an incidence of 3.7%. We believe that choice of surgical incision should be made based on mechanism of injury and clinical suspicion. Our experience showed that thoracotomy incision provided an excellent exposure in the surgical repair of vascular injuries as well as in the presence of associated pathologies including pulmonary lacerations, rib fractures and diaphragmatic injury. On the other hand, median sternotomy provided excellent access to the heart in isolated cardiac injuries, but this incision was used in rare cases.

Penetrating injuries cause damage to the cardiac chambers or vessels through the tract of predisposing trauma. There may be an isolated injury to the cardiac chambers or a combined pathology with surrounding structures such as the lungs, pericardium or pleura. [13] Conversely, possible mechanisms of injuries after blunt trauma differ from penetrating injuries on several points. The predisposing mechanisms include a direct blow to the chest, compression of the heart through bidirectional forces, deceleration, or rapid rotation with fixation of the great vessels, transmission of venous pressure following compression of the abdomen, and rupture of the myocardium by a fractured rib.[14] Of note, deceleration trauma can be responsible for cardiac lacerations. The vena cava, aorta, pulmonary trunk, and the pulmonary arteries and veins firmly support the superior and posterior portion of the heart. During deceleration, the anterior part of the heart moves rapidly forward and this may cause cardiac injury in the absence of sternum or rib fractures. In survivors of cardiac injury, hemorrhage can sometimes be tamponaded by surrounding tissues in the mediastinum or pericardial sac, and this may allow the survivors to admit to the hospital. Cardiac con428

In our series, the right ventricle was the most commonly injured chamber in both penetrating and blunt chest trauma; 58.5% of patients with cardiac injury presented with right ventricular injury, of which 38.2% was due to penetrating injury and 20.2% to a blunt injury. There was no injury to more than one cardiac chamber in this series. Our results were similar to the literature. [3,11-13] Rodrigues et al.[16] noted that 94.3% of the cases with penetrating injury had only one cardiac chamber injured, which was usually the right ventricle (37%).

The overall mortality in this experience was 18.2%, and the operative mortality accounted for 73.6% of deaths. The operative mortality rate was 13.4% for all cases, and was generally associated with penetrating cardiac injuries. All these cases were unstable at admission, and they were early operations. Nevertheless, the operative mortality in penetrating injuries was 15.3%. Most cardiac injuries were due to stab wounds, and this ratio was lower than the operative mortality of penetrating cardiac injuries from gunshot wounds, reported as between 20% to 35%.[18,19] Rodrigues et al.[16] noted that overall mortality in penetrating cardiac injury was 32.9% for patients who arrived at the hospital alive. In our series, the mortality rates of penetrating and blunt injuries in unstable patients were 18.1% and 16.6%, respectively. Meanwhile, we observed that penetrating injuries had a significantly higher operative mortality than blunt injuries. In blunt trauma, operative mortality occurred in 3.8% of the patients. These cases were unstable on admission due EylĂźl - September 2011


Cardiac and great vessel injuries after chest trauma: our 10-year experience

to rupture of the right atrium and subclavian vein injury; however, the mortalities occurred due to associated injuries, such as liver laceration. Of note, the entire operative mortality of penetrating cardiac injuries was associated with primary chest injury. In our series, 26.3% of the mortality developed during the ICU follow-ups and in patients with blunt chest injury; there was no operative mortality for late operations. Considering the high mortality risk of cardiovascular injuries, this late mortality might be related to hemodynamically stable presentation at admission and the presence of associated injuries. Multiple injuries such as cranial injuries associated with cardiovascular trauma and renal failure in the postoperative period were the major cause for mortality in this series. Conversely, there was no mortality in the ICU follow-ups for penetrating injuries; all deaths occurred in the perioperative period. In addition to laceration or rupture of cardiac chambers, intracardiac pathologies are important predictors of survival after penetrating or blunt injuries.[14] These pathologies include valvular damage, chordal or papillary muscle rupture and defect in the atrioventricular septum. Although the risk of intracardiac injuries in penetrating chest trauma is more frequent, blunt trauma may cause such pathologies in the early or late period of trauma.[14] Penetrating injuries causing a septal defect or acute valvular insufficiency may cause rapid deterioration in a patient’s hemodynamic state, necessitating an urgent intervention. The diagnosis can be established by preoperative or intraoperative echocardiography.[9] Surgical repair necessitates the use of CPB. In our series, only one patient with penetrating injury had ventricular septal defect. Unfortunately, the diagnosis in this patient was made postmortem. The role of CPB in the treatment of penetrating cardiac injuries is still controversial. Equipment for CPB and related staff are occasionally provided in trauma centers. Technically, injuries to the cardiac chambers can be treated with different surgical techniques without using CPB. However, CPB can be used to repair a proximal lesion of coronary arteries, multiple-chamber wounds and intra-cardiac lesions such as septal defects and valve dysfunction. In such cases, patients should be promptly transferred to a specialized center if preoperative diagnosis is made by echocardiography and the patients are hemodynamically stable. Nevertheless, this may not be possible in most trauma centers because of unstable presentation of most patients on admission. In conclusion, cardiac and great vessel trauma after blunt and penetrating trauma carries a high mortality, and most patients present with unstable hemodynamics. All stable patients should undergo CT scanning of the chest and echocardiographic examination. Any penetrating wound of the thorax or upper abdomen Cilt - Vol. 17 Sayı - No. 5

should alert physicians to the possibility of cardiac injury. The emergency staff should be aware of the necessity of prompt surgical exploration. Operative timing should be based on hemodynamic status and the presence of other life-threatening injuries.

REFERENCES 1. Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A. Blunt thoracic trauma. Analysis of 515 patients. Ann Surg 1987;206:200-5. 2. American College of Surgeons Subcommittee on Trauma. Advanced trauma life support program for doctors. 7th ed. Chicago, IL: American College of Surgeons; 2004. 3. Graeber GM, Prabhakar G, Shields TW. Blunt and penetrating injuries of the chest wall, pleura and lungs. In: Shields TW, editor. General thoracic surgery. Philadelphia PA: Lippincott Williams and Wilkins; 2005. p. 951-71. 4. Demirhan R, Onan B, Oz K, Halezeroglu S. Comprehensive analysis of 4205 patients with chest trauma: a 10-year experience. Interact Cardiovasc Thorac Surg 2009;9:450-3. 5. Wall MJ Jr, Mattox KL, Chen CD, Baldwin JC. Acute management of complex cardiac injuries. J Trauma 1997;42:905-12. 6. Feghali NT, Prisant LM. Blunt myocardial injury. Chest 1995;108:1673-77. 7. Mattox KL, Feliciano DV, Burch J, Beall AC Jr, Jordan GL Jr, De Bakey ME. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987. Ann Surg 1989;209:698-707. 8. Burack JH, Kandil E, Sawas A, O’Neill PA, Sclafani SJ, Lowery RC, et al. Triage and outcome of patients with mediastinal penetrating trauma. Ann Thorac Surg 2007;83:377-82. 9. Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg 2003;23:374-8. 10. Gao JM, Gao YH, Wei GB, Liu GL, Tian XY, Hu P, et al. Penetrating cardiac wounds: principles for surgical management. World J Surg 2004;28:1025-9. 11. Degiannis E, Loogna P, Doll D, Bonanno F, Bowley DM, Smith MD. Penetrating cardiac injuries: recent experience in South Africa. World J Surg 2006;30:1258-64. 12. Asensio JA, Soto SN, Forno W, Roldan G, Petrone P, Salim A, et al. Penetrating cardiac injuries: a complex challenge. Injury 2001;32:533-43. 13. Kang N, Hsee L, Rizoli S, Alison P. Penetrating cardiac injury: overcoming the limits set by Nature. Injury 2009;40:919-27. 14. Porzionato A, Montisci M, Basso C. Multiple heart and pericardial lacerations due to blunt trauma from assault. Cardiovasc Pathol 2004;13:168-72. 15. Wisner DH, Reed WH, Riddick RS. Suspected myocardial contusion. Triage and indications for monitoring. Ann Surg 1990;212:82-6. 16. Rodrigues AJ, Furlanetti LL, Faidiga GB, Scarpelini S, Barbosa Evora PR, de Andrade Vicente WV. Penetrating cardiac injuries: a 13-year retrospective evaluation from a Brazilian trauma center. Interact Cardiovasc Thorac Surg 2005;4:212-5. 17. Demetriades D. Penetrating injuries to the thoracic great vessels. J Card Surg 1997;12:180. 18. Renz BM, Cava RA, Feliciano DV, Rozycki GS. Transmediastinal gunshot wounds: a prospective study. J Trauma 2000;48:416-22. 19. Degiannis E, Benn CA, Leandros E, Goosen J, Boffard K, Saadia R. Transmediastinal gunshot injuries. Surgery 2000;128:54-8. 429


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):430-434

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.23427

Still an unknown topic: child abuse and “shaken baby syndrome” Hala bilinmeyen bir konu: Çocuk istismarı ve “Sarsılmış Bebek Sendromu” Elçin BALCI,1 İskender GÜN,1 Şule MUTLU ŞARLI,1 Fatma AKPINAR,1 Fatih YAĞMUR,2 Ahmet ÖZTÜRK,1 Osman GÜNAY1

BACKGROUND

AMAÇ

Shaken baby syndrome (SBS) is a severe form of physical child abuse, and can even cause death. In this study, we aimed to investigate whether or not the primary healthcare workers had received any education regarding child abuse and neglect, whether they could diagnose the cases, whether they had sufficient knowledge about SBS as a part of child abuse, and whether they were in need of education on the topic.

Sarsılmış bebek sendromu (SBS) çocuğa yapılan fiziksel istismarın ciddi bir formu olup ölüme dahi sebep olmaktadır. Bu araştırmada birinci basamak sağlık çalışanlarının çocuk istismarı ve ihmali konusunda eğitim alıp almadıkları, istismar olgularını tanıyıp tanıyamayacakları, bir istismar türü olan SBS konusunda bilgili olup olmadıklarının araştırılması amaçlandı.

METHODS

GEREÇ VE YÖNTEM

Health workers in the primary healthcare centers in the province of Kayseri were enrolled. A questionnaire was applied.

Araştırma kapsamına Kayseri birinci basamak sağlık kuruluşlarında hizmet veren sağlık personeli alındı. Katılımcılara anket uygulandı.

RESULTS

BULGULAR

In this study, 35.0% of the study group were physicians. 43.7% of the study group stated that they had not recieved any education regarding child abuse and neglect, and 52.1% stated that they believed that physical abuse was the most prominent form of abuse in society. While 64.1% of the participants stated that they had heard about SBS, 10.4% of these stated that they had heard about it, but did not have adequate knowledge on the topic.

Araştırma grubunun %35,0’i hekimdi. Grubun %43,7’si daha önce çocuk istismarı ve ihmaline ilişkin herhangi bir eğitim almadıklarını, %52,1’i toplumda en çok fiziksel istismarın görüldüğünü düşündüklerini ifade etti. Katılımcıların %64,1’i SBS’yi daha önceden duymuş olduğunu söylerken; duyanların %10,4’ü duyduğunu ancak bilmediğini ifade etti. İstismar konusuyla ilgili eğitim alma durumu meslek grupları arasında anlamlı olarak farklı bulundu.

CONCLUSION

SONUÇ

There is a lack of knowledge and a need for education regarding child abuse and neglect among the personnel working in primary healthcare, especially on the subject of SBS. Undergraduate and postgraduate education regarding child abuse and SBS will help to increase the number of people well-informed and sensitive to this important issue.

Çocuk istismarı, ihmali ve istismarın bir alt başlığı olan SBS konusunda, birinci basamak sağlık personelinin bilgi eksiği ve eğitim ihtiyacı vardır. Mezuniyet öncesi ve sonrası eğitimlerde çocuk istismarı ve SBS konularına yeterince yer verilmesi farkındalık ve duyarlı birey sayısının artmasına yardımcı olacaktır.

Key Words: Child abuse; education; health personnel; in-service training; shaken baby syndrome.

Anahtar Sözcükler: Çocuk istismarı; eğitim; sağlık personeli; hizmet içi eğitim; sarsılmış bebek sendromu.

Departments of 1Public Health, 2Forensic Medicine, Erciyes University Faculty of Medicine, Kayseri, Turkey.

Erciyes Üniversitesi Tıp Fakültesi 1Halk Sağlığı Anabilim Dalı, 2 Adli Tıp Anabilim Dalı, Kayseri.

Correspondence (İletişim): Elçin Balcı, M.D. Erciyes Üniversitesi Tıp Fakültesi Halk Sağlığı Anabilim Dalı, 38039 Kayseri, Turkey. Tel: +90 - 352 - 437 49 37 / 23728 e-mail (e-posta): drelcin71@gmail.com

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Still an unknown topic: child abuse and “shaken baby syndrome”

Intentional or unintentional behavior by an adult that affects a child’s health or psychosocial and physical development negatively is defined as child abuse. Child abuse is classified into four groups as: neglect, physical abuse, sexual abuse, and emotional abuse.[1] Primary healthcare workers, who should give priority to preventive medicine, have an important responsibility for educating society, and for diagnosing, reporting and preventing possible abuse cases. In order to educate and advise society regarding child abuse, these health workers should possess the necessary knowledge and acquirements on this topic in addition to general health issues.[2] If an abused child is not diagnosed when first brought to the center and sent back home, this abuse will most likely continue and can even result in death. [3] The insufficiency in undergraduate and postgraduate education regarding child abuse complicates the physicians’ diagnosis of an abused child and prevents its consideration within the differential diagnosis.[4] Shaken baby syndrome (SBS) is a severe form of physical child abuse, first defined by pediatric radiologist John Caffey in 1946. It is a syndrome that presents with cerebral hemorrhage, retinal hemorrhage and/or fractures (especially posterior rib fractures), resulting from being shaken by an adult, grabbed by the arms or body. Due to the weakness of the neck muscles, there is an excessive movement of the head during this shaking movement, which in turn leads to tearing in the cortical bridge veins, which traverse from the cortex to the dural venous sinus. The diagnostic triad for SBS is accepted as subdural hemorrhage, retinal hemorrhage and encephalopathy. [5,6] Among the children exposed to abuse, SBS ranks first in the etiology of death especially in children aged 0-4 years.[7,8] The signs and symptoms show a wide range from trivial signs such as anxiety, shaking and Table 1. Distribution of the study group according to some descriptive characteristics Characteristics Profession Physician Nurse Midwife Others (Health officer, Environment technician, etc.) Gender Male Female Marital status Married Single Divorced + Widowed Total Cilt - Vol. 17 Sayı - No. 5

Number

%

229 79 228

35.0 12.1 34.9

118

18.0

245 409

37.5 62.5

581 55 18 654

88.8 8.4 2.8 100.0

vomiting, to severe signs such as lethargy, convulsions, coma, stupor, and even death. Twenty percent of the cases are usually lost within a few days following the trauma. There is still a serious lack of knowledge in society regarding the hazards created by SBS.[9] In this study, we aimed to investigate whether the primary healthcare personnel have received any education regarding child abuse and neglect, whether they can diagnose it, whether they are aware of SBS as a form of child abuse, and whether better education on the topic is needed.

MATERIALS AND METHODS Study Group This study was performed in April 2010, and 729 primary healthcare personnel working in the province of Kayseri were enrolled. As it was aimed to reach the whole universe, sampling was not done. Data Collection A questionnaire developed for the study, which comprised 34 questions covering sociodemographic characteristics, educational status regarding child abuse, and their attitude, behaviors and knowledge regarding SBS, was completed via face-to-face method and by the investigators. Eleven personnel who were not on duty during the investigation (on leave, ill, etc.) and 64 who did not accept to participate were excluded. The study was completed with 654 participants (participation rate 89.7%). Their knowledge regarding child abuse and their educational status were evaluated by the participants’ own statements. Knowledge about SBS was evaluated by the response to the question inquiring about the diagnostic triad. Those who gave the correct answer were accepted as being well-informed about SBS. The questions about the signs and medical investigations were open-ended with more than one choice. Analysis Data were evaluated by computer, following the questionnaire application, and chi- square test was used for statistical evaluation, with values of p<0.05 accepted as significant. The necessary administrative permission for the study was obtained from the Provincial Directorate of Health, with ethical approval from Erciyes University.

RESULTS The study was completed with 654 participants. 35.0% of the study group were physicians, 62.5% were female, and 88.8% were married (Table 1). 43.7% of the group stated that they had not received any education regarding child abuse and neglect. 52.1% of the group thought that physical abuse was the most commonly seen form of abuse in society. 53.5% of the 431


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Table 2. The general awareness of the study group regarding shaken baby syndrome

Number

%

419 235 654

64.1 35.9 100.0

92 260 68 419

14.1 39.6 10.4 64.1

186 166 352

28.4 25.4 53.8

102 30 220 352

15.6 4.6 33.6 53.8

Shaken baby syndrome Has heard Has not heard Total Level of knowledge about SBS (n: 419) Good Poor Has heard, but does not know Total Knowledge about the SBS diagnostic triad (n: 352) No Yes Total Ability to diagnose SBS cases (n: 352) Yes No Undecided Total

group stated that they would determine abuse cases if encountered, and 99.6% thought that this topic was very important. 86.6% of the participants thought that abuse could be prevented with education (87.8), law enforcement (4%) and by increasing the interest (2.6%). While 64.1% of the participants (n: 419) stated that they had heard about SBS, 10.4% (n: 68) of those stated: “I have heard of it but I do not know what it is” (Table 2). The educational status regarding child abuse differed significantly between professions. While 71.9% of the midwives stated that they had received postgraduate education, 75.4% of health personnel other than physician-midwife and nurse had never received any education on this topic. The rate of correct responses to the question about the diagnostic triad of SBS was again significantly different between professions. While 55.5% of the physi-

cians had answered correctly, 60.0% of the midwives and 69.7% of the other personnel did not respond correctly to the diagnostic triad question (Table 3). 42.3% of the group stated that they thought that the most common person causing SBS would be the stepmother, followed by the biological mother (19.8%). 42.2% of the participants answered the question “Should SBS be reported?” as: “It should be reported to the police and to the prosecution office”; 4.1% did not know to which agency abuse should be reported. When their usual mode of cuddling a baby was questioned, 13.1% of the participants stated that they liked to cuddle babies harshly, bouncing them and making them cry. In response to the question “If someone shows their affection to your baby harshly, how would you intervene?”, 63.6% answered: “I would be angry, take the baby away, and warn them”. The participants who responded correctly regarding the SBS diagnostic triad stated that they liked to cuddle babies gently without battering them, and this was significantly different from those who did not know the correct answer (X2: 9.976, p<0.05). There was no difference in the response to “If someone cuddles your baby harshly, what would you do?” between those who knew the diagnostic triad and those who did not, and they all answered that they would take their child away, become angry and tell the offender (X2: 4.984, p>0.05).

DISCUSSION Of the whole group, 43.7% stated that they had not received any education regarding child abuse and neglect. In a study performed by Yağmur et al.[2] in Kayseri among primary healthcare workers, it was established that 83.4% of the healthcare workers did not have any education regarding child abuse and neglect. The difference between studies may be due to the contribution of in-service training courses in the meantime, which increased the number of people who received education. Physicians should be able to: diagnose the signs and symptoms of child abuse and neglect with the hope

Table 3. Distribution of the rate of knowledge about the SBS diagnostic triad according to professional groups

Does not know

Correct answer

Total

Profession

Number

%

Number

%

Number

%

Physician Nurse Midwife Other Total

73 21 69 23 186

44.5 52.5 60.0 69.7 52.8

91 19 46 10 166

55.5 47.5 40.0 30.3 47.2

164 40 115 33 352

100.0 100.0 100.0 100.0 100.0

X2: 10.695; p<0.05.

432

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Still an unknown topic: child abuse and “shaken baby syndrome”

of not skipping any child abuse cases; evaluate medically the injuries these can cause; and take the necessary and emergent precautions in order to prevent any further damage to the child.[4,10] 53.5% of the participants stated that they could diagnose child abuse cases when encountered. The educational status regarding child abuse was significantly different between professional groups. It was established that, while 62.5% of those who received undergraduate education and 35.0% of those who received no education at all were physicians, 45.6% of those who received postgraduate in-service training were nurses. Although they are deficient in undergraduate education, it was seen that nurses are more reachable with in-service training courses. This fact emphasizes the need to motivate physicians to participate more in in-service trainings and other meetings and educational activities in order to progress in their profession. In addition, the fact that health workers other than physicians, nurses and midwives are the group least informed regarding child abuse and SBS is very striking, and points to the need to prioritize their education. While 52.1% of the group thought that physical abuse was the most common form of abuse in society, according to a study regarding child abuse in Turkey, emotional abuse is the most frequent form.[11] The fact that there are visible concrete physical signs and symptoms in physical compared to emotional abuse, resulting in examination by a physician, may be the reason for this misinterpretation. Improved awareness and knowledge about child abuse and neglect, a correct diagnosis and meticulous notification will provide true interpretations on this topic, with more precise numbers. Child abuse is a crime, and these cases should be reported as soon as possible to the prosecution office, social services or hospital security.[12] While 42.2% of the participants stated that SBS should be reported to “police stations, police or the prosecution office”, 4.1% did not know the appropriate avenue for reporting the abuse. Keeping in mind that lack of knowledge does affect attitude and behaviors, it was noticed that even if these cases are diagnosed, notification is usually disregarded. 64.1% of the participants stated that they had heard about SBS before, but of these, 10.4% stated: “I have heard about it but I am not well-informed”. Knowledge about SBS, the reporting of deaths due to SBS and scientific literature knowledge are insufficient in other countries as well.[13] This situation may be due to insufficient awareness of this topic, and the fact that it has gained in importance only recently. 42.3% of the group stated that they would suspect the “real/biological” mother as the probable offender. Cilt - Vol. 17 Sayı - No. 5

In the literature from abroad, the biological father or the new partner of the mother was reported as the more common suspect.[9,13] Due to the sociocultural structure of our country, this interpretation based on the experiences and observations of health personnel may be assumed to be correct, considering that fathers usually abstain from embracing their children, especially in infancy. The mothers are usually responsible for the care of the baby, and stepmothers, who also become responsible for the child automatically, may not be as caring as the biological mothers. Furthermore, any traumatic or violent behavior from the father is usually accepted as natural in our society, thus excluding fathers from ranking first as the abusers. However, the fact that divorce rates and the number of step-parents that join the family by remarriage are also lower in our country should not be overlooked. When the baby cuddling habits of participants were queried, 13.1% stated that they cuddle harshly, bouncing infants up and down and making them cry. Those who were aware of SBS liked to embrace babies more gently, perhaps because knowledge about a topic ��������������������������������������������� creates�������������������������������������� a change in people’s attitude and behavior, causing them to be more gentle. This is quite promising,��������������������������������������������� in the sense that any educational and informational efforts will have a good result, and individuals will exhibit greater care while caressing or showing love to a child. The response to the question “What would you do if someone showed their love to your baby harshly” was the same by both those who were and were not aware of child abuse, with both groups stating that they would remove their child, and this may be perceived as reflecting a protective instinct. In conclusion, primary healthcare workers have inadequate knowledge on the topic of SBS, a form of child abuse and neglect, and there is a real need for education. Providing enough education through undergraduate and postgraduate trainings on child abuse and SBS will increase awareness on this topic, as well as the number of people who become sensitive to possible cases. Overcoming the lack of knowledge facilitates an improvement in attitude and behavior, and is promising for obtaining a better and gentler approach to babies and improving how they are shown love and affection. Early diagnosis and treatment of SBS cases will prevent complications, and forensic notification will intimidate people and help to prevent the development of new cases. We also believe that there is a need for extensive education and investigation among people actively involved with children other than health personnel, such as parents, teachers, and caregivers, etc. It should not be forgotten that diagnosing the cases, recording any possible signs of abuse, reporting abuse, 433


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and providing medical treatment are legal responsibilities, apart from the medical aspect; physicians and all health personnel should be educated, and parents and teachers should be well-instructed in this matter. More studies and new case series will enable us to make better comments especially regarding the differing risk factors in our country.

REFERENCES 1. Dubowitz H. Preventing child neglect and physical abuse: a role for pediatricians. Pediatr Rev 2002;23:191-6. 2. Yağmur F, Balcı E. Kayseri ili merkez ve ilçeleri birinci basamak sağlık çalışanlarının, çocuk istismarı ve ihmali konusunda bilgi düzeyleri: Anket çalışması. Adli Bilimler Dergisi 2009;8:7-11. 3. Kirschner RH, Wilson H. Pathology of fatal abuse. In: Reece RM, Ludwing S, editors. Child abuse medical diagnosis and management. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 503-5. 4. Yağmur F, Asil H, Canpolat M, Per H, Coşkun A. Kısa mesafeli düşme ve sarsılmış bebek sendromu. Türkiye Klinikleri J Med Sci 2010;30:766-71. 5. Akar T. (Shaken Baby Syndrome). Çocuk istismarı ve ihma-

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line multidisipliner yaklaşım. 1st ed. Ankara: Ankara University Press; 2006. p. 47-53. 6. Ulukol B. Sarsılmış bebek sendromu. Türkiye Klinikleri J Pediatr Surg-Special Topics 2008;1:28-36. 7. Rimsza ME, Schackner RA, Bowen KA, Marshall W. Can child deaths be prevented? The Arizona Child Fatality Review Program experience. Pediatrics 2002;110:11. 8. American Academy of Pediatrics: Committee on Child Abuse and Neglect. Shaken baby syndrome: rotational cranial injuries-technical report. Pediatrics 2001;108:206-10. 9. Ward MG, Bennett S, King WJ. Prevention of shaken baby syndrome: Never shake a baby. Paediatr Child Health. 2004;9:319-21 10. Önal Ç. Çocuk istismarı. Türkiye Klinikleri J Pediatr Sci 2007;3:27-9. 11. Turhan E, Sangün Ö, İnandı T. Birinci basamakta çocuk istismarı ve önlenmesi. Sürekli Tıp Eğitimi Dergisi (STED) 2006;15:153-7. 12. Hancı İH, Eşiyok B. Child abuse and legal arrangements in penal code. Türkiye Klinikleri J Pediatr Sci 2006;2:91-3. 13. Matschke J, Herrmann B, Sperhake J, Körber F, Bajanowski T, Glatzel M. Shaken baby syndrome: a common variant of non-accidental head injury in infants. Dtsch Arztebl Int 2009;106:211-7.

Eylül - September 2011


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):435-439

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.89804

Delayed presentation of posttraumatic diaphragmatic hernia Geç bulgu veren travmatik diyafram hernileri İsmail OKAN,1 Gürhan BAŞ,2 Sedat ZİYADE,3 Orhan ALİMOĞLU,2 Ramazan ERYILMAZ,2 Deniz GÜZEY,2 Aydın ZİLAN2

BACKGROUND

AMAÇ

Missed diaphragmatic injuries after trauma may present with herniation of intraabdominal organs into the thoracic cavity. We aimed to review our patients who presented with delayed posttraumatic diaphragmatic hernia.

Travma sonrası gözden kaçan diyafram yaralanmaları karın içi organların toraksa fıtıklaşması ile sonuçlanabilir. Bu çalışmada, travma sonrası gecikmiş diyafram yaralanması nedeniyle tedavi edilen hastalar değerlendirildi.

METHODS

GEREÇ VE YÖNTEM

A retrospective review of the medical records of patients with delayed diagnosis of posttraumatic diaphragmatic hernia between 2001 and 2009 was performed.

2001-2009 yılları arasında travma sonrası geç bulgu veren diyafram hernisi tanısı alan hastaların dosyaları geriye dönük olarak incelendi.

RESULTS

BULGULAR

Ten patients with a mean age of 44.3 years were included. Six patients were female. Blunt injuries (n: 7) were more common. Mean duration between trauma and presentation to the hospital was 5.9 years (4 months - 19 years). Nine patients had left-sided diaphragmatic hernia. All patients had chest X-ray and most were diagnostic (n: 8). Additional diagnostic imaging with computerized tomography (CT) and magnetic resonance (MR) was used in seven patients. For the repair, laparotomy incision was chosen for seven patients and thoracotomy incision for two patients. One patient underwent left thoracoabdominal approach. Mesh repair was used in seven patients. Postoperative mean hospitalization was 10.6 days. Empyema and atelectasis were the morbidities in one patient. No postoperative mortality was detected.

Çalışmaya alınan 10 hastanın yaş ortalaması 44,3 yıl idi. Hastaların altısı kadındı. Etyolojide künt travma daha sık (n=7) olarak saptandı. Travma ile travma sonrası diyafram hernisi tanısıyla hastaneye başvuru arasında geçen süre ortalama 5,9 yıl (4 ay-19 yıl) idi. Dokuz hastada diyafram hernisi soldaydı. Tüm hastaların arka-ön akciğer grafisi çekildi ve çoğunda sadece grafi ile tanı kondu (n=8). Yedi hastada ilave olarak bilgisayarlı tomografi ve manyetik rezonans görüntüleme kullanıldı. Herni tamiri için yedi hastada laparotomi iki hastada torakotomi yapılırken, bir hastada sol torakoabdominal insizyon kullanıldı. Onarım için yedi hastada yama kullanıldı. Ameliyat sonrası ortalama hastanede kalış süresi 10,6 gündü. Bir hastada ampiyem ve atelektazi saptandı. Ameliyat sonrası mortalite saptanmadı.

CONCLUSION

SONUÇ

Delayed presentation of posttraumatic diaphragmatic hernia is a serious challenge for trauma surgeons. Prompt diagnosis and treatment prevent serious morbidity and mortality associated with complications such as gangrene and/or perforation of the herniated organ.

Travma sonrası geç bulgu veren diyafram hernisi travma cerrahları için ciddi bir problemdir. Tanı ve tedavinin doğru ve hızlı uygulanması fıtıklaşmış organların perforasyon veya gangreni sonrası gelişebilecek morbidite ve mortaliteyi engeller.

Key Words: Diaphragmatic hernia; delayed presentation; posttraumatic; traumatic diaphragmatic injury.

Anahtar Sözcükler: Diyafram hernisi; gecikmiş tanı; travma sonrası; travmatik diyafram yaralanması.

Department of General Surgery, Gaziosmanpasa University, Faculty of Medicine, Tokat; Departments of 2General Surgery, 3Thoracic Surgery, Vakif Gureba Training and Research Hospital, Istanbul, Turkey.

1 Gaziosmanpaşa Üniversitesi, Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Tokat; Vakıf Gureba Eğitim ve Araştırma Hastanesi, 2Genel Cerrahi Servisi, 3Göğüs Cerrahisi Servisi, İstanbul.

1

Correspondence (İletişim): Ismail Okan, M.D. Gaziosmanpaşa Üniversitesi, Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, 60100 Tokat, Turkey. Tel: +90 - 356 - 213 32 94 e-mail (e-posta): hismailok@yahoo.com

435


Ulus Travma Acil Cerrahi Derg

Traumatic diaphragmatic injury is a serious condition associated with severe blunt and penetrating trauma. It has been detected more commonly in recent times owing to the advancement of diagnostic modalities and the awareness of medical staff. However, it still poses a great dilemma for trauma surgeons. The incidence has been reported as approximately 2% in blunt trauma and between 9-42% in penetrating thoracoabdominal trauma.[1-3] Acute diaphragmatic injuries are mostly associated with multiple organ injuries.[4-6] The mortality was related with the initial presentation of the patient and severity of hemorrhagic shock rather than the diaphragmatic injury itself.[6] The diagnosis of isolated diaphragmatic injury is difficult since the early clinical and radiological findings are not clear. It is usually made on the table during operation. However, in some patients, there is risk of missing the diagnosis even in the operation.[7,8] In recent decades, with the institution of nonoperative management, the diagnosis rather depends on a high level of suspicion and sophisticated diagnostic modalities. Unrecognized patients with diaphragmatic injury may present later in life with a great variety of symptoms ranging from vague dyspepsia and dyspnea to incarceration and perforation due to herniated abdominal organs into the thoracic cavity. The true incidence of delayed diagnosis of diaphragmatic injury is unknown. However, a recent study indicated that 2.7% of diaphragmatic injuries were detected after four months.[9] The literature about the management of delayed diaphragmatic hernia consists mainly of sporadic�������������������������������������������� cases and very few well-documented but limited case series.[7,10,11] Since these case series are more than a decade old, the use of sophisticated diagnostic modalities such as multislice computerized tomography (CT) and magnetic resonance imaging (MRI) in delayed presentation has not been evaluated. Moreover, with the progress in postoperative patient care, morbidity and mortality have been improved. Here, we aimed to present our management of delayed diaphragmatic injuries with the emphasis on diagnosis and the patient outcome.

MATERIALS AND METHODS Patients treated in Vakif Gureba Training and Research Hospital between 2001 and 2009 with the diagnosis of delayed posttraumatic diaphragmatic hernia were reviewed. The study was approved by the institutional board of our hospital. Three patients with acute abdominal symptoms were reported earlier.[12] Delayed presentation of posttraumatic diaphragmatic hernia was defined as the diaphragmatic hernia not detected during the initial hospitalization after the trauma. The medical records of patients were reviewed for the demographic data, mechanism of injury, clinical presentation, diagnostic modalities, operations, and the outcome. 436

RESULTS During the specified time, 10 patients were treated for delayed presentation of posttraumatic diaphragmatic hernia. The mean age of patients was 44.3 years (range: 20-78 years). Six patients were female. Blunt trauma was predominant, in 7 cases, while 3 cases had penetrating injuries. The mean duration between trauma occurrence and the delayed presentation to the hospital was 5.9 years (range: 4 months - 19 years). Nine patients had left and 1 patient had right diaphragmatic hernia. Three patients were admitted with mechanical intestinal obstruction symptoms. Five patients had respiratory symptoms like dyspnea with varying severity as their main complaints and 4 patients had abdominal pain. The initial diagnostic work-up was chest X-ray for all patients, and it was diagnostic in 8 patients (Fig. 1), whereas it was recorded as atypical in 2 patients. Additional imaging with CT and MRI was used in 7 patients. Both CT and MRI detected the diaphragmatic hernia with preoperative diagnosis of 100% (Fig. 2). Laparotomy was chosen for 7 patients as the surgical incision. Two patients underwent thoracotomy, whereas in 1 patient, a thoracoabdominal approach was necessary. The most common herniated organ was the colon (n=7). Stomach and omentum were herniated in 5 patients, spleen in 4 patients, small bowel in 2 patients, and left kidney in 1 patient. Herniated organs were reduced in 9 patients without resection. One patient underwent colon resection due to microperforation. The mean diameter of the defect in the diaphragm after reduction was 7.4

Fig. 1. A diagnostic posteroanterior chest X-ray of a patient presenting with vague abdominal pain one year after penetrating thoracoabdominal injury. Eylül - September 2011


Delayed presentation of posttraumatic diaphragmatic hernia (a)

(b)

Fig. 2. (a) An abdominal CT scan of a patient with a history of blunt trauma 15 years ago, showing the presence of colonic segments in the left pleural cavity. (b) Magnetic resonance image of the patient with a penetrating trauma history of 19 years. The herniated organs through the defect in the left hemidiaphragm are noted.

cm (range: 2-10 cm). Primary repair was used in 3 patients. While Prolene mesh was used in 5 patients, special meshes (Bard® Composix® mesh, Davol Inc., UK) were used in 2 patients. Iatrogenic spleen injury resulting in splenectomy was recorded as the only perioperative complication, in 1 patient. Postoperative mean hospitalization of patients was 10.6 days (±4.4 days). ����������������������������������������������� During����������������������������������������� hospitalization, there were two morbidities with empyema and atelectasis in the same patient, who was treated with percutaneous drainage and proper antibiotics. There was no postoperative mortality. Characteristics of patients are summarized in Table 1.

DISCUSSION Diaphragmatic injury after trauma has been well recognized for centuries although the exact number of cases is unknown. The incidence may change according to trauma mechanism, location of injuries, and the modalities used for detection. Early reports are mainly based on findings in laparotomy, since most trauma patients had associated multiple injuries in addition to the diaphragmatic injury requiring surgery. Diaphragmatic injury was detected in 1.3% of patients with an Injury Severity Score of >15 on admission to a trauma center.[9] Small isolated injuries of the diaphragm may go unrecognized especially in patients nonoperatively treated after penetrating injuries of thoracic and abdominal traumas. Indeed, the use of laparoscopy in hemodynamically stable asymptomatic patients with thoracoabdominal wound detects diaphragmatic injury with an incidence of nearly 20% in some studies. [13,14] Concerning the specific location of the wound in the body, the diaphragmatic injury was found as high as 42% in patients with left thoracoabdominal injuries detected by either laparotomy or laparoscopy.[3] Due to the high incidence of diaphragmatic injury in left thoracoabdominal penetrating trauma, diagnostic laparoscopy is strongly recommended to exclude the Cilt - Vol. 17 Sayı - No. 5

possibility of isolated diaphragmatic injury otherwise unnoticed by conventional diagnostic modalities such as ultrasonography (US) and CT. Almost half of the cases herniated through the diaphragmatic tear in the acute phase. Herniation is more common in the left hemidiaphragm with blunt trauma. [9] If it goes undetected, the patient enters a relatively symptom-free period lasting from months to years. The delayed presentation is the last period when patients present with chronic abdominal or respiratory sympTable 1. Demographic features, clinical findings, diagnosis, and management of patients Patients Number (n) 10 Age (mean) 44.3 Gender (M/F) 4/6 Hospitalization time (mean, day) 10 Time interval between trauma and operation (year) 5.9 Mechanism of injury (Blunt: Penetrating) 7/3 Presenting symptoms Acute abdomen 3 (Mechanic intestinal obstruction, perforation) Respiratory 5 Abdominal pain 4 Localization (L:R) 9/1 Diameter (cm, mean) 7.4 Chest X-ray Diagnostic 8 Atypical 2 Additional radiologic imaging (CT, MR) 7 Incision Laparotomy 7 Thoracotomy 2 Both 1 Organ resection (Colon) 1 (10%) Complication (Splenic injury) 1 437


Ulus Travma Acil Cerrahi Derg

toms and/or obstructive signs.[11] The obstruction can be associated with strangulation and/or perforation of the herniated contents. However, the natural history of the diaphragmatic injury is unknown in most cases. For years, it has been stated that any injuries to the diaphragm result in diaphragmatic hernia owing to the pressure gradient between the thoracic and abdominal cavities and to the mobile nature of the diaphragm. Recently, some animal studies have challenged the thought with the findings that the diaphragm can heal without development of hernia.[15,16] Clearly, the studies cannot be extended to humans. However, the scarcity of reports raises the possibility that some small injuries especially in the right diaphragm might not proceed to hernia. Nearly all hernias were on the left side, possibly due to the protective effect of the liver on the right diaphragm. The only patient with right-sided diaphragmatic hernia was a 59-year-old female with a history of blunt trauma (fall from height) 15 years ago. The patient had symptoms of chronic cough and pain. During the operation, a diaphragmatic defect of 8 cm was detected, through which the hepatic flexure of the colon was herniated. Primary repair of the diaphragm was performed to restore the defect. Herniation in most of our cases followed blunt trauma. The two cases of penetrating abdominal wounds were stab wounds and one case was due to gunshot. Although trauma dates were old and their first admission was not to our clinic, it is logical to say that the use of diagnostic laparoscopy in stab wounds during the first admission might have prevented the occurrence of delayed left-sided diaphragmatic hernia. In acute settings, the initial chest X-ray is diagnostic in only one-fourth of patients (25%) due to interfering hemopneumothorax.[9] This figure can be doubled with the attending radiologistâ&#x20AC;&#x2122;s reading of the X-ray films.

CT scan could add 10% to the preoperative diagnosis.[9] Since the diaphragmatic injuries due to blunt trauma are more prone to hernia development in the acute setting, it may be easier to detect the injuries preoperatively after blunt trauma. A recent report with the use of multidetector CT in penetrating diaphragmatic injuries has shown promising results, with sensitivity, specificity and accuracy rates of 87%, 72% and 77%, respectively. [17] Although chest X-ray findings in delayed presentation were more diagnostic than in acute admission in this study and in others,[10] since most patients without acute symptoms had long-term complaints, additional diagnostic tests other than chest X-ray were routinely used. While older case series used upper gastrointestinal (GI) contrast studies,[11] recent reports commonly used CT or MRI.[18,19] With additional imaging, the rate of preoperative diagnosis in our patients with delayed diaphragmatic hernia without obstructive symptoms reaches 100%. Therefore, if the patientâ&#x20AC;&#x2122;s clinical situation allows some time to perform additional diagnostic tests, further tests like CT or MRI should be performed to achieve the correct diagnosis and plan the operation. The choice of incision for the repair also differs in acute and delayed admission of diaphragmatic hernia. Most authors agreed on the transabdominal approach in acute injuries owing to the high incidence of associated abdominal injuries.[9,20,21] However, in chronic hernias, some authors, referring to the strong adhesions between the herniated viscera and pleura, advocated thoracotomy.[7] The disadvantage of thoracotomy is the requirement of additional laparotomy if the small or large bowel has to be resected. On the contrary, some authors used transabdominal approach with great success.[10] It seems that the choice of incision is a matter of personal preference and expertise, since adhesion take-

Table 2. Comparative analysis of patient characteristics and their management with previous reports Hegarty et al.[11] Feliciano et al.[7] Reber et al.[10] Number (n) Time between operation and trauma (mean)

25 NA (5 months8 years) 3:22 24:1 Upper gastrointestinal contrast study

7 1 year (8.5-14 years) 7* 7:0 Upper gastrointestinal contrast study

Repair type

Primary

Primary

Morbidity

2:25 (empyema and fecal fistula)

Mortality

5:25 (20%)

5:7 (empyema, pneumonia, wound infection) None

Mechanism of injury (Blunt:Penetrating) Localization (L:R) Additional radiology

Present study

10 10 4.1 years (20 5.9 years (4 days-28 years) months-19 years) 8:2 7:3 8:2 9:1 Upper CT, MRI gastrointestinal contrast study, scintigraphy, CT Primary 3:7 Primary: Mesh None 2:10 (empyema and atelectasis) 1:10 (10%)

None

* Included only penetrating injuries.

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Delayed presentation of posttraumatic diaphragmatic hernia

down was successful with both options. We preferred mainly a transabdominal approach with the exception of three patients. One patient required additional thoracotomy after laparotomy for iatrogenic spleen injury during the operation due to the dense adhesions. The preferred method of closure of the defect in our series was to use prosthetic material, contrary to the published case series.[7,10,11] Table 2 compares the main characteristics of earlier reports and the present study. The reason for discrepancies could be due to the defect size and the duration, since both may cause the loss of elasticity of the diaphragm. The mean diameter of the defect was 7.4 cm in this series, and the mean duration was longer than in the above-mentioned studies. Indeed, in recent reports, the use of prosthetic mesh was readily favored.[22,23] There was no mortality in our series. We had one complication of spleen injury during the operation and two postoperative morbidities with empyema and atelectasis. Clearly, the mortality rates of acute injury (7%-28%) differ from those of delayed diaphragmatic hernia.[1,9,24,25] In the former situation, the presence of shock, brain injury (only in blunt trauma) and Injury Severity Score of >15 determine the mortality.[9] Indeed, isolated diaphragmatic injuries in the absence of other surgical injuries were associated with low mortality.[6,24,25] The reported mortality rates of delayed diaphragmatic hernia have changed in recent decades attributable to the earlier diagnosis and the improved postoperative patient management, decreasing from 25% to 10%.[10,11] Recent case reports have reported low mortality rates in the treatment of delayed diaphragmatic hernias.[12,19] However, the presence of strangulation with gangrene and perforation was related with increased morbidity and mortality.[11] In conclusion, the delayed presentation of diaphragmatic hernia necessitates prompt awareness of the surgeon since the symptoms are usually vague and the trauma history is remote. Earlier diagnosis with the use of sophisticated radiologic modalities prevents the major morbidity and mortality associated with complications of diaphragmatic hernia like gangrene and perforation.

REFERENCES

1. Chughtai T, Ali S, Sharkey P, Lins M, Rizoli S. Update on managing diaphragmatic rupture in blunt trauma: a review of 208 consecutive cases. Can J Surg 2009;52:177-81. 2. Leppäniemi A, Haapiainen R. Occult diaphragmatic injuries caused by stab wounds. J Trauma 2003;55:646-50. 3. Murray JA, Demetriades D, Cornwell EE 3rd, Asensio JA, Velmahos G, Belzberg H, et al. Penetrating left thoracoabdominal trauma: the incidence and clinical presentation of diaphragm injuries. J Trauma 1997;43:624-6. 4. Ward RE, Flynn TC, Clark WP. Diaphragmatic disruption secondary to blunt abdominal trauma. J Trauma 1981;21:35-8. 5. Shah R, Sabanathan S, Mearns AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg 1995;60:1444-9. 6. Williams M, Carlin AM, Tyburski JG, Blocksom JM, Harvey Cilt - Vol. 17 Sayı - No. 5

EH, Steffes CP, et al. Predictors of mortality in patients with traumatic diaphragmatic rupture and associated thoracic and/ or abdominal injuries. Am Surg 2004;70:157-63. 7. Feliciano DV, Cruse PA, Mattox KL, Bitondo CG, Burch JM, Noon GP, et al. Delayed diagnosis of injuries to the diaphragm after penetrating wounds. J Trauma 1988;28:1135-44. 8. Clarke DL, Greatorex B, Oosthuizen GV, Muckart DJ. The spectrum of diaphragmatic injury in a busy metropolitan surgical service. Injury 2009;40:932-7. 9. Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg 2008;85:1044-8. 10. Reber PU, Schmied B, Seiler CA, Baer HU, Patel AG, Büchler MW. Missed diaphragmatic injuries and their longterm sequelae. J Trauma 1998;44:183-8. 11. Hegarty MM, Bryer JV, Angorn IB, Baker LW. Delayed presentation of traumatic diaphragmatic hernia. Ann Surg 1978;188:229-33. 12. Alimoglu O, Eryilmaz R, Sahin M, Ozsoy MS. Delayed traumatic diaphragmatic hernias presenting with strangulation. Hernia 2004;8:393-6. 13. Powell BS, Magnotti LJ, Schroeppel TJ, Finnell CW, Savage SA, Fischer PE, et al. Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma. Injury 2008;39:530-4. 14. Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma. J Trauma 2005;58:789-92. 15. Gamblin TC, Wall CE Jr, Morgan JH 3rd, Erickson DJ, Dalton ML, Ashley DW. The natural history of untreated penetrating diaphragm injury: an animal model. J Trauma 2004;57:989-92. 16. Zierold D, Perlstein J, Weidman ER, Wiedeman JE. Penetrating trauma to the diaphragm: natural history and ultrasonographic characteristics of untreated injury in a pig model. Arch Surg 2001;136:32-7. 17. Bodanapally UK, Shanmuganathan K, Mirvis SE, Sliker CW, Fleiter TR, Sarada K, et al. MDCT diagnosis of penetrating diaphragm injury. Eur Radiol 2009;19:1875-81. 18. Walchalk LR, Stanfield SC. Delayed presentation of traumatic diaphragmatic rupture. J Emerg Med 2010;39:21-4. 19. Eren S, Kantarci M, Okur A. Imaging of diaphragmatic rupture after trauma. Clin Radiol 2006;61:467-77. 20. Murray JA, Demetriades D, Asensio JA, Cornwell EE 3rd, Velmahos GC, Belzberg H, et al. Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest. J Am Coll Surg 1998;187:626-30. 21. Demetriades D, Kakoyiannis S, Parekh D, Hatzitheofilou C. Penetrating injuries of the diaphragm. Br J Surg 1988;75:824-6. 22. Seket B, Henry L, Adham M, Partensky C. Right-sided posttraumatic diaphragmatic rupture and delayed hepatic hernia. Hepatogastroenterology 2009;56:504-7. 23. Palanivelu C, Rangarajan M, Rajapandian S, Amar V, Parthasarathi R. Laparoscopic repair of adult diaphragmatic hernias and eventration with primary sutured closure and prosthetic reinforcement: a retrospective study. Surg Endosc 2009;23:978-85. 24. Bergeron E, Clas D, Ratte S, Beauchamp G, Denis R, Evans D, et al. Impact of deferred treatment of blunt diaphragmatic rupture: a 15-year experience in six trauma centers in Quebec. J Trauma 2002;52:633-40. 25. Sözüer EM, Ok E, Avşaroğullari L, Küçük C, Kerek M. Traumatic diaphragmatic ruptures. Ulus Travma Derg 2001;7:176-80. 439


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):440-444

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.66750

10-year evaluation of train accidents Tren kazalarının 10 yıllık değerlendirilmesi Meltem AKKAŞ,1 Didem AY,2 Nalan METİN AKSU,1 Müge GÜNALP3

BACKGROUND

AMAÇ

Although less frequent than automobile accidents, train accidents have a major impact on victims’ lives.

Otomobil kazaları ile karşılaştırıldığında tren kazaları daha az görülmekle beraber, kazazedelerin hayatları üzerinde ciddi etkisi vardır.

METHODS

Records of patients older than 16 years of age admitted to the Adult Emergency Department of Hacettepe University Medical Center due to train accidents were retrospectively evaluated.

GEREÇ VE YÖNTEM

RESULTS

BULGULAR

44 patients (30 males, 14 females) with a mean age of 31.8±11.4 years were included in the study. The majority of the accidents occurred during commuting hours. 37 patients were discharged, 22 of them from the emergency department. The mortality rate was 7/44 (16%). Overall mean Revised Trauma Score (RTS) was 10.5 (3 in deaths and 11.9 in survivors). In 5 patients, the cause of death was pelvic trauma leading to major vascular injury and lower limb amputation. In 1 patient, thorax and abdomen trauma and in 1 patient head injury were the causes of mortality. Primary risk factors for mortality were alcohol intoxication (100%), cardiopulmonary resuscitation on admittance (100%), recurrent suicide attempt (75%), presence of psychiatric illness (60%), and low RTS.

30 erkek, 14 kadın toplam 44 hastanın yaş ortalaması 31,8±14,3 idi. Yaralanmaların çoğu işe gidiş-çıkış saatlerindeydi. Yirmi ikisi acil servisten olmak üzere toplam 37 hasta taburcu edildi. Mortalite 7/44 (%16) saptandı. Revize travma skoru (RTS) ortalama 10,5 olup, ölenlerde 3, yaşayanlarda 11,9 idi. Ölüm nedeni 5 hastada majör vasküler hasar ve alt ekstremite amputasyonuna yol açan pelvik travma, 1 hastada torakal ve abdominal travma, 1 hastada kafa travması idi. Mortalite için primer risk faktörleri; alkollü olmak (%100), başvuru anında kardiyopulmoner resüsitasyon yapılması (%100), tekrarlayan intihar girişimi (%75), psikiyatrik hastalık öyküsü (%60) ve düşük RTS puanı idi.

CONCLUSION

In this study, most train accidents causing minor injuries were due to falling from the train prior to acceleration. Nevertheless, train accidents led to a mortality rate of 16% and morbidity rate of 37%. These findings draw attention to the importance of developing preventive strategies.

Tren kazalarının çoğunluğunu, yeterince hız kazanmamış trenden kaza ile düşmeye bağlı oluşmuş minör yaralanmalar oluşturmaktadır. Buna rağmen tren kazaları %16 mortalite ve %37 morbiditeye neden olmuştur. Bu bulgular yaralanmaları önleyici tedbirlerin geliştirilmesinin önemine dikkat çekmektedir.

Key Words: Train accident/mortality/morbidity.

Anahtar Sözcükler: Tren kazası/mortalite/morbidite.

Department of Emergency Medicine, Hacettepe University Faculty of Medicine, Ankara; 2Department of Emergency Medicine, Yeditepe University Faculty of Medicine, Istanbul; 3Department of Emergency Medicine, Ankara University Faculty of Medicine, Ankara, Turkey.

1

Hacettepe Üniversitesi Tıp Fakültesi Hastanesi Acil Kliniğine başvuran 16 yaş üzerinde, tren kazasına maruz hastaların dosyaları geriye dönük olarak incelendi.

SONUÇ

1 Hacettepe Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Ankara; 2Yeditepe Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İstanbul; 3Ankara Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Ankara.

Correspondence (İletişim): Meltem Akkas, M.D. Hacettepe University School of Medicine, Emergency Department, Sıhhıye, Ankara, Turkey. Tel: +90 - 312 - 305 25 05 e-mail (e-posta): meltemakkas@hotmail.com

440


10-year evaluation of train accidents

Railway transportation is especially preferred in underdeveloped countries like South Africa and India. However, it is also a common transportation form in developed countries due to its low cost. The fatality rate is about 60 per 100 million passengers a year in South Africa and 150 in India.[1,2] Railway-related accidents result in 18,000 injuries and 1,200 fatalities annually in the United States.[3] In Turkey, the approximate annual fatality rate is 213 per 100 million passengers.[4] This rate is higher than the rates in developed and developing countries. When compared with automobile accidents, railway accidents are rare; nevertheless, they are morbid, commonly debilitating and frequently fatal.[5-10] The literature related to railway accidents is limited in our country as in the rest of the world. The Medical Center of Hacettepe University is one of four hospitals located near the train station. Many employees use this station for daily transport from suburban areas since the station is located in the city center. Due to the close proximity of the railway station to our hospital, railway accidents and injuries are usually admitted to this center. The present study aimed to evaluate the demographic and clinical features of victims and the causes and outcomes of train accidents.

MATERIALS AND METHODS We retrospectively analyzed patients who presented to the adult Emergency Department of Hacettepe University Medical Center from January 1, 1998 to January 31, 2008 due to railway accidents. All encountered patients were above the age of 16 years. A total of 51 patients were admitted due to railway accidents. The records of 7 patients could not be obtained, and they were excluded from the study. Railway accidents were evaluated in three groups as: train-train collisions or overturned train, trainmotor vehicle collision and train-pedestrian collision.

Train-pedestrian collisions were grouped as suicides, accidental train-pedestrian collision, stepping off a train, and falling from a train. We also searched for the velocity of the train in the patient records. Demographic characteristics of victims, causes of injuries, morbidities, and mortalities were evaluated. Categorical data were given as frequencies and percentages.

RESULTS Of the evaluated patients, 30 (68%) were male and 14 (32%) were female. The mean (range) age of patients was 31.8±14.3 years. Accidents occurred between 16:00 - 19:00 in 18 (41%) patients and between 06:00 - 09:00 in 9 (20%) patients. The time elapsed from accidents to admittance to hospital was <15 minutes (min) in 22 patients, 15-29 min in 17 patients and >60 min in 1 patient. With respect to the causes of injuries, no relevant case regarding overturned train or train-train collision was determined. There were 2 cases (4.5%) of trainmotor vehicle collision, and 42 cases (95.5%) of trainpedestrian collisions. Of the train-pedestrian crashes, 26 cases were due to accidental fall while the train was slowing down or gathering speed, 8 cases were suicidal, 4 cases were due to train-pedestrian collision while accelerating, and 4 cases were due to jumping from train while it was moving (Table 1). Of the 8 suicidal cases, 5 jumped from the train, 2 threw themselves in front of a moving train, and 1 was lying on the railways. Two cases were found to have alcohol in the blood. Both had a history of psychiatric illness and committed suicide. Apart from these 2 cases, 3 additional cases had a history of some psychiatric illnesses. Of the 5 cases who had a history of psychiatric illness, 4 committed suicide and 1 was an accidental injury.

Table 1. Causes of injuries Causes of injuries Overturned train Train-train collision Train-motor vehicle collision Train-pedestrian collision a) Accidental fall while train was slowing down or gathering speed b) Suicide c) Train-pedestrian collision while accelerating d) Jump from train while moving Total Cilt - Vol. 17 Sayı - No. 5

Total (n)

Total age

Male (n)

Male age

Female (n) Female age

0 (0%) 0 (0%) 2 (4.5%) 42 (95.5%)

– – 33±16.9 31.7±14.3

– – 2 (4.5%) 28

– – 33±16.97 33.6±15.7

– – – 14

– – – 27.8±10.6

26 8

31,4±15 36.8±13.3

12 8

36±17.7 36.8±13.3

14 –

27.8±10.6 –

4 4 44

31±18.1 23±11.4 31.8±14.3

4 4 30

31±18.1 23±11.4 33.7±15.5

– – 14

– – 27.8±10.6 441


Ulus Travma Acil Cerrahi Derg

Four cases had a previous history of suicidal attempt, all of whom had an accompanying psychiatric illness. Two of them had selected the train in previous suicide attempts. Accompanying system/organ injuries included: 16 soft tissue injuries, 1 sternum fracture, 1 clavicle fracture, 7 rib fractures, 4 hemothorax, 6 pneumothorax, 3 pulmonary contusion, 14 lower limb fractures, 3 upper limb fractures, 12 lower limb amputations, 2 upper limb amputations, 2 intracranial hemorrhages, 5 vertebral fractures, 8 pelvic fractures, 3 intraabdominal bleeding, 5 major blood vessel injury, 4 maxillofacial injury, and 1 renal injury. A total of 19 limb amputations were performed in 14 patients: 8 leg, 5 thigh, 4 ankle, and 2 finger amputations. Although 6 of the amputations were subtotal, all had Mangled Extremity Severity Score (MESS) of >7, and therefore no amputated part could be saved. The overall mean Revised Trauma Score (RTS) was 10.5; 3 in deaths and 11.9 in survivors. The mortality rate was 7/44 (16%). Cardiopulmonary arrest was present on admission in 1, and 6 patients died within 3 hours of arrival. In all mortalities, accidents were between 16:30-19:30. All deaths were resuscitated. In 5 patients, the cause of death was pelvic trauma leading to major vascular injury and lower limb amputation. In 1 patient, thorax and abdominal trauma and in 1 patient head injury were the causes of mortality. Causes of trauma in the mortal cases were trainmotor vehicle collision in 2 cases and train-pedestrian collision in 5 cases (Table 2). The remaining 37 survivors did not need resuscitation. Eighteen cases required liquid or blood products replacement therapy. Alcohol intoxication (100%), cardiopulmonary resuscitation on admittance (100%), recurrent suicide attempt (75%), presence of psychiatric illness (60%), and low RTS were related with high mortality. A total of 37 patients were discharged, 22 of them

from the emergency department. Of those 22 patients discharged from the emergency department, 16 had soft tissue injury and 6 had isolated bone fractures. These 6 isolated bone fractures were as follows: 2 closed extremity fractures, 2 pelvic fractures, 1 vertebra fracture, and 1 maxillofacial injury. Distribution of patients according to departments of hospitalization was as follows: 9 orthopedics and traumatology, 4 general surgery, 1 plastic and reconstructive surgery, and 1 neurosurgery. Mean duration of hospitalization was 15.7 (min 1-max 180) days.

DISCUSSION Train accidents have a high impact in both human and financial terms. Although train accidents result in no serious injury in general, they may cause death or high morbidity such as amputations of limbs.[7,11] In the United States, they cost more than $300 million. [11] Data regarding characteristics of train accidents are scarce. In this study, we present our experience with respect to the clinical features of train accidents and their outcomes, with the hope to contribute to the literature. In accordance with the previous studies, the majority of the accidents occurred during commuting hours, and the majority of the victims were male, implying that train accidents are closely related to being en route to business or during rush hours.[4,5,1217] A previous study from our region also reported a peak number of accidents during commuting hours.[18] Thirty-six cases (81%) were brought to the emergency department within 30 min. Delayed arrival was mostly due to transportation of victims from accidents occurring at stations remote from our hospital. Along with the improvement in ambulance services in our country during recent years, the lag time has considerably shortened with respect to that in the past, when the transportation of patients was largely dependent on non-organized transportation with private vehicles. Train-pedestrian collisions are less common than other forms of pedestrian accidents such as pedestrians-motor vehicle collisions on the roads. However, they are more likely to result in death or irreparable

Table 2. Causes of death Causes of death Train-motor vehicle collision Train-pedestrian collision a) Accidental fall while train was slowing down or gathering speed b) Suicide c) Train-pedestrian collision while accelerating Total 442

Death (n)

Death age

Male (n)

Male age

Female (n) Female age

2 5

33±16.9 39.8±14.5

2 4

33±16.9 37.7±15.9

– 1

– 48

1 3

48 38±20.2

– 3

– 38±20.2

1 –

48 –

1 7

37 37.8±14.1

1 6

37 36.1±14.6

– 1

– 48

Eylül - September 2011


10-year evaluation of train accidents

damage, such as extremity amputations or paralysis. [1,3,8,19,20] The kinetic energy transferred by a moving train to a pedestrian is proportional to the mass and velocity of the train. Therefore, an enormous amount of energy is transferred to the body during impact, resulting in massive injuries and a high mortality rate.[18] In accordance with the previous reports, falling from a train was a common form of train-pedestrian collision in our study population.[13,18,19] Accidents of this type mostly resulted in non-serious injuries, likely due to their occurrence before acceleration. This observation was supported by the findings of Goldberg et al.,[3] who reported that train accidents do not always cause considerable morbidity or mortality. The injuries as described by previous studies were mostly soft tissue injuries and uncomplicated bone fractures.[14,21-23] The mean mortality rate in our study was 16%. The highest mortality rate among the victims of train-motor vehicle collisions, at 100%, supports the findings of previous reports.[18,24] Meanwhile, the mortality rate among suicide attempts was 37.5%. Train accident-related fatalities vary between 12% - 75%, irrespective of whether the cause is a fall or suicide attempt. In our study, 4 of 5 (80%) suicidal cases had a history of psychiatric illness as well as of previous suicide attempts, suggesting a true suicide. Some intoxicated cases might be misleadingly reported as suicide, when in fact the fall may have been accidental.[1,15,18,19] Mortality and morbidity related with accidents usually correlate with MESS and Injury Severity Score (ISS).[3,13] We also found that RTS was positively correlated with mortality and morbidity. Pelvic trauma causing major vessel injury associated with lower limb amputations was the major cause of mortality in our study. Thirty-two percent (14/44) of our cases underwent amputations. Traumatic amputations are more common in train accidents than in motor vehicle accidents. Lower limb amputations are encountered mostly.[3-5,11] Amputation rates in the literature vary between 35% - 82%[3,5,16,23] and head, thorax and abdominal injuries to a lesser extent.[11] Amputations associated with higher MESS could not be saved.[3] Alcohol intake is common in train accidents. and intoxication is related with a mortality rate of 80%.[15] Although the frequency of alcohol intoxication was low in our study, with a rate of 4.5%, likely as a result of the low alcohol consumption in our population, among the 7 deaths, 2 of them were intoxicated (28%). Symonds[26] identified alcohol as a major risk factor, but he stated that alcohol contributed less in railway-related suicides than in non-railway related suicides. [1,5,7,13,15,17,23,25]

Authorities have been forced to take measures to improve railway safety.[18] Causes of train-pedestrian Cilt - Vol. 17 Sayı - No. 5

accidents vary with social, geographic and cultural backgrounds. Therefore, precautions to be taken need to be addressed on the basis of these factors. Trainpedestrian collisions can partially be reduced by environmental modifications such as warning devices and protection systems.[27,28] It was reported that unsafe behavior may be unintentional due to errors in perception, knowledge or judgement.[27,29] In fact, research on interventions to reduce trainpedestrian accidents is very limited. Various authors have proposed interventions such as limitation of pedestrian access to the rail corridor, public education about risk and illegality, or reward or punishment for safe and unsafe railway crossing behavior, as means to prevent unsafe pedestrian railway crossing behavior, but few have evaluated the efficacy of any of these interventions.[1,11] Rail safety education in school and punishment for every unsafe crossing were associated with significant decreases in unsafe crossing compared with that observed prior to any intervention. General discussions about rail safety were not associated with significant decreases in unsafe crossing.[17] In conclusion, mostly musculoskeletal injuries and amputations are seen in train accidents. It should be noted that these kinds of injuries could cause serious morbidity and mortality. To prevent accidents, public education should be continuous and preventive measures should be taken.

REFERENCES 1. Lerer LB, Matzopoulos R. Meeting the challenge of railway injury in a South African city. Lancet 1996;348:664-6. 2. Rautji R, Dogra TD. Rail traffic accidents: a retrospective study. Med Sci Law 2004;44:67-70. 3. Goldberg BA, Mootha RK, Lindsey RW. Train accidents involving pedestrians, motor vehicles, and motorcycles. Am J Orthop (Belle Mead NJ) 1998;27:315-20. 4. Agalar F, Cakmakci M, Kunt MM. Train-pedestrian accidents. Eur J Emerg Med 2000;7:131-3. 5. Shapiro MJ, Luchtefeld WB, Durham RM, Mazuski JE. Traumatic train injuries. Am J Emerg Med 1994;12:92-3. 6. Kligman MD, Knotts FB, Buderer NM, Kerwin AJ, Rodgers JF. Railway train versus motor vehicle collisions: a comparative study of injury severity and patterns. J Trauma 1999;47:928-31. 7. Moore TJ, Wilson JR, Hartman M. Train versus pedestrian accidents. South Med J 1991;84:1097-8, 1102. 8. Evans AW. Accidental fatalities in transport. J. Royal Stat Soc Series A (Statistics in Society) 2003;166:253-60. 9. Miller TR, Douglass JB, Pindus NM. Railroad injury: causes, costs, and comparisons with other transport modes. J Safety Research 1994;25:183-95. 10. Matzopoulos R, Peden M, Bradshaw D, Jordaan E. Alcohol as a risk factor for unintentional rail injury fatalities during daylight hours. Int J Inj Contr Saf Promot 2006;13:81-8. 11. Blazar PE, Dormans JP, Born CT. Train injuries in children. J Orthop Trauma 1997;11:126-9. 12. Bloch-Bogusławska E, Engelgardt P, Wolska E, Paradowska A. Analysis of deaths caused by rail-vehicles in the mate443


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rials collected by the Department of Forensic Medicine in Bydgoszcz in the years 1992-2002. Arch Med Sadowej Kryminol 2006;56:181-6. [Abstract] 13. Spaite D, Criss E, Valenzuela T, Meislin HW, Ogden JR. Railroad accidents: a metropolitan experience of death and injury. Ann Emerg Med 1988;17:620-5. 14. Kong LB, Lekawa M, Navarro RA, McGrath J, Cohen M, Margulies DR, et al. Pedestrian-motor vehicle trauma: an analysis of injury profiles by age. J Am Coll Surg 1996;182:17-23. 15. Cina SJ, Koelpin JL, Nichols CA, Conradi SE. A decade of train-pedestrian fatalities: the Charleston experience. J Forensic Sci 1994;39:668-73. 16. Chattar-Cora D, Tutela RR Jr, Daum AN, Cromack DT. Experience with railroad injuries at a major urban trauma center serving the United States-Mexico border. J Trauma 2007;62:1123-6. 17. Lobb B, Harré N, Terry N. An evaluation of four types of railway pedestrian crossing safety intervention. Accid Anal Prev 2003;35:487-94. 18. Ozdoğan M, Cakar S, Ağalar F, Eryilmaz M, Aytaç B, Aydinuraz K. The epidemiology of the railway related casualties. Ulus Travma Acil Cerrahi Derg 2006;12:235-41. 19. Nixon J, Corcoran A, Fielding L, Eastgate J. Fatal and nonfatal accidents on the railways-a study of injuries to individuals, with particular reference to children and to nonfatal trauma. Accid Anal Prev 1985;17:217-22.

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20. Smith G. Incidents involving trains. J Emerg Care 1995;2:304. 21. Singer G, Thordarson D. Train-versus-pedestrian injuries. Orthopaedic management. Orthop Rev 1994:Supp:30-4. 22. Isenberg JS. Boxcar heel: an unusual etiology of hindfoot amputation requiring microvascular reconstruction. J Foot Ankle Surg 1998;37:165-8. 23. Moody DE, Crouch DJ, Smith RP, Cresalia CW, Francom P, Wilkins DG, et al. Drug and alcohol involvement in railroad accidents. J Forensic Sci 1991;36:1474-84. 24. Gitelman V, Hakkert AS. The evaluation of road-rail crossing safety with limited accident statistics. Accid Anal Prev 1997;29:171-9. 25. Pelletier A. Deaths among railroad trespassers. The role of alcohol in fatal injuries. JAMA 1997;277:1064-6. 26. Symonds RL. Psychiatric and preventative aspects of rail fatalities. Soc Sci Med 1994;38:431-5. 27. Ward NJ, Wilde GJ. Field observation of advance warning/ advisory signage for passive railway crossings with restricted lateral sightline visibility: an experimental investigation. Accid Anal Prev 1995;27:185-97. 28. Wigglesworth EC. A human factors commentary on innovations at railroad-highway grade crossings in Australia. J Safety Research 2001;32:309-21. 29. Lobb B, Harre N, Suddendorf T. An evaluation of a suburban railway pedestrian crossing safety programme. Accid Anal Prev 2001;33:157-65.

Eylül - September 2011


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):445-449

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.55649

Kadınların başına gelen ev kazaları ve ilk yardım bilgi düzeyleri Domestic accidents involving women and first aid knowledge Mustafa SERİNKEN,1 İbrahim TÜRKÇÜER,1 Özgür KARCIOĞLU,2 Semih AKKAYA,3 Emrah UYANIK1 AMAÇ

BACKGROUND

Ev kazaları (EK), bir evin içinde veya bahçesinde, havuzunda veya garajında meydana gelen, çoğunlukla önlenebilir kazalardır. Ülkemiz için önemli bir halk sağlığı sorunudur. Bu çalışmada amaç, ülkemizde yetişkin kadınların EK ile ilişkili profilini ve bilgi düzeylerini ortaya koymaktır.

Domestic accidents (DA) are preventable and untoward events occurring in a house, pool or garage. Those events constitute a major issue in the context of public health. The objective of this study was to highlight the characteristics of female involvement in DA and their level of knowledge regarding first aid.

GEREÇ VE YÖNTEM

METHODS

Altı aylık zaman diliminde bir üniversite acil servisine gelen kadın hasta yakınları çalışma grubunu oluşturdu. Katılımcılara daha önceden hazırlanmış olan ve 23 sorudan oluşan çalışma anket formundaki soruları cevaplandırmaları istendi.

Adult female relatives of patients presenting at the university-based emergency department within the six-month study period comprised the study sample. They were asked to answer a 23-item self-reported questionnaire, and the responses were analyzed.

BULGULAR

RESULTS

Çalışma süresince 1017 kadın çalışmaya dahil edildi. Yaş ortalamaları 29,2±11,1 olarak belirlendi. Sırasıyla, sıklıkla el kesileri (n=924, %90,8), burkulma-incinmeler (n=904, %88,8) ve yanıklar (n=803, %78,9) en sık bildirilen EK’lar idi. Çarpma, burkulma ve incinme tarzı yaralanmaların çocukların başına gelen en sık EK olduğu (n=478, %91,7), bunu düşme ve kaymaların (n=452, %86,7) takip ettiği saptandı. Ambulansın en çok bilinen (n=871, %85,6), zehir danışmanın en az bilinen (n=48, %4,7) numaralar olduğu belirlendi. Eğitim düzeyi yüksek olan kadınların diğerlerine oranla doğru yanıt sayıları anlamlı yüksek bulundu (p=0,001). Çalışan kadınların bilgi düzeyi, çalışmayanlarla karşılaştırıldığında ise anlamlı düşük bulundu (p=0,02).

A total of 1017 women (mean age: 29.2±11.1 years) were enrolled in the study. Hand lacerations (n=924, 90.8%), sprain and contusions (n=904, 88.8%) and burns (n=803, 78.9%) were the most commonly reported types of DA. The children were reported to suffer mostly from hits, sprains and contusions (n=478, 91.7%), followed by falls and slipping (n=452, 86.7%). The telephone number of emergency medical services was recalled most frequently (n=871, 85.6%), while that of the poison control center was known least commonly (n=48, 4.7%). The group with the highest level of education had a significantly higher mean number of correct answers than that of the group with the lowest level of education (p=0.001). The knowledge level of the women who worked was significantly lower than that of the unemployed women (p=0.02).

SONUÇ

Ev kazaları konusunda kadınlara yönelik yaygın kurslar planlanmalı ve bu amaçla görsel medyadan yararlanılmalıdır.

CONCLUSION

Anahtar Sözcükler: Eğitim düzeyi; ev kazaları; ilk yardım; kadınlar.

Key Words: Knowledge levels; domestic accidents; first aid; women.

Pamukkale Üniversitesi Tıp Fakültesi, 1Acil Tıp Anabilim Dalı, Ortopedi ve Travmatoloji Anabilim Dalı, Denizli; 2Acıbadem Üniversitesi, Acil Tıp Anabilim Dalı, İstanbul.

Departments of 1Emergency Medicine, 3Orthopedics and Traumatology, Pamukkale University Faculty of Medicine, Denizli; Department of Emergency Medicine, Acıbadem University, Istanbul, Turkey.

3

Extensive training of women on DA should be undertaken and the mass media should be utilized to achieve this goal.

İletişim (Correspondence): Dr. Mustafa Serinken. Pamukkale Üniversitesi Tıp Fakültesi Hastanesi Acil Servisi, 20070 Kınıklı, Denizli, Turkey. Tel: +90 - 258 - 212 71 94 e-posta (e-mail): mserinken@hotmail.com

445


Ulus Travma Acil Cerrahi Derg

Ev kazaları, bir evin içinde veya bahçesinde, havuzunda veya garajında meydana gelen, çoğunlukla önlenebilir kazalardır. Ülkemiz için önemli bir halk sağlığı sorunudur. Kaza nedeniyle ölümlerin %25’i evlerde meydana gelmekte, ayrıca tüm yaralanmaların %54’ünü ev kazaları oluşturmaktadır.[1] Kazaların sosyal yönü yanında neden olduğu ekonomik kayıplarda büyük boyutlardadır. Örneğin İtalya’da her yıl acil servislere 1,5 milyon ev kazası başvurusu olmakta ve bunların 130 bin’i hastaneye yatırılmaktadır.[2] Çocuklarda görülen kazaların büyük kısmı evde meydana gelmektedir.[3] Yapılan bir çalışmada, okul öncesi çocuklar, 30-40 yaş arası erkekler ve 60 yaş üzeri kadınlar ev kazaları yönünden yüksek risk grubunu oluşturmuştur.[2] Ev kazaları çeşitli faktörlere bağlı olarak meydana gelebilir. Kaza oluşumunda etkili nedenler, güvensiz koşullar (çevre faktörü) ve güvensiz davranışlar (insan faktörü) olmak üzere iki gruba ayrılarak incelenmektedir. Ev kazalarının nedenleri arasında insan faktörü birinci sırada, çevresel düzensizlikler ikinci sırada yer almaktadır.[4] Bu çalışmada, kadınların başına gelen ev kazalarının özellikleri ve bu kazalar karşısında ilk yardım bilgi düzeylerinin nasıl olduğu araştırılmış, sorunun çözümüne yönelik veriler elde edilmeye çalışılmıştır. Çalışma verileri, ilimizde ev kadınlarına yönelik olarak yapmayı planladığımız bir kursla ilgili, eğitim konularının belirlenmesi ve kadınların bu konudaki beklentilerine ışık tutmuştur.

GEREÇ VE YÖNTEM Kesitsel tipteki bu araştırmada, 1 Temmuz 2009 - 1 Aralık 2009 tarihleri arasındaki 6 aylık zaman diliminde bir üniversite acil servisine gelen kadın hasta yakınları çalışma grubunu oluşturdu. Çalışmanın amacı açıklandıktan sonra anket sorularını yanıtlamayı kabul edenlerin tümü çalışmaya alındı. Çalışmaya katılmayı kabul etmeyen, kabul eden fakat soruları cevaplarken herhangi bir nedenle anketi yarıda bırakan ve 15 yaşından küçük olan kadınlar çalışma dışı bırakıldı. Katılımcıların daha önceden hazırlanmış olan ve 23 sorudan oluşan çalışma anket formundaki soruları cevaplandırmaları istendi. Bu sorulardan 10’u sosyodemografik verileri elde etmeye yönelikti. On üç tanesi ise ilk yardım bilgi düzeylerine yönelik çoktan seçmeli sorulardan oluşturuldu. Öncesinde çalışmayı katılmayı kabul eden fakat soruları cevaplarken herhangi bir nedenle anketi yarıda bırakan kadınlar çalışma dışı bırakıldı. Çalışmadan elde edilen tüm veriler, “SPSS for Windows 11” adlı standart programa kaydedildi ve değerlendirmeleri yapıldı. Sayısal değişkenler ortalama ± SD, kategorik değişkenler sayı ve yüzde olarak özetlendi. İstatiksel analizlerde t test ve ANOVA kullanıldı. p<0,05 değeri anlamlı kabul edildi. 446

BULGULAR Çalışma süresince acil servise hasta yakını olarak gelen toplam 1195 kadın hasta yakını ile görüşüldü. Çalışma kriterlerine uyan ve katılmayı kabul eden 1017 kadın çalışmaya dahil edildi (%85,1). Yaş ortalamaları 29,2±11,1 (dağılım, 15-62 yaş) olarak belirlendi. Kadınların medeni durumları; 644’ü evli (%63,3), 269’u bekar (%26,5) ve 104’ü (%10,2) dul veya ayrı yaşıyor olarak saptandı. Katılımcıların %4,2’si ilköğretim, %28,4’ü ortaokul, %45,2’si lise ve %22,2’si üniversite mezunu idi. Katılımcılar içinde çalışan kadın sayısı 376 (%36,9) olarak belirlendi. Kadınların 521’i (%51,2) bir veya daha fazla çocuğa sahip olduğunu belirtti. Katılımcıların bildirdikleri, son bir yılda evde kendi başlarına gelen ev kazaları ve oranları Tablo 1’de verildi. En sık el kesileri ile karşılaştıkları belirlendi (n=924, %90,8). Bir başka soruda da çocuklu kadınlarda, son bir yılda çocuklarının başına gelen ev kazaları sorgulandı. Çarpma, burkulma ve incinme tarzı yaralanmaların çocukların başına gelen en sık ev kazaları olduğu (n=478, %91,7), bunu düşme ve kaymaların (n=452, %86,7) takip ettiği belirlendi (Tablo 2). İlk yardım bilgi düzeyini belirlemeye yönelik sorularda, ilk olarak önemli bazı telefon numaraları soruldu. Ambulansın en çok bilinen (n=871, %85,6), zehir danışmanın en az bilinen (n=48, %4,7) numaralar olduğu belirlendi (Tablo 3). Diğer 12 soruya katılımcıların verdikleri yanıtlar, Tablo 4’de sunuldu. Katılımcılar tarafından en az doğru yanıt verilen boğulmalarda ilkyardım uygulaması ile ilgili soruydu (n=355, Tablo 1. Katılımcıların kendi başına gelen ev kazaları ve oranları (n=1017) Belirtilen ev kazaları El kesisi Burkulma, incinme Direk ısıyla yanık (ütü, soba vb.) Düşmeler ve kaymalar Sıvı ile yanık (su, çay vb.) Böcek, arı sokması Ayağa keskin cisim batması Elde delici tarzda yaralanma Elektrik çarpması Hayvan ısırığı Yangın, dumandan etkilenme Göze kimyasal madde kaçması Boğaza kılçık ya da katı cisimlerin kaçması CO2 zehirlenmesi Klorin gazı inhalasyonu Gıda zehirlenmesi Tüp gazdan etkilenme Diğer

n

%

924 904 803 679 648 617 411 226 172 132 111 87 81 62 43 39 24 41

90,8 88,8 78,9 66,7 63,7 60,6 40,4 22,2 16,9 13,0 10,9 8,5 7,9 6,0 4,2 3,8 2,3 4,0

Eylül - September 2011


Kadınların başına gelen ev kazaları ve ilk yardım bilgi düzeyleri

Tablo 2. Katılımcıların çocuklarının başına gelen ev kazaları ve oranları (n=521) Belirtilen ev kazaları Çarpma, burkulma, incinme, Düşmeler ve kaymalar Böcek, arı sokması Sıvı ile yanık (su, çay vb) Direk ısıyla yanık (ütü,soba vb) El kesisi Hayvan ısırığı Ayağa keskin cisim batması Temizlik maddeleri ile temas Boğaza kılçık ya da katı cisimlerin kaçması Gıda zehirlenmesi Diğer

n

%

478 452 387 311 246 221 134 121 75 23 14 32

91,7 86,7 74,3 59,7 47,2 42,4 25,7 23,2 14,4 4,4 2,7 6,1

Tablo 3. Önemli telefon sorularına verilen yanıtlar

Hatırlamıyorum Yanlış cevap Doğru cevap n

%

İtfaiye 173 17,0 Ambulans 70 6,9 Polis 222 21,8 Zehir danışma 877 86,2

n

%

n

%

297 76 176 92

29,2 7,5 17,3 9,1

547 871 619 48

53,8 85,6 60,9 4,7

%34,9). Bunu bilincini kaybeden hastaya yapılması gereken ilk yardım uygulaması ile ilgili soru takip etti (n=400, %39,3). Katılımcılar içinde tüm sorulara doğru yanıt veren olmamış, 11 soruya dogru yanıt veren

332 kişi, 10 soruya dogru yanıt veren 389 kişi olduğu belirlenmiştir. Tüm grubun ortalama doğru cevap sayısı 7,9±3,1 olarak belirlendi. Eğitim düzeyi yüksek olan kadınların diğerlerine oranla doğru yanıt sayıları anlamlı yüksek bulundu (p=0,001). Çalışan kadınların bilgi düzeyi, çalışmayanlarla karşılaştırıldığında ise anlamlı düşük bulundu (p=0,02). Anketin sonunda katılımcıların ev kazalarına yönelik ilk yardım eğitim kursları düzenlenmesi ile ilgili görüşleri araştırıldı ve “böyle bir eğitim düzenlenirse katılırım” diyen kadınların çoğunlukta olduğu görüldü (n=846, %83,2). Bu kadınlara “eğitimlerin nasıl olmasını istersiniz” diye açık uçlu bir soru da soruldu. Ücretsiz olması (n=951, %93,5) ve gece saatlerinde olması (n=685, %67,4) en sık bildirilen yanıtlardı. Diğer taraftan bu konularda kendi bilgi düzeyini yeterli gören kadın sayısı 215 (%21,1) olarak belirlendi. Tüm katılımcılara ev kazaları ile ilgili var olan ilk yardım bilgilerini en çok nereden edindikleri sorulduğunda 831 (%81,7) kişi televizyon yanıtı verdi.

TARTIŞMA Bu çalışmada, kadınların evlerde sıklıkla el kesileri, burkulma ve incinme tarzı yaralanmalarla karşılaştığı, eğitim düzeyi yüksek olan kadınların ilk yardım bilgi düzeylerinin de yüksek olduğu, çalışan kadınların ev hanımlarına oranla daha az bilgi düzeyine sahip olduğu, kadınların ev kazaları ile ilgili edinilmiş bilgi ve tecrübelerinde, televizyon programlarının önemli bir yer tuttuğu belirlenmiştir. Katılımcıla-

Tablo 4. İlk yardım bilgi soruları ve verilen yanıtlar Sorular 1. Elinizi kaynar su ile yaktınız. Aşağıdakilerden hangisini yapmazsınız? 2. Sandalyeden düşüp kafasını yere çarpan çocuklar için hangisi doğrudur? 3. Yemek yerken nefes borusunda tıkanıklık olup nefes alamayan kişiye yapılacak ilkyardım uygulaması için aşağıdakilerden hangisi doğrudur? 4. Mutfakta kırılan cam tabak elinizi kesti ve kanamaya başladı. İlkyardım uygulaması için aşağıdakilerden hangisi doğrudur? 5. Çocuğunuzun ayağı kayıp kolunun üzerine düştü ve kolunda şişlik, şekil bozukluğu ve şiddetli ağrı oluştu. İlkyardım uygulaması için aşağıdakilerden hangisi yanlıştır? 6. Elektrik çarpması durumundan yapılması gereken ilkyardım uygulamaları ile ilgili olarak aşağıdakilerden hangisi yanlıştır? 7. Köpek ya da kedi tarafından ısırılma durumunda yapılması gerekenlerle ilgili olarak aşağıdakilerden hangisi yanlıştır? 8. Banyoda küvette oynarken suyun içine batan ve boğulma tehlikesi atlatan çocukta ilkyardım uygulamaları ile ilgili olarak aşağıdakilerden hangisi doğrudur? 9. Arı sokması durumunda yapılacak ilkyardım uygulamaları ile ilgili olarak aşağıdakilerden hangisi doğrudur? 10. Kaza ile temizlik maddesi (klorak vb) içen bir çocuğa ilkyardım uygulamaları ile ilgili olarak aşağıdakilerden hangisi yanlıştır? 11. Bilincini kaybeden kişiye yapılması gerekenlerle ilgili olarak aşağıdakilerden hangisi doğrudur? 12. Soba zehirlenmeleri ile ilgili aşağıdakilerden hangisi yanlıştır? Cilt - Vol. 17 Sayı - No. 5

Doğru

Yanlış

Boş

63,9 75,1

28,0 17,0

8,1 7,9

41,9

45,1

13,0

72,0

21,0

7,0

65,9

29,5

4,6

58,0

31,5

10,5

49,5

37,8

12,7

34,9

43,1

22,0

68,8

16,9

14,3

57,7

12,2

30,1

39,3 76,7

31,9 14,9

28,8 8,4 447


Ulus Travma Acil Cerrahi Derg

rın büyük bir bölümü, ücretsiz ve gece saatlerinde olması tercihiyle, ev kazalarına yönelik bir eğitime katılabileceğini bildirmiştir. Çalışmamızda kadınların, el kesileri, burkulmaincinme, yanık ve düşme-kayma şeklinde ev kazalarına daha çok maruz kaldığını görülmüştür. Ülkemizde ve diğer ülkelerde kadınların başına gelen ev kazalarına yönelik araştırmalar sınırlı sayıdadır. İtalya da ev kazaları nedeniyle yapılan acil servis başvurularını araştıran bir çalışmada, bizim çalışmamızla benzer şekilde en sık yaralanma-incinme, ezilmelerin görüldüğü, el ve el bileğinin en fazla etkilenen anatomik bölge olduğu bildirilmiştir.[2] Ülkemizde, Sütoluk ve arkadaşlarının[5] bir üniversite hastanesi acil servisine ev kazaları başvurularını inceledikleri çalışmada, ilk sırada düşmelerin daha sonra delici-kesici alet yaralanmaları ile yanmaların sıklıkla görüldüğünü, ayrıca yaşlılarda erişkin yaş gruplarına göre düşmelerin daha fazla oranda olduğunu bildirmişlerdir. Panatto ve arkadaşlarının[6] yaşlı popülasyonda yaptığı çalışmada ise yaralanmalara bağlı çürükler, kırıklar ve kesilerin daha sık görüldüğü saptanmıştır. Bu sonuçlardan çalışmanın yapıldığı popülasyondaki yaş gruplarına göre kaza ve yaralanma şeklinin değiştiği sonucuna ulaşmak mümkün olmaktadır. Çünkü yaşlılar ve çocuklarda düşmeler sık görülürken, erişkin yaş grubunda özellikle kadınlarda ise kesi, burkulma-incinme daha sık görülmektedir. Bhanderi ve arkadaşlarının[7] yaptığı çalışmada ev kazalarının sıklıkla sabah ve akşam saatlerinde meydana geldiği, çocuk ve yaşlılar ile kadın cinsiyeti etkilediği bildirilmiştir. Ayrıca ev kazalarına bağlı hastaneye başvuruların yüksek oranda olduğu tespit edilmiştir. Panatto ve arkadaşları[6] ile Majori ve arkadaşlarının[2] yaptıkları çalışmalarda yaşlı popülasyonda kırıklar, kafa travmaları gibi ciddi yaralanmalara yol açan kazaların meydana geldiği bildirilmiştir. Çocuk yaş grubunda ev kazalarına yönelik yapılan çalışmalarda ise düşmelerin en sık karşılaşılan kazalar olduğu, çocukların başına gelen kazaların büyük çoğunluğunun ebeveyn gözetimi altında iken gerçekleştiği saptanmıştır.[8,9] Ayrıca çocuklarda oluşan yaralanmaların %5’inin hastaneye yatışı gerektirdiği belirtilmiştir.[3] Ülkemizde yapılan diğer bir çalışmada da çocuklarda en sık düşme-kayma, yanma-haşlanmanın görüldüğü bildirilmiştir.[10] Bizim çalışmamızda da çocukların başına sıklıkla burkulma-incinme, düşme-kayma, böcek-arı sokması ve yanık gibi durumların geldiği tespit edilmiş olup diğer çalışmalarda belirtilenin aksine düşmeler ikinci sırada yer almaktadır. Çalışmamızın ilk yardım bilgi düzeylerini ölçmeye yönelik bölümünde ise, karbon monoksit zehirlenmesi, kafa travması, kanamalar, böcek-arı sokması, kırıkçıkıklarda da ilk yardım uygulamaları ilgili sorulara katılımcıların yüksek oranda doğru yanıt verdiği tes448

pit edilmiştir. Bu kazaların, yazılı ve görsel medyada yer alan haber ve programlarda daha fazla irdelenmesi nedeniyle doğru cevap oranlarının olumlu etkilendiğini düşünüyoruz. Karbon monoksit zehirlenmeleri, böcek-arı sokmaları, zehirlenmeler gibi konular doğurduğu dramatik sonuçlar nedeniyle kadınlar tarafından daha fazla ilgi görüyor olabilir. Tüm bunlara rağmen, katılımcıların telefon numaraları içinde en az zehir danışma merkezinin numarasını bilmeleri (%4,7) ilginçtir. Henüz kadınlar arasında, zehir danışma merkezlerinin çok fazla bilinmediği ve dolayısıyla kullanılmadığı sonucu çıkartılabilir. Katılımcıların, bilinç kaybı, boğulma ve yanık ile ilgili olan sorularda yanlış cevap oranlarının yüksek olduğu belirlenmiştir. Özelikle yanık olmak üzere, bu sorularda kadınların geleneksel kulaktan dolma bilgilerin etkisinde daha fazla kalması bu sonuçları doğurmuş olabilir. İlkyardım yaparken ne yapılacağı kadar nelerin yapılmasından kaçınılması gerektiği de önemlidir. Diğer bir ifadeyle ilk yardım, bazı uygulamaları yapma bazılarının ise yapılmasını engelleme ya da yapmaktan kaçınma becerisidir.[4,11] Bunun için çalışmamızda ilk yardım ile ilgili sorular, yapılması ve yapmaktan kaçınılması gereken durumlara yönelik olarak hazırlanmıştır. Böylece kişinin sahip olduğu ilk yardım bilgi düzeyinin yanında yanlış uygulamalar hakkında da bilgi sahibi olarak ilk yardım yapma konusunda farkındalık oluşmasına katkı sağlanacağı öngörülmüştür. Kadınlara ev kazalarına yönelik hazırlanacak eğitimlerde, halk arasında yaygın kabul gören geleneksel ve yanlış uygulamalardan kaçınılması, kaynak gözetilerek görsel ve yazılı medyada da yer alan bilgilere daha çok güvenilmesi vurgulanmalıdır. Çalışmamızda katılımcılara ev kazaları ilgili ilk yardım bilgilerini en fazla nereden edindikleri ile ilgili soruya %81,7 gibi yüksek oranda televizyon yanıtı alınmıştır. Televizyon programlarının tüm toplum kesimlerine hitap ettiği düşünüldüğünde olumlu yönde kullanıldığında ne kadar etkin bir eğitim aracı olduğu görülecektir. Çalışmamızda, çalışan kadınların ev kazalarına yönelik bilgi düzeyinin düşük olması, çalışmanın yapıldığı il genelinde kadınların sıklıkla tekstilde istihdam edilmeleri ve bu kadınların genellikle eğitim düzeylerinin çok yüksek olmaması ile açıklanabilir. Bu sonuçun bir diğer nedeni ise, çalışan kadınların televizyonda bu tür programların yayın saatlerinde işte olması olabilir. Televizyonlarda bu tür sağlık konulu programlar ev hanımları dikkate alınarak, gündüz 10:00-16:00 saatlerinde yayınlanmaktadır. Bu programların, ticari kaygılardan ziyade bir eğitim aracı olarak kullanılması hedefleniyorsa yayın saatlerinin yeniden gözden geçirilmesi düşünülebilir. Yapılan araştırmalarda ilk yardım bilgi düzeyinin bireylerin eğitim durumundan etkilendiği ve eğitim seviyesi yükseldikçe arttığı bildirilmiştir.[12-14] Coşkun Eylül - September 2011


Kadınların başına gelen ev kazaları ve ilk yardım bilgi düzeyleri

ve arkadaşları[13] 0-14 yaş arası çocuğu olan annelerde, Uskun ve arkadaşları[4] ev hanımlarında yaptıkları çalışmalarında eğitim durumu arttıkça ilk yardım bilgi düzeylerinin de arttığını saptamışlardır. Ayrıca çalışan kadınların bilgi düzeylerinin çalışmayanlara göre daha yüksek olduğu saptanmıştır.[4] Bizim çalışmamızda da eğitim seviyesi ile sorulara verilen doğru cevap oranlarının uyumlu olduğu belirlendi. İlk yardımı herkesin her koşulda yapması gerektiği düşünüldüğünde ilk yardım eğitimlerinin toplumun her kesimini içine alacak şekilde yaygınlaştırılması gerekmektedir. Bu çalışmada, kadınların maruz kaldıkları ev kazalarını araştırmak için, ulaşma kolaylığı nedeniyle acil servise hastalarını getiren hasta yakınları örneklem olarak seçilmiştir. Biz çalışma süresini uzun tutarak, çalışma grubumuzun geniş olması sağladık fakat yine de belirlediğimiz bu grubun genel popülasyonu ne ölçüde temsil ettiği tartışmalıdır. Çalışmamızın bir başka kısıtlığı, elde edilen verilerinin acil servis gibi stresli bir ortamda elde edilmiş olmasıdır. Yapılacak olan benzer anket çalışmalarının, ev gibi daha rahat ortamlarda gerçekleştirilmesi verilerin daha sağlıklı olmasını sağlayabilir.

SONUÇ Tüm dünya ülkelerinde ev kazaları önemli bir halk sağlığı sorunudur. Toplumumuzda kadınlar geleneksel konumları gereği ailede önemli görevler üstlenmektedir. Evde erkeklerden daha fazla zaman geçirdikleri düşünüldüğünde, ev kazalarının önlenmesi ve ilkyardım uygulamalarında kadınların rolü daha iyi anlaşılacaktır.[2] Bundan dolayı çalışan ya da çalışmayan tüm kadınların ilkyardım bilgi düzeylerinin yeterli seviyede olması ilk yardım uygulamalarının etkinliğini artıracak ve olumsuz sonuçları en aza indirecektir. Sonuç olarak ev kazaları konusunda kadınlara yönelik kurslar planlanmalı ve görsel medyanın daha doğru kullanımı konusunda hassasiyet gösterilmelidir. KAYNAKLAR 1. Kılıç B, Meseri R, Sönmez Y, Kaynak C, Demiral Y, Ergör A. Ev kazaları ve etkileyen etmenler. Sendrom 2006;18:68-74. 2. Majori S, Ricci G, Capretta F, Rocca G, Baldovin T, Buono-

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core F. Epidemiology of domestic injuries. A survey in an emergency department in North-East Italy. J Prev Med Hyg 2009;50:164-9. 3. Sarto F, Roberti S, Renzulli G, Masiero D, Veronese M, Simoncello I, et al. Domestic accidents: a study on children attending the emergency department of the city of Padua. Epidemiol Prev 2007;31:270-5. [Abstract] 4. Uskun E, Alptekin F, Oztürk M, Kişioğlu AN. The attitudes and behaviors of housewives in the prevention of domestic accidents and their first aid knowledge levels. Ulus Travma Acil Cerrahi Derg 2008;14:46-52. 5. Sütoluk Z, Savaş N, Demirhindi H, Özdener N, Akbaba M. Çukurova Üniversitesi Tıp Fakültesi büyük acil servisine ev kazaları nedeniyle başvuranların etiyolojik ve demografik özellikleri. Toplum Hekimliği Bülteni 2007;26:29-34. 6. Panatto D, Gasparini R, Vitale A, Sasso T, Lugarini J, Cremonesi I, et al. Survey of domestic accidents in the elderly in the Province of Genoa (northern Italy). J Prev Med Hyg 2009;50:53-7. 7. Bhanderi DJ, Choudhary S. A study of occurrence of domestic accidents in semi-urban community. Indian J Community Med 2008;33:104-6. 8. Atak N, Karaoğlu L, Korkmaz Y, Usubütün S. A household survey: unintentional injury frequency and related factors among children under five years in Malatya. Turk J Pediatr 2010;52:285-93. 9. Erkal S. Identification of the number of home accidents per year involving children in the 0-6 age group and the measures taken by mothers to prevent home accidents. Turk J Pediatr 2010;52:150-7. 10. Köse Ö, Bakırcı N. Çocuklarda ev kazaları. STED 2007;16:31-5. 11. Güler Ç, Bilir N. Temel ilkyardım. Çevre Sağlığı Temel Kaynak Dizisi No:17. Ankara: T.C. Sağlık Bakanlığı Temel Sağlık Hizmetleri Genel Müdürlüğü; 1994. s. 31. 12. Altundağ S, Oztürk MC. The effects of home safety education on taking precautions and reducing the frequency of home accidents. Ulus Travma Acil Cerrahi Derg 2007;13:180-5. 13. Coşkun C, Özkan S, Maral I. Çankırı Eldivan ilçe merkezi’nde 0-14 yaşlar arasında çocuğu olan annelerin ilkyardım bilgi düzeyleri ve ilkyardım gerektiren durumların sıklığı. IX. Halk Sağlığı Kongresi, Bildiri Özet Kitabı, 3-6 Kasım 2004; Ankara: 2004. s. 11. 14. Kendrick D, Pritchard A, Cloke J, Barley M. Randomised controlled trial assessing the impact of increasing information to health visitors about children’s injuries. Arch Dis Child 2001;85:366-70.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):450-454

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.47124

Karın içi ateşli silah yaralanmalarında komplikasyon oranlarını etkileyen faktörler The affecting factors on the complication ratio in abdominal gunshot wounds Hüseyin TAŞ,1 Ayhan MESCİ,2 Mehmet ERYILMAZ,3 Nazif ZEYBEK,2 Yusuf PEKER2

AMAÇ

BACKGROUND

Çatışma bölgelerinde meydana gelen karın içi ateşli silah yaralanmalarında (KASY) komplikasyon oranlarını etkileyen faktörler değerlendirildi.

We aimed to investigate the affecting factors on the complication ratio in abdominal gunshot wounds.

GEREÇ VE YÖNTEM

Twenty-one patients with abdominal gunshot wounds were analyzed between February 2002 and May 2005. The effects of the interval between trauma and presentation to the hospital, the number of injured abdominal and extraabdominal organs, penetrating abdominal trauma index (PATI), and blood transfusion were evaluated.

Şubat 2002 - Mayıs 2005 tarihleri arasında yüksek kinetik enerjili KASY’li 21 hasta incelendi. Travma-hastane intervali, yaralanan karın içi organ ve sayısı, yaralanan ekstraabdominal organ sayısı, penetran abdominal travma indeksi (PATİ) ve kan transfüzyonu miktarının komplikasyon oranlarına etkisi geriye dönük olarak değerlendirildi. BULGULAR

Hastaların %90,4’ünün ilk iki saat içerisinde transportu gerçekleştirilerek ilk girişimlerine başlandı. Yaralanan organ sayısı <3 olan hastalarda %7,1, ≥3 olanlarda ise %71 oranında komplikasyon gelişti (p<0,0001). Hastaların %71,4’ünde (n=15) izole karın yaralanması, %28,6’sında (n=6) ek olarak ekstra-abdominal organ yaralanması vardı. PATİ skoru <25 olan 13 hastada %7,7, ≥25 olan 8 hastada ise %62,5 oranında komplikasyon geliştiği görüldü (p<0,0001). ≥3 Ü kan transfüzyonu yapılan %47,6 (n=10) hastanın %50’inde (n=5) komplikasyon tespit edildi (p<0,0001). SONUÇ

METHODS

RESULTS

90.4% of all patients were transported to the hospital and underwent their first evaluation in the first two hours. The complication rate was 7.1% in patients who had <3 injured organs and 71% in the others (p<0.0001). 71.4% of the patients had isolated abdominal trauma, while 28.6% had additional extra-abdominal organ trauma. The complication rate was 7.7% in 13 patients with PATI score <25 and 62.5% in 8 patients with a PATI score ≥25 (p<0.0001). In 10 patients who underwent blood transfusion of ≥3 units, the complication rate was 50% (p<0.0001). CONCLUSION

Çalışmamızda KASY’de PATİ skoru, multipl kan transfüzyonu ve yaralanan karın içi organ sayısı ameliyat sonrası dönemde gelişebilecek komplikasyon oranlarını etkileyen en önemli faktörlerken, travma-hastane intervali ile yaralanan ekstra-abdominal organ sayısının komplikasyon oranlarına etkisi istatistiksel olarak anlamlı bulunmadı.

In our study, PATI score, multiple blood transfusions and the number of injured intra-abdominal organs were the most important factors affecting the rate of postoperative complications in penetrating abdominal gunshot wounds. We found that the interval between trauma and presentation to the hospital and number of injured extra-abdominal organs did not affect the complication rate.

Anahtar Sözcükler: Ateşli silah yaralanmaları; penetran karın travma indeksi; komplikasyon oranları.

Key Words: Gunshot wounds; penetrating abdominal trauma index; complication rate.

1 Şırnak Askeri Hastanesi, Genel Cerrahi Kliniği, Şırnak; Gülhane Askeri Tıp Akademisi, 2Genel Cerrahi Anabilim Dalı, 3 Acil Tıp Anabilim Dalı, Ankara.

Department of General Surgery, Şırnak Military Hospital, Şırnak; Departments of 2General Surgery, 3Emergency Surgery, Gülhane Military Medical Academy, Ankara, Turkey.

1

İletişim (Correspondence): Dr. Hüseyin Taş. GATA Lojmanları, Serter Apartmanı, No: 3, Etlik, Ankara, Turkey. Tel: +90 - 312 - 304 20 00 e-posta (e-mail): drhuseyintas@gmail.com

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Karın içi ateşli silah yaralanmalarında komplikasyon oranlarını etkileyen faktörler

Çatışma bölgelerinde meydana gelen karın içi ateşli silah yaralanmaları (KASY) hem tanı hem de tedavi alanlarındaki yeniliklere rağmen halen yüksek mortalite ve morbidite oranlarına sahiptir. Bunun en önemli nedeni bu tür yaralanmalara neden olan yüksek kinetik enerji taşıyan mermi ve patlayıcı silah parçalarının karın içinde ilerlerken blast etkisine (geçici kavite) bağlı olarak etraf dokulara da zarar verebilmesidir.[1,2] Ayrıca yüksek kinetik enerjili silahların kalıcı ve geçici kavite etkileri dışında karın içinde ilerlerken kemik dokulara çarpması sonucu hem yön değiştiren mermi parçalarının (primer fragmantasyon) hem de parçaladığı kemik dokuların etkileri (sekonder fragmantasyon) ile verdikleri hasar artmaktadır. Bu nedenle hastalardaki gerçek yaralanmanın boyutu ile gelişebilecek komplikasyonları tahmin etmekte son derece güçleşmektedir. [3,4] Bu tür travmalardaki hem mortalite hem de morbidite oranlarını belirleyebilmek için birtakım skorlama yöntemleri geliştirilmiştir ki bunlardan penetran karın travmalarında en yaygın kullanılanı penetran abdominal travma indeksidir (PATİ).[5] Dünyanın birçok bölgesinde olduğu gibi ülkemizde de karşılaştığımız penetran travmalarda karın içi organlarda hasar oluşma oranı %90’ların üzerindedir.[6] Travma- başvuru intervalinin ≥6 saat, şok varlığı, ameliyat süresinin ≥6 saat, PATİ >25, karın içi yaralanan organ sayısı >2, ekstra-abdominal yaralanan organ sayısı >2 ve multipl kan transfüzyonu, penetran karın travmalarında komplikasyon oranını artırdığı bilinmektedir.[7] Ateşli silah yaralanmaları halen yüksek olan morbidite ve mortalite oranları nedeniyle birçok araştırmacının ilgi odağı olmaya devam etmektedir. Konu ile ilgili araştırmalardaki temel amaç bu oranları mümkün olduğu kadar aşağı seviyelere indirmektir.

GEREÇ VE YÖNTEM Bu çalışmada çatışma bölgelerindeki ateşli silah yaralanmalarına ilk müdahale merkezi olan bölge hastanesinde Şubat 2002 - Mayıs 2005 tarihleri arasında yüksek kinetik enerjili KASY nedeniyle getirilen, ilk girişimi ve tedavisi yapılan 21 hasta geriye dönük olarak değerlendirildi. Hastalar acil servise geldiklerinde hızlı bir şekilde multidisipliner yaklaşım ile genel durumları değerlendirildi. Vital bulguları değerlendirilip damar yolu açıldıktan sonra hem laboratuvar incelemeleri hem de kan grubu tayini için kan örneği alındı. Tüm hastaların, dijital rektal incelemesi ve üretral foley kataterizasyonu yapıldı. Ayrıca hastalar, profilaktik olarak tetanoz aşısı ve antibiyotik kombinasyonu (I. kuşak sefalosporin, metranidazol ve amino glikozit) ile intravenöz izotonik solüsyonu verilerek monitörize edildi. Merkezimiz ilk müdahale hastanesi olması nedeniyle şok tablosundaki hastalara operasyondan önce uygulanan transfüzyonda hasta başı cross-match ile tam kan kullanıldı. Hemodinamik olarak stabil olmayan ve sistolik kan basıncı <90 mmHg olan hastalar acil laparotomiye alındı. Stabil olan hastalar acil incelemeleri tamamlandıktan sonra ameliyat edildi. Her hastanın yaş, cinsiyet, yaralanmaya neden olan silah türü, yaralanma anı ile hastaneye gelinceye kadar geçen süre, yaralanan karın içi organ ve sayısı, yaralanan ekstra-abdominal organ sayısı, PATİ, kan transfüzyonu miktarı ile gelişen komplikasyonlar kayıt altına alındı. İstatistiksel analizler için “SPSS for Windows” 13.0 programı kullanıldı. Parametrelerin gruplar arası karşılaştırmalarında Student’s t testi ve Mann-Whitney U testi kullanıldı. Sayısal değerlerin ilişkisi korelasyon analizi ile araştırıldı. Niteliksel veriler ise ki-kare testi kullanılarak karşılaştırıldı. Sonuçların istatistiksel anlamlılığı p<0,05 düzeyinde değerlendirildi.

Tablo 1. Hastaların demografik verileri, sistolik kan basıncı, yaralanma etkeni ve başvuru süresi

Yaş (yıl) Erkek Kadın SKB <90 mmHg Yüksek kinetik enerjili Yaralanma etkeni Mermi Şarapnel blast / Frag. Başvuru süresi (saat) 0-1 1-2 2-3 3-4

Median

Sayı

Yüzde

21

20 1 7

95,2 4,8 33, 3

17 4 11 8 1 1

81 19 52, 4 38 4,8 4,8

p

AD

AD: Anlamlı değil; SKB; Sistolik kan basıncı.

Cilt - Vol. 17 Sayı - No. 5

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Ulus Travma Acil Cerrahi Derg

Tablo 2. Yaralanan karın içi organlar ve oranları Organ Kolon İnce bağırsak Mide Böbrek Karaciğer Dalak Rektum Diyafragma Duodenum Safra yolları Vasküler

Sayı

Yüzde

9 8 4 4 3 3 3 4 1 1 1

22,5 20 10 10 7,5 7,5 7,5 7,5 2,5 2,5 2,5

BULGULAR Değerlendirmeye alınan 21 hastanın yaş, cinsiyet, ilk başvurudaki sistolik kan basıncı ve başvuru süresi ile yüksek kinetik enerjili yaralanmanın etkenini içeren veriler Tablo 1’de gösterildi. Yaş ve cinsiyetin hasta popülasyonumuzda farklılık göstermemesi ve tüm hastaların yaralanma mekanizmalarının yüksek kinetik enerjili etkenler olması nedeniyle istatistiksel analizlerde değişken olarak kullanılmadı. Hastaların %52,4’ü (n=11) yaralanmadan sonraki ilk bir saat içinde, %38’i (n=8) ilk iki saat içinde ilk girişim merkezine getirildi. Yani ilk iki saat içerisinde hastaların yaklaşık %90’nının hastanede girişimleri başladı. Hastaların transport süresi ile gelişen kompli-

kasyon oranları karşılaştırıldığında istatistiksel olarak anlamlı bulunmadı. Hemodinamik olarak stabil olmayan ve sistolik kan basıncı <90 mmHg olan 7 hasta (%33,3) acil laparotomiye alındı. Hastaların %66,6’sı (n=14) hemodinamik olarak stabilitesi sağlanıp, acil incelemeleri tamamlanıp değerlendirmeleri yapıldıktan sonra ameliyata alındı. Hastalarda en sık yaralanan karın içi organlar sırasıyla kolon (%22,5), ince bağırsak (%20), mide (%10) ve böbrek (%10) olduğu tespit edildi (Tablo 2). Hastaların %42,8’inde (n=9) yalnızca bir organ, %43,5’inde (n=7) ise ≥3 organ yaralanması tespit edildi (Tablo 3). Yaralanan organ sayısı <3 olan hastalarda %7,1, ≥ 3 olanlarda ise %71 oranında komplikasyon gelişti ve bu oran istatistiksel olarak anlamlı bulundu (p<0,0001). Hastaların %71,4’ünde (n=15) izole karın yaralanması varken %14,3 (n=3) hastada karın yaralanmasına ek olarak toraks yaralanması ve diğer %14,3 (n=3) hastada da ekstremite yaralanması vardı (Tablo 3). Komplikasyon gelişme oranlarında anlamlılık bulunmadı. PATİ skoru %42,8 hastada (n=9) 15 ve altında tespit edilirken, %19’unda (n=4) 16-25 arası, %33,4’de (n=7) 26-50 arası ve %4,8’de (n=1) 50 üzeri skorlar saptandı (Tablo 3). PATİ skoru <25 olan 13 hastada %7,7, ≥25 olan 8 hastada ise %62,5 oranında komplikasyon geliştiği görüldü ve bu oran istatistiksel olarak anlamlı bulundu (p<0,0001).

Tablo 3. Yaralanan alan ve organ sayısı, PATI, kan transfüzyonu ile komplikasyon oranları arasındaki ilişki

Yaralanan organ sayısı 0 1 2 3 4 5 Yaralanan alan Abdominal (+) Toraks (+) Ekstremite PATİ ≤15 16-24 25-50 >50 Kan transfüzyonu (Ü) ≤2 3-5 >5

Hasta (n) Yüzde 2 9 3 3 3 1 15 3 3 9 4 7 1 11 6 4

9,5 42,8 14,3 14,3 14,5 4,8 71,4 14,3 14,3 42,8 19 33,4 4,8 52,4 28,6 19

Komplikasyon (n) Yüzde – – 1 2 2 1 3 2 1 – 1 4 1 1 3 2

– – 33,3 66,6 66,6 100 14,2 9,5 4,8 – 25 57,1 100 16,7 50 33,3

p <0,0001

AD

<0,0001

<0,0001

AD: Anlamlı değil; PATI: Penetran abdominal travma indeksi.

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Karın içi ateşli silah yaralanmalarında komplikasyon oranlarını etkileyen faktörler

Tablo 4. Komplikasyonlar Komplikasyonlar Karın içi hemoraji CAE Seroma İleus + CAE + Pnömoni Toplam

Sayı

Yüzde

2 2 1 1 6

9,5 9,5 4,8 4,8 28,6

CAE: Cerrahi alan enfeksiyonu.

Hastaların %52,4’üne (n=11) <2 ünite (Ü), %28,6’sına (n=6) 3-5 Ü ve %19’una da (n=4) >5 Ü kan transfüzyonu uygulandı (Tablo 3). ≥3 Ü kan transfüzyonu yapılan %47,6 (n=10) hastanın %50’sinde (n=5) komplikasyon gelişti ve bu oran istatistiksel olarak anlamlıydı (p<0,0001). Ameliyat öncesi ve sonrası dönemde mortalite gözlenmedi. Karın içi hemoraji, cerrahi alan enfeksiyonu (CAE), seroma, ileus ve pnömoni gibi komplikasyonların altı hastada (%28,6) geliştiği saptandı (Tablo 4).

TARTIŞMA Çatışma bölgelerinde görülen yüksek kinetik enerjili etkenlerin neden olduğu yaralanmalarda oluşan blast etki nedeniyle vücutta meydana gelen hasarın şiddeti de doğal olarak artmaktadır. Bunun sonucu olarak da bu tür yaralanmalarda yüksek mortalite ve morbidite oranları görülmektedir.[8] KASY’de mortalite ve morbidite oranının, değişik serilerde sırası ile %3-22,5 ve %7-46 arasında olduğu bildirilmiştir.[9-11] Yapılan çalışmalarda yaralanma anı ile ameliyat zamanı arasında geçen süre, hemorajik şokun varlığı, kraniyal travmanın birlikteliği ve yüksek PATİ skoru mortalite ve morbiditeyi artıran etkenler olarak sıralanmaktadır.[10-12] Geriye dönük olan çalışmamızda ölümle sonuçlanan yaralanmalar tespit edilmediği için mortalite oranlarını etkileyen faktörler hakkında bize ait verileri sunamamaktayız. Morbidite oranımız ise %28,6 olarak tespit edildi. Yaralanma anından hastaneye gelinceye kadar geçen süre ile komplikasyon oranları karşılaştırıldığında literatür bilgilerine aksine anlamlı sonuç elde edilemedi.[13] Bunun nedeni son yılarda Türk ordusunda gelişen sağlık hizmetleri, gece-gündüz hasta naklindeki olanak ve kabiliyetinin artması ile hasta triyajı kolaylaşmakta nakil süresi kısalmakta ve böylece hastaların stabilitesi bozulmadan ilk girişim merkezine ulaştırılması sağlanabilmektedir. Ateşli silah yaralanmalarında en sık ince bağırsağın etkilendiği bilinirken çalışmamızda en sık kolon yaralanması tespit edilmiştir.[14,15] İnce bağırsak ise ikinci sıklıkla etkilenen organ olmuştur. Penetran karın yaralanmalarda karın içi kirlenme ile anastomoz kaçağın en önemli kaynağı olan ve savaş sırasındaki Cilt - Vol. 17 Sayı - No. 5

yaralanmalarda %5-10, sivil yaşamdaki yaralanmalarda %1-3 oranında görülen kolon yaralanmaları çeşitli yayınlarda %27-41 morbiditeye, %7-10’da mortaliteye neden oldukları bildirilmektedir.[16,17] Çalışmamızda tespit ettiğimiz %9,5 olan negatif laparotomi oranımız ise literatür verileri ile benzerlik göstermektedir. Larson çalışmasında, penetran travmalarda yaralanan organ sayısının artması ile gelişebilecek komplikasyon oranı da benzer şekilde artış gösterdiğini belirtmiştir.[18] Yaralanan karın içi organ sayısının artması daha fazla hemoraji, daha fazla kan transfüzyonu, daha fazla karın içi kirlenme, daha uzun ameliyat süresi, yüksek PATİ skoru anlamına gelmekte bu da morbidete ve mortalite oranının artması demektir. Çalışmamızda üç ve daha üstü organ yaralanması tespit edilen hastalarda komplikasyon görüldü ve bu oran istatistiksel olarak anlamlı bulundu (p<0,05). Morbiditeyi etkileyen bir diğer faktör de karın organları dışında ekstra-abdominal organ yaralanmasının bulunmasıdır.[19] Serimizde ekstra-abdominal organ yaralanmasının eşlik ettiği penetran karın travmalı 6 hastada %50 oranında komplikasyon geliştiği görüldü ancak izole karın travmalı grup ile ayrı ayrı değerlendirildiğinde istatistiksel olarak anlamlı bulunmadı. Moore ve arkadaşları[5] penetran karın travmalı hastalarda mortalite ve morbidite oranlarının önceden tahmin edilmesi amacıyla PATİ skorunu tanımlamışlar ve ateşli silah yaralanmalarında 25 ve üzerinde skora sahip hastalarda komplikasyon oranlarını %46, 25’in altında olanlarda ise komplikasyon oranlarını %7 olarak bildirmişlerdir. Bu indeks daha sonra yapılan farklı çalışmaların sonuçlarıyla da desteklenmiştir.[11,12,20-22] Çalışmamızda, PATİ skoru <25 olan 13 hastada %7,7, ≥25 olan 8 hastada ise %62,5 oranında komplikasyon geliştiği görüldü. PATİ skoru ile komplikasyon oranları arasındaki ilişki istatistiksel olarak anlamlı bulundu (p<0,0001). Multipl kan transfüzyonunun hem mortaliteyi hem de morbiditeyi artırdığı bilinmektedir.[22] Bu nedenle kan transfüzyonun gerçekte ihtiyaç duyulan hastalara yapılması önem kazanmaktadır. Ancak çalışmamızdaki tüm hastalara sıvı resüstasyonun yeterli gelmemesi nedeni ile hemodinamik stabilite için kan transfüzyonu yapıldı. Yaralanma şekli nedeni ile geniş doku ve kas kaybı olan ve karın içi organ yaralanması olmayan iki olguda bile sıvı resüstasyonuna rağmen <2 Ü kan transfüzyonuna ihtiyaç duyuldu. Kan transfüzyonu ≥3 Ü uygulanan %47,6 (n=10) hastanın 5’inde (%50) komplikasyon geliştiği görüldü ve oran istatistiksel olarak anlamlıydı (p<0,0001). Çalışmamızda iki olguda komplikasyon olarak görülen karın içi hemorajilerin nedeni hastaların hemodinamilerinin düzelmesi sonucu önceki cerrahi müdahale yerlerindeki sızıntı şeklindeki kanamalar oldu453


Ulus Travma Acil Cerrahi Derg

ğu saptandı. Hastaların cerrahi olarak kanama denetimleri yapılarak tedavileri sağlandı. Çatışma ortamının yaratığı aşırı yara kirliği ve blast etkinin yaratığı doku harabiyetinin muhtemel neden olduğu iki olgudaki CAE ise antibiyoterapi ile tedavi edildi. Son yıllarda hemodinamik durumu stabil ve peritonit bulguları olmayan seçilmiş KASY olan hastalarda cerrahi dışı tedavi modeli gündeme gelmiştir.[23,24] Buna karşın günümüzde toplumsal terör olaylarında, yüksek enerjili ve parça etkili silahların yaygın olarak kullanıldığı ve meydana gelen yaralanmaların da askeri ortamlardakinden farklı olmadığı bilinmelidir. Bu nedenledir ki karın içi yüksek kinetik enerjili mermi ve patlayıcı silah parçalarına bağlı yaralanması olan hastalara stabil olsalar dahi eksploratif laparotomi yapılamasının zorunlu olduğu kanısındayız. Gelişen teknolojik olanaklar sayesinde artık çatışma ortamında bile her türlü sağlık hizmeti sunulabilmektedir. Bunun sayesinde hasta triyajı çatışma sahasında dahi yapılıp nakil önceliği belirlenebilmektedir. Gece ve gündüz en uzak yerdeki stabil olmayan hastalar en geç bir saat içinde ilk girişim merkezine transport edilmektedir. Eğer Türk ordusunun lojistik sağlık hizmetleri yapılanması model alınabilirse, sivil ortamlardaki yaralanmalarda da travma-hastane intervalinin komplikasyon üzerine olan etkisinin giderek azalacağı kanısındayız. Sonuç olarak, çalışmamızda KASY de PATİ skoru, multipl kan transfüzyonu ve yaralanan organ sayısı ameliyat sonrası dönemde gelişebilecek komplikasyon oranlarını etkileyen en önemli faktörler olarak tespit edilmiştir.

KAYNAKLAR 1. Peters CE, Sebourn CL. Wound ballistics of unstable projectiles. Part II: temporary cavity formation and tissue damage. J Trauma 1996;40:S16-21. 2. Mesci A, Arıcı C. Travma kinematiği. Ulusal Cerrahi ve Travma Resüsitasyon Kurs Kitabı, 2008. 3. Uzar Aİ, Güleç B, Kayahan C, Özer MT, Öner K, Alpaslan F. Yara balistiği kalıcı ve geçici yara boşluğu (kavite) etkileri. Ulus Travma Derg 1998;4:225-9. 4. Uzar AI, Dakak M, Sağlam M, Ozer T, Ogunç G, Ide T, et al. The magazine: a major cause of bullet fragmentation. Mil Med 2003;168:969-74. 5. Cothren CC, Biffl WL, Moore EE. Trauma. In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Pollock RE, editors. Schwartz’s principles of surgery. 9th ed. New York: McGraw-Hill; 2010. 6. Moore EE, Dunn EL, Moore JB, Thompson JS. Penetrating abdominal trauma index. J Trauma 1981;21:439-45.

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7. Girgin S, Gedik E, Uysal E, Taçyildiz IH. Independent risk factors of morbidity in penetrating colon injuries. Ulus Travma Acil Cerrahi Derg 2009;15:232-8. 8. Smaniotto B, Bahten LC, Nogueira Filho DC, Tano AL, Thomaz Junior L, Fayad O. Hepatic trauma: analysis of the treatment with intrahepatic balloon in a university hospital of Curitiba. Rev Col Bras Cir 2009;36:217-22. [Abstract] 9. Coupland R. Abdominal wounds in war. Br J Surg 1996;83:1505-11. 10. Aldemir M, Taçyildiz I, Girgin S. Predicting factors for mortality in the penetrating abdominal trauma. Acta Chir Belg 2004;104:429-34. 11. Uludağ M, Yetkin G, Citgez B, Yener F, Akgün I, Coban A. Effects of additional intra-abdominal organ injuries in patients with penetrating small bowel trauma on morbidity and mortality. Ulus Travma Acil Cerrahi Derg 2009;15:45-51. 12. Adesanya AA, da Rocha-Afodu JT, Ekanem EE, Afolabi IR. Factors affecting mortality and morbidity in patients with abdominal gunshot wounds. Injury 2000;31:397-404. 13. Leppäniemi AK. Abdominal war wounds-experiences from Red Cross field hospitals. World J Surg 2005;29:S67-71. 14. Feliciano DV, Burch JM, Spjut-Patrinely V, Mattox KL, Jordan GL Jr. Abdominal gunshot wounds. An urban trauma center’s experience with 300 consecutive patients. Ann Surg 1988;208:362-70. 15. Rignault DP. Abdominal trauma in war. World J Surg 1992;16:940-6. 16. Hudolin T, Hudolin I. The role of primary repair for colonic injuries in wartime. Br J Surg 2005;92:643-7. 17. Kahya MC, Derici H, Cin N, Tatar F, Peker Y, Genç H, et al. Our experience in the cases with penetrating colonic injuries. Ulus Travma Acil Cerrahi Derg 2006;12:223-9. 18. Larson CR, White CE, Spinella PC, Jones JA, Holcomb JB, Blackbourne LH, et al. Association of shock, coagulopathy, and initial vital signs with massive transfusion in combat casualties. J Trauma 2010;69:26-32. 19. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma 1987;27:370-8. 20. Sikic N, Korac Z, Krajecic I, Zunic J. War abdominal trauma: usefulness of Penetrating Abdominal Trauma Index; Injury Severity Score, and number of injured abdominal organs as predictive factors. Mil Med 2001;7:258-61. 21. Celen O, Oğuz S, Doğan M. Abdominal gunshot wounds: retrospective analysis of 164 patients. Ulus Travma Derg 2001;7:258-61. 22. Mickevicius A, Klizaite J, Tamelis A, Saladzinskas Z, Pavalkis D. Penetrating colorectal trauma: index of severity and results of treatment. Medicina (Kaunas) 2003;39:562-9. [Abstract] 23. Morrison JJ, Clasper JC, Gibb I, Midwinter M. Management of penetrating abdominal trauma in the conflict environment: the role of computed tomography scanning. World J Surg 2011;35:27-33. 24. Pryor JP, Reilly PM, Dabrowski GP, Grossman MD, Schwab CW. Nonoperative management of abdominal gunshot wounds. Ann Emerg Med 2004;43:344-53.

Eylül - September 2011


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):455-457

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.67934

Masked urinary bladder injury with a bullet expulsed spontaneously during voiding Ateşli silah yaralanmasıyla oluşan gizli mesane yaralanması ve kurşunun spontan miksiyonla üretradan atılması Müjgan ÇALIŞKAN,1 İsmail EVREN,2 İsmail KABAK,1 İbrahim ATAK,1 Recai GÖKCAN3

We report a case with gunshot to the pelvis. The injury site was the soft tissue between the rectum and urinary bladder. Several days later, the bullet was expulsed spontaneously during voiding. In the literature, only a few case reports have described spontaneous expulsion of an intravesical bullet. A 19-year-old male was wounded on the left hip by gunshot. Radiographic examinations showed a bullet in the pelvis, which was localized in the soft tissue between the rectum and urinary bladder, with no accompanying visceral injury on abdominopelvic computerized tomography. Macroscopic hematuria was noticed after urethral catheterization. Rectosigmoidoscopy and retrograde cystoscopic examinations were both negative. The patient was monitored closely and treated conservatively with no surgical intervention. The urinary catheter was removed on the fifth postoperative day, and the bullet was expulsed spontaneously via the urethra during normal voiding three hours after catheter removal. Thereafter, a retrograde urethrography was performed, which showed no evidence of urinary tract or bladder injury.

Bu yazıda, ateşli silahla pelvis yaralanması olan hasta sunuldu. Yaralanma bölgesi mesane ve rektum arasındaki yumuşak doku idi. Birkaç gün sonra kurşun spontan miksiyon esnasında üretra yolu ile atıldı. Literatürde kurşunun kendiliğinden olarak üretra yolu ile atıldığı birkaç nadir olgu bildirilmiştir. On dokuz yaşında erkek hastanın sol kalçasında ateşli silah yaralanması mevcut idi. Hemodinamik olarak stabil olan hastaya yapılan direkt grafi ve bilgisayarlı tomografide pelvis içinde, mesane ve rektum arasındaki yumuşak dokuda, organ hasarı oluşturmayan kurşun tespit edildi. Üretral kateterizasyon sonucu makroskopik hematüri tespit edildi. Rektosigmoidoskopi ve retrograd sistoskopik değerlendirmeler negatif idi. Cerrahi girişim yapılmaksızın, hasta konservatif takip edildi. Beşinci gün, üriner kateteri çıkarıldıktan üç saat sonra kurşun üretradan kendiliğinden miksiyon esnasında atıldı. Bunun üzerine retrograd üretrosistografi yapıldı, üriner trakt ve mesane hasarına rastlanmadı.

Key Words: Bladder; gunshot wound; hip; penetrating pelvic trauma.

Anahtar Sözcükler: Mesane; kurşun yaralanması; kalça; penetran pelvis travması.

Gunshot wounds to the pelvis can result in injuries in various organ systems. High velocity penetrating pelvic injuries represent one of the most difficult and challenging situations for the emergency surgeons and require a multidisciplinary trauma team approach.

erature, only a few case reports have described spontaneous expulsion of an intravesical bullet.[1-5]

We report a case that suffered a gunshot to the pelvis. The injury site was the soft tissue between the rectum and urinary bladder. Several days later, the bullet was expulsed spontaneously via the urethra. In the lit-

CASE REPORT A 19-year-old male wounded on the left hip by gunshot was referred to our medical center. As the patient was hemodynamically stable, it was possible to perform several radiographic and endoscopic studies, including computerized tomography, rectosigmoidoscopy, cystography, and retrograde urethrography,

Departments of General Surgery, Urology, Radiology, Umraniye Training and Research Hospital, Istanbul, Turkey.

Ümraniye Eğitim ve Araştırma Hastanesi, 1Genel Cerrahi Kliniği, 2 Üroloji Kliniği, 3Radyoloji Bölümü, İstanbul.

Correspondence (İletişim): İsmail Evren, M.D. Department of Urology, Umraniye Training and Research Hospital, Umraniye, Istanbul, Turkey. Tel: +90 - 216 - 632 18 18 e-mail (e-posta): drevrenis@hotmail.com

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Ulus Travma Acil Cerrahi Derg

in addition to the clinical evaluation. The patient was normotensive. Physical examination showed two entrance wounds, one on the left side of the left hip and one on the left side of the right hip, and one exit wound on the right side of the left hip. Abdominal examination showed no suspected suprapubic or abdominal tenderness, and digital rectal examination showed no bleeding per rectum. Urinalysis showed hematuria and hematocrit was at 50.2%. As there was no blood on the external urethral meatus, a urethral catheter was inserted. Urine was hematuric for about three hours. Plain pelvic films located the bullet as seen in Figure 1a. Abdominopelvic computerized tomography confirmed that the bullet was located in the soft tissue between the rectum and urinary bladder, with no accompanying visceral injury (Fig. 1b). The bladder was filled with 300 cc contrast material and full and post-drainage cystograms were obtained, which were all negative, as was the retrograde urethrography (Fig. 1c). Thereafter, no cystoscopy was performed. Additionally, no injury was detected on rectosigmoidoscopy. The patient was monitored closely and treated conservatively with no surgical intervention. The urinary

catheter was removed on the fifth postoperative day, and three hours after removal, the bullet was expulsed spontaneously during normal voiding (Fig. 1d). A retrograde urethrography was performed, which showed no evidence of urinary tract or bladder injury. The patient was discharged from the hospital on the same day, and at the follow-up visit one month after the trauma, he was completely normal without any complaint.

DISCUSSION Due to the complex anatomy, pelvic gunshot wounds can result in various degrees of injuries in several organ systems. The most prevalent injuries have included soft tissue loss, pelvic bone fractures, vascular disruptions, and various genitourinary tract, rectum and bowel injuries. These injuries are often complex, morbidity and mortality rates are expected to be high, and a multidisciplinary trauma team approach is required in their management. In their series of 28 patients with severe penetrating pelvic injuries, Arthurs et al.[6] reported that the most lethal combination of injuries are hemorrhage and sepsis, vascular injury (particularly iliac vein) and rectal injury.

(a)

(b)

(c)

(d)

Fig. 1. (a) Plain pelvic X-ray. (b) Abdominal computerized tomography. (c) Retrograde cystography. (d) A view of the bullet. 456

Eyl端l - September 2011


Masked urinary bladder injury with a bullet expulsed spontaneously during voiding

An empty bladder is much less vulnerable to injury. Using retrograde cystography, bladder injuries can be divided into extraperitoneal and intraperitoneal injuries. In extraperitoneal injuries, the treatment is catheter drainage and antibiotic treatment. The bladder usually heals in a few days. On the contrary, intraperitoneal injuries usually require surgical treatment. The healing of the bladder injury can be exhibited with cystography. Our proposed explanation for this case is that the bullet was slowed because of the exit and a second entrance to the hip and was fixed to the wall of the urinary bladder. Edema formation had surrounded the bullet. During the healing of the bladder wall, the extravesical bullet surface was covered with epithelization, and due to subsequent bladder contractions, the bullet moved into the intravesical cavity. A few days later, a 7.65-caliber bullet was spontaneously expulsed via the urethra with normal urination. Penetrating pelvic gunshot wounds require careful clinical follow-up with complete laboratory and radiological investigations, and a multidisciplinary trauma

Cilt - Vol. 17 Sayı - No. 5

team approach is required in their management. Physicians should always be aware of the possibility of an immediate operation. Nevertheless, it remains exceptional to witness spontaneous passage of a bullet during normal voiding after a pelvic gunshot wound without any intrapelvic organ injuries.

REFERENCES 1. Kiliç D, Kilinç F, Ezer A, Guvel S. Spontaneous expulsion of a bullet via the urethra. Int J Urol 2004;11:576-7. 2. DiDomenico D, Guinan P, Sharifi R. Spontaneous expulsion of an intravesical bullet. J Am Osteopath Assoc 1997;97:4156. 3. Sankari BR, Parra RO. Spontaneous voiding of a bullet after a gunshot wound to the bladder: case report. J Trauma 1993;35:813-4. 4. Abdelsayed MA, Bissada NK, Finkbeiner AE, Redman JF. Spontaneous passage of bullet during voiding. South Med J 1978;71:83-4. 5. Cohen SP, Varma KR, Goldman SM. Spontaneous expulsion of intravesical bullet. Urology 1975;05:387-9. 6. Arthurs Z, Kjorstad R, Mullenix P, Rush RM Jr, Sebesta J, Beekley A. The use of damage-control principles for penetrating pelvic battlefield trauma. Am J Surg 2006;191:604-9.

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Ulus Travma Acil Cerrahi Derg 2011;17 (5):458-460

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.27048

Spondylolisthesis mimicking the progression of dissection in a case of chronic Stanford type B aortic dissection Kronik Tip-B aort diseksiyonlu bir olguda diseksiyonun ilerlemesini taklit eden lomber spondilolistezis Mustafa GÖZ,1 Mehmet Fuat TORUN,2 Cengiz MORDENİZ,3 Mehmet Salih AYDIN,1 Abbas Heval DEMİRKOL,1 Hamza KARABAĞ2 Aortic dissection is an acute lethal cardiovascular condition. A 67-year-old hypertensive woman was admitted to our Emergency Department with an abrupt onset of tearing pain in the interscapular area. A thoracic computed tomography scan with contrast showed chronic type B aortic dissection. The patient was transferred to intensive care and medical therapy was initiated. Upon spread of the pain to the lumbar area, the dissection was thought to have progressed. The patient, being hemodynamically stable, was examined using ultrasonography, and the dissection did not show any progression. In the neurological examination for the lumbar pain, the lumbar processus spinosus was found to be sensitive, and the sciatic nerve stretch test was positive at 30 degrees. Magnetic resonance imaging revealed spondylolisthesis and a centrally located disc herniation at the L3-4 level. No operation for the dissection was planned, but discectomy and fusion surgery was scheduled. Since the patient refused surgery, she was discharged with medical therapy. Our aim in this report was to emphasize the importance of spondylolisthesis mimicking the progression of dissection in the differential diagnosis of a chronic type B aortic dissection case.

Aort diseksiyonu akut ve ölümcül olan kardiyovasküler bir durumdur. Altmış yedi yaşında hipertansif kadın hasta, ani başlayan, bıçak saplanır tarzında alt sırt ağrısı nedeniyle, acil servise geldi. Kontrastlı toraks tomografisinde kronik Tip-B aort diseksiyonu tanısı konuldu. Yoğun bakıma transfer edilen hastaya medikal tedavi başlandı. Hastanın ağrılarının lomber bölgeye yayılması nedeniyle diseksiyonun ilerlediği düşünüldü. Hemodinamik olarak stabil hastaya karın ultrasonografisi yapıldı ve diseksiyonun ilerlemediği görüldü. Nörolojik incelemesinde lomber spinoz proçes hassasiyeti, her iki bacak germe testinin 30 derecede pozitif olması üzerine cekilen manyetik rezonans görüntülemede L3-L4’te spondilolistezis ve merkez yerleşimli disk hernisi tespit edildi. Mevcut bulgularla diseksiyon yönünden operasyon endikasyonu olmadığı düşünüldü. Diskektomi ve füzyon cerrahisi önerildi. Hastanın cerrahi tedaviyi kabul etmemesi üzerine, ilaç tedavisi verilerek taburcu edildi. Bu çalışmada, kronik Tip-B aort diseksiyonlu bir olguda diseksiyonun ilerlemesini taklit eden lomber spondilolistezis’in ayırıcı tanıdaki önemini vurgulamayı amaçladık.

Key Words: Aortic dissection; spondylolisthesis.

Anahtar Sözcükler: Aort diseksiyonu; spondilolistezis.

Aortic dissection is an aortic wall condition. All the mechanisms weakening the media layer cause aortic dissection by increasing the stress applied to the wall. Early diagnosis and prompt therapy together are lifesaving in this patient group.[1] In the differential diagnosis, cardiac, pulmonary and musculoskeletal system and hepatobiliary diseases etc. are to be kept in mind. Degenerative spondylolisthesis (DS) is common in elderly patients.[2]

It is characterized by the displacement, usually anteriorly, of one vertebral body upon another. Lumbar DS is a major cause of spinal canal stenosis and is often related to low back and leg pain.[2-4]

Departments of 1Cardiovascular Surgery, 2Neurosurgery, 3 Anesthesiology and Intensive Care, Harran University Faculty of Medicine, Şanlıurfa, Turkey.

The aim of this paper was to emphasize the importance of spondylolisthesis mimicking the progression of dissection in the differential diagnosis of a chronic type B aortic dissection case. Harran Üniversitesi Tıp Fakültesi, 1Kalp Damar Cerrahisi Anabilim Dalı, Nöroşirürji Anabilim Dalı, 3Anesteziyoloji ve Yoğun Bakım Anabilim Dalı, Şanlıurfa.

2

Correspondence (İletişim): Mustafa Goz, M.D. Harran Üniversitesi Tıp Fakultesi Kalp ve Damar Cerrahisi Anabilim Dalı, 63100 Şanlıurfa, Turkey. Tel: +90 - 414 - 248 80 01 (4506-4309) e-mail (e-posta): mustafagoz@harran.edu.tr

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Spondylolisthesis mimicking the progression of dissection in a case of chronic Stanford type B aortic dissection

CASE REPORT A 67-year-old woman receiving therapy for hypertension for the previous three years was referred to our department for abrupt onset of tearing pain in the interscapular area. In her echocardiograph, a suspected flap was seen, and in the following thorax computerized tomography (CT), chronic type B aortic dissection was diagnosed. Thorax CT showed a dilatation in the descending aorta up to 4 cm in diameter and its chronic dissection (Fig. 1). Although the patient had chronic obstructive pulmonary disease with older age, no organ hypoperfusion or uncontrollable hypertension was detected. The patient was transferred to intensive care and medical therapy was started. Spreading of the pain to the lumbar area and high risk factors led us to consider progression of the dissection. The patient was hemodynamically stable and her abdomen was examined through ultrasonography, but no sign of progression was found. In the neurological examination, the lumbar processus spinosus was found to be sensitive, and the sciatic nerve stretch test was found positive at 30 degrees. In her conventional lumbosacral radiography, spondylolisthesis was diagnosed at the L3-4 level. In her magnetic resonance imaging (MRI), along with spondylolisthesis, a centrally located disc herniation was determined (Fig. 2). No operation for the dissection was indicated by the findings. Discectomy and fusion surgery were indicated by the patient’s score of 60 on the Karnofsky scale, her complaint of neurogenic claudication at 25 meters, and the positive results in both legs at 30 degrees in the leg stretch test. Refusing surgical treatment, the patient was discharged with medical therapy. DISCUSSION Early diagnosis and prompt therapy are very important in aortic dissection. The most commonly seen clinical finding is abrupt onset of severe chest and back pain. Especially in type B dissection cases, the

Fig. 1. Type B chronic dissection in computerized tomography with contrast. Descending aortic diameter was found to be 4 cm. Cilt - Vol. 17 Sayı - No. 5

differential diagnosis should be made with a detailed radiological imaging method following a very thorough physical examination. Differential diagnoses should include musculoskeletal pathologies. Degenerative spondylolisthesis (DS) with foraminal stenosis is common in elderly patients. When symptomatic, severe pain and the resultant neurogenic claudication often lead to a diminished quality of life.[2] The Karnofsky performance status scale was designed to measure the patient’s activity level and medical care requirements.[5] A score of 50-70 indicates inability to work, but ability to live at home with varying amounts of assistance required for most personal needs. The score was 60 in this case. Although the diagnosis is easily made on radiographic evaluation, the pathoetiology and appropriate treatment modality are not always as clear.[4] A nonsurgical approach is an appropriate first step. Nonoperative treatment should be the initial course of action in most cases of DS, with or without neurologic symptoms.[2] Treatment options include the use of analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) to control pain. However, those who suffer from neurological symptoms, such as intermittent claudication or vesicorectal disorder, will most probably experience neurological deterioration if they are not operated.[3] Treatment of this pathology has evolved over the past 20 years with the publication of numerous prospective randomized trials assessing the influence of fusion and instrumentation following decompression. Recently, soft-tissue stabilization devic(a)

(b)

Fig. 2. (a) Sagittal MRI at T2 demonstrates spondylolisthesis at L3-4 level and narrowing of this subarachnoidal space due to the disc herniation; (b) bilateral narrowing of the neural foramen at the axial plane at T2; and especially edema at the neural root of the right L3. 459


Ulus Travma Acil Cerrahi Derg

es have been advocated as an alternative to fusion.[2] In our case, the nerve root at L3 was displaced anteriorly due to spondylolisthesis and central disc herniation, which caused back pain and pain in both legs, limiting the patientâ&#x20AC;&#x2122;s daily activities. Additionally, the patient described neurogenic claudication, and the bilateral leg stretch test was found positive at 30 degrees. Spreading of the pain to the lumbar area can be associated with the dissection. However, in this reported case, the cause of the pain was related to spondylolisthesis. Therefore, discectomy and instrumented fusion by posterior approach were planned. The patient refused surgical treatment and was discharged. She was advised to try a lumbar corset, an anti-inflammatory treatment and a physical exercise program. In conclusion, the differential diagnosis of aortic

460

dissection is quite difficult in many cases. Thus, we think that spinal pathologies should be considered in the differential diagnosis of dissection.

REFERENCES 1. Shirakabe A, Hata N, Yokoyama S, Shinada T, Suzuki Y, Kobayashi N, et al. Diagnostic score to differentiate acute aortic dissection in the emergency room. Circ J 2008;72:986-90. 2. Majid K, Fischgrund JS. Degenerative lumbar spondylolisthesis: trends in management. J Am Acad Orthop Surg 2008;16:208-15. 3. Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J 2008;17:327-35. 4. Metz LN, Deviren V. Low-grade spondylolisthesis. Neurosurg Clin N Am 2007;18:237-48. 5. Karnofsky D, Abelmann W, Craver L, Burchenal J. The use of nitrogen mustard in the palliative treatment of cancer. Cancer 1948;1:634.

EylĂźl - September 2011


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):461-463

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.50103

Multidetector computed tomography diagnosis of ileal and antropyloric gallstone ileus İleum ve antropilorik yerleşimli safra taşı ileusunun çok kesitli bilgisayarlı tomografi ile tanısı Naime ALTINKAYA,1 Zafer KOÇ,1 Özlem ALKAN,1 Şenay DEMİR,1 Sedat BELLİ2 Gallstone-induced ileus is a rare complication of cholelithiasis, and gastric outlet obstruction is even rarer. We describe the multidetector computed tomographic diagnosis of small bowel obstruction resulting from a gallstone impacted in the distal ileum and of gastric outlet obstruction from a gallstone impacted in the pyloric antrum (Bouveret syndrome).

Safra taşı ileusu kolelithiasisin nadir görülen bir komplikasyonu olmakla birlikte mide çıkış yolu tıkanıklığı çok daha nadir görülür. Bu yazıda, distal ileuma impakte safra taşı sonucu gelişen ince bağırsak tıkanıklığı ve pilorik antruma impakte safra taşı sonucu gelişen mide çıkış yolu tıkanıklığının (Bouveret sendromu) çok kesitli bilgisayarlı tomografi bulgularını tanımladık.

Key Words: Bouveret syndrome; gallstone ileus; multidetector computed tomography.

Anahtar Sözcükler: Bouveret sendromu; safra taşı ileusu; çok kesitli bilgisayarlı tomografi.

Gallstone-induced ileus is a rare complication of cholelithiasis, and gastric outlet obstruction is even rarer.[1] The morbidity and mortality of gallstone ileus remain very high, partly because of misdiagnosis and delayed diagnosis. Therefore, early diagnosis and prompt treatment could reduce the mortality.[2] Small bowel ileus caused by gallstones has become more commonly encountered with the increased use of computed tomography (CT).[3]

An erect abdominal plain film showed mildly dilated bowel loops.

We report two cases in which gallstone ileus was initially diagnosed using multidetector computed tomography (MDCT).

CASE REPORTS Case 1- A 58-year-old male was admitted to the emergency department with a one-week history of abdominal pain, constipation, flatus, defecation, intermittent nausea, and vomiting. His vital signs were stable, and the physical examination disclosed only mild tenderness in the right upper quadrant. The patient was admitted from the emergency department for evaluation of small bowel obstruction. Positive laboratory values included an elevated alkaline phosphatase of 326 U/L and alanine aminotransferase of 206 U/L. Departments of 1Radiology, 2General Surgery, Baskent University, Faculty of Medicine, Adana, Turkey.

Computed tomography (CT) showed the classic triad of findings in gallstone ileus: dilated loops of the small bowel, air in the gallbladder, and an ectopic stone in the ileum. The gallbladder and duodenal walls were thickened, and a cholecystoduodenal fistula was noted (Fig. 1). During surgery, a 3-cm gallstone was extracted via an enterotomy, a cholecystectomy was performed, and the wall of the duodenum was repaired. Case 2- A 70-year-old male with a history of diabetes mellitus presented to the emergency department with a one-week history of abdominal pain, intermittent nausea and vomiting. The physical examination disclosed tenderness in the right upper quadrant. Pertinent positive laboratory values included an elevated white blood cell count at 15×109/L and alkaline phosphatase of 167 U/L. Right upper quadrant sonography failed to show the gallbladder because of overlying gas. CT of the abdomen showed air and oral contrast material in a partially contracted gallbladder with a thickened, enBaşkent Üniversitesi Tıp Fakültesi, 1Radyoloji Anabilim Dalı, 2 Genel Cerrahi Anabilim Dalı, Adana.

Correspondence (İletişim): Naime Altınkaya, M.D. Dadaloğlu Mah., Serin Evler 39. Sk., No: 6, Yüreğir, 01250 Adana, Turkey. Tel: +90 - 322 - 327 27 27 / 1025 e-mail (e-posta): naimeto@yahoo.com

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(a)

(b)

Fig. 1. (a) Axial CT shows a cholecystoduodenal fistula with evidence of gas in the gallbladder (arrow). (b) Volume-rendered coronal CT images show the gallstone impacted in the distal ileum (arrow) and dilated loops of the small bowel.

hancing wall that appeared to communicate with the dilated stomach and a large stone in the pyloric antrum (Fig. 2). The diagnosis of Bouveret syndrome and cholecystitis was made, and he underwent an emergent laparotomy. During surgery, a cholecystogastric fistula was confirmed. Gastrotomy and extraction of the 4-cm gallstone, cholecystectomy and repair of the cholecystogastric fistula were performed.

(a)

DISCUSSION Gallstone ileus occurs secondary to erosion and perforation of the gallbladder wall by a gallstone (usually >2.5 cm in diameter) that enters the intestinal lumen via a cholecystoenteric fistula. Most commonly, it erodes into the duodenum, but occasionally can erode into the stomach or colon.[4,5] The terminal ileum and ileocecal valve are the most common locations of the gallstone. Gastric outlet obstruction from an impacted

(b)

Fig. 2. (a) Axial CT images showing a cholecystogastric fistula. The gallbladder is contracted and contains gas and oral contrast material (arrow). (b) CT shows the gallstone impacted in the pylorus (arrow) and a very distended stomach. 462

Eyl端l - September 2011


Multidetector computed tomography diagnosis of ileal and antropyloric gallstone ileus

gallstone is called Bouveret syndrome, and is a rare complication of a biliodigestive fistula, where a large stone occludes the pyloroduodenal region.[1,2] Antropyloric gallstones, a variant of Bouveret syndrome, are a very rare cause of gastric outlet obstruction.[6]

vides an early, accurate diagnosis of gallstone ileus, enabling surgical treatment, as in our cases. The treatment of gallstone ileus requires an emergency laparotomy, removal of the impacted stone, cholecystectomy, and a fistula repair.[7]

The mortality rate is between 12 and 27%, due to concomitant diseases and the delayed diagnosis. The average age of patients with this rare condition is 70 to 75 years, with a 5 to 1 female-to-male predominance. [7] The presenting clinical situation is variable and nonspecific, but often includes nausea, vomiting and epigastric pain.[2,3,7]

In conclusion, gallstone-induced ileus is a rare complication of cholelithiasis, and gastric outlet obstruction is an even rarer variant that requires a rapid diagnosis and treatment. With the increased use of CT for patients presenting with acute abdomen and in view of its superiority over abdominal plain radiographs, radiologists should be aware of Rigler’s triad for the diagnosis of gallstone ileus on CT. Early diagnosis and treatment may decrease the high mortality encountered in this disease.

The classic radiographic triad of small bowel obstruction, pneumobilia and an ectopic gallstone, as described by Rigler (1941),[7,8] is specific for gallstone ileus. Unfortunately, this triad of findings is suggested in only 30-35% of abdominal plain radiographs in the reported cases. With the increased use of CT for acute abdominal diseases, bowel obstruction, air in the biliary tree and, above all, ectopic gallstones, such conditions are now demonstrated more easily.[7] Pneumobilia can be classified as intrahepatic (gas within the intrahepatic bile ducts) or cholecystic (gas within the gallbladder).[9] In our cases, the CT images showed intrahepatic pneumobilia in one patient, while cholecystic pneumobilia was identified in both patients. Computed tomography (CT) allows a correct diagnosis of gallstone ileus with greater accuracy. The information obtained on CT is used to make a rapid diagnosis and aids in the decision of whether surgical or conservative treatment would be most effective. This approach may decrease the rather high morbidity and mortality seen in this disease. CT is also useful for estimating the size of an impacted gallstone, especially at the transition point between dilated and collapsed bowel.[9] In our cases, CT showed a cholecystoduodenal or cholecystogastric fistula and the transition point between the dilated and collapsed bowel. MDCT pro-

Cilt - Vol. 17 Sayı - No. 5

REFERENCES 1. Brennan GB, Rosenberg RD, Arora S. Bouveret syndrome. Radiographics 2004;24:1171-5. 2. Chou JW, Hsu CH, Liao KF, Lai HC, Cheng KS, Peng CY, et al. Gallstone ileus: report of two cases and review of the literature. World J Gastroenterol 2007;13:1295-8. 3. Ji JS, Zhang SZ, Shao CX, Zhao ZW, Wang ZF, Lü GJ, et al. Imaging diagnosis of two unusual forms of gallstone ileus. Chin Med J (Engl) 2007;120:938-40. 4. Matur R, Yucel T, Gurdal SO, Akpinar A. Bouveret’s syndrome: gastric outlet obstruction by a gallstone. Ulus Travma Derg 2002;8:179-82. [Article in Turkish] 5. Masannat YA, Caplin S, Brown T. A rare complication of a common disease: Bouveret syndrome, a case report. World J Gastroenterol 2006;12:2620-1. 6. Astolfi A, De Berardinis O, Lalli T, Del Cimmiuo P, Saragani C, Colecchia G. Antropyloric lithiasic obstruction: a variant of Bouveret’s syndrome. Minerva Chir 1996;51:347-50. [Abstract] 7. Delabrousse E, Bartholomot B, Sohm O, Wallerand H, Kastler B. Gallstone ileus: CT findings. Eur Radiol 2000;10:938-40. 8. Gürleyik G, Gürleyik E. Gallstone ileus: demographic and clinical criteria supporting preoperative diagnosis. Ulus Travma Derg 2001;7:32-4. 9. Reimann AJ, Yeh BM, Breiman RS, Joe BN, Qayyum A, Coakley FV. Atypical cases of gallstone ileus evaluated with multidetector computed tomography. J Comput Assist Tomogr 2004;28:523-7.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):464-466

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.99266

Gunshot injury to the penis in a patient with penile prosthesis: a case report Penis protezli hastanın penisinde ateşli silah yaralanması: Olgu sunumu Metin İshak ÖZTÜRK, Abdullah İLKTAÇ, Orhan KOCA, Senad KALKAN, Cevdet KAYA, Muhammet İhsan KARAMAN

Civilian penetrating injuries to the penis are quite rare. We present the case of a 48-year-old man with prosthetic implant surgery who referred to the emergency department of our clinic with penetrating gunshot injury to the penis. The damaged implant was removed and the defect on the anterior urethra was repaired primarily. To the best of our knowledge, there is no such report in the literature regarding penile gunshot injury in a patient with penile prosthesis.

Sivil hayatta penise penetran ateşli silah yaralanmaları enderdir. Bu yazıda, acil servise penise penetran ateşli silah yaralanması ile başvuran ve daha önce penis protez implantasyonu yapılmış olan 48 yaşındaki erkek hasta sunuldu. Hasarlı implant çıkarıldı ve anterior üretradaki yaralanma primer olarak onarıldı. Bildiğimiz kadarıyla bu yazıda, literatürde penis protezi olup penis ateşli silah yaralanması olan ilk hasta sunuldu.

Key Words: Penile prosthesis; gunshot injury; penile trauma.

Anahtar Sözcükler: Penis protezi; ateşli silah yaralanması; penis travması.

Although during periods of war, genital wounds account for a large percentage of urologic injuries (4060%),[1,2] civilian penetrating injuries to the penis are quite rare[3] probably due to its anatomical location. Patients with penile gunshot wounds commonly have associated injuries (in up to 80% of cases). Penile prosthesis implantation to correct irreversible erectile dysfunction is a common, well-established treatment,[4] providing a suitable option for the surgical treatment of erectile dysfunction in men in whom conservative therapy fails. To our knowledge, there has been no previous report in the literature about penile gunshot injury in a patient with malleable penile prosthesis.

CASE REPORT A 48-year-old male presented to the emergency department of our clinic with penetrating gunshot injury with a handgun to his penis. The patient was hemodynamically stable. The entrance wound of the bullet was on the right dorsolateral aspect and the exit wound was located on the right ventral aspect of the distal

penile shaft. There were also entrance and exit wounds in the superior part of the scrotum and proximal onethird of the right thigh on the medial side. There was blood at the urethral meatus. Pelvic plain radiographs showed perforated right and intact left malleable penile prosthetic implant. Immediate retrograde urethrogram was performed, showing contrast medium extravasation from the anterior urethra. The patient had a history of malleable penile prosthetic implant surgery 12 years ago because of erectile dysfunction due to diabetes. During the physical examination, it was seen that the implant located on the right corpus was damaged. No testicular injury or active bleeding or hematoma was detected on the physical examination or ultrasound. A suprapubic catheter was placed and the patient was taken to surgery. Cefazolin (1 g), gentamicin (80 mg) and metronidazole (500 mg) was injected 1 hour before surgery for prophylaxis. After a circumferential incision, the penis was degloved and the right penile prosthesis was removed. There was an approximately 1 cm defect on the anterior urethra

2nd Department of Urology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey.

Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, 2. Üroloji Kliniği, İstanbul.

Correspondence (İletişim): Orhan Koca, M.D. Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, 2. Üroloji Kliniği, Üsküdar, İstanbul, Turkey. Tel: +90 - 216 - 414 45 02 / 1225 e-mail (e-posta): drorhankoca@hotmail.com

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Gunshot injury to the penis in a patient with penile prosthesis

Fig. 2. Prosthesis perforated by the bullet.

Fig. 1. Defect on the anterior urethra.

(Fig. 1). It was sutured with 4/0 Vicryl suture over an 18F urethral catheter. The damaged part of the corpora cavernosa was repaired with 2/0 Vicryl. The prosthesis was perforated by the bullet and inner metallic parts of the prosthesis had migrated to the scrotum (Fig. 2). During the surgery, the left penile prosthesis was checked manually and was determined to be functional and was thus retained in place. Five days after surgery, the patient was discharged from the hospital. The Foley catheter was removed 14 days after surgery. The patient had spontaneous micturition. During the follow-up at six months, he was found to have no lower urinary tract symptoms. He had a Qmax of 19 ml/sec. He was capable of performing sexual intercourse with the remaining prosthesis (International Index of Erectile Function [IIEF] score: 22).

DISCUSSION The most important part of the evaluation of a patient with penetrating penile trauma is physical examination of the wound. The presence of active bleeding and/or hematoma, assessment of missile trajectory, recognition of blood at the meatus as well as search for other associated injuries are essential.[5] Generally, urethrography is suggested for all patients with penetrating penile injury because up to 50% have urethral involvement.[6,7] Incidence of urethral injury in patients with penile gunshot injury was reported as 33% in a series of 43 cases.[8] Exploratory surgery has been recommended for all penetrating injuries of the external genitalia.[3] Most patients with penile gunCilt - Vol. 17 Say覺 - No. 5

shot injury require surgical debridement and closure. [9] A minority of patients with minimal injury can be managed nonoperatively, representing approximately 10% of all patients, and all have superficial penetration or trivial penile injury.[6,7,10] Management of associated anterior urethral injury has been controversial.[11] Some authors suggest that patients with low velocity urethral gunshot wounds have excellent healing rates with suprapubic diversion alone, whereas others state that treatment of partial urethral disruption by primary repair over a Foley catheter has lower stricture rates than when primary repair was not attempted.[12,13] The presence of a penile prosthesis complicated this case. To the best of our knowledge, there is no such report in the literature about penile gunshot injury in a patient with penile prosthesis. We removed the urethral catheter 14 days after surgery after which the patient had spontaneous micturition. In this case, no urethral stricture development or lower urinary tract symptom was present six months after surgery. The corporal body injury was repaired primarily. We aimed to keep at least one prosthesis in place and, if necessary, to place an implant to the damaged part later. However, the patient indicated that he was satisfied with his sexual life with the remaining prosthesis and he did not want any additional treatment. Results after gunshot injury to the penis are quite satisfactory, but careful assessment is essential. In gunshot injuries, the wound and pelvic radiographs should be examined carefully, as some pieces of the prosthesis may migrate to other parts of the pelvis. Retrograde urethrography should be performed in all patients except for selected cases. To our knowledge, there has been no other report in the literature about penile gunshot injury in a patient with penile prosthesis. In this case, removal of one prosthetic implant did not affect the sexual life of the patient. 465


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REFERENCES 1. Salvatierra O Jr, Rigdon WO, Norris DM, Brady TW. Vietnam experience with 252 urological war injuries. J Urol 1969;101:615-20. 2. Selikowitz SM. Penetrating high-velocity genitourinary injuries. Part II: Ureteral, lower tract, and genital wounds. Urology 1977;9:493-9. 3. Phonsombat S, Master VA, McAnnich JW. Penetrating external genital trauma: a 30-year single institution experience. J Urol 2008;180:192-6. 4. Garber BB. Inflatable penile prostheses for the treatment of erectile dysfunction: an update. Expert Rev Med Devices 2008;5:133-44. 5. Goldman HB, Dmochowski RR, Cox CE. Penetrating trauma to the penis: functional results. J Urol 1996;155:551-3. 6. Jankowski JT, Spirnak JP. Current recommendations for imaging in the management of urologic traumas. Urol Clin North Am 2006;33:365-76. 7. Cline KJ, Mata JA, Venable DD, Eastham JA. Penetrating trauma to the male external genitalia. J Trauma 1998;44:492-4.

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8. Cavalcanti AG, Krambeck R, Araujo A, Manes CH, Favorito LA. Penile lesion from gunshot wound: a 43-case experience. Int Braz J Urol 2006;32:56-63. 9. Bandi G, Santucci RA. Controversies in the management of male external genitourinary trauma. J Trauma 2004;56:136270. 10. Morey AF, Rozanski TA. Genital and lower urinary tract trauma. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbellâ&#x20AC;&#x2122;s urology. Vol 3, 9th ed., Philadelphia: W.B. Saunders Co.; 2007. p. 2649-62. 11. Brandes SB, Buckman RF, Chelsky MJ, Hanno PM. External genitalia gunshot wounds: a ten-year experience with fiftysix cases. J Trauma 1995;39:266-72. 12. Pontes JE, Pierce JM Jr. Anterior urethral injuries: four years of experience at the Detroit General Hospital. J Urol 1978;120:563-4. 13. Husmann DA, Boone TB, Wilson WT. Management of low velocity gunshot wounds to the anterior urethra: the role of primary repair versus urinary diversion alone. J Urol 1993;150:70-2.

EylĂźl - September 2011


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):467-469

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.48295

Inflamed vermiform appendix within the sac of incarcerated left inguinal hernia Boğulmuş sol kasık fıtığı içinde inflame vermiform apendiks Sevim TURANLI, Murat Ulvi YÜKSEL, Yavuz PİRHAN, Abdullah ÇETİN

A 54-year-old male complained of a continuous pain together with an irreducible swelling of the left inguinal region 8 hours prior to admission to the surgical emergency department. His physical examination revealed a very painful, erythematous, irreducible swelling in the left inguinal region without abdominal peritoneal irritation. Routine blood tests disclosed mild leukocytosis. Abdominal plain X-ray film was not specific, and ultrasonography revealed a 10 cm in length inactive, edematous intestinal section within the inguinal hernia. With the diagnosis of strangulated inguinal hernia, he underwent surgical exploration through a transverse inguinal incision. By opening the hernia sac, 6-8 cc inflammatory fluid drained out, and an inflamed vermiform appendix adhered to the inner surface of the sac was seen. Appendicectomy and primary hernia repair were performed at the same time through the inguinal incision. The postoperative course was uneventful, and the histological examination of the specimen revealed an inflamed appendix.

Elli dört yaşında erkek hasta, 8 saat önce başlayan sol kasıkta sürekli ağrı ve redükte olmayan şişlik şikayeti ile acil cerrahi servisine başvurdu. Fiziksel incelemede karında hassasiyet yoktu, sol kasıkta oldukça ağrılı, eritemli ve redükte olmayan şişlik vardı. Rutin kan testlerinde hafif lökositoz saptandı. Düz karın grafisinde özellik yoktu, ultrasonografide sol inguinal kanalda 10 cm uzunluğunda, hareketsiz, ödemli ince bağırsak ansı görüldü. Boğulmuş sol kasık fıtığı tanısıyla hasta ameliyata alındı. Kasığa transvers kesi yapılarak fıtık kesesi ortaya konuldu. Kese açıldığında 6-8 cc pürülan sıvı geldi, vermiform apendiks inflame ve kese iç duvarına yapışık durumdaydı. Aynı seansta hem apendektomi hemde primer fıtık onarımı yapıldı. Ameliyat sonrası komplikasyon gelişmedi. Patolojik inceleme inflame apendiks ile uyumluydu.

Key Words: Amyand’s hernia; left side; surgical treatment.

Anahtar Sözcükler: Amyand fıtığı; sol taraf; cerrahi tedavi.

Acute abdomen syndrome due to inflamed or perforated vermiform appendix is very common and mostly diagnosed preoperatively. However, it does not come to mind if it is atypically localized. In 1735, Claudius Amyand was the first to define perforated appendix within the sac of an inguinal hernia while operating on a male patient who had a right inguinal hernia together with a fistula draining to the groin.[1] Since then, the presence of a vermiform appendix in an inguinal hernia sac has been referred to as Amyand’s hernia, and it remains a rare occurrence. We point out the need to consider acute appendicitis in left-sided incarcerated inguinal hernia and we briefly review the literature on this topic.

CASE REPORT A 54-year-old male was admitted to our surgical emergency department with an incarcerated inguinal hernia. In his medical history, he reported intermittent groin pain over the last six months and a sudden onset of a continuous pain together with an irreducible swelling of the left inguinal region 8 hours prior to admission. He was not experiencing disturbances of bowel function or symptoms such as anorexia, nausea, vomiting, or abdominal discomfort. Physical examination������������������������������������������� revealed a very painful, erythematous, irreducible swelling in the left inguinal region without abdominal peritoneal irritation. There was no bowel sound on the swelling and very few bowel sounds in

Department of General Surgery, Ankara Oncology Training and Research Hospital, Ankara, Turkey.

Ankara Onkoloji Eğitim ve Araştırma Hastanesi, 1. Cerrahi Kliniği, Ankara.

Correspondence (İletişim): Sevim Turanlı, M.D. Turk-İs Blokları, No: 200/6, Aydinlikevler 06130 Ankara, Turkey. Tel: +90 - 312 - 336 09 09 e-mail (e-posta): turanlisevim@hotmail.com

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the abdominal region on auscultation. Digital rectal examination revealed no pathological findings. Routine blood tests disclosed mild leukocytosis. Urinary analyses were normal. Abdominal plain X-ray film was not specific and ultrasonography revealed a 10 cm in length inactive, edematous intestinal section within the inguinal hernia. With a diagnosis of strangulated inguinal hernia, he underwent surgical exploration through a transverse inguinal incision. The inguinal canal itself was found to be edematous. On opening the hernia sac, 6-8 cc inflammatory fluid drained out, and an inflamed vermiform appendix adhered to the inner surface of the sac was seen (Fig. 1). The omentum and base of the cecum had closed the deep inguinal orifice. Appendicectomy and primary hernia repair were performed at the same time through the inguinal incision. The postoperative course was uneventful, and the histological examination of the specimen revealed an inflamed appendix.

DISCUSSION Incarcerated groin hernia is very common among patients who are admitted to the emergency surgery department. The omentum majus or small bowel is usually found in the hernia sac. However, certain unusual contents may also be encountered, such as the bladder, ovary, fallopian tube, large bowel diverticula with the form of diverticulitis or abscess, Meckel’s diverticulum, a portion of the circumference of the intestine, or foreign bodies. Presence of vermiform appendix in the hernia sac is another rare situation, though because of normal anatomical localization of the vermiform appendix, it may logically be present in the right inguinal hernia sac. However, left-sided Amyand’s hernia is also defined as a highly rare situation[2-4] and may be associated with situs inversus,

intestinal malrotation or mobile cecum.[5] Amyand’s hernia is also seen in neonates or children[6,7] as well as adults, and is more frequent in males.[8] When patients diagnosed as Amyand’s hernia are examined retrospectively, the absence of acute abdominal symptoms is determined in most of them. Although there is an inflamed or perforated appendix, symptoms and signs are only on the hernia sac localization.[2,9,10] It is usually misdiagnosed as an irreducible������������������������������������������� or strangulated inguinal hernia, acute hydrocele, acute epididymitis, testicular torsion, Richter’s hernia, or inguinal lymphadenitis.[4] As a result, any patient with painful swelling of the inguinal region, especially when accompanied by inflammation of the surrounding soft tissue, should raise suspicion of Amyand’s hernia. Ultrasonography is not adequate for a clear diagnosis, and preoperative abdominal tomography is performed only in certain situations to determine some other diagnoses. Some published cases were diagnosed by tomography preoperatively.[11,12] The correct diagnosis is important if emergent surgery is indicated for deciding the form of incision. Inguinal incision is applied in most of the patients because Amyand’s hernia is usually diagnosed intraoperatively. The selection of surgical intervention is based on the presence or absence of inflammation of the appendix in the sac. If the vermiform appendix is not inflamed, the common approach is to not perform appendectomy. Peritoneal contamination in the abdomen may lead to laparotomy, where appendectomy together with hernia repair is sufficient if the inflammation or abscess in the vermiform appendix is confined to the hernia sac.[6,9] In the present case, the patient had no abdominal discomfort, and although inflammatory fluid was seen in the sac, the cecum and omentum had tightly closed the deep inguinal orifice, so laparotomy was not needed. Repair of Amyand’s hernia with prosthetic mesh is controversial. Some authors claim the use of prosthetic mesh is not suitable due to the contaminated operating field[8,10,13,14] while others say that primary hernia repair could be difficult in an inflamed and edematous area, and could thus increase the risk of recurrence.[8] In our patient, edema and inflammation were present in the field though primary repair was possible, and we did not prefer prosthetic mesh repair.

Fig. 1. The view of the vermiform appendix in the operating room. 468

The physiopathology of Amyand’s hernia is unknown. One of the theories is that following increased intraabdominal pressure for any reason, the vermiform appendix is compressed in the inguinal canal, which leads to poor blood supply and bacterial overgrowth, inflammation and subsequent perforation.[15] Another theory is that Amyand’s hernia with acute appendicitis is an incidental finding.[16] Eylül - September 2011


Inflamed vermiform appendix within the sac of incarcerated left inguinal hernia

In conclusion, preoperative diagnosis of appendicitis in an inguinal hernia, especially on the left side, requires high clinical suspicion. The choice of surgical procedure depends on the presence or absence of appendicular inflammation. If the vermiform appendix is normal, hernia repair alone is sufficient. The inflammatory status of the appendix determines the type of hernia repair and the surgical approach.

REFERENCES 1. Hutchinson R. Amyand’s hernia. J R Soc Med 1993;86:1045. 2. Gupta S, Sharma R, Kaushik R. Left-sided Amyand’s hernia. Singapore Med J 2005;46:424-5. 3. Breitenstein S, Eisenbach C, Wille G, Decurtins M. Incarcerated vermiform appendix in a left-sided inguinal hernia. Hernia 2005;9:100-2. 4. Carey LC. Acute appendicitis occurring in hernias: a report of 10 cases. Surgery 1967;61:236-8. 5. Bakhshi GD, Bhandarwar AH, Govila AA. Acute appendicitis in left scrotum. Indian J Gastroenterol 2004;23:195. 6. Livaditi E, Mavridis G, Christopoulos-Geroulanos G. Amyand’s hernia in premature neonates: report of two cases. Hernia 2007;11:547-9. 7. Martins JL, Peterlini FL, Martins EC. Neonatal acute appendicitis: a strangulated appendix in an incarcerated inguinal hernia. Pediatr Surg Int 2001;17:644-5.

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8. Torino G, Campisi C, Testa A, Baldassarre E, Valenti G. Prosthetic repair of a perforated Amyand’s hernia: hazardous or feasible? Hernia 2007;11:551-4. 9. Kueper MA, Kirschniak A, Ladurner R, Granderath FA, Konigsrainer A. Incarcerated recurrent inguinal hernia with covered and perforated appendicitis and periappendicular abscess: case report and review of the literature. Hernia 2007;11:189-91. 10. Salemis NS, Nisotakis K, Nazos K, Stavrinou P, Tsohataridis E. Perforated appendix and periappendicular abscess within an inguinal hernia. Hernia 2006;10:528-30. 11. Ash L, Hatem S, Ramirez GA, Veniero J. Amyand’s hernia: a case report of prospective ct diagnosis in the emergency department. Emerg Radiol 2005;11:231-2. 12. Luch JS, Halpern D, Katz DS. Amyand’s hernia: prospective CT diagnosis. J Comput Asist Tomogr 2000;24:884-6. 13. D’Alia C, Lo Schiavo MG, Tonante A, Taranto F, Gagliano E, Bonanno L, et al. Amyand’s hernia: case report and review of the literature. Hernia 2003;7:89-91. 14. Sharma H, Gupta A, Shekhawat NS, Memon B, Memon MA. Amyand’s hernia: a report of 18 consecutive patients over a 15-year period. Hernia 2007;11:31-5. 15. Abu-Dalu J, Urca I. Incarcerated inguinal hernia with a perforated appendix and periappendicular abscess: report of a case. Dis Colon Rectum 1972;15:464-5. 16. Bar-Maor JA, Zeltzer M. Acute appendicitis located in a scrotal hernia of a premature infant. J Pediatr Surg 1978;13:1812.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (5):470-472

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.63308

Late recognized nail aspiration in a child: case report Çocukta geç farkedilen çivi aspirasyonu: Olgu sunumu Ufuk ÇOBANOĞLU,1 Muhammed CAN,2 İsmail BİRİNCİOĞLU,3 Yeşim EDİRNE,4 Mehmet MELEK4

Foreign body (FB) aspiration is common in children aged 0-3 years. Our case, a 2.5-year-old girl, presented with sudden onset of cough, fever and sputum; she had been treated twice for acute bronchitis four months ago. Resisting complaints led to an esophagoscopic examination in our Chest Surgery Clinic after a chest X-ray suggested FB in the esophagus, but no FB could be detected. A lateral chest X-ray revealed a FB with its sharp end targeting the trachea and its round end to the right hemithorax. Removal of the FB with forceps was not possible during rigid bronchoscopy. The FB was removed by thoracotomy and bronchotomy under general anesthesia. The removed FB was a nail measuring 6 cm in length. This case report should serve to stress the diversity of FB aspirations in childhood, the role of parental neglect, and that physicians should be aware of the possibility of FB in children with persistent cough.

Çocuklarda 0-3 yaş arası yabancı cisim (YC) aspirasyonu sık görülmektedir. Kız olgu, 4 ay önce ani başlayan öksürük, ateş ve balgam çıkarma şikayetiyle bir sağlık merkezinde akut bronşit tanısı ile iki kez tedavi edildi. Şikayetinin sürmesi üzerine, çekilen akciğer grafisinde özofagusta yabancı cisim şüphesi ile Göğüs Cerrahisi Kliniğimize sevk edilen olguya yapılan özofagoskopide YC görülmedi. Çekilen akciğer yan grafisinde, keskin ucu trakea orta hatta, yuvarlak ucu sağ hemitoraksa yönelmiş YC saptandı. Rijit bronkoskopi ile çıkarılamayan YC, torakotomi ve bronkotomi yöntemiyle genel anestezi altında çıkarıldı. YC 6 cm boyunda çivi idi. Bu sunum, çocukluk çağındaki YC aspirasyonlarının çeşitliliğini, hekimlerin sağlık kurumlarına inatçı öksürük şikayeti ile başvuran çocuklarda YC aspirasyonu olasılığına her zaman dikkat etmeleri gerektiğini ve ebeveyn ihmalini göstermek amacıyla hazırlanmıştır.

Key Words: Aspiration; forensic case; foreign body.

Anahtar Sözcükler: Aspirasyon; adli olgu; yabancı cisim.

Foreign body (FB) aspiration is a very common pediatric emergency, is especially seen in infants and children from lower socioeconomic groups and may be associated with high mortality and morbidity.[1-6] Inhalation of a FB is usually accompanied by acute severe coughing, stridor, wheezing, and respiratory distress. This acute episode may escape the notice of parents, and the problem may manifest as an insidious chronic pulmonary problem, the cause of which may remain occult for a long period.[3,7] In our study, we aimed to show an unusual case of FB aspiration from the Van area.

CASE REPORT Our case was a 2.5-year-old girl, the seventh child of her parents; the family lived in a very small house. Her family was poor, with a monthly income of under US$500. Four months ago, she has been admitted to a health center with recurrent cough, fever and sputum, and was diagnosed as acute bronchitis. In spite of medical treatment, her symptoms persisted and chest radiography was performed, which showed a FB measuring 6 cm in length. She was sent to a medical faculty in June 2008, where a chest X-ray performed in the chest clinic revealed a suspected nail, with the

Presented at the 1st International Eurasian Forensic Sciences Congress (October 8-11, 2008, Istanbul, Turkey).

1. Uluslararası Avrasya Adli Bilimler Kongresi’nde poster bildirisi olarak sunulmuştur (8-11 Ekim 2008, İstanbul).

Departments of 1Chest Surgery, 2Forensic Medicine, 4Pediatric Surgery, Yuzuncu Yil University Faculty of Medicine, Van; Department of Forensic Medicine, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey.

Yüzüncü Yıl Üniversitesi Tıp Fakültesi, 1Göğüs Cerrahisi Anabilim Dalı, 2 Adli Tıp Anabilim Dalı, 4Çocuk Cerrahisi Anabilim Dalı, Van; 3 Karadeniz Teknik Üniversitesi Tıp Fakültesi, Adli Tıp Anabilim Dalı, Trabzon.

Correspondence (İletişim): Ufuk Çobanoğlu, M.D. Yüzüncü Yıl Üniversitesi Tıp Fakültesi, Araştırma Hastanesi, 65100 Van, Turkey. Tel: +90 - 432 - 215 05 42 e-mail (e-posta): drucobanoglu@hotmail.com

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Late recognized nail aspiration in a child

sharp end located in the mid-trachea and the round tip in the hemithorax (Fig. 1a, b). She was hospitalized. Laboratory results were normal except for an elevated white blood cell count of 11,000/mm. Rigid esophagoscopy and bronchoscopy were planned. After endotracheal intubation, no FB was seen in the lumen of the esophagus by rigid esophagoscopy. The FB was identified in the trachea by fiberoptic bronchoscopy through the endotracheal tube. Rigid bronchoscopy was attempted, but after determining that the FB had

travelled from the right main bronchus to the carina, an open surgical procedure was planned. Under general anesthesia, after entering the thorax through the 5th intercostal space, the azygos vein was tied and cut to ease approaching the main right bronchus. After appropriate and careful dissection, the right main bronchus was exposed. After sensation of the FB in right main bronchus by palpation, bronchotomy was done with a 0.5 cm incision (Fig. 1c). The FB in the bronchus was pushed to the trachea by means of a clamp.

(a)

(b)

(c)

(d)

(e) Fig. 1. (a) A direct chest X-ray revealed a foreign body with its sharp end targeting the trachea and its round end to the right hemithorax. (b) View of the foreign body in the lateral chest X-ray. (c) View of the foreign body in right main bronchus. (d) Extraction of the foreign body from the bronchotomy site. (e) Rusty nail extracted from the right main bronchus. (f) Postoperative chest X-ray of the patient. Cilt - Vol. 17 Say覺 - No. 5

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Ulus Travma Acil Cerrahi Derg

After visualization of the nail tip from the bronchotomy site, the FB was extracted by a clamp (Fig. 1d). The extracted FB was a nail as commonly used in construction. The nail was 6 cm in length and 1.2 cm in diameter and the top of the nail measured 0.6 cm (Fig. 1e). X-ray imaging of the chest on days 1, 3, 5, and 9 and follow-up bronchoscopy on day 7 revealed no complication (Fig. 1f). Tetanus vaccination was not necessary according to her immunization history. The patient was discharged on day 9 and has been followed without any problem up to the 4th month.

DISCUSSION More than 75% of FB aspiration cases are seen in children between 0-3 years old. Additionally, 7% of deaths in children aged 0-3 years occur because of FB aspiration.[8,9] Males are exposed more to FB aspiration, but with no known explanation. The ratio is approximately 2:1.[9-11] FB aspiration is closely related to age, sex, culture, socioeconomic condition, and tradition. FB aspiration is seen frequently due to inadequate education and negligence, especially in developing countries. Poor safety precautions in construction areas may be dangerous for the neighboring community and especially children.[12] Parents should carefully monitor small children playing around construction areas. FB in the airway of children requires prompt removal. Ideal diagnostic methods would minimize unnecessary bronchoscopy for conditions that mimic airway FBs and avoid delay when patients with FBs require bronchoscopy. Textbook and journal articles have emphasized the importance of radiographic indicators of airway FBs.[13-16] Early recognition and treatment of FB are very important because of possible early and late serious complications. Rigid bronchoscopy is the preferred method for removal of FB in children.[15] In postponed cases, inflammation and granulation develop around the FB. Edema and/or purulent secretion are the basic mucosal changes observed in children. In cases treated in less than 24 hours, reaction is only expected in 0.8% of cases. Between 2-20 days or after 30 days, a tissue reaction is observed in 20% and 100%, respectively. In these cases, thoracotomy and bronchotomy are applied.[16,17] In our case, the FB was located in the right main bronchus for 4 months and a diffuse tissue reaction was detected. Therefore, bronchotomy was applied after rigid bronchoscopy failed to remove the FB. In our study, we aimed to present an unusual case

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of FB aspiration from the Van area. This case report should remind physicians of the forensic perspective with respect to parental neglect, and physicians should be aware of the possibility of FBs in children with persistent cough.

REFERENCES 1. Anyanwu CH. Foreign body airway obstruction in Nigerian children. J Trop Pediatr 1985;31:170-3. 2. O’Neill JA Jr, Holcomb GW Jr, Neblett WW. Management of tracheobronchial and esophageal foreign bodies in childhood. J Pediatr Surg 1983;18:475-9. 3. Kosloske AM. Bronchoscopic extraction of aspirated foreign bodies in children. Am J Dis Child 1982;136:924-7. 4. Altmann AE, Ozanne-Smith J. Non-fatal asphyxiation and foreign body ingestion in children 0-14 years. Inj Prev 1997;3:176-82. 5. Thompson GP, Utz JP, McDougall JC. Pediatric tracheobronchial foreign bodies. A case report. Minn Med 1993;76:1921. 6. Byard RW. Mechanisms of unexpected death in infants and young children following foreign body ingestion. J Forensic Sci 1996;41:438-41. 7. Aytaç A, Yurdakul Y, Ikizler C, Olga R, Saylam A. Inhalation of foreign bodies in children. Report of 500 cases. J Thorac Cardiovasc Surg 1977;74:145-51. 8. Steen KH, Zimmermann T. Tracheobronchial aspiration of foreign bodies in children: a study of 94 cases. Laryngoscope 1990;100:525-30. 9. Mantor PC, Tuggle DW, Tunell WP. An appropriate negative bronchoscopy rate in suspected foreign body aspiration. Am J Surg 1989;158:622-4. 10. Carluccio F, Romeo R. Inhalation of foreign bodies: epidemiological data and clinical considerations in the light of a statistical review of 92 cases. Acta Otorhinolaryngol Ital 1997;17:45-51. [Abstract] 11. Ludemann JP, Holinger LD. Management of foreign bodies of the airway. In: Shields TW, LoCicero J, Ponn RB, editors. General thoracic surgery. 5th ed. Philadelphia: W.B. Saunders; 2000. p. 853-62. 12. Elhassani NB. Tracheobronchial foreign bodies in the Middle East. A Baghdad study. J Thorac Cardiovasc Surg 1988;96:621-5. 13. Orenstein DM. Foreign bodies in the larynx, trachea, and bronchi. In: Behrman RE, Kleigman RM, editors. Nelson textbook of pediatrics. 15th ed. Philadelphia, PA: Saunders; 1996. p. 1205-8. 14. Boyd AD. Endoscopy: Bronchoscopy and esophagoscopy. In: Sabiston DC, Spencer FC, editors. Surgery of the chest. 6th ed. Philadelphia, PA: Saunders; 1995. p. 81-4. 15. Yıldırım M, Doğusoy I, Okay T, Yasaroğlu M, Demirbağ H, Aydemir B, et al. Trakeobronsiyal yabancı cisimler. Türk Göğüs Kalp Damar Cer Derg Surg 2003;11:228-31. 16. Karakoç F, Karadağ B, Akbenlioğlu C, Ersu R, Yildizeli B, Yüksel M, et al. Foreign body aspiration: what is the outcome? Pediatr Pulmonol 2002;34:30-6. 17. Wei JL, Holinger LD. Management of foreign bodies of the airway. In: Shields TW, editor. General thoracic surgery. Volume 1, 6th ed. Philedelphia: Lippincott Williams Wilkins; 2005. p. 995-1005.

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Travma 2011-5