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Cilt - Volume 19

Say› - Number 2

www.tjtes.org

Mart - March 2013

Cilt - Volume 19

Sayı - Number 2

Mart - March 2013

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 ACİL CERRAHİ DERGİSİ 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 Murat Aksoy Şeref Aktaş Ali Akyüz Ömer Alabaz Orhan Alimoğlu Nevzat Alkan Edit Altınlı Acar Aren Gamze Aren Cumhur Arıcı Oktar Asoğlu Ali Atan Bülent Atilla Levent Avtan Yunus Aydın Önder Aydıngöz Erşan Aygün Mois Bahar Akın Eraslan Balcı Emre Balık Umut Barbaros Semih Baskan M Murad Başar Mehmet Bayramiçli Ahmet Bekar Orhan Bilge Mustafa Bozbuğa Mehmet Can 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 Kemal Dolay Levent Döşemeci Murat Servan Döşoğlu Kemal Durak Engin Dursun

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

Atilla Elhan Mehmet Eliçevik İmdat Elmas Ufuk Emekli 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 İbrahim İkizceli 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 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 Cemal Özçelik İlgin Özden Mehmet Özdoğan

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

Şükrü Özer Halil Özgüç Ahmet Özkara Mahir Özmen Vahit Özmen Niyazi Özüçelik Süleyman Özyalçın Emine Özyuvacı Salih Pekmezci İzzet Rozanes Kazım Sarı Esra Can Say Ali Savaş İskender Sayek Tülay Özkan Seyhan Gürsel Remzi Soybir Yunus Söylet Erdoğan Sözüer Mustafa Şahin Cüneyt Şar Mert Şentürk Feridun Şirin İbrahim Taçyıldız Gül Köknel Talu Ertan Tatlıcıoğlu Gonca Tekant Cihangir Tetik 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 Cumhur Yeğen Ebru Yeşildağ Hüseyin Yetik Cuma Yıldırım Bedrettin Yıldızeli Sezai Yılmaz Kaya Yorgancı Coşkun Yorulmaz Tayfun Yücel

Konya Bursa İstanbul Ankara İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul Ankara Ankara İstanbul Tekirdağ İstanbul Kayseri Tokat İstanbul İstanbul İstanbul Diyarbakır İstanbul Ankara İstanbul İstanbul Manisa İstanbul İstanbul Kocaeli Ankara İstanbul İstanbul Kocaeli Urfa İzmir Adana İstanbul İstanbul İstanbul Trabzon İstanbul İstanbul Tekirdağ İstanbul Gaziantep İstanbul Malatya Ankara İstanbul İstanbul

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 Şehremini Mah., Köprülü Mehmet Paşa Sok. Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul

Tel: +90 212 - 588 62 46 - 588 62 46 Faks (Fax): +90 212 - 586 18 04 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 Şehremini Mah., Köprülü Mehmet Paşa Sok., Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul +90 212 - 531 12 46 - 588 62 46 +90 212 - 586 18 04

Abonelik: 2013 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 (karepublishing) • 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): Mart (March) 2013 • 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.

Abstract: The abstract should be structured and serve as an informative guide for the methods and results sections of the study. It must be prepared with the following subtitles: Background, Methods, Results and Conclusions. Abstracts should not exceed 200 words. Figures, illustrations and tables: All figures and tables should be numbered in the order of appearance in the text. The desired position of figures and tables should be indicated in the text. Legends should be included in the relevant part of the main text and those for photomicrographs and slide preparations should indicate the magnification and the stain used. Color pictures and figures will be published if they are definitely required and with the understanding that the authors are prepared to bear the costs. Line drawings should be professionally prepared. For recognizable photographs, signed releases of the patient or of his/her legal representatives should be enclosed; otherwise, patient names or eyes must be blocked out to prevent identification. References: All references should be numbered in the order of mention in the text. All reference figures in the text should be given in brackets without changing the font size. References should only include articles that have been published or accepted for publication. Reference format should conform to the “Uniform requirements for manuscripts submitted to biomedical journals” (http://www.icmje.org) and its updated versions (February 2006). Journal titles should be abbreviated according to Index Medicus. Journal references should provide inclusive page numbers. All authors, if six or fewer, should be listed; otherwise the first six should be listed, followed by “et al.” should be written. The style and punctuation of the references should follow the formats below: Journal article: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5.

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

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

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.

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

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”.

Review articles: Only reviews written by distinguished authors based on the editor’s invitation will be considered and evaluated. Review articles must include the title, summary, text, and references sections. Any accompanying tables, graphics, and figures should be prepared as mentioned above. Case reports: A limited number of case reports are published in each issue of the journal. The presented case(s) should be educative and of interest to the readers, and should reflect an exclusive rarity. Case reports should contain the title, summary, and the case, discussion, and references sections. These reports may consist of maximum five authors. Letters to the Editor: “Letters to the Editor” are only published electronically and they do not appear in the printed version of TJTES and PUBMED. The editors do not issue an acceptance document as an original article for the ‘’letters to the editor. The letters should not exceed 500 words. The letter must clearly list the title, authors, publication date, issue number, and inclusive page numbers of the publication for which opinions are released. Informed consent - Ethics: Manuscripts reporting the results of experimental studies on human subjects must include a statement that informed consent was obtained after the nature of the procedure(s) had been fully explained. Manuscripts describing investigations in animals must clearly indicate the steps taken to eliminate pain and suffering. Authors are advised to comply with internationally accepted guidelines, stating such compliance in their manuscripts and to include the approval by the local institutional human research committee.

ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY C‹LT - VOL. 19

SAYI - NUMBER 2 MART - MARCH 2013

İçindekiler - Contents

Deneysel Çalışma - Experimental Study 89-97 Sıçanlarda, antiödem olarak kullanılan ilaçların diffüz beyin ödemine etkileri: Deneysel çalışma Effects of anti-edema drugs on diffuse cerebral edema in rats: Experimental study Akyüz F, İş M, Aytekin H, Anlar M, Akgül O 98-102 Thermoelastic stress analysis to validate tibial fixation technique in total ankle prostheses a pilot study Total diz protezlerinde tibial fiksasyon tekniğinin validasyonunda termoelastik gerilme analizi: Bir pilot çalışma Ficklscherer A, Wegener B, Niethammer T, Pietschmann MF, Müller PE, Jansson V, Trouillier HH

Klinik Çalışma - Original Articles 103-108 Assessment of the severity of acute pancreatitis by contrast-enhanced computerized tomography in 350 patients Kontrastlı bilgisayarlı tomografi ile akut pankreatitli 350 hastada hastalığın şiddet derecesinin değerlendirilmesi Mir MA, Bali BS, Mir RA, Wani H 109-114 The functional results of acute nerve grafting in traumatic sciatic nerve injuries Travmatik siyatik sinir yaralanmalarında uygulanan akut sinir greftlemesinin fonksiyonel sonuçları Vayvada H, Demirdöver C, Menderes A, Yılmaz M, Karaca C 115-118 Posttraumatic intraocular pressure elevation and associated factors in patients with zone I open globe injuries Zon I açık göz yaralanması olan olgularda posttravmatik göz içi basıncı yükselmesi ve ilişkili faktörler Acar U, Yıldız EH, Ergintürk Acar D, Altıparmak UE, Yalnız Akkaya Z, Burcu A, Ünlü N 119-122 Hepatic hydatid disease requiring urgent treatment during pregnancy Hamilelik sırasında acil tedavi gerektiren karaciğer kist hidatiği Erçetin C, Özden İ, İyibozkurt C, Güven K, Serin K, Bilge O, Tekant Y, Alper A, Emre A 123-126 Epidemiology of pediatric burn injuries in Istanbul, Turkey İstanbul’daki pediatrik yanıklı hastaların epidemiyolojisi Arslan H, Kul B, Derebaşınlıoğlu H, Çetinkale O 127-132 Künt toraks travmasında mortaliteye etki eden faktörler Factors affecting mortality in blunt thoracic trauma Hasbahçeci M, Özpek A, Başak F, Çalışkan M, Ener BK, Alimoğlu O 133-139 Dieulafoy lezyonuna bağlı akut gastrointestinal sistem kanaması nedeniyle acil servise başvuran olguların tedavi sonuçlarının değerlendirilmesi Evaluation of treatment results among patients with acute gastrointestinal bleeding due to Dieulafoy’s lesion admitted to the emergency department Beyazit Y, Dişibeyaz S, Suvak B, Purnak T, Torun S, Parlak E Cilt - Vol. 19 Sayı - No. 2

vii

ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY C‹LT - VOL. 19

SAYI - NUMBER 2 MART - MARCH 2013

İçindekiler - Contents 140-144 Pediatrik travma skorunun yüksek kinetik enerjiye sahip parça etkili yaralanmalardaki analizi: İlk müdahale merkezi sonuçları Analysis of the pediatric trauma score in patients wounded with shrapnel; the effect of explosives with high kinetic energy: results of the first intervention center Taş H, Mesci A, Demirbağ S, Eryılmaz M, Yiğit T, Peker Y 145-151 Mid-term results of calcaneal plating for displaced intraarticular calcaneus fractures Eklemiçi kalkaneus kırıklarında cerrahi tedavi yöntemimizin orta dönem sonuçları Gülabi D, Sarı F, Şen C, Avcı CC, Sağlam F, Erdem M, Bulut G 152-156 An analysis of 45 patients with pure nasal fractures İzole nazal fraktürü olan 45 hastanın değerlendirilmesi Çil Y, Kahraman E 157-163 Distribution of occult fractures detected in emergency orthopedic patient trauma with computerized tomography Acil ortopedik travma hastalarında bilgisayarlı tomografi ile tanınan gizli kırıkların dağılımı İmerci A, Canbek U, Kaya A, Sürer L, Savran A

Olgu Sunumu - Case Reports 164-166 A rare complication of aortobifemoral bypass operation: internal herniation Aortobifemoral baypas ameliyatının nadir bir komplikasyonu: İnternal herniasyon Çitgez B, Yetkin G, Uludağ M, Akgün İ, Ekici U, Kartal A 167-172 Use of radiofrequency ablation for controlling liver hemorrhage in the emergency setting; report of two cases and review of the literature Acil ortamlarda karaciğer kanamasının kontrolünde radyofrekans ablasyonun kullanılması: İki olgu sunumu ve literatürün gözden geçirilmesi Maroulis I, Spyropoulos C, Kalogeropoulou C, Karavias D 173-176 Management of acute myocardial infarction after a blunt chest trauma Künt göğüs travması sonrası gelişen akut miyokart enfarktüsünün tedavisi Özdoğan Ö, Karaçelik M, Ekmekçi C, Özbek C 177-179 Multiple magnet ingestion resulting in small bowel perforation: a case report Çoklu mıknatıs yutulmasına bağlı bağırsak perforasyonu: Olgu sunumu Gün F, Günendi T, Kılıç B, Çelik A 180-182 Isolated unilateral vagus nerve palsy secondary to trauma Travmaya sekonder izole tek taraflı nervus vagus yaralanması Aygün D, Acar E 183-185 Intestinal stenosis from mesenteric injury after blunt abdominal trauma in children: case reports Çocuklarda künt karın travması sonrası oluşan mezenterik yaralanmadan kaynaklanan bağırsak darlığı: Olgu sunumları İmamoğlu M, Sarıhan H 186-188 Bilateral isolated cut of sensory branch of radial nerve Radial sinir duyusal dalının iki taraflı izole kesisi Akkaya N, Özcan HR, Gökalan Kara İ, Şahin F viii

Mart - March 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):89-97

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2013.24478

Sıçanlarda, antiödem olarak kullanılan ilaçların diffüz beyin ödemine etkileri: Deneysel çalışma Effects of anti-edema drugs on diffuse cerebral edema in rats: Experimental study Fevzullah AKYÜZ,1 Merih İŞ,2 # Hikmet AYTEKİN,3 Murat ANLAR,4 Osman AKGÜL5 AMAÇ

BACKGROUND

Travmatik beyin ödemi, nöroşirürji pratiğinde sık karşılaşılan önemli sorunlardan biridir. Beyin ödemi, kafaiçi basıncını yükseltmekte, morbidite ve mortalite artışına yol açmaktadır. Bu çalışmanın amacı travmatik beyin ödemi tedavisinde hiperozmolar tuzların tedavi etkinliğinin saptanması ve mannitole göre karşılaştırılmasıdır.

Traumatic brain edema is one of the most common problems encountered in neurosurgical practice and it leads to morbidity and mortality via increased intracranial pressure. The aim of this study was to examine the effect of hypertonic saline on traumatic brain edema in comparison to mannitol.

GEREÇ VE YÖNTEM

METHODS

Bu deneysel çalışmada ağırlıkları 300-350 g arasında değişen 80 adet erkek erişkin Spraque-Dawley sıçanı kullanıldı. Sıçanlar kontrol; travma; sadece mannitol; travma sonrası mannitol; sadece %3 NaCl; travma sonrası %3 NaCl; sadece %7,5 NaCl; travma sonrası %7,5 NaCl; sadece %23,4 NaCl; travma sonrası %23.4 NaCl gruplarına ayrıldı. Tüm ilaçlar periton içine verildi. Travma ve ilaç uygulaması sonrası 24. saatte sıçanlar dekapite edildi, örnekler histopatolojik olarak incelendi.

Eighty adult male Sprauge-Dawley rats weighting 300350 g were used in this experimental study. Rats were randomly divided into control (C); trauma (T); mannitol only trauma+mannitol; NaCl 3% only; Trauma+NaCl 3%; NaCl 7.5% only; trauma+NaCl 7.5%; NaCl 23.4% only and trauma+NaCl 23.4% groups. All medications were given intraperitoneally. Rats were sacrificed and decapitated 24 hours after trauma with or without medications and the brains were examined histopatologically.

BULGULAR

RESULTS

Travma grubu ile travma sonrası %23,4 NaCl verilen grup arasında kanama açısından bir fark olmadığı (p=0,473), ödem açısından ise anlamlı fark (p=0,003) olduğu saptandı. Gruplar plazma osmolaritesi ve serum sodyum değerleri açısından karşılaştırıldığında kontrollerle diğer tüm gruplar arasında anlamlı fark bulunmadı.

Although no difference was observed with regard to hemorrhage between trauma only and trauma+NaCl 23.4% groups, there was a statistically significant difference in brain edema within these two groups (p=0.003). There were no statistically significant differences within groups with respect to plasma osmolarity and serum sodium levels.

SONUÇ

CONCLUSION

Travma sonrası beyin ödemi önlemek amacıyla verilen %23,4 NaCl’nin diğer hipertonik salinlerden ve mannitolden daha etkili olduğu görülmüştür. Bu bulgunun hipertonik salinlerin farklı doz, konsantrasyon ve sürelerde verildiği daha geniş klinik çalışmalarla desteklenmesi gerekmektedir.

This study demonstrates that 23.4% NaCl is more effective than other concentrations of hypertonic saline or mannitol in the prevention of posttraumatic brain edema. Further clinical studies with different dosages and concentrations of hypertonic saline are required.

Anahtar Sözcükler: Beyin ödemi; hipertonik tuz; travmatik beyin hasarı.

Key Words: Brain edema; hypertonic saline; traumatic brain injury.

Düzce Atatürk Devlet Hastanesi, Nöroşirürji Kliniği, Düzce; 2 Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, Nöroşirürji Kliniği, İstanbul; 3Ağrı Devlet Hastanesi, Nöroşirürji Kliniği, Ağrı; 4Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Patoloji Kliniği, Ankara; 5Düzce Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Düzce. # Şimdiki kurumu: Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Nöroşirürji Kliniği, İstanbul

Department of Neurosurgery, Düzce Atatürk State Hospital, Düzce; 2 Department of Neurosurgery, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul; 3Department of Neurosurgery, Ağrı State Hospital, Ağrı; 4Department of Pathology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara; 5Department of Neurosurgery, Düzce University Faculty of Medicine, Düzce, Turkey. # Current affiliation: Department of Neurosurgery, Fatih Sultan Mehmet, Training and Research Hospital, Istanbul.

1

1

İletişim (Correspondence): Merih İş, M.D. Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Nöroşirürji Kliniği, İstanbul, Turkey. Tel: +90 - 216 - 578 30 00 e-posta (e-mail): merihis@yahoo.com

89

Ulus Travma Acil Cerrahi Derg

Kafa travması sonrası görülen beyin ödemi ve oluşturduğu kötü sonuçlar nöroşirürjinin önemli sorunlarından biridir. Beyin ödemi kafaiçi basıncını yükseltmekte ve etkin bir şekilde tedavi edilmemesi durumunda morbidite ve mortalite artışına neden olmaktadır. Hipotansiyon ve hipoksi durumunda ise mortalite %75’ler düzeyine kadar çıkmaktadır.[1-3]

T+%7,5 NaCl: Travma sonrası %7,5 NaCl verilenler;

Hiperozmolar ajanlar artmış doku suyunu azaltmada hızlı ve etkili maddelerdir.[4-7] En sık kullanılan hiperozmolar ajan mannitoldür. Mannitol plazma ve beyin arasında bir ozmotik basınç farkı oluşturarak beyin dokusundaki artmış sıvının damar yatağına çekilmesini sağlar. Hiperozmolar salinler de son yıllarda antiödem amaçlı kullanılımı artan ilaçlardandır.[8] Mannitolde olduğu gibi ozmotik gradyent oluşturarak hücrelerarası ödemi azaltırlar. Farklı çalışmalarda çeşitli yoğunluklardaki hiperozmolar salinlerin beyin ödemini azaltmada etkili oldukları görülmüştür.

Anestezi öncesi tüm deneklerin ağırlıkları tartılarak periton içine 50 mg/kg ketamin hidroklorür (Ketalar, Parke Davis, Eczacıbaşı) uygulandı. Yeterli sedasyonu takiben hayvanların 0. ve 24. saat solunum, nabız ve rektal ısıları gibi fizyolojik değerler kaydedildi. Ardından deneklerden femoral arterden kan alınarak örneklerde glukoz, üre, BUN, Na, K, Cl, tayini yapıldı. Tüm gruplarda 24 saat sonra kan örneği tekrar alınarak sonuçlar değerlendirildi.

Bu çalışmadaki amacımız travmatik beyin ödemi tedavisinde hiperozmolar tuzların tedavi etkinliğini saptamak ve mannitole göre karşılaştırmak olacaktır.

GEREÇ VE YÖNTEM Bu çalışmada ağırlıkları 300-350 g arasında değişen, daha önce herhangi bir deneyde kullanılmamış toplam 80 adet erkek erişkin Spraque-Dawley sıçanı kullanıldı. Sıçanlar Düzce Üniversitesi, Deney Araştırma ve Uygulama laboratuvarından sağlandı. Deney aşamasına kadar standart sıçan yemi ve çeşme suyuyla beslendiler ve 12 saat gece, 12 saat gündüz olacak şekilde kafes ortamında tutuldular. Deneylerin gerçekleştirilmesinde Amerika Birleşik Devletleri, Ulusal Sağlık Enstitüsü’nün ortaya koyduğu esaslara uyuldu. Tüm gruplarda travma oluşturulması ve deneyin devamı Düzce Üniversitesi Tıp Fakültesi, Deneysel Hayvan Araştırma Üretim Laboratuvarı’nda gerçekleştirildi. Düzce Üniversitesi Tıp Fakültesi deney hayvanları etik kurul alt kurulundan 28.12.2008 tarih ve 100/40 sayı numarası ile etik kurul komite onayı alınmıştır. Gruplar: Denekler her grupta 8 sıçan olmak üzere 10 gruba ayrıldı. K: Kontrol (Hiçbir travma ve tedavi verilmeyen grup); T: Travma (Travma uygulanan ancak tedavi verilmeyen grup); M: Sadece mannitol verilenler; T+M: Travma sonrası mannitol verilenler; %3 NaCl: Sadece %3 NaCl verilenler; T+%3 NaCl: Travma sonrası %3 NaCl verilenler; %7,5 NaCl: Sadece %7,5 NaCl verilenler; 90

%23,4 NaCl: Sadece %23,4 NaCl verilenler; T+%23,4 NaCl: Travma sonrası %23,4 NaCl verilenler. Anestezi ve travmanın oluşturulması

Travma oluşturulacak gruplarda denekler yüz üstü yatırıldı. Orta hatta bregma ve lambdoid dikiş görülecek şekilde bir cilt insizyonu yapıldı. Periost, dikiş önde ve arkada tümü ile ortaya konacak şekilde yana sıyrıldı. Orta hatta koronal ve lambdoid dikiş arasına 10 mm çapında 3 mm kalınlığında çelik disk kondu. Takiben sıçanlar 12x12x43 cm boyutlarındaki sünger bir zemin üzerine yüzüstü yerleştirildi ve Marmarou’nun tarif ettiği travma aleti pozisyonlandı.[9] İç çapı 19 mm, dış çapı 25 mm olan bir tüpün içinden 450 g ağırlığındaki çelik çubuk 2 metre yükseklikten bırakılarak deneğin kafasına çarpması sağlandı. Travmadan hemen sonra solunumu kaybolan, pupillaları genişleyen ve bazılarında da nöbet görülen denekler (toplam 10 sıçanda solunum durması, 3 sıçanda nöbet görüldü) hemen entübe edilip ventilatöre bağlandı (Harvard rodent ventilatör model 683, ABD), kalp masajı yapılarak resüsütasyon uygulandı, yeterli düzeyde solunumları gelene kadar desteğe devam edildi. Açılan cilt kesileri 2/0 ipek ile dikildi. Solunumları düzelen denekler kafeslerine alındı. Travma sırasında kaybedilen 3 sıçan yerine yeniden travma yapılarak grupların sayısı eşit hale getirildi. Denekler bulundukları grupta uygulanacak tedavi protokolüne göre yeniden canlandırmadan hemen sonra mannitol ve tarif edildiği şekilde ve değişik oranlarda hipertonik salin (HTS) intraperitoneal (İP) olarak uygulandı. 24. saatte tüm denekler dekapite edilerek beyin ve beyin sapı bir bütün halinde çıkarıldı. Beyinler %10 formole konularak fikse edildi. İntraperitoneal mannitol ve salin uygulanması Sadece mannitol ve travma sonrası mannitol verilenlere %20 mannitolden 0,5 g/kg İP uygulandı. Daha sonra 0,5 g/kg/gün dozu 6 saatte bir 4 eşit parçada İP verilerek aynı son (4.) doz tedavi 24. saatte tamamlandı. Sadece salin (%3, %7,5 ve %23,4) ve travma sonrası salin verilenlere ise 4 ml/kg/saat dozunda 4 saate bir 6 eşit parçada İP verilerek son doz (6.) tedavi 24. saatte tamamlandı. Tüm denekler girişim sonrası Mart - March 2013

Sıçanlarda, antiödem olarak kullanılan ilaçların diffüz beyin ödemine etkileri

Miyelinozis varlığı beyaz cevherde miyelin kaybına bağlı beyaz alan oluşması, histiyositik hücre varlığı araştırılarak yapıldı.

kafeslerine kondu ve 24. saatte tekrar anestezi verildikten sonra dekapite edildi. Histopatolojik değerlendirme

İstatistik yöntemleri

%10’luk tamponlu formalin ile tespit edilen dokulardan hipokampal ve pons-serebellum seviyelerinden alınan örneklerden hazırlanan aksiyel kesitler, hematoksilen eozin yöntemiyle boyandı. Histopatolojik değerlendirmede kanama varlığı ve şiddeti, ödem varlığı ve şiddeti, enflamasyon ve miyelinoliz varlığı, şiddeti ve yerleşimleri değişken olarak alındı.

İstatistiksel karşılaştırmada non-parametrik (Mann-Whitney, Wilcoxon, bağımsız örneklem testi, Kruskall-Wallis), parametrik (eşleştirilmiş örneklem testi) ve Medyan Shapiro-Wilk testleri kullanıldı, p değerinin 0,05’in altı istatistiksel olarak anlamlı kabul edildi.

Kanama varlığı; serbest eritrositlerin parankim ve ventrikülde bulunup bulunmadığına göre, kanamanın şiddeti ise mikroskopta 20 büyütme alanında kanamanın %10’un altında olması 1+; %10-50 arasında olması 2+; %50’nin üzerinde olması 3+ olarak değerlendirildi.

BULGULAR Travmanın ve sonrasında verilen tedavilerin fizyolojik değerlerde bir değişiklik yapıp yapmayacağını anlamak için sıçanlarda 0. saatte ve 24. saatte ağırlık, rektal ısı, solunum sayısı ve kalp atım hızı gibi fizyolojik parametrelere bakıldı. Yapılan istatistiksel karşılaştırma sonucu bu değerler açısından gruplar arasında anlamlı bir fark tespit edilmedi. 0. saatte ve 24. saatte bakılan biyokimyasal değerler Tablo 1 ve Tablo 2’de gösterilmiştir. Plazma osmolaritesini hesaplayabilmek için Na, glukoz, BUN, üre ve K değerlerine bakıldı. Kontrol grubu ile diğer gruplar arasında 24.

Ödem varlığı parankimde hücrelerin arasının açılarak mikrokistik alanların oluşmasına göre, ödem şiddeti ise mikroskopta 20 büyütme alanında ödemin %10’un altında olması 1+, %10-50 arasında olması 2+, %50’nin üzerinde olması 3+ olarak değerlendirildi. Enflamasyon varlığı PMN lökosit, lenfosit, plazma hücresi ve eozinofil varlığı araştırılarak yapıldı. Tablo 1. Deneklerin 0. saat biyokimyasal değer ortalamaları Gruplar

n

Plazma osmolalitesi Ort.±SS

Glukoz Ort.±SS

Üre Ort.±SS

BUN Ort.±SS

Na Ort.±SS

K Ort.±SS

K T M T+M %3 NaCl T+%3 NaCl %7,5 NaCl T+%7,5 NaCl %23,4 NaCl T+%23,4 NaCl

8 8 8 8 8 8 8 8 8 8

287,463±4,513 292,013±2,568 296,913±2,998 293,063±4,874 290,488±1,658 289,625±2,286 297,788±2,982 295,875±3,735 295,800±5,829 296,513±4,848

130,500±19,640 175,000±19,610 148,875±12,778 137,375±8,070 169,000±23,183 158,625±22,532 162,500±25,618 162,625±10,042 172,750±22,493 160,500±21,206

36,375±4,534 37,750±3,284 39,750±9,483 42,000±4,629 39,625±4,104 39,250±3,454 37,750±5,625 41,125±5,566 40,000±3,464 40,000±4,870

17,375±2,264 17,625±1,768 18,625±4,241 19,375±2,134 18,500±1,852 18,375±1,685 17,500±2,673 19,125±2,696 18,750±1,909 18,500±2,390

137,000±1,852 138,000±0,926 141,000±1,309 139,250±2,121 137,250±0,707 137,125±0,991 141,250±1,488 140,000±1,512 139,750±3,059 140,500±2,000

4,900±0,656 4,785±0,414 5,055±0,740 5,330±0,514 5,021±0,528 5,381±0,798 5,594±1,048 5,684±0,492 5,158±0,372 4,930±0,413

SS: Standart sapma; BUN: Kan üre azotu; Na: Sodyum; NaCl: Sodyum klorür; K: Kontrol; T: Travma; M: Mannitol; T+M: Travma sonrası mannitol verilenler.

Tablo 2. Deneklerin 24. saat biyokimyasal değer ortalamaları Gruplar

n

Plazma osmolalitesi Ort.±SS

Glukoz Ort.±SS

Üre Ort.±SS

BUN Ort.±SS

Na Ort.±SS

K Ort.±SS

K T M T +M % 3 NaCl T+% 3 NaCl %7.5 NaCl T+%7.5 NaCl %23.4 NaCl T+%23.4 NaCl

8 8 8 8 8 8 8 8 8 8

285,075±42,264 295,163±7,124 299,288±5,564 291,475±8,289 300,038±7,903 291,975±22,737 294,925±5,837 299,788±5,968 294,913±4,554 297,563±9,222

142,000±40,010 130,750±10,593 178,625±75,855 187,750±68,104 190,250±38,964 192,875±67,226 150,000±28,097 139,750±11,622 138,750±10,264 189,625±141,506

47,625±20,206 39,750±4,132 39,000±6,234 37,875±6,105 43,375±7,190 30,125±2,416 33,750±3,882 41,750±6,182 35,500±4,472 36,125±5,139

22,250±9,270 18,625±1,923 18,500±3,071 17,625±2,925 20,250±3,454 14,000±0,926 15,625±1,847 19,625±2,925 16,625±2,134 16,875±2,295

134,625±22,557 140,625±3,623 141,375±2,326 137,375±3,204 141,125±4,051 138,125±10,670 140,500±2,449 142,500±2,777 140,625±2,264 140,500±2,390

6,640±1,113 6,720±0,325 7,209±1,895 7,224±2,864 6,803±2,629 7,594±4,524 6,043±0,965 6,343±0,654 5,860±0,469 5,461±2,004

SS: Standart sapma; BUN: Kan üre azotu; Na: Sodyum; NaCl: Sodyum klorür; K: Kontrol; T: Travma; M: Mannitol; T+M: Travma sonrası mannitol verilenler.

Cilt - Vol. 19 Sayı - No. 2

91

Ulus Travma Acil Cerrahi Derg

Normal hipokampüs

Parankimal kanama

Ventriküler kanama

Parankimal ödem

Şekil 1. Ödem ve kanamanın görülmediği kontrol grubu.

saat Na değerlerinin karşılaştırılması sonrası bulunan p değerlerinin karşılaştırma sonuçları; K-T (p=0,525), K-%3 NaCl (p=0,874), K-T+%3 NaCl (p=0,792), K -%7,5 NaCl (p=0,314), K-T+%7,5 NaCl (p=0,634), K-%23,4 NaCl (p=0,29), K-T+%23,4 NaCl (p=0,288) sonuçlar arasında anlamlı bir fark görülmedi. K-T+M (p=0,035) travma sonrası mannitol verilen grupta istatistiksel olarak anlamlı hiponatremi görüldü. Kontrol grubu ile diğer gruplar arasında 24. saat plazma osmolaritesi değerlerinin karşılaştırılması sonrası bulunan p değerlerinin karşılaştırma sonuçları; K-T (p=0,345), K-M (p=0,916), K-T+M (p=0,093), K-%3 NaCl (p=0,227), K-T+%3 NaCl (p=0,916), K-%7,5 NaCl (p=0,248), K-T+%7,5 NaCl (p=0,6), K-%23,4 NaCl (p=0,115), K-T+%23,4 NaCl (p=0,345) gruplar arasında istatistiksel olarak anlamlı bir fark görülmedi. Histopatolojik bulgular Olgularda ödem varlığı daha çok periventriküler yerleşimli izlenirken kanamalar daha çok subpial olmak üzere parankimal ve ventriküler yerleşimli olarak izlendi. Travmalı olgularda ödemin az görülmesi dikkati çekti. Hiçbir olguda miyelinoliz ve enflamasyon bulgusu gözlenmedi.

Şekil 2. Travma grubu; ödem, ventriküler ve parenkimal kanama görülüyor. Renkli şekiller derginin online sayısında görülebilir

(www.tjtes.org).

miyelinoz negatif (%100) olup, enflamasyon yoktu (%100) (Şekil 2). Mannitol grubunda 8 denekte de ödem, kanama ve enflamasyon tespit edilmedi (%100) ve miyelinoz negatif (%100 negatif) bulundu. T+M grubunda 6 denekte ödem tespit edilmedi (%75), 2 denekte 1+ seviyesinde ödem tespit edildi (%25). Dört denekte kanama tespit edilmezken (%50), 4 denekte 1+ seviyesinde parenkimal bölgede kanama (%50) tespit edildi. Kanamaların %100’ü parenkimal bölgede tespit edildi. Sekiz denekte de miyelinoz (%100) ve enflamasyon saptanmadı (Şekil 3). %3 NaCl grubunda 8 denekte de ödem tespit edilmedi (%100). Altı denekte kanama tespit edilmedi (%75), 1 denekte 1+ seviyesinde (%12,5), 1 denekte 2+ seviyesinde kanama tespit edildi (%12,5). Kanamalar subpial olduğundan iyatrojenikti. Sekiz denekte de miyelinoz negatif (%100) olup, enflamasyon yoktu (%100).

Gruplara göre patolojilerin değerlendirilmesi; Kontrol grubunda 8 denekte de ödem, kanama ve enflamasyon tespit edilmedi (%100-0) ve yine 8 denekte de miyelinoz negatifti (%100 negatif) (Şekil 1). Travma grubunda 6 denekte 1+ seviyesinde ödem tespit edildi (%75), 2 denekte ödem tespit edilmedi (%25). İki denekte kanama tespit edilmedi (%25), 3 denekte 1+ seviyesinde (%37,5), 2 denekte 2+ seviyesinde (%25), 1 denekte 3+ seviyesinde (%12,5) kanama saptandı. Kanamaların %50’si ventriküler bölgede, %16,66’sı parankimal bölgede, %16,67’si parenkimal ve subpial bölgede, %16,67’si parenkimal, serebellar ve ventriküler bölgede tespit edildi. Sekiz denekte de 92

Parankimal ödem

Şekil 3. Travma sonrası mannitol verilen grup; ödem görülüyor. Mart - March 2013

Sıçanlarda, antiödem olarak kullanılan ilaçların diffüz beyin ödemine etkileri

Ventriküler kanama

Parankimal kanama

Parankimal kanama

Şekil 5. Travma sonrası %7,5 NaCI verilen grup; parankimal kanama var, ödem görülmüyor.

Şekil 4. Travma sonrası %3 NaCI verilenler; parenkimal ve ventriküler kanama var; ödem görülmüyor.

T+%3 NaCl grubunda 8 denekte de ödem tespit edilmedi (%100). Üç denekte 1+ seviyesinde kanama (%37,5), 5 denekte 2+ seviyesinde kanama (%62,5) tespit edildi. Kanamaların %50’si sadece subpial bölgede görülürken, %50’si parenkimal, serebellar, ventriküler ve subpial bölgede görüldü. Sekiz denekte de miyelinoz negatif (%100) olup, enflamasyon yoktu (%100) (Şekil 4). %7,5 NaCl grubunda 4 denekte ödem tespit edilmedi (%50), 3 denekte 1+ seviyesinde ödem (%37,5), 1 denekte 2+ seviyesinde ödem (%12,5) tespit edildi. 7 denekte kanama tespit edilmedi (%87,5), 1 denekte 1+ seviyesinde kanama (%12,5) tespit edildi. Kanama parenkimal bölgede görüldü. Sekiz denekte de miyelinoz negatif (%100) olup, enflamasyon yoktu (%100). T+%7,5 NaCl grubunda 5 denekte ödem tespit edilmedi (%62,5), 3 denekte 3+ seviyesinde ödem (%37,5) tespit edildi. İki denekte kanama görülmezken (%25), 3 denekte 1+ seviyesinde kanama (%37,5), 1 denekte 2+ seviyesinde kanama (%12,5), 2 denekte 3+ seviyesinde kanama (%25) tespit edildi. Kanamaların %50’si parenkimal bölgede, %16,67’si ventriküler bölgede, %16,67’si serebellar bölgede, %16,66’sı subpial bölgede görüldü. Sekiz denekte de miyelinoz negatif (%100) olup, enflamasyon yoktu (%100) (Şekil 5). %23,4 NaCl grubunda 8 denekte de ödem tespit edilmedi (%100). Altı denekte kanama tespit edilmedi (%75), 1 denekte 1+ seviyesinde kanama (%12,5), 1 denekte 2+ seviyesinde kanama (%12,5) tespit edildi. Kanamaların %100’ü parenkimal bölgede görüldü. Sekiz denekte de miyelinoz negatif (%100) olup, enflamasyon yoktu (%100). Kanamalar subpial olduğu için iyatrojenikti (Şekil 6). T+%23,4 NaCl grubunda 8 denekte de ödem tespit edilmedi (%100). Dört denekte kanama tespit edilmedi (%50), 3 denekte 2+ seviyesinde kanama (%37,5), Cilt - Vol. 19 Sayı - No. 2

Subpial kanama

Şekil 6. Sadece %23,4 NaCI verilen grup; ödem görülmemekte, iyatrojenik subpial kanama var. Renkli şekiller derginin online sayısında görülebilir

(www.tjtes.org).

1 denekte 1+ seviyesinde kanama (%12,5) tespit edildi. Kanamaların %50’si ventriküler bölgede, %25’i parenkimal bölgede, %25’i subpial bölgede görüldü. Sekiz denekte de miyelinoz negatif (%100) olup, enflamasyon yoktu (%100) (Şekil 7).

Parenkimal kanama

Şekil 7. Travma sonrası %23,4 NaCI verilen grup; parenkimal kanama var, ödem görülmüyor. 93

Ulus Travma Acil Cerrahi Derg

TARTIŞMA Ağır kafa travması günlük nöroşirürji pratiğinde sık görülen, acil çözüm bekleyen yüksek morbidite ve mortalitesi olan önemli bir sorundur. Ağır kafa travmalı hastaların, prognozunda en önemli faktörlerden biri travma sonucu gelişen beyin ödemi ve bunun tedavisidir. Son 20 yıldaki klinik ve laboratuvar çalışmalar, beyin ödeminin fizyopatolojisinde gizli kalmış pek çok yönün aydınlanmasını sağlamıştır. Beyin ödemi ve neden olduğu kafa içi basınç artması sendromunun (KİBAS) tedavisindeki yetersizlikleri aşmak amacıyla çeşitli deneysel modeller oluşturulmuştur. Deneysel modellerde oluşturulan yaralanmanın mekanizması, beyinde hasar oluşturulan yer, travmanın süresi ve ciddiyeti gibi pek çok etmen, oluşacak travmayı ve sonuçlarını etkiler. Konunun aydınlatılmasına yönelik olarak literatürde geliştirilmiş modeller; yaralanmaya karşı oluşacak morfolojik, serebrovasküler, metabolik ve reseptör değişiklikleriyle ilgili yanıtları kısa ve uzun dönemde değerlendirilmişlerdir. Kullanılan deneysel travma modelleri arasında santral ve lateral sıvı çarpma, sert cisimle yaralama, akselerasyon, enjeksiyon, lokal gerilim, soğuk hasar, penetran yaralanma modelleri sayılabilir.[9-11] Yaptığımız çalışmada Marmarou ve arkadaşlarının oluşturduğu yüksekten ağırlık düşürme (akselerasyon) travma modeli kullanılmıştır. Bu modelin kolay uygulanabilir oluşu, kapalı kafa travma modeli olarak sıçanlarda uygulanabilmesinin yanı sıra diğer modellere göre bazı avantajları da vardır. Birincisi, direkt duraya çarpma modellerinde görülen beyin sapı hasarı oluşmadan ağır kafa travması meydana gelir.[12] İkincisi, ağır travmalarda çarpmadan hemen sonra görülen geçici kan basıncı artışı görece hafiftir, serebral kan akımı otoregülasyonunun ve kan beyin bariyerinin devamlı bozulacağı seviyeye ulaşmaz, böylece hipertansiyon olmadan travmanın etkisi izole edilebilir. Üçüncüsü, insanda ağır kafa travmalarından sonra sık görülen diffûz aksonal yaralanmanın bu modelde oluşturulabilmesidir. Dördüncüsü ise, ağır kafa travmalı olgularda yaşayanlarda 4-6 hafta sonra gözlemlenebilen posttravmatik ventrikülomegalinin gözlemlenmesidir. [13-15] Bu nedenlerle antiödem olarak kullanılan ilaçların insandaki ağır kafa travmasına en yakın model olan yüksekten ağırlık düşürme (akselerasyon) modelinde araştırıldı. Kafa travması sonrası gelişen beyin ödemi önemli bir problemdir. Kafa travmasında beyin ödemi ve takiben KİBAS gelişimi sıklıkla ölüme neden olduğu gibi yaşayanlarda ağır sekellere yol açar,[16,17] Beyin travması sonrası kan beyin bariyerinin (KBB) yıkılmasını izleyerek gelişen vazojenik ödemin, beyin şişmesinde ve sonrasında gelişen kafaiçi basınç artışında en önemli faktör olduğu düşünülmüştür.[18,19] Yapılan manyetik rezonans görüntüleme (MRG) çalışmala94

rında kan-beyin bariyerinin travmadan hemen sonra açıldığı, travma sonrası yaklaşık 30. dakikada ise kapandığı saptanmıştır. Bu gözlemler travma sonrası gelişen sabit ekstrasellüler sıvı artışını ve vazojenik ödem gelişimini açıklamaktadır.[20] Ayrıca ödem, gelişen KİBAS’ye bağlı oluşan sistemik hipertansiyonla ile de artmaktadır. Son yıllarda yapılan morfolojik ve MRG çalışmaları travmatik beyin ödeminde vazojenik ödemin rolünün gereğinden fazla abartıldığını göstermektedir.[9,20,21] Travmatik beyin ödeminde KBB’nin yıkılması sonucu gelişen vazojenik ödemin klinik kötüleşmede tek başına bir neden olmadığı, buna iskemiyle ilişkili sellüler ödemin de katıldığı yapılan çalışmalarda gösterilmiştir.[22] Serbest radikaller ve eksitatör aminoasitlerin fazla salınımı da sodyum ve kalsiyum dengesinin bozulmasına neden olarak iskemik (ya da nörotoksik) ödemin oluşmasına yol açar.[23-25] Sonuç olarak travma sonrası oluşan ödemin gelişiminin iki evreli olduğu anlaşılmaktadır. İlk önce travmanın direkt etkisine bağlı olarak geçici KBB açılmakta ve belirgin vazojenik ödem gelişmektedir. Bu aşamada ödem 4. saatte bir tepe yapmaktadır. Daha sonra daha yaygın ve yavaş bir şekilde sellüler ödem (iskemik veya nörotoksik) gelişmekte, 24. saatte maksimum düzeye ulaşıp, 1 veya 2 hafta sabit kalmaktadır.[26] Deneysel beyin ödeminin tedavisinde kullanılan hipertonik salinlerin avantajları mannitole göre daha fizyolojik olmaları, hipotansiyon durumunda dahi verilebilmeleri, fizyolojik boşluklara rahatlıkla dağılmaları ve buradaki dengeleri bozmamaları, beyin perfüzyonunu arttırmaları, immünreaktif özelliğinin olmasıdır. Kullanımında intravenöz ve İP yollar kullanılabilir. HTS’lerin dezavantajları ise zor elde edilebilirliği ve etki sürelerinin kısa olmasıdır. Yaptığımız çalışmada travma grubu ile kontrol grubu arasında beyin ödemi (p=0,003) ve kanaması (p=0,004) açısından istatistiksel olarak anlamlı fark vardır. Kontrol grubunda hiç ödem ve kanama görülmezken, travma grubunda 6 denekte (1+) ödem, parenkimal, ventriküler, serebellar kanamalar görülmüştür. Ancak 2 denekte ödem ve kanama görülmemesi travmanın yeterli şiddette olmamasına bağlanmıştır. Kontrol grubu ile travma sonrası mannitol verilenler arasında kanama (p=0,025) açısından istatistiksel anlamlı bir fark görülmüş, ancak ödem (p=0,143) açısından bir fark görülmemiştir. Kanamada olan farklılık travmanın ağır olduğunu ve ödemde farklılığın olmaması mannitolün tedavide etkili olduğunu göstermiştir. Kontrol grubu ile travma sonrası %3 NaCl verilenler arasında kanama (p=1,000) ve ödem (p=0,143) açısından bir fark görülmemiştir. Kanamada farklılık olmaması travmanın yetersizliğinden kaynaklanıyor olabilir. Dört denekte kanama görülmemiştir. Bu nedenle %3 NaCl verilenlerde ödem olmamasını tedaviMart - March 2013

Sıçanlarda, antiödem olarak kullanılan ilaçların diffüz beyin ödemine etkileri

ye bağlıdır diyemeyiz. Hipertonik saline bağlı miyelinozis görülmemiştir. Kontrol grubu ile travma sonrası %7,5 NaCl verilenler arasında kanama (p=0,004) açısından istatistiksel anlamlı bir fark görülmüş, ödem (p=0,063) açısından bir fark görülmemiştir. Kanamada olan farklılık travmanın ağır olduğunu ve ödemde farklılığın olmaması %7,5 NaCl’nin tedavide etkili olduğunu gösteriyor. Hipertonik saline bağlı miyelinozis görülmemiştir. Kontrol grubu ile travma sonrası %23,4 NaCl verilenler arasında kanama (p=0.027) açısından istatistiki anlamlı bir fark görülmüş, ödem (p=1,000) açısından bir fark görülmemiştir. Kanamada olan farklılık travmanın ağır olduğunu ve ödemde farklılığın olmaması %23,4 NaCl’nin tedavide etkili olduğunu gösteriyor. Hipertonik saline bağlı miyelinozis görülmemiştir. Travma grubu ile travma sonrası mannitol verilenler arasında kanama (p=0,114) ve ödem (p=0,053) değerleri arasında bir fark görülememiştir. Bu da bize mannitolün ödemi yeterince çözemediğini göstermektedir. İki denekte ödem görülmüştür. Travma grubu ile travma sonrası %3 NaCl verilenler arasında kanama (p=0,112) açısından bir fark olmadığı, ödem (p=0,003) açısından farklı olduğu görülmüştür. Bu da %3 NaCl’nin başlangıçta ödemi çözdüğünü düşündürse de, daha sonradan kanamaların daha çok subpial olması nedeniyle travmanın yetersiz olduğu düşündürmüştür. Travma grubu ile travma sonrası %7,5 NaCl verilenler arasında kanama (p=0,87) ve ödem (p=0,734) açısından bir fark olmadığı görülmüştür. Bu da %7,5 NaCl’nin kontrol grubuna göre ödem çözücü etkisinin görülmesine rağmen ödem düzeyi açısından travma grubundan farklı olmamasının yeterince ödemi çözemediğini göstermiştir. Travma grubu ile travma sonrası %23,4 NaCl verilenler arasında kanama (p=0,473) açısından bir fark olmadığı, ödem (p=0,003) açısından farklı olduğu görülmüştür. Bu da %23,4’ün ödem çözmede etkili olduğunu göstermektedir. Travma sonrası %7,5 NaCl verilenler ile travma sonrası %23,4 NaCl verilenler arasında kanama (p=0,38) ve ödem (p=0,063) açısından bir fark görülmemiştir. Sadece %3 NaCl verilenler ile travma sonrası %3 NaCl verilenler arasında kanama (p=0,89) ve ödem (p=1,000) açısından bir fark görülmemiştir. Bu da %3 NaCl’nin etkili olmadığını göstermiştir. Sadece %7,5 NaCl verilenler ile travma sonrası %7,5 NaCl verilenler arasında kanama (p=0,012) değerleri arasında istatistiksel açıdan anlamlı bir fark mevcut ama ödem (p=0,816) açısından bir fark görülmemiştir. Bu da %7,5 NaCl’nin etkili olduğunu gösCilt - Vol. 19 Sayı - No. 2

termiştir. Sadece %23,4 NaCl verilenler ile travma sonrası %23,4 NaCl verilenler arasında kanama (p=0,014) değerleri arasında istatistiksel açıdan anlamlı bir fark mevcut ama ödem (p=1,000) açısından bir fark görülmemiştir. Bu da %23,4 NaCl’nin etkili olduğunu göstermiştir. Vassar ve arkadaşları[27] sistolik kan basıncı 100 mmHg’nin üzerinde olan 166 travmalı olguda %7,5 HTS / %4,2 deksran ile Ringer laktat bolus ve devamında Ringer laktat içeren sıvı infüzyon tedavisini karşılaştırmışlar. Bu çalışmada gruplar arasında Glasgow koma skoru (GCS), Injury Severity Score (ISS), “revised” travma skorları arasında fark bulunamamıştır. HTS verilen grupta daha az sıvı verilerek yüksek arteriyel basınç ve hemodinamik denge sağlandı. Ek olarak ciddi travmatik beyin hasarlı olgularda HTS resüsitasyonu ile yüksek sağ kalım sağlandı. Wade ve arkadaşları[28] hipotansif kafa travmalı hastalara HTS/deksran ile izotonik sıvı verilen randomize 8 ayrı çalışmayı metaanaliz yöntemiyle derlemişlerdir. Sekiz çalışmada da HTS/deksran verilen gruplarda 24 saat tedavi sonrası nörolojik değerlendirilmesinde istatistiksel olarak anlamlı (p=0,048) düzelme olduğu görülmüştür. Yakın zamanda yapılan bir çalışmada GKS <9 ve hipotansif (SKB <100 mmHg) TBH’li 229 hastaya %7,5 HTS ile Ringer laktat resüsitasyonu yapılmıştır. Ek olarak her gruba 250 ml bolus %7,5 HTS veya Ringer laktat verilmiştir.[29] Ortalama SBP, ortalama yaş, GKS, ortalama ISS, maximum abbreviated injury score (MAIS), baş yaralanma skoru, ateş, entübasyon oranı ve transport zamanı her iki grupta ele alındı. İki grup arası mekanik ventilasyon veya inotropik ajana ihtiyaç, gaz değişimi, serebral perfüzyon basıncının 70 mmHg olması, KİB ve SKB arası fark saptanmamıştır. Taburcu nörolojik değerlendirmeler arası ve 3 ay sonraki Glasgow çıkış skoru (GOS) arasında da anlamlı bir fark görülmemiştir. Birçok olgu sunumu ve küçük serilerde HTS tedavisinin KİB’yi düşürdüğü gösterilmiştir. Mannitole dirençli kontrol edilemeyen ve idrar çıkışı olmayan yüksek KİB’li 2 hastaya %29,2’lik HTS’den 20 ml verildiği zaman renal işlev ve KİB’de düzelme gözlenmiştir.[30] Tedaviye dirençli artmış KİB’li bir hastada tek doz %7,5’lik bolus HTS ile %50’nin üzerinde düzelme gözlenmiştir.[31] Suares,[32] mannitole dirençli 8 hastada %23,4 HTS’den 30 ml bolus şeklinde bir tedavi denemiştir. Bütün hastaların KİB değeri birkaç saat içinde 41,5’ten 17 mmHg düşmüştür. Farklı dozlar denenmesine rağmen serum Na değeri artmamıştır. Fakat CVP veya idrar çıkışı değişmemiştir. Berger ve arkadaşları[33] yatak başının kaldırılması, hiperventilasyon, sedasyon, barbitürat, normotermi ve mannitol 95

Ulus Travma Acil Cerrahi Derg

tedavisi uygulanan izole ciddi kafa travmalı 2 hastada KİB’nin 20 mmHg’nin altına düşmemesi üzerinde 30 ml bolus HTS verilmesi sonrası KİB’yi düşmüşlerdir. Simma ve arkadaşları[34] HTS ile ilgili ilk ileriye dönük randomize çalışmayı yapmışlardır. Ciddi TBH olan 32 pediatrik hastaya ilk 72 saat içerisinde RL ile %1,7 HTS içeren sıvıyı kontrollü olarak vermişlerdir. Amaç HTS tedavisi ile serum Na değerini 145-150 mEq/l düzeyinde tutmaktı. HTS verilen hastalarda İKB’de azalma görüldü. Respiratuvar distres sendromu riski azaldı. Mekanik ventilasyon zamanının kısaldığı ve sağkalımın arttığı izlendi. Serum Na ve İKB değerlerinin birbiriyle ilişkili olduğu not edildi. Gruplar arasında serum Na değerleri arasında fark bulunmadı. Genellikle sağkalım oranının yüksek olduğu görüldü. [34] Cooper ve arkadaşları[29] tek bolus HTS ve Ringer laktat resüsitasyonunun farklı olmadığını tespit etmiştir. Fakat resüsitasyon sıvısının toplam miktarında fark olmadığı saptanmıştır. Bu yüzden yeterli sıvı verilmesi ve hemodinamik resüsitasyonun nörolojik defisitin önlenmesinde etkili olan tek gerçek faktördür. Bu çalışmada aynı zamanda sınırlı sıvı miktarının kullanımı ve HTS resüsitasyonda kullanıldığı zaman kardiyovasküler parametrelerden etkiler de ortaya konmuştur. Hipertonik salin tedavisi esnasında hemodinamik parametreler dikkatli izlenmelidir. Kesinlikle diğer ilaçların etkili olamadığı yükselmiş KİB kontrolünde HTS kullanılmalıdır. Farklı dozda kullanım protokolleri ve uygulanış şekilleri olguya göre hekim tarafından değerlendirilmelidir. Gelecekte yapılacak laboratuvar deneyler ve klinik çalışmalar kullanım protokollerinin ve dozlarının standardize edilmesi açısından faydalı olacaktır. Bu çalışmada üç farklı konsantrasyondaki hipertonik salin (%3, %7,5, %23,4) aynı dozlarda ve fraksiyone edilerek uygulanmıştır. Mannitol plazma osmalaritesi 320 mOsm/L’nin üzerine çıktığı zaman etki gösteremez, fakat HTS plazma osmalaritesi 360 mOsm/L’ye çıkıncaya kadar etkisini gösterebilir. Bu HTS’nin kullanımda bir avantajıdır.[35] Aralıksız 72 saat süren HTS tedavisinden sonra serum Na düzeyinde yalnızca 10-15 mEq/l’lik artış görülmüştür. Yapılan çalışmalar, Na değerinin 170 mEq/l’nin üzerine çıkmadığı sürece herhangi bir komplikasyonun olmadığını göstermiştir. Ayrıca Na değeri belli bir seviyeye çıktıktan sonra HTS atriyal natriüretik hormon (ANH) salınımını uyararak ve artırarak serum Na düzeyinin düşmesini de sağlamaktadır.[36] Grup içi ve gruplar arası karşılaştırmalar sonrası yapılan istatistiksel değerlendirmelere göre yaptığımız bu çalışmada; %3 NaCl’nin etkisinin yeterli olmadığı, %7,5 NaCl ile mannitolün etkilerinin aynı düzeyde olduğu, %23,4’ün ise diğer iki tedavi yönteminden daha 96

etkili olduğunu gösterilmiştir. Suares’in yaptığı çalışmada da %23,4’lük NaCl’nin mannitolden etkili olduğu benzer şekilde bulunmuştur.[32] Ayrıca hiçbir yoğunluktaki hipertonik salinde patolojik olarak santral pontin miyelinozise ait bir bulguya rastlanmamıştır. Bulgular birlikte değerlendirildiğinde, uygulanan deneysel modelde her iki hemisferde de ödem geliştiği tespit edilmiştir. Bu çalışmada beyin parenkimi, pons, serebellar doku ve ventrikül içinde kanamaların olduğu, kafa travmasının ciddi ve diffüz oluşturulduğu gösterilmiştir. Kullanılan hipertonik salin formlarından hiçbirinde serum Na ve plazma osmolarite değerlerinde kullanıma bağlı istatistiksel olarak anlamlı bir fark gelişmemiştir. Bu da bizim yoğunluk oranı ne olursa olsun 48-72 saatlik hipertonik salin kullanımına bağlı serum Na ve plazma osmolaritesinde bir değişiklik olmayacağı kuramımızı doğrulamaktadır. Yapılan patolojik incelemelerde travma sonrası hipertonik salin verilen gruplar ile kontrol grubu arasında ödem açısından bir fark görülmemesi, travmaya bağlı kanama açısından ise ciddi farkın olması, tedavide etkili olduklarını göstermiştir. Gruplar arası yaptığımız karşılaştırmalar sonucu hipertonik salinlerden %23,4 NaCl’nin diğer hipertonik salinlerden ve mannitolden daha etkili olduğu görülmüştür. Ayrıca ponsun patolojik incelemelerinde hiçbir salin grubuna bağlı santral pontin miyelinozis bulgusuna rastlanmamıştır. Bu sonuçlar doğrultusunda litaratürde klinik çalışmalarda da gösterilen antiödem tedavisinde mannitol yerine hipertonik salin kullanımının daha etkin olduğu söylenebilir. Bu sonuçlar ile yaptığımız deneysel çalışma sonuçları literatürdeki diğer çalışmalarla uyumlu olarak değerlendirilmiştir. Bundan sonraki yapılacak çalışmalarda hipertonik salinler farklı dozlarda, farklı konsantrasyonlarda ve farklı sürelerde (48. saat ve 7 gün) denenebilir ve yan etkiler arasındaki fark karşılaştırılabilir. Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması yoktur.

KAYNAKLAR 1. Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216-22. 2. Miller JD, Sweet RC, Narayan R, Becker DP. Early insults to the injured brain. JAMA 1978;240:439-42. 3. Pigula FA, Wald SL, Shackford SR, Vane DW. The effect of hypotension and hypoxia on children with severe head injuries. J Pediatr Surg 1993;28:310-6. 4. Pigula FA, Wald SL, Shackford SR, Vane DW. Continuous monitoring of cerebral oxygenation in acute brain injury: injection of mannitol during hyperventilation. J Neurosurg 1990;73:725-30. 5. Hariri RJ. Cerebral edema. Neurosurg Clin N Am 1994;5:687706. 6. Hartwell RC, Sutton LN. Mannitol, intracranial pressure, and vasogenic edema. Neurosurgery 1993;32:444-50. Mart - March 2013

Sıçanlarda, antiödem olarak kullanılan ilaçların diffüz beyin ödemine etkileri

7. Kaufmann AM, Cardoso ER. Aggravation of vasogenic cerebral edema by multiple-dose mannitol. J Neurosurg 1992;77:584-9. 8. Doyle JA, Davis DP, Hoyt DB. The use of hypertonic saline in the treatment of traumatic brain injury. J Trauma 2001;50:367-83. 9. Marmarou A, Foda MA, van den Brink W, Campbell J, Kita H, Demetriadou K. A new model of diffuse brain injury in rats. Part I: Pathophysiology and biomechanics. J Neurosurg 1994;80:291-300. 10. Thibault LE, Meaney DF, Anderson BJ, Marmarou A. Biomechanical aspects of a fluid percussion model of brain injury. J Neurotrauma 1992;9:311-22. 11. Toulmond S, Duval D, Serrano A, Scatton B, Benavides J. Biochemical and histological alterations induced by fluid percussion brain injury in the rat. Brain Res 1993;620:2431. 12. Shima K, Marmarou A. Evaluation of brain-stem dysfunction following severe fluid-percussion head injury to the cat. J Neurosurg 1991;74:270-7. 13. Hawkins TD, Lloyd AD, Fletcher GI, Hanka R. Ventricular size following head injury: a clinico-radiological study. Clin Radiol 1976;27:279-89. 14. Levin HS, Meyers CA, Grossman RG, Sarwar M. Ventricular enlargement after closed head injury. Arch Neurol 1981;38:623-9. 15. van Dongen KJ, Braakman R. Late computed tomography in survivors of severe head injury. Neurosurgery 1980;7:1422. 16. Becker DP, Miller JD, Ward JD, Greenberg RP, Young HF, Sakalas R. The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 1977;47:491-502. 17. Miller JD, Becker DP, Ward JD, Sullivan HG, Adams WE, Rosner MJ. Significance of intracranial hypertension in severe head injury. J Neurosurg 1977;47:503-16. 18. Marmarou A, Anderson RL, Ward JD. NINCDS Traumatic Coma Data Bank. Intracranial pressure monitoring methodology. J Neurosurg 1991;75:S21-7. 19. Marmarou A, Poll W, Shulman K, Bhagavan H. A simple gravimetric technique for measurement of cerebral edema. J Neurosurg 1978;49:530-7. 20. Barzó P, Marmarou A, Fatouros P, Corwin F, Dunbar J. Magnetic resonance imaging-monitored acute blood-brain barrier changes in experimental traumatic brain injury. J Neurosurg 1996;85:1113-21. 21. Ito J, Marmarou A, Barzó P, Fatouros P, Corwin F. Characterization of edema by diffusion-weighted imaging in experimental traumatic brain injury. J Neurosurg 1996;84:97103. 22. Klatzo I. Presidental address. Neuropathological aspects of brain edema. J Neuropathol Exp Neurol 1967;26:1-14. 23. Faden AI, Demediuk P, Panter SS, Vink R. The role of excit-

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atory amino acids and NMDA receptors in traumatic brain injury. Science 1989;244:798-800. 24. Katayama Y, Becker DP, Tamura T, Hovda DA. Massive increases in extracellular potassium and the indiscriminate release of glutamate following concussive brain injury. J Neurosurg 1990;73:889-900. 25. Kontos HA. Oxygen radicals in CNS damage. Chem Biol Interact 1989;72:229-55. 26. Barzó P, Marmarou A, Fatouros P, Hayasaki K, Corwin F. Contribution of vasogenic and cellular edema to traumatic brain swelling measured by diffusion-weighted imaging. J Neurosurg 1997;87:900-7. 27. Vassar MJ, Perry CA, Gannaway WL, Holcroft JW. 7.5% sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter transport. Arch Surg 1991;126:106572. 28. Wade CE, Grady JJ, Kramer GC, Younes RN, Gehlsen K, Holcroft JW. Individual patient cohort analysis of the efficacy of hypertonic saline/dextran in patients with traumatic brain injury and hypotension. J Trauma 1997;42:S61-5. 29. Cooper DJ, Myles PS, McDermott FT, Murray LJ, Laidlaw J, Cooper G, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA 2004;291:1350-7. 30. Worthley LI, Cooper DJ, Jones N. Treatment of resistant intracranial hypertension with hypertonic saline. Report of two cases. J Neurosurg 1988;68:478-81. 31. Einhaus SL, Croce MA, Watridge CB, Lowery R, Fabian TC. The use of hypertonic saline for the treatment of increased intracranial pressure. J Tenn Med Assoc 1996;89:81-2. 32. Suarez JI, Qureshi AI, Bhardwaj A, Williams MA, Schnitzer MS, Mirski M, et al. Treatment of refractory intracranial hypertension with 23.4% saline. Crit Care Med 1998;26:111822. 33. Berger S, Schwarz M, Huth R. Hypertonic saline solution and decompressive craniectomy for treatment of intracranial hypertension in pediatric severe traumatic brain injury. J Trauma 2002;53:558-63. 34. Simma B, Burger R, Falk M, Sacher P, Fanconi S. A prospective, randomized, and controlled study of fluid management in children with severe head injury: lactated Ringer’s solution versus hypertonic saline. Crit Care Med 1998;26:126570. 35. Adelson PD, Bratton SL, Carney NA, Chesnut RM, du Coudray HE, Goldstein B, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 19. The role of anti-seizure prophylaxis following severe pediatric traumatic brain injury. Pediatr Crit Care Med 2003;4:S72-5. 36. Doyle JA, Davis DP, Hoyt DB. The use of hypertonic saline in the treatment of traumatic brain injury. J Trauma 2001;50:367-83.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):98-102

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2013.37880

Thermoelastic stress analysis to validate tibial fixation technique in total ankle prostheses - a pilot study Total diz protezlerinde tibial fiksasyon tekniğinin validasyonunda termoelastik gerilme analizi: Bir pilot çalışma Andreas FİCKLSCHERER,1 Bernd WEGENER,1 Thomas NİETHAMMER,1 Matthias F. PİETSCHMANN,1 Peter E. MÜLLER,1 Volkmar JANSSON,1 Hans-Heinrich TROUİLLİER2 BACKGROUND

AMAÇ

Recent literature has shown a persistently high rate of aseptic loosening of the tibial component in total ankle prostheses.

Güncel literatür total diz protezlerinde tibial komponentin aseptik gevşemesinin yüksek oranda oluştuğunu göstermektedir.

METHODS

GEREÇ VE YÖNTEM

We analyzed the interface between the tibial bone and tibial component with a thermoelastic stress analysis to demonstrate load transmission onto the distal tibia. In this regard, we used two established ankle prostheses, which were implanted in two human cadaveric and in two thirdgeneration composite tibia bones (Sawbones®, Sweden). Subsequently, the bones were attached to a hydropulser and a sinusoidal load of 700 N was applied.

Distal tibiaya yük aktarımını göstermek amacıyla tibial kemikle, tibial komponentin arayüzünü bir termoelastik gerilme analiziyle inceledik. Bu amaçla, iki insan kadavrasına ve iki üçüncü kuşak kompozit tibia kemiklerine implante edilmiş iki diz protezini kullandık (Sawbones®, İsveç). Daha sonra kemikler bir hidropulsere monte edilip 700 N gücünde bir sinüzoidal yük uygulandı.

RESULTS

BULGULAR

Both prostheses had an inhomogeneous load transmission onto the distal tibia. Instead of distributing load equally to the subarticular bone, forces were focused around the bolting stem, accumulating as stress maxima with forces up to 90 MPa. Furthermore, we were able to demonstrate load transmission into the metaphysis of the bone.

Her iki protez de distal tibiaya homojen olmayan bir yük aktarımı gerçekleştirdi. Yükü eşit olarak subartiküler kemiğe dağıtmak yerine kuvvetler protezin stemine odaklanmış, 90 MPa’ya varan bir kümülatif maksimal gerilme kuvveti oluşmuştur. Ayrıca, kemik metafizi içine yük aktarımını göstermeyi başardık.

CONCLUSION

SONUÇ

As demonstrated in this study, anchoring systems with stems used in all established total ankle prostheses lead to an inhomogeneous load transmission onto the distal tibia, and furthermore, to a distribution of load into the weaker metaphyseal bone. For these reasons, we favor a prosthetic design with minimal bone resection and without any stem or stem-like anchoring system, which facilitates a homogeneous load transmission onto the distal tibia. Thermoelastic stress analysis proved to be a fast and easy-to-perform method to visualize load transmission.

Bu çalışmada gösterildiği gibi tüm total diz protezlerinde kullanılan stemlerle yapılan ankrajlar distal tibiaya homojen olmayan bir yük aktarımı ve yükün daha zayıf olan kemik metafizine dağılmasına yol açmaktadır. Bu nedenlerle minimal kemik rezeksiyonuyla birlikte tespit çubuğu veya benzeri malzemenin kullanılmadığı bir ankraj sistemini ve bu nedenle distal tibiaya homojen yük aktarımını tercih etmekteyiz.

Key Words: Aseptic loosening; thermoelastic stress analysis; total ankle replacement.

Anahtar Sözcükler: Aseptik gevşeme; termoelastik gerilme analizi; total diz replasmanı.

Department of Orthopaedic Surgery, University Hospital of Munich (LMU), Munich; 2Franziskus Hospital, Bielefeld, Germany.

1

Münih Üniversite Hastanesi, Ortopedi Cerrahisi Kliniği, Münih; 2 Franziskus Hastanesi, Bielefeld, Almanya.

1

Correspondence (İletişim): Andreas Ficklscherer, M.D. Department of Orthopaedic Surgery, University Hospital of Munich (LMU)-Campus Grosshadern, Marchioninistr 15, 81377 Munich, Germany. e-mail (e-posta): andreas.ficklscherer@med.uni-muenchen.de

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Thermoelastic stress analysis to validate tibial fixation technique in total ankle prostheses

Tibiotalar arthrodesis is the preferred method of treatment of posttraumatic, degenerative or inflammatory disease of the ankle when conservative treatment options have failed.[1,2] Prosthetic replacements of the ankle joint have so far eventually failed or have yielded unsatisfactory results.[3-5] This likely explains why arthroplasty at the upper ankle joint remains a questionable procedure, despite the fact that the first total ankle replacements (TARs) were performed in 1970, while the number of total hip and knee arthroplasties performed steadily increases.[6-8] With implant loosening rates around 60-90% within the first 10 years, the number of failed systems was considerably higher than in knee or hip replacement. [9-11] Even if numbers dropped to 16-42% by changing the implantation technique from cemented to non-cemented, aseptic loosening is still the biggest challenge.[12-14] Newer implant designs therefore put more attention on rebuilding the natural anatomy.[15] Kinematic aspects have also been considered as well as ligament stability and mechanical alignment within the joint. The implant-to-bone interface has been unburdened by introducing two- and three-component implants, now allowing sliding and rotary motion. Anatomical studies, published in the 1980s and 1990s, demonstrated that only the subarticular bone has the strength needed to support the tibial component.[16-19] Still, most ankle prostheses feature anchoring systems, e.g. stems, to enhance stability. These components extend into the weaker metaphyseal bone with reduced trabecular architecture.[20] Because it is the tibial component that is more often loosened aseptically,[12,21] the purpose of the present study was to investigate load transmission at the implant-to-bone interface. We chose a thermoelastic stress analysis model instead of using finite element methods, a computational model by approximation. Based on the so-called Kelvin effect, thermoelastic stress analysis is a well-established test procedure in industrial material testing, but relatively new in medicine.[22] The hypothesis was that the high failure rate of aseptic loosening is due to inappropriate load transmission onto the distal tibia, and that this can be displayed optically.

MATERIALS AND METHODS We chose two established third-generation threecomponent ankle prostheses, which have been followed up by several authors and have an acceptable outcome compared to other ankle prostheses (STAR®, Waldemar Link, Germany and Salto®, Tornier, France). [12,21,23,24] Two human tibial bones (male, age 34) were obtained from the Institute of Legal Medicine of the Ludwig-Maximilian University of Munich within 24 hours after donor death. Soft tissue was removed Cilt - Vol. 19 Sayı - No. 2

preserving cortical bone. In addition, two third-generation composite tibia bones (Sawbones®, Sweden) were used. The prostheses were implanted by a skilled surgeon (HHT) in one session according to the manufacturer. X-ray scans were performed to assure proper implantation. Bones were then stored at -20°C until analysis and thawed to room temperature before testing.[25,26] For testing, bones were affixed in an aluminum drum with polymethylmethacrylate and mounted on the testing bench. To serve as a regular bearing, the talar components were affixed to the hydropulser plunger in a neutral position. Based on the so-called Kelvin effect, thermoelastic stress analysis is a well- established test procedure in industrial material testing, but relatively new to human bone.[22] Load-dependent distension of a body causes changes in temperature. Metal, for example, grows warm under pressure load and cools down under tensile load. Performing a rapid change between pressure and tensile load, one can assume an adiabatic system (a system in which heat is neither applied nor discharged). Local change of temperature is then proportional to local change of tension and can be detected by the infrared camera system. In this study, we used a JADE MWIR infrared camera (CEDIP Infrared Systems, Germany) with an array resolution of 320 x 256 and a pixel pitch of 30 µm. The system measures infrared radiation with a wavelength of 3-5 µm, which is emitted by the specimen under cyclic loading. Generally, the infrared camera works just as a normal camera, but instead of a CCD-Chip or a negative film, the infrared camera features a resistance detector. This device transfers infrared radiation into heat and changes its resistance proportional to the heat applied. According to that change in resistance, the camera then displays load transmission in megapascal (MPa; 1 MPa = 1 N/mm2).

Fig. 1. The testing setup. (Color figure can be viewed in the online issue, which is available at www.tjtes.org).

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To match the sinusoidal signal captured by the camera with a reference signal transmitted by the hydropulser, a correlator was used. In doing so, the measured signal was assigned by frequency, size and phase eliminating errors such as optical reflection or infrared radiation from another source. To simulate ligament tension and to avoid luxation of the polyethylene sliding core in the status of complete unloading, a preload of 100 N was applied. After finishing all preparations, a sinusoidal oscillation frequency of 10 Hz was installed.[22] The peak load was limited to 700 N. The camera was focused on the implant-to-bone interface. Scans were taken from ventral, lateral and dorsal views. According to the experimental setup, the images are upside down, and were flipped for better viewing. The testing setup can be seen in Fig. 1.

RESULTS Figure 2a shows the STAR ankle prosthesis implanted in a human tibia from ventral view. The talar

implant as well as the polyethylene gliding core can be seen at the bottom. The rugged and turbulent appearance of the surface can be attributed to the preparation (periosteum). Pressure load is shown as negative values. As can be seen, load transmission covers the whole distal tibia with irregular appearance and values from -20 N/mm2 to - 100 N/mm2 (=MPa; megapascal). Load transmission extends more into the metaphysis on the lateral side than medially. Figures 2b and 2c (seen from ventral and medial views) show the same type of prosthesis implanted into a third-generation composite tibia. Because of the smooth bone surface load, there is a much better display of distribution. Still distribution patterns are similar. The load transmission is inhomogeneous with an accentuation around the medial stem. Values range from -27 N/mm2 to -90 N/mm2. In the medial view, load transmission is more ribbon-like. Values range between -27 N/mm2 and -46 N/mm2. Figure 2d shows the Salto ankle prosthesis implanted in a human tibia from ventral view. Again,

(a)

(b)

(c)

(d)

(e)

(f)

Fig. 2. See text for detailed information. (Color figures can be viewed in the online issue, which is available at www.tjtes.org). 100

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Thermoelastic stress analysis to validate tibial fixation technique in total ankle prostheses

because of the remaining periosteum, the surface appears disturbed. Load transmission is distributed homogeneously along the base-plate with pressure loads ranging from -60 N/mm2 to -20 N/mm2. Around the anchoring stem, pressure load ranges from -60 N/mm2 to -100 N/mm2. Figures 2e and 2f represent the Salto prosthesis implanted into composite tibias from ventral and medial views. On the ventral side, a more homogenous band of load distribution is seen, with values between -25 N/mm2 and -45 N/mm2, putting slightly more stress on the malleolus medialis.

DISCUSSION Despite the multitude of designs and the many changes that have been made in the approach of TAR, aseptic loosening of the tibial component remains a drawback to match the successes with arthrodesis or hip and knee arthroplasty.[9-11] Even though anatomic and kinematic aspects have been implemented in newer prosthetic designs, all prostheses[15] come with an anchoring system reaching from the joint space into the metaphysis (in our study 8 mm with STAR and 15 mm with Salto). Although the prosthetic design has been an issue for many years, this method of anchoring has been hardly questioned. Our hypothesis was that the relatively high failure rate of aseptic loosening in current total ankle prostheses is due to an inappropriate load transmission onto the distal tibia and that this can be displayed optically. We therefore investigated the tibial anchoring system in two established total ankle prostheses and introduced thermoelastic stress analysis as a method to visualize stress load at the implant-to-bone interface. As published in several anatomical studies describing the distal tibia, bone density and bone stability diminish within the very first 10 mm due to architectural reasons concerning the cancellous bone.[16-20,27,28] Therefore, bone resection should be minimized to the extent possible and structural conditions should be considered.[20,27] In contrast to the above, the subchondral bone plate is routinely removed or at least depleted during surgery when performing TAR. In this study, we found that due to the anchoring system, stress load is transferred into weaker, metaphyseal bone, and accumulates there to stress maxima. These stress maxima, with values up to 100 MPa, stand in total contrast to what Kimizuka et al.[29] described as a normal load-bearing pattern. He measured a maximum peak pressure at 13 MPa with 1500 N load in eight human ankle joints (average 9.9 MPa at 1500 N). Moreover, we compared the load transmission we visualized with thermoelastic stress analysis with Xray scans published in literature. Our hypothesis was confirmed by Bonnin et al.[21] and Anderson et al.,[12] Cilt - Vol. 19 Say覺 - No. 2

who described an accumulation of radiolucency-lines and aseptic loosening, respectively, where we found stress maxima. As demonstrated in this study with two established TAR prostheses, load transmission accumulates with high maxima around the anchoring systems (stems), and because of the stem length, these maxima are directed into the weaker metaphyseal bone. This effect was more prominent in the Salto than in the STAR prosthesis. For these reasons, we favor a prosthetic design with minimal bone resection and without any stem or stem-like anchoring system, which facilitates a homogeneous load transmission onto the distal tibia. In contrast to finite element analysis, thermoelastic stress analysis is fast, easy-to-perform and wellestablished in industrial material testing. With this relatively new method, we were able to demonstrate visually stress load in human bones. In our opinion, this non-invasive method can be helpful in optimizing the design of next-generation total ankle prostheses. The limitations of our study include the relatively small number of specimens and the evaluation of only two prosthetic models. Furthermore, thermoelastic stress analysis is limited to the bone surface and therefore only displays changes in heat on the very surface. Acknowledgement This work was presented at the DGOOC Berlin (German Congress for Orthopedic and Trauma Surgery). There has been no funding or sponsoring of this study.

REFERENCES 1. Katcherian DA. Treatment of ankle arthrosis. Clin Orthop Relat Res 1998;349:48-57. 2. Nihal A, Gellman RE, Embil JM, Trepman E. Ankle arthrodesis. Foot Ankle Surg 2008;14:1-10. 3. Kitaoka HB, Patzer GL. Clinical results of the Mayo total ankle arthroplasty. J Bone Joint Surg [Am] 1996;78:1658-64. 4. Saltzman CL. Perspective on total ankle replacement. Foot Ankle Clin 2000;5:761-75. 5. Schernberg F. Current results of ankle arthroplasty: European Multi Center Study of Cementless Ankle Arthroplasty. In: Kofoed H, editor. Current status of ankle arthroplasty. Berlin: Springer-Verlag; 1998. p. 41-6. 6. Healy WL, Iorio R, Ko J, Appleby D, Lemos DW. Impact of cost reduction programs on short-term patient outcome and hospital cost of total knee arthroplasty. J Bone Joint Surg [Am] 2002;84-A:348-53. 7. K繹nig A, Kirschner S. Long-term results in total knee arthroplasty. Orthopade 2003;32:516-26. 8. Lord G, Marotte JH. Total ankle prosthesis. Technic and 1st results. Apropos of 12 cases. Rev Chir Orthop Reparatrice Appar Mot 1973;59:139-51. 9. Bolton-Maggs BG, Sudlow RA, Freeman MA. Total ankle arthroplasty. A long-term review of the London Hospital ex101

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perience. J Bone Joint Surg Br 1985;67:785-90. 10. Demottaz JD, Mazur JM, Thomas WH, Sledge CB, Simon SR. Clinical study of total ankle replacement with gait analysis. A preliminary report. J Bone Joint Surg [Am] 1979;61:976-88. 11. Wynn AH, Wilde AH. Long-term follow-up of the Conaxial (Beck-Steffee) total ankle arthroplasty. Foot Ankle 1992;13:303-6. 12. Anderson T, Montgomery F, Carlsson A. Uncemented STAR total ankle prostheses. Three to eight-year follow-up of fiftyone consecutive ankles. J Bone Joint Surg [Am] 2003;85A:1321-9. 13. Knecht SI, Estin M, Callaghan JJ, Zimmerman MB, Alliman KJ, Alvine FG, et al. The Agility total ankle arthroplasty. Seven to sixteen-year follow-up. J Bone Joint Surg [Am] 2004;86-A:1161-71. 14. Kofoed H, Sørensen TS. Ankle arthroplasty for rheumatoid arthritis and osteoarthritis: prospective long-term study of cemented replacements. J Bone Joint Surg [Br] 1998;80:32832. 15. Giannini S, Leardini A, O’Connor JJ. Total ankle replacement: review of the designs and of the current status. Foot Ankle Surg 2000;6:77-88. 16. Aitken GK, Bourne RB, Finlay JB, Rorabeck CH, Andreae PR. Indentation stiffness of the cancellous bone in the distal human tibia. Clin Orthop Relat Res 1985;201:264-70. 17. Fiala P, Hert J. Principal types of functional architecture of cancellous bone in man. Funct Dev Morphol 1993;3:91-9. 18. Hvid I, Rasmussen O, Jensen NC, Nielsen S. Trabecular bone strength profiles at the ankle joint. Clin Orthop Relat Res 1985;199:306-12. 19. Takechi H, Ito S, Takada T, Nakayama H. Trabecular archi-

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tecture of the ankle joint. Anat Clin 1982;4:227-33. 20. Mühlhofer H, Ercan Y, Drews S, Matsuura M, Meissner J, Linsenmaier U, et al. Mineralisation and mechanical strength of the subchondral bone plate of the inferior tibial facies. Surg Radiol Anat 2009;31:237-43. 21. Bonnin M, Judet T, Colombier JA, Buscayret F, Graveleau N, Piriou P. Midterm results of the Salto Total Ankle Prosthesis. Clin Orthop Relat Res 2004;424:6-18. 22. Krüger-Franke M, Heiland A, Plitz W, Refior HJ. Thermoelastic stress analysis of human bones. Z Orthop Ihre Grenzgeb 1995;133:389-93. 23. Kofoed H. Scandinavian Total Ankle Replacement (STAR). Clin Orthop Relat Res 2004;424:73-9. 24. Wood PL, Deakin S. Total ankle replacement. The results in 200 ankles. J Bone Joint Surg Br 2003;85:334-41. 25. Pietschmann MF, Fröhlich V, Ficklscherer A, Hausdorf J, Utzschneider S, Jansson V, et al. Pullout strength of suture anchors in comparison with transosseous sutures for rotator cuff repair. Knee Surg Sports Traumatol Arthrosc 2008;16:504-10. 26. Schneider E, Eulenberger J, Steiner W, Wyder D, Friedman RJ, Perren SM. Experimental method for the in vitro testing of the initial stability of cementless hip prostheses. J Biomech 1989;22:735-44. 27. Loskutov AE. Biomechanical substantiation of prosthetics of the ankle joint. [Article in Russian] Ortop Travmatol Protez 1990;9:21-4. [Abstract] 28. Müller-Gerbl M. Anatomy and biomechanics of the upper ankle joint. Orthopade 2001;30:3-11. 29. Kimizuka M, Kurosawa H, Fukubayashi T. Load-bearing pattern of the ankle joint. Contact area and pressure distribution. Arch Orthop Trauma Surg 1980;96:45-9.

Mart - March 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):103-108

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.12080

Assessment of the severity of acute pancreatitis by contrast-enhanced computerized tomography in 350 patients Kontrastlı bilgisayarlı tomografi ile akut pankreatitli 350 hastada hastalığın şiddet derecesinin değerlendirilmesi Mohd Altaf MIR,1 Biant Singh BALI,1 Riyaz Ahmad MIR,2 Hamza WANI1

BACKGROUND

AMAÇ

This prospective study has been conducted with the aim to assess the severity of acute pancreatitis.

Bu çalışma, akut pankreatitin şiddet derecesini değerlendirmek amacıyla yapıldı.

METHODS

GEREÇ VE YÖNTEM

The study included 350 consecutive patients with acute pancreatitis admitted over a period of five years. All these patients were subjected to detailed history and clinical examination and investigations to ascertain the diagnosis. The severity was assessed by contrast - enhanced computed tomography (CT). Data collected were tabulated and subjected to appropriate statistical analysis.

Çalışma beş yıllık dönem içinde hastaneye kabul edilen akut pankreatitli ardışık 350 hastayı kapsadı. Tanıyı belirlemek için bu hastaların tümünden ayrıntılı anamnezler alınıp, fiziksel incelemeler ve araştırmalar yapıldı. Hastalığın şiddet derecesi kontrastlı bilgisayarlı tomografiyle (BT) değerlendirildi. Toplanan veriler tablolar halinde gösterilip, uygun istatistiksel analizler yapıldı.

RESULTS

BULGULAR

On the basis of the CT Severity Index (CTSI), the severity of acute pancreatic was classified into Group A (mild), Group B (moderate), or Group C (severe). Group C patients had the most complications (in 77 [91.67%] patients), and Group A patients had the least (in 7 [6.25%] patients). Mortality was found to be highest among Group C (14 [16.67%] patients), indicating the severe nature of disease in these patients, while no mortality was noted in Group A patients. The mean duration of hospital stay of patients in Group A was 9.25 days, Group B 12.0 days and Group C 24.58 days. CONCLUSION

BT şiddet derecesi indeksine (BTDI) dayanarak, hastalığın şiddet derecesi A (hafif), B (orta derecede) ve C (şiddetli) grupları şeklinde sınıflandırıldı. En fazla komplikasyon C grubunda (n=77, %91,67), en az komplikasyon ise A grubunda (n=7, %6,25) kaydedildi. C grubunda ölüm oranlarının en yüksek düzeyde (%16,67) saptanmış olması bu hastalarda hastalığın şiddetli seyrettiğine işaret etmektedir. A grubu hastalarında ise hiçbir ölüm olayı kaydedilmedi. Ortalama hastanede kalış süresi A, B ve C gruplarında sırasıyla 9,25, 12,0 ve 24,58 gün idi. SONUÇ

The use of contrast-enhanced computed tomography as a routine investigation in patients to predict a severe attack of acute pancreatitis early in the course of the disease decreases overall mortality and burden of disease.

Hastalarda, hastalıklarının erken evresinde şiddetli akut pankreatit atağını önceden tahmin amacıyla kontrastlı BT’nin rutin inceleme yöntemi olarak kullanılması genel mortalite ve hastalığın yükünü azaltmaktadır.

Key Words: Acute pancreatitis; computed tomography severity index; morbidity; mortality.

Anahtar Sözcükler: Akut pankreatit; bilgisayarlı tomografi hastalığın şiddeti indeksi; morbidite; mortalite.

Departments of 1Surgery, 2Medicine, Government Medical College Srinagar, India.

Srinagar Devlet Tıp Koleji, Cerrahi Bölümü, Tıp Bilimleri Bölümü, Srinagar, Hindistan.

Correspondence (İletişim): Mohd Altaf Mir, M.D. Shilvath, Sumbal Sonawari, Kashmir India, 193501 Srinagar, India. Tel: +0091 - 194 - 941909 2564 e-mail (e-posta): draltafmir@gmail.com

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In the majority of cases, acute pancreatitis has a mortality of less than 2%.[1] Despite considerable improvements in treatment, mortality remains between 15% and 25%[2] in severe cases and reaches up to 40% if pancreatic necrosis is infected.[3] Clinical assessment by the clinician is poor in predicting the severity of acute pancreatitis on admission, and it fails to identify up to two-thirds of patients, who eventually develop complications or die.[4] Beneficial results have been obtained with the early management of patients, correctly classified as severe, in intensive care units, with early endoscopic retrograde cholangiopancreatography (ERCP) and biliary drainage in gallstoneinduced disease and prophylactic antibiotics.[5] Criticism of the Atlanta severity classification system is growing, however, because it is retrospective, the duration of organ failure is unspecified, and because local complications do not seem to increase mortality. [6] Ranson Criteria is a clinical scoring system for pancreatitis that takes into account age along with other physiological parameters to determine the severity of pancreatitis. Presence of three or more criteria predicts severe acute pancreatitis.[7] The Acute Physiology and Chronic Health Evaluation II (APACHE II) is the most commonly used severity of illness scoring system in North America. A score of â&#x2030;Ľ8 points characterizes severe acute pancreatitis.[8] However, the system is complex. For the staging of acute pancreatitis, Balthazar et al.[9] developed a computed tomographic (CT)-based scoring system, in which severity of pancreatitis was graded from A to E on the basis of pancreatic enlargement and presence of peri-pancreatic fluid collections on un-enhanced CT scan. However, its main drawback was its inability to reliably depict pancreatic necrosis and, consequently, further define the risk of complications in patients with retroperitoneal fluid collections at the time of presentation. A major improvement in the CT grading of pancreatitis was made in 1990, when the Balthazar Computed Tomography Severity Index (CTSI) was introduced, which in addition to the presence of peri-pancreatic fluid collections, took into consideration the presence of pancreatic necrosis, depicted on CT scan as areas of diminished or no enhancement, when oral and intravenous contrast material was given. An excellent correlation was documented between necrosis, length of hospitalization, development of complications, and death.[10]

MATERIALS AND METHODS This prospective study was conducted in the Department of General Surgery, in collaboration with the Department of Radiodiagnosis and Imaging Government Medical College, Srinagar. The study included 350 consecutive patients with acute pancreatitis who were admitted over a period of five years from 1 June 2006 to 3 May 2011. All these patients were subjected 104

to detailed history and clinical examination and investigations. The severity of acute pancreatitis was assessed by contrast-enhanced computed tomography (CECT). Written and informed consent was taken from all of the patients who were subjected to CECT. Hypersensitivity to contrast material was ruled out and patients were subjected to CECT as per the appropriateness criteria laid down by the American College of Radiology (2001), which were revised in 2006. As per these criteria, the appropriateness of a particular imaging modality in a given clinical setting is rated on a scale of 1 to 9. A rating of 1 means that a particular imaging modality is least appropriate and a rating of 9 suggests that the investigation is most appropriate in a given clinical scenario. For patients with suspected acute pancreatitis, rating for appropriateness of CT of the abdomen and pelvis is as follows:[1] 1: Etiology unknown, first episode of pancreatitis (Rating=6); 2: Severe abdominal pain, elevated serum amylase and serum lipase, no fever or evidence of fluid loss at admission (Rating=7); 3: Severe abdominal pain, elevated serum amylase and serum lipase, 48 hours later assuming no improvement or degradation (assume no prior imaging) (Rating=8); 4: Severe abdominal pain, elevated serum amylase and serum lipase, fever and elevated white blood cell count (Rating=9); 5: Severe abdominal pain, elevated serum amylase and serum lipase, oliguria, tachycardia (Rating=9). Abdominal CECT was done on a single-slice helical scanner Fxi-GE Medical System, typically 72 hours after admission when it was optimum to rule out pancreatic necrosis and properly delineate the areas of necrosis. Patients were given 20 ml of contrast in 1 liter of water orally 2 hours before the scan. 7 mm contiguous cuts were taken from the dome of the diaphragm up to the iliac crest after intravenous (IV) administration of 100 ml of 60% iodinated contrast agent (Lek-Pamidol 300/Iomeron300/Omnipaque) at 1 ml/sec10. Oral contrast was withheld in patients with vomiting. The CT scan was reported by an experienced radiologist and CTSI, as given below: Grade of acute pancreas points (Balthazar Score) A=Normal pancreas

B=Pancreatic enlargement alone

0

1

C=Inflammation confined to the pancreas and peripancreatic fat 2 D=One pancreatic fluid collection

3

E=Two or more peripancreatic fluid collections 4 Mart - March 2013

Assessment of the severity of acute pancreatitis by contrast-enhanced computerized tomography

Degree of pancreatic necrosis No necrosis

0

Necrosis of one-third of pancreas (30%)

2

Necrosis of one-half of pancreas (50%)

4

Necrosis of more than one-half of pancreas 6 (>50%) The CTSI was calculated by grade + degree of necrosis points[10] (Table 1). Patients were divided into three categories: Group A - Mild (0-3 points) (Fig. 1a) Group B - Moderate (4-6 points) (Fig. 1b) Group C - Severe (7-10 points) (Fig. 1c) The patients were managed according to the standardized protocols of acute pancreatitis and were observed for the development of any complication or any operative intervention needed. Standard operative procedure in our study remained laparotomy with pancreatic necrosectomy (Fig. 1d) and closed lavage. The hospital stay of the patients was noted. Any deaths occurring were recorded. The CTSI was used to predict the morbidity and mortality of patients with acute

Table 1. CTSI vs mortality and morbidity Severity index (CTSI) 0-1 2-3 4-6 7-10

Predicted mortality

Predicted complications

0% 3% 6% 17%

0% 8% 35% 92%

pancreatitis and duration of hospital stay. The results were tabulated and subjected to appropriate statistical analysis. To calculate the p value, Fisherâ&#x20AC;&#x2122;s exact test or unpaired t test was used, as and when needed. A p value of <0.05 was taken as indicating statistical significance. The following 55 patients were excluded from the study: 1) Patients with known contrast allergy (n=15), 2) Patients with deranged kidney function (n=16), 3) Hemodynamically unstable patients (n=13), 4) As per the appropriateness criteria (n=11).

RESULTS The majority of our patients were in the age range of 41-60 years; the average age of male patients was

(a)

(b)

(c)

(d)

Fig. 1. (a) Bulky pancreas with fat stranding (CTSI 2). (b) Bulky pancreas, peripancreatic fat stranding and fluid collection (CTSI 4). (c) Necrosis of head, neck, body and tail of pancreas (CTSI 9). (d) Pancreatic necrosectomy. (Color figures can be viewed in the online issue, which is available at www.tjtes.org). Cilt - Vol. 19 SayÄą - No. 2

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cant when comparing Group A and Group C patients in terms of complications (p:0.0001). Mortality was found to be highest among Group C, in 14 (16.67%) patients, indicating the severe nature of their disease, while no mortality was noted in Group A patients (Table 5). The mean duration of hospital stay of patients in Group A was 9.25 days, Group B 12.0 days and Group C 24.58 days. The p value when comparing the duration of hospital stay between Group A and Group C patients was found to be statistically significant (Table 6). In Group A and B, no patient required operative intervention, whereas among Group C patients, 28 (25%) were operated, and 14 (50%) of them expired in the postoperative period (Table 7). The mean surgical intervention time was 21.4 days in Group C.

Table 2. CT findings in patients of acute pancreatitis CECT findings

n (%)

Enlarged pancreas Peripancreatic fat stranding Peripancreatic fluid collection Single 2 or more Necrosis Nil 30% Nil 50% Nil >50% Emphysematous pancreatitis Pancreatic ascites Thickened root of mesentery Worm in pancreatic duct Pleural effusion Left Right Bilateral

14 (40%) 28 (20) 308 (88%) 210 (60%) 98 (28%) 217 (62%) 133 (32.29%) 63 (18%) 21 (6%) 14 (4%) 84 (24%) 35 (10%) 14 (4%) 42 (12%) 21 (6%) 7 (2%) 14 (4%)

47.71 years and of female patients was 51.48 years. Females were predominant, with a male: female ratio of 1: 1.38. A larger proportion of our patients were from rural areas of Kashmir, with a rural: urban ratio of 1.38: 1. Biliary tract pathology was the predominant etiology. The most common finding on CECT was that of peripancreatic fluid collection, noted in 308 (88%) patients, and emphysematous pancreatitis, which is often due to infective necrosis, was seen in 14 (4%) of our patients, as revealed by gas in the lesser sac or in the pancreatic substance (Table 2). The mean CTSI observed was 5.9. As shown in Tables 3 and 4, patients in Group C had the most complications, in 77 (91.67%) patients, and those in Group A had the least, in 7 (6.25%) patients. The p value was statistically signifi-

DISCUSSION Acute pancreatitis is a common ailment encountered by surgeons in any part of the world, and it forms a good proportion of emergency admissions in surgical emergency units. Staging of the severity of this disease, with early recognition of severe cases, is essential so that the most suitable treatment can be provided for each patient, with the aims of reducing morbidity, mortality, and duration of hospital stay, thus ensuring important hospital resources are not wasted, especially in a developing country, like ours. Clinical assessment of acute pancreatitis is not reliable, with as many as 50% of patients being classified incorrectly. It is of utmost importance to assess the diagnosis and severity of acute pancreatitis in the beginning to identify those patients with severe or necrotizing disease who would benefit from an early-initiated intensive care therapy. With regards to morbidity, among patients with a CTSI of 0-1 and 2-3 (mild), complications were present in only 7 (6.25%) patients, whereas among those with CTSI of 4-6 (moderate) 56 (36.37%) had complications, and among those with CTSI of 7-10 (se-

Table 3. CTSI vs mortality and morbidity Complications

No. of patients

Patients with complications

Percentage

p

Mild (A) Moderate (B) Severe (C)

112 (32%) 154 (44%) 84 (24%)

7 56 77

6.25% 36.37% 91.67%

A vs. B 0.0525 B vs. C 0.0031 A vs. C <0.0001

Table 4. CTSI vs mortality and morbidity Complication Mild (A) Moderate (B) Severe (C)

Pleural effusion

Acute fluid collection

7 (6.25%) 0 (0%) 21 (13.64%) 21 (13.64%) 14 (16.66%) 14 (16.66%)

Acute renal failure

Pancreatic ascites

ARDS

Sepsis

0 (0%) 7 (4.55%) 21 (25%)

0 (0%) 7 (4.55%) 14 (16.66%)

0 (0%) 0 (0%) 7 (8.33%)

0 (0%) 0 (0%) 7 (8.33%)

ARDS: Acute respiratory distress syndrome.

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Mart - March 2013

Assessment of the severity of acute pancreatitis by contrast-enhanced computerized tomography

Table 5. CTSI vs mortality Mortality

No. of patients

Patients expired

Percentage

p*

112 154 84

0 7 14

0% 4.5% 16.67%

A vs. B 1.000 B vs. C 0.2794 A vs. C 0.1746

Mild (A) Moderate (B) Severe (C)

Table 6. CTSI vs mortality and morbidity Hospital stay (days) Mild (A) Moderate (B) Severe (C)

No. of patients 112 154 84

Mean±SD

SEM

p*

9.250±3.000 0.7500 A vs. B <0.05 12.000±1.877 0.4002 B vs. C <0.001 24.583±4.441 1.282 A vs. C <0.001

SD: Standard deviation; SEM: Standard error of mean.

Table 7. CTSI vs mortality and morbidity Group Mild (A) Moderate (B) Severe (C)

No. of cases

Surgical intervention

Mortality

112 154 84

0 (0%) 0 (0%) 28 (25%)

0 (0%) 0 (0%) 14 (50%)

p: 0.0242; Relative risk: 1.50; Remarks - Significant.

vere), 77 (91.67%) had complications, indicating an increasing trend towards occurrence of complications, varying in nature, in conjunction with an increase in severity grade as determined on CTSI. Our study is comparable to that of Balthazar,[10] who noted morbidity of 0% in patients with CTSI of 0-1, 8% in patients with CTSI of 2-3, 35% in patients with CTSI of 4-6, and 92% in patients with CTSI of 7-10; that of Ros[11] and Vriens[12] who observed a morbidity of 100% with CTSI of 7-10; and that of Chisty,[13] who noted morbidity of 100% in patients with severe pancreatitis (CTSI 7-10). The various complications noted in our patients belonging to the severe group (84 [24%]), in order of frequency, were azotemia 21 (25%), pleural effusion 14 (16.7%), pancreatic ascites 14 (16.66%), acute fluid collection 14 (16.66%), acute respiratory distress syndrome (ARDS) 7 (8.33%), and sepsis 7 (8.33%). None of our patients had pancreatic abscess. Overall, the most common as well as the most common extrapulmonary complication was pleural effusion, in 42 (12%) of the cases, which was also reported by Wongnai Anchalee et al.[14] Beger et al.[15] noted pancreatic edema (71%) as the most common complication. Viedma et al.,[16] Lankisch et al.,[17] Toh et al.,[18] and Heath et al.[19] noted that respiratory failure was the most common type of organ failure in acute pancreatitis, but in our study, the acute renal failure in 28 (8%) cases was the most common organ failure observed. In our study, we found a mortality of 0 (0%) in patients with CTSI of 0-1 and 2-3 (mild), of 7 (4.5%) in patients with CTSI of 4-6 (moderate) Cilt - Vol. 19 Sayı - No. 2

and of 14 (16.67%) in patients with CTSI of 7-10 (severe), revealing an increasing trend towards mortality with an increase in CTSI, which was also observed by Balthazar,[10] Simchuk et al.,[20] Bradley,[21] and Vriens. [12] The mean duration of hospital stay (SD) of patients in Group A was 9.25 (3) days, Group B 12.0 (1.87) days and Group C 24.58 (4.44) days, and hence, the duration of hospital stay increased with the severity, which was also observed by Balthazar,[9] Balthazar,[10] Chisty,[13] and Wongnai Anchalee[22] in their studies. Operative intervention in the form of laparotomy with pancreatic necrosectomy (Figure 4) and closed lavage was required in 28 (25%) of our patients in Group C. The need for abdominal exploration was on the basis of the presence of necrosis with clinical signs of infection, emphysematous pancreatitis on CT scan, and failure of medical management, and the decision was further reinforced by clinical deterioration of the patients, indicated by increase in pulse rate, decrease in blood pressure and silent abdomen. Patients were subsequently managed in the surgical intensive care unit. Fourteen (50%) of the operated patients died, due to uncontrolled sepsis and ARDS (in 7 patients each). The higher rate of surgical intervention and postoperative mortality in severe acute pancreatitis observed in our study was also published by Simchuck et al.,[20] Shah et al.[23] and Sivsankar.[24] In conclusion, in this study, it was shown that the CECT can prognosticate patients with acute pancreatitis, predict morbidity, mortality and the duration of 107

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hospital stay in patients with acute pancreatitis, and predict which patients may require surgical intervention to prevent the progression of disease and the likelihood of postoperative mortality. Since improved outcome in the severe form of acute pancreatitis is based on early identification of disease severity and subsequent focused management of these high-risk patients, we advocate the use of CECT as a routine investigation in patients of acute pancreatitis in order to predict a severe attack of acute pancreatitis early in the course of disease, and thus decrease overall mortality and burden of disease. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Steinberg W, Tenner S. Acute pancreatitis. N Engl J Med 1994;330:1198-210. 2. Fernández-Cruz L, Navarro S, Valderrama R, Sáenz A, Guarner L, Aparisi L, et al. Acute necrotizing pancreatitis: a multicenter study. Hepatogastroenterology 1994;41:185-9. 3. Beger HG, Isenmann R. Surgical management of necrotizing pancreatitis. Surg Clin North Am 1999;79:783-800. 4. Wilson C, Heath DI, Imrie CW. Prediction of outcome in acute pancreatitis: a comparative study of APACHE II, clinical assessment and multiple factor scoring systems. Br J Surg 1990;77:1260-4. 5. Nordback I, Sand J, Saaristo R, Paajanen H. Early treatment with antibiotics reduces the need for surgery in acute necrotizing pancreatitis-a single-center randomized study. J Gastrointest Surg 2001;5:113-20. 6. Isenmann R, Rau B, Zoellner U, Beger HG. Does the atlanta classification of severe acute pancreatitis really correlate with outcome in patients with pancreatic necrosis? Gastroenterology 2001;120 Suppl. 1:A485-6. 7. Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 1974;139:69-81. 8. Khan AA, Parekh D, Cho Y, Ruiz R, Selby RR, Jabbour N, et al. Improved prediction of outcome in patients with severe acute pancreatitis by the APACHE II score at 48 hours after hospital admission compared with the APACHE II score at admission. Acute Physiology and Chronic Health Evaluation. Arch Surg 2002;137:1136-40. 9. Balthazar EJ, Ranson JH, Naidich DP, Megibow AJ, Caccavale R, Cooper MM. Acute pancreatitis: prognostic value of CT. Radiology 1985;156:767-72. 10. Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute

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pancreatitis: value of CT in establishing prognosis. Radiology 1990;174:331-6. 11. Ros PR, Bree RL, Foley WD, Gay SB, Glick SN, Heiken JP, et al. Expert panel on gastrointestinal imaging. In: Acute pancreatitis. Reston (VA): American College of Radiology (ACR); 2006. 12. Vriens PW, Linde P, Warmerdon PE. Computed Tomography Severity Index is an early prognostic tool for acute pancreatitis. Journal of American College of Surgeons 2004;201:497502. 13. Chisty IA, Vaqar B, Sajida P, Dawar B, Zishan H. Role of CT in acute pancreatitis and it’s complications among age groups. Journal of Pakistan Medical Association 2005;55:431-5. 14. Wongnai A, Mai WNC. Computed Tomography findings of acute pancreatitis in Maharaj Nakorn Chiang Mai Hospital. Chiang Mai Medical Journal 2007;46:45-91. 15. H. G. Beger, B. Rau, J. Mayer, U. Pralle. Natural course of acute pancreatitis. World Journal of Surgery 1997;21:130-5. 16. Viedma JA, Pérez-Mateo M, Agulló J, Domínguez JE, Carballo F. Inflammatory response in the early prediction of severity in human acute pancreatitis. Gut 1994;35:822-7. 17. Lankisch PG, Pflichthofer D, Lehnick D. Acute pancreatitis: which patient is most at risk? Pancreas 1999;19:321-4. 18. Toh SK, Phillips S, Johnson CD. A prospective audit against national standards of the presentation and management of acute pancreatitis in the South of England. Gut 2000;46:23943. 19. Heath D, Alexander D, Wilson C, Larvin M, Imrie C, McMahon M. Which complications of acute pancreatitis are most lethal? A prospective multi-centre clinical study of 719 episodes. Gut 1995;36:A478. 20. Simchuk EJ, Traverso LW, Nukui Y, Kozarek RA. Computed tomography severity index is a predictor of outcomes for severe pancreatitis. Am J Surg 2000;179:352-5. 21. Bradley EL 3rd, Murphy F, Ferguson C. Prediction of pancreatic necrosis by dynamic pancreatography. Ann Surg 1989;210:495-504. 22. Edison de Oiveira FF, Shigweoka D, Bilkar D, Yansada AF. Reproducibility in the assessment of acute pancreatitis with computed tomography. Radiol Bras 2007:383-7. 23. Shah SSH, Ansari MA, Ali S. Early prediction of severity and outcome of acute severe pancreatitis. Pak J Med. Sci 2009;25:619-23. 24. Sivasankar A, Kannan DG, Ravichandran P, Jeswanth S, Balachandar TG, Surendran R. et al. Outcome of severe acute pancreatitis: is there a role for conservative management of infected pancreatic necrosis? Hepatobiliary Pancreat Dis Int 2006;5:599-604.

Mart - March 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):109-114

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.33279

The functional results of acute nerve grafting in traumatic sciatic nerve injuries Travmatik siyatik sinir yaralanmalarında uygulanan akut sinir greftlemesinin fonksiyonel sonuçları Haluk VAYVADA, Cenk DEMİRDÖVER, Adnan MENDERES, Mustafa YILMAZ, Can KARACA

BACKGROUND

AMAÇ

The sciatic and peroneal nerves are the most frequently injured in lower extremities, followed by tibial and femoral nerves. The aim of this study is to evaluate the functional results of acute nerve grafting in traumatic sciatic nerve injuries.

Siyatik ve peroneal sinirler alt ekstremitede en fazla yaralanan sinirler olup, bunları tibial ve femoral sinirler takip eder. Bu çalışmanın amacı travmatik siyatik sinir yaralanmalarında uygulanan akut sinir greftlemesinin fonksiyonel sonuçlarının değerlendirilmesidir.

METHODS

GEREÇ VE YÖNTEM

A total of 9 patients with sciatic nerve defect were treated with primary nerve grafting. The mean age was 31.7 years. The etiologic factors were gunshot wounds, traffic accident, and penetrating trauma.

Siyatik sinir defekti olan toplam 9 hasta primer sinir greftlemesi ile tedavi edildi. Hastaların ortalama yaşı 31,7’idi. Etyolojik faktörler ateşli silah yaralanmaları, trafik kazaları ve penetran yaralanmalardı. BULGULAR

RESULTS

All of the patients had sciatic nerve defects ranging from 3.4 to 13.6 cm. The follow-up period ranged between 25 and 84 months. The tibial nerve motor function was “good” or “very good” (M3-M4) in 5 patients (55.6%). The plantar flexion was not sufficient for the rest of the patients. The peroneal nerve motor function was also “good” and “very good” in 3 patients (33.3%). CONCLUSION

Hastaların tümünde 3,4 cm ile 13,6 cm arasında değişen siyatik sinir defektleri vardı. Hastaların takip süreleri 25 ile 84 ay arasında değişmekteydi. Tibial sinir motor fonksiyonu 5 hastada (%55,6) ‘‘iyi’’ ve ‘‘çok iyi’’ (M3-M4) olarak değerlendirilirken diğer hastalarda plantar fleksiyon yetersizdi. Peroneal sinir motor fonksiyonu ise 3 hastada (%33,3) ‘‘iyi’’ ve ‘‘çok iyi’’ olarak değerlendirildi. SONUÇ

The functional results of the acute nerve grafting of the sciatic nerve within the first week after the injury are poorer than reported in the related literature. This protocol should only be applied to select patients who have adequate soft tissue coverage and healthy nerve endings.

Siyatik sinir defektlerinde travma sonrasındaki bir haftalık dönemde uygulanan akut sinir greftlemesinin fonksiyonel sonuçları ilgili literatür ile kıyaslandığında daha düşüktür. Bu işlem yeterli yumuşak doku örtüsü bulunan ve sağlıklı sinir uçlarının belirlenebildiği seçilmiş hastalarda uygulanmalıdır.

Key Words: Acute nerve grafting; peripheral nerve injury; sciatic nerve.

Anahtar Sözcükler: Akut sinir greftlemesi; periferik sinir yaralanmaları; siyatik sinir.

Department of Plastic Reconstructive and Aesthetic Surgery, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey.

Dokuz Eylül Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İzmir.

Correspondence (İletişim): Haluk Vayvada, M.D. Dokuz Eylül Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İnciraltı, İzmir, Turkey. Tel: +90 - 232 - 412 22 22 e-mail (e-posta): haluk.vayvada@deu.edu.tr

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Lower extremity peripheral nerve injuries are less common compared to upper extremity injuries. The sciatic and peroneal nerves are the most frequently injured, followed by tibial and femoral nerves.[1,2] Intramuscular injections in the buttocks, hip fractures and hip surgery, contusions, penetrating trauma, and compression (priformis muscle entrapment or positional) at the buttock level are the most common causes of sciatic nerve injuries. Gunshot wounds, lacerations, penetrating trauma, femoral shaft fractures, contusion, compression, and iatrogenic injuries are the etiologic causes of many injuries at the thigh level.[3,4] Anatomically, the sciatic nerve is the longest and the largest diameter nerve of the body. It is composed of two different independent tibial and peroneal components.[5] These two nerves are covered with a common sheath at the thigh level, however there is no significant interfascicular communications during their courses. Each of these sciatic nerve components can be easily dissected separately for the surgical procedures such as nerve repair and grafting. The functional results and recovery after surgical interventions are not identical.[6,7] The peroneal division of the sciatic nerve is usually composed of one major bundle and located laterally to the tibial division. It is more susceptible to trauma. The peroneal nerve also has poor blood supply and less protective connective tissue compared to the tibial nerve. For these reasons, surgical treatment of the peroneal nerve is not as favorable as the tibial division.[5,6,8-11] The nature of the trauma and the severity of the sciatic nerve damage are also important factors affecting the final outcome. Some traumatic causes of sciatic nerve injury, such as gunshot wounds and motor vehicle accidents, may result in nerve defects which require nerve grafting. The trauma to the surrounding tissues including vascular structures, soft tissue, and bone may also accompany the nerve injury. The functional results of the nerve grafting of sciatic nerve defects are poorer than primary repair at any level. Nerve grafting procedure can be used for nerve defect in the acute period (primary nerve grafting) or the late period (secondary nerve grafting). Secondary nerve grafting is usually advised for circumstances such as nerve defect caused by high energy trauma such as gunshot wounds or accompanying soft tissue defects. It is difficult to determine the extent of nerve damage and the presence of healthy ends for grafting in high energy trauma. However, regarding the literature there is no sufficient data regarding the functional results of acute sciatic nerve grafting. The aim of this study is to evaluate the functional results of acute nerve grafting in traumatic sciatic nerve injuries.

MATERIALS AND METHODS Between January 1999 and May 2007, nine patients with sciatic nerve defect caused by high energy 110

Fig. 1. Patient 7. 20-year-old female, gunshot injury at the middle third of the thigh. Intraoperative view of the patient. Anastomosis site of the vascular injury and 8 cm-long nerve graft are seen. Soft tissue defect was also reconstructed with local fasciocutaneous flap. Flap donor site was grafted. (Color figures can be viewed in the online issue, which is avail able at www.tjtes.org).

trauma were treated with primary nerve grafting at the Department of Plastic Reconstructive and Aesthetic Surgery of Dokuz Eylul University Medical Faculty. Six patients were male (66.7%) and the others were female. The mean age was 31.7 years (ranged between 20 and 42 years). The etiologic factors were gunshot wounds (6 patients, 66,7%), traffic accident (2 patients, 22.2%), and penetrating trauma (1 patient, 11.1%). The injury was located at the upper third of the thigh (2 patients, 22.2%), middle third of the thigh (3 patients, 33.3%), and lower third of the thigh (4 patients, 44.5%). There was vascular trauma in 3 patients (33.3%) and soft tissue defect in 4 patients (44.4%), (Fig. 1). All of the patients had sciatic nerve defects ranging from 3.4 to 13.6 cm (average of 6.5 cm) and underwent acute nerve grafting procedure. The mean follow-up time was 47.9 months (ranging from 25 to 84 months). The demographic data of the patients including age, etiologic factors, localization, accompanying injuries, the length of the nerve graft, and follow-up time are shown in Table 1. Patient management Five patients were admitted to the emergency department just after the trauma while the rest of the patients were referred from the other centers for definitive surgery after emergency management within 7 days. The neurological examination was performed including individual muscle strength and sensory examination. Electromyographical studies were not performed because the abnormal findings appear in target Mart - March 2013

The functional results of acute nerve grafting in traumatic sciatic nerve injuries

Table 1. The demographic data of the patients including age, etiologic factors, localization, accompanying injuries, the length of the nerve graft, and follow-up time Patient number

1 2 3 4 5 6 7 8 9

Age

Etiology

Localization in the thigh

Follow-up time (month)

33 37 29 42 40 32 20 28 25

Penetrating trauma Gunshot wound Gunshot wound Traffic accident Gunshot wound Gunshot wound Gunshot wound Gunshot wound Traffic accident

1/3 superior 1/3 inferior 1/3 inferior 1/3 middle 1/3 inferior 1/3 superior 1/3 middle 1/3 inferior 1/3 middle

84 66 62 43 40 37 35 39 25

muscles after 2-3 weeks.[12] There was a complete transection of the sciatic nerve in all patients and they were operated in the early period within the 7 days after the trauma. We also conducted postsurgical tests on all patients to determine the degree of recovered sensitivity and motor improvement. Muscle strength was evaluated using the British Medical Research Council (MRC) scale. The Semmes-Weinstein monofilament test was used for sensory evaluation (Table 2, 3). The motor and sensitivity improvements were graded on a five point scale. According to this scale; M5 and S1 were considered as excellent, M4 and S2 are very good, M3 and S3 are good but represent an improvement which is not enough for normal function. M0-M2 and S4-S5 were classified as inadequate.[13,14] Surgical technique Operations were performed under general anesthesia using an operating microscope (magnification x12). All of the patients had additional lacerations beside the sciatic nerve injury. In four patients (44.4%) extensive soft tissue defect was present requiring reconstructive procedures. In two patients (22.2%), additional incisions were used to define the extension of the injury and accompanying structures, whereas in the rest of the patients the existing lacerations were sufficient for exploration. As soon as the distal and proximal nerve stumps were determined, the tibial and common peroneal components of the sciatic nerve were dissected separately. Each nerve stump was examined under the operating microscope magnification. If there was suspicion regarding the normal anatomy and vascularization of the nerve, the nerve was resected to access the normal fascicular architecture, vascularization, and healthy epineurium. Final defect size was determined while the knee was in full extension. Then, the nerve grafting procedure was employed to repair the nerve defects. The sural nerve was used as a nerve graft in all patients. In three patients (33.3%), bilateral sural nerves were harvested to reconstruct longer nerve defects. In order to compansate retracCilt - Vol. 19 Say覺 - No. 2

tion and shrinkage, nerve grafts 10 percent longer than the actual size of the defect were harvested.[15] In nerve grafting, grouped interfascicular technique with 9-0 and 10-0 nylon sutures was performed. The vascular injuries were also repaired in the same session. Interpositional vein grafting was used in 2 patients (22.2%) while end-to-end arterial repair was employed for one patient (Fig. 1). The soft tissue defects of the four patients (44.4%) were reconstructed with local fasciocutaneous flaps and skin grafts. During the postoperative period, the lower extremity was routinely immobilized for 7 to 15 days. After the immobilization period, patients underwent intensive physical therapy for a longer period of time. The evaluation of patients in the postoperative period was based on serial clinical examination and electrodiagnostic studies. Each patient was followedup at the 3rd week, 6th week, 3rd month, and 3-month intervals up to 24 months and at 6-month intervals thereafter. Table 2. Classification of motor functions Grade

Motor function

Total paralysis Flicker Movement with gravity eliminated Movement against gravity (with no resistance) Movement against the gravity and resistance Full improvement

M0 M1 M2 M3 M4 M5

Table 3. Classification of sensation test groups Grade

Sensation

Normal Diminished light touch Diminished protective sensation Loss of protective sensation Not testable

S1 S2 S3 S4 S5

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RESULTS There was no major complication in the early postoperative period. The revascularization of the extremities in three patients was also successful. Local wound infection was encountered in two patients (22.2%) which were treated with local wound care and systemic antibiotics. No revisional surgery was required in the early postoperative period. All of the local flaps and skin grafts used to reconstruct the soft tissue defects survived. Two patients (22.2%) were also operated on for secondary procedures such as scar revisions with excision and tissue expanders at the late postoperative period. Two patients (22.2%) underwent tibialis posterior tendon transfers for foot dorsiflexion at the third postoperative years after the trauma. The follow-up period ranged between 25 and 84 months. The tibial nerve motor function (soleus and gastrocnemius muscle strength) was “very good” (M4)

in 4 patients (44%) and “good” (M3) in 1 patients (11%). The plantar flexion was not sufficient for the rest of the patients. The peroneal nerve motor function (tibialis anterior muscle strength) was also “good” in 1 patient (11%) and “very good” in 2 patients (22%). (Fig. 2a-e) The postoperative results of the electrodiagnostic examinations were relevant with the physical examinations (Table 4). The sensory recovery rate (Grade S2) was 44% (4 patients) and 22% (2 patients) for the tibial nerve and peroneal nerve respectively.

(e)

DISCUSSION The primary goal of sciatic nerve repair is restoration of the protective sensibility of the sole. Secondary goals include restoration of the plantar flexion to achieve push-off during walking for tibial division and correction of drop foot for peroneal division.[16] The outcomes of recent studies of sciatic nerve repairs are more successful in comparison to the results of the large series previously published in the literature. During World War II, two studies were published on the sciatic nerve by Beebe-Woodhall and Sunderland including 1308 and 365 patients respectively. Their results were poor and disappointing.[6] Nowadays, improvement in microsurgical skills, techniques, and equipment (better magnification, fine instruments etc.), the use of longer nerve grafts, and re(b) sults of neurobiological studies have also enabled better results following sciatic nerve repair. [17] Fig. 2. (a) Patient 2. 37-year-old Kim et al.[3] analyzed results female, gunshot injury at of sciatic nerve repairs and rethe inferior third of the ported that sharp lacerations thigh. Postoperative 48th undergoing primary end-to-end month view of the patient. repair suture repair within 72 Plantar flexion of the foot. hours result in good outcomes (b) Patient 2. Dorsiflexion at the buttock and thigh levof the foot. (c) Patient 4. els for both tibial and peroneal 42-year-old male, injury divisions as follows: buttock at the middle third of the thigh. Postoperative 34th 73% and 30%, and thigh 93% month view of the patient. and 69% for tibial and peroneal (d) Patient 4. Plantar flexdivisions, respectively. The reion. (e) Patient 4. Dorsisults for nerve grafts repair at flexion of the foot. similar levels were: buttock (Color figures can be viewed 62% and 24%, and thigh 80% in the online issue, which is and 45%, respectively.Millesi available at www.tjtes.org). reported the management of 39 patients with sciatic nerve

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(a)

(c)

(d)

The functional results of acute nerve grafting in traumatic sciatic nerve injuries

Table 4. Concomitant soft tissue and vascular injuries, nerve graft length and functional recovery of the patients Patient number

1 2 3 4 5 6 7 8 9

Vascular injury

Soft tissue defect

Nerve graft length (cm)

Tibial N. motor function

Peroneal N. motor function

Plantar sensory recovery

– – + _ _ + + – –

– – + _ + _ + + –

4.7 5.6 4.2 3.4 4.8 7.8 8.0 13.6 6.5

M4 M4 M2 M4 M4 M2 M2 M2 M3

M4 M3 M0 M4 M1 M0 M1 M0 M1

S2 S2 S4 S2 S2 S4 S4 S4 S3

injury. The results of cases requiring neurolysis and split repair was excellent, with 21 of 25 patients (84%) achieving good recovery. The nerve grafting results among 14 patients in the same study were less satisfactory, with only 7 of 14 patients (50%) achieving adequate recovery. After evaluation of the results, Millesi[16] also proposed simultaneous tendon transfer for patients with a significant nerve defects. According to their extensive experience with 380 sciatic nerve injuries, Kline et al.[4] stated that when nerve grafting was required, functional outcomes were poor rate 71% recovery for the tibial nerve and 32% for the peroneal nerve. They also recommended that secondary tendon transfers reserved in poor peroneal division recovery after 3-5 years of follow-up. Murovic et al.[18] have reported successful results for graft repair of tibial (62%) and peroneal (45%) nerves at thigh level. The functional recovery rates of peroneal and tibial division are poorer in this study than those reported in the literature. This result may be caused by acute repair, but it should be also considered that the recovery rates of sciatic nerve grafting also depend on concomitant factors such as length of the graft, age of the patient and comorbidities at the repair sites. There are few studies in the literature regarding the relationship between graft length and functional outcomes. There is no consensus on the critical length of the nerve graft affecting the final recovery rate. Several authors also propose a critical nerve graft length of 5 to 12 cm for good results.[19,20] Matejcik[13] reported that the best results were observed in grafts of up to 5 cm. Roganovic also suggested that the critical value for a successful outcome related to the length of the nerve defect was 5 cm.[21] Kim and Kline[20] reported good motor recovery with grafts shorter than 6 cm. Our patients had sciatic nerve defects ranging from 3.4 to 13.6 cm (average of 6.5 cm) and our results were similar to these studies. The patients with a nerve graft shorter than 6 cm had better results while those with a nerve graft of longer than 6 cm had poor motor and sensory recovery. Cilt - Vol. 19 Sayı - No. 2

The age of patients may be important factor for nerve grafting and recovery. Taha and Taha[7] reported that good results were achieved for sciatic nerve injuries at any level among children. In our study, the mean age was 31.7 and we had no patients within the pediatric age group. There are no precise data in the literature regarding the effects of comorbidities associated with the functional results of nerve repair. Matsuyama et al.[22] suggested that longer nerve grafts are usually associated with other factors such as more extensive and more proximal nerve injuries, corresponding with poorer functional results. Roganovic reported that associated comorbidities may affect the nerve repair outcome. Main artery lesion influences the results through ischemia, and bone fragments cause additional nerve trauma or subsequent callus spreads around the repaired nerve. Soft tissue defects frequently cause decreased muscle mass of the peroneal nerve effectors.[21] Major vascular injuries (3 patients, 33.3%) and extensive soft tissue defects (4 patients, 44.4%) were also encountered in our patients. The nerve injuries in these patients required longer grafts (>6 cm). The results among patients with no comorbidities include better functional outcomes. High energy traumas such as gun shot wounds may also cause associated soft tissue, bone and vascular injuries. Progressive necrosis of the nerve endings in this kind of trauma may compromise the identification of the healthy nerve ends. For these reasons acute nerve grafting should not be used for reconstruction after high energy traumas. The timing of surgical repair of the sciatic nerve lesions is variable in the literature. A complete and severe loss of sciatic nerve function with no evidence of recovery during the first few months is generally accepted as indication for surgical repair.[4,20,23] The management of sciatic nerve injuries depends on loss of nerve continuity or lesion in continuity. If there is good vascularity and soft tissue coverage, sharp lacerations should be managed within a few days using 113

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the end-to-end technique.[10] Primary nerve repair has not been advocated in the literature for nerve lacerations with contusion and traction.[23,24] Some authors also suggested that a period of 2-4 weeks is necessary for distinct delineation of the injured nerve segments. [10,25,26] Extensive comorbidities (fractures, vascular injury, and loss of soft tissue coverage) are also reasons for delaying of the definitive nerve repair. We operated on all the patients within the acute period of the injury. Nerve grafting and repair of the associated injuries were completed in the same session for early functional recovery. Although there was improvement in all patients, functional recovery rates in the presented patient group are poorer than secondary nerve grafting procedures of the sciatic nerve that have been reported in the literature. It is important that sufficient soft tissue coverage is supplied and the healthy ends of the disrupted nerve must be identified for acute nerve grafting of the sciatic nerve. In conclusion, the functional results of acute nerve grafting of the sciatic nerve within the first week after the injury were poorer than among the related literature. This protocol should only be applied among select patients who have adequate soft tissue coverage and healthy nerve endings after wound debridement. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Noble J, Munro CA, Prasad VS, Midha R. Analysis of upper and lower extremity peripheral nerve injuries in a population of patients with multiple injuries. J Trauma 1998;45:116-22. 2. Robinson LR. Traumatic injury to peripheral nerves. Muscle Nerve 2000;23:863-73. 3. Kim DH, Murovic JA, Tiel R, Kline DG. Management and outcomes in 353 surgically treated sciatic nerve lesions. J Neurosurg 2004;101:8-17. 4. Kline DG, Kim D, Midha R, Harsh C, Tiel R. Management and results of sciatic nerve injuries: a 24-year experience. J Neurosurg 1998;89:13-23. 5. Gousheh J, Babaei A. A new surgical technique for the treatment of high common peroneal nerve palsy. Plast Reconstr Surg 2002;109:994-8. 6. Sunderland S. Nerves and nerve injuries. 2nd ed. Edinburgh: Churchill Livingstone; 1978. 7. Taha A, Taha J. Results of suture of the sciatic nerve after missile injury. J Trauma 1998;45:340-4. 8. Samardzić MM, Rasulić LG, Vucković CD. Missile injuries of the sciatic nerve. Injury 1999;30:15-20. 9. Sunderland S. Nerve injuries and their repair. Edinburgh:

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Churchill Livingstone; 1991. 10. Wood MB. Peripheral nerve injuries to the lower extremity. In: Gelberman RH, editor. Operative nerve repair and reconstruction. Philadelphia: J.B. Lippincott; 1991. p. 489-504. 11. Wood MB. Peroneal nerve repair. Surgical results. Clin Orthop Relat Res 1991;267:206-10. 12. Howard FM Jr. Electromyography and conduction studies in peripheral nerve injuries. Surg Clin North Am 1972;52:134352. 13. Matejcík V.Peripheral nerve reconstruction by autograft. Injury 2002;33:627-31. 14. Aydin A, Ozkan T, Aydin HU, Topalan M, Erer M, Ozkan S, et al. The results of surgical repair of sciatic nerve injuries. Acta Orthop Traumatol Turc 2010;44:48-53. 15. Millesi H. Indications and techniques of nerve grafting. In: Gelberman RH, editor. Operative nerve repair and reconstruction. Vol 1., Philadelphia: JB Lippincott; 1991. p. 52543. 16. Millesi H. Lower extremity nerve lesions. In: Terzis JK, editor. Microreconstruction of nerve injuries. Philadelphia: W.B. Saunders; 1987. p. 239-51. 17. Gousheh J, Arasteh E, Beikpour H. Therapeutic results of sciatic nerve repair in Iran-Iraq war casualties. Plast Reconstr Surg 2008;121:878-86. 18. Murovic JA. Lower-extremity peripheral nerve injuries: a Louisiana State University Health Sciences Center literature review with comparison of the operative outcomes of 806 Louisiana State University Health Sciences Center sciatic, common peroneal, and tibial nerve lesions. Neurosurgery 2009;65(4 Suppl):A18-23. 19. Durandeau A, Piton C, Fabre T, Lessaur E, Andre D, Geneste M. Results of the 14 nerve grafts of the common peroneal nerve after a severe valgus strain of the knee. J Bone Joint Surg [Br] 1997;79(Suppl 1):S54. 20. Kim DH, Kline DG. Management and results of peroneal nerve lesions. Neurosurgery 1996;39:312-20. 21. Roganovic Z. Missile-caused complete lesions of the peroneal nerve and peroneal division of the sciatic nerve: results of 157 repairs. Neurosurgery 2005;57:1201-12. 22. Matsuyama T, Mackay M, Midha R. Peripheral nerve repair and grafting techniques: a review. Neurol Med Chir (Tokyo) 2000;40:187-99. 23. Sedel L. Surgical management of lower extremity nerve lesions (clinical evaluation, surgical technique, results). In: Terzis JK, editor. Microreconstruction of nerve injuries. Philadelphia: W.B. Saunders; 1987. p. 253-65. 24. Mackinnon SE. New directions in peripheral nerve surgery. Ann Plast Surg. 1989;22:257-73. 25. Grant GA, Goodkin R, Kliot M. Evaluation and surgical management of peripheral nerve problems. Neurosurgery 1999;44:825-40. 26. Kline DG, Hackett ER. Reappraisal of timing for exploration of civilian peripheral nerve injuries. Surgery 1975;78:5465.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):115-118

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.51437

Posttraumatic intraocular pressure elevation and associated factors in patients with zone I open globe injuries Zon I açık göz yaralanması olan olgularda posttravmatik göz içi basıncı yükselmesi ve ilişkili faktörler Uğur ACAR,1 # Elvin H. YILDIZ,2 Damla ERGİNTÜRK ACAR,1 Uğur Emrah ALTIPARMAK,2 Züleyha YALNIZ AKKAYA,2 Ayşe BURCU,2 Nurten ÜNLÜ2 BACKGROUND

AMAÇ

The object of this study was to determine factors that might be associated with intraocular pressure (IOP) elevation after anterior segment open globe injuries (zone I).

Ön segment (zon I) açık göz yaralanmalarında göz içi basıncı (GİB) yükselmesi ile ilişkili risk faktörlerini belirlemektir.

METHODS

GEREÇ VE YÖNTEM

Data were obtained from the records of 68 patients who experienced zone I open globe injury between January 2008 and October 2010. Group I was composed of patients with chronically elevated IOP of at least 21 mmHg within a 1-year follow-up period. The rate of posttraumatic IOP elevation and associated structural and functional risk factors were evaluated.

Ocak 2008-Ekim 2010 tarihleri arasında zon I açık göz yaralanması geçirmiş 68 hastanın kayıtları incelendi. İlk bir yıllık takiplerde GİB kronik olarak 21 mmHg ve üzerinde seyreden olgular grup I, 21 mmHg’nin altında seyreden olgular grup II olarak belirlendi. Postravmatik GİB yükselme oranı ve ilişkili yapısal ve fonksiyonel risk faktörleri değerlendirildi.

RESULTS

BULGULAR

Of the 68 patients, 17 (25%) developed posttraumatic IOP elevation (Group 1). The mean age in group I was significantly older compared to group II (36.8±24.4 and 15.7±15.3 years, respectively [p=0.003]). Iris damage, postoperative inflammation, and use of long-term corticosteroids were significantly greater in group I (p<0.001, p<0.001, p=0.005 respectively). In group I, 13 of 17 patients (76.5%) had a wound size larger than 6 mm compared to only one patient (1/51, 2%) in group II, and the result was statistically significant (p<0.001). The size of wound larger than 6 mm also retained its statistical significance in multivariate analysis (p<0.001, odds ratio: 162.5).

Altmışsekiz hastanın 17’sinde (%25) postravmatik GİB yüksekliği saptandı (Grup I). Ortalama yaş grup I’de grup II’ye kıyasla anlamlı oranda yüksek idi (sırasıyla 36,8±24,4 ve 15,7±15,3 yıl [p=0,003]). Grup I’de iris hasarı, ameliyat sonrası enflamasyon ve uzun dönem kortikosteroid kullanımı anlamlı oranda daha sık idi. (sırasıyla p<0,001, p<0,001, p=0,005). Grup I’deki 17 hastanın 13’ünde (%76,5), grup II’de sadece 1 hastada (1/51, %2) yara boyutu 6 mm’den uzun idi ve bu sonuç istatistiksel olarak anlamlı idi (p<0,001). Ayrıca çok değişkenli analizde, yara boyutunun 6 mm’den fazla olmasının istatistiki anlamlılığı korundu (p<0,001, odd oranı: 162,5).

CONCLUSION

SONUÇ

This study shows a significant relationship between larger wound size (>6 mm) and elevation of IOP after trauma in zone I open globe injuries.

Bu çalışma, zon I açık göz yaralanmalarında yara boyutunun 6 mm ve üzeri olması ile posttravmatik GİB yükselme arasında çok yakın ilişki olduğunu göstermektedir.

Key Words: Intraocular pressure elevation; ocular trauma; penetrating ocular injury; traumatic glaucoma.

Anahtar Sözcükler: Göz içi basıncı yükselmesi; oküler travma; penetran oküler yaralanma; travmatik glokom.

Department of Ophthalmology, Kastamonu State Hospital, Kastamonu; Department of Ophthalmology, Ankara Training and Research Hospital, Ankara, Turkey. # Current affiliation: Department of Ophthalmology, Hacettepe University, Kastamonu Faculty of Medicine, Ankara, Turkey.

Kastamonu Devlet Hastanesi, Göz Kliniği, Kastamonu; 2 Ankara Eğitim ve Araştırma Hastanesi, Göz Kliniği, Ankara. # Şimdiki kurumu: Hacettepe Üniversitesi Kastamonu Tıp Fakültesi Göz Hastalıkları Anabilim Dalı, Ankara.

1

2

1

Correspondence (İletişim): Uğur Acar, M.D. Kazakistan Caddesi 90/7 Emek, Ankara, Turkey. Tel: +90 - 366 - 214 10 53 e-mail (e-posta): druguracar@gmail.com

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Open globe injury, defined as a full-thickness laceration of the eye wall,[1] is one of the major causes of monocular blindness.[2] In cases with open globe injuries, damage to the trabecular meshwork, intraocular hemorrhage, and inflammation predisposes traumatized eyes to the prolonged elevations in intraocular pressure (IOP), which can lead to glaucomatous changes in the optic nerve. Several studies have focused on the development of IOP elevation after blunt ocular injuries and specific traumatic sequelae such as traumatic hyphema and angle recession.[3-6] However, there are only a few articles examining the overall risk of developing IOP elevation and its risk factors after penetrating ocular injury.[7,8] A 3.4% incidence of IOP elevation and secondary glaucoma after ocular contusion has been reported during six-month follow-up.[3] During the 10 years after trauma, the percent of incidence could rise up to 10%.[9] The injury zone is defined by the location of the most posterior, full-thickness aspect of the globe opening.[10] Zone I injuries are limited to cornea and limbus. Zone II injuries involve the anterior 5 mm of the sclera. Zone III injuries extend more than 5 mm posterior to the corneoscleral limbus. The aim of our study is to analyze a group of patients with zone I open globe injuries who developed posttraumatic IOP elevation to determine whether any risk factors could be identified that might relate to IOP elevation.

MATERIALS AND METHODS The investigations were performed according to the guidelines of the Declaration of Helsinki and the Institutional Ethic Committee approval was obtained. Operating department records were reviewed to identify all patients who had undergone repair of an open globe injury from 1 January 2008 to 1 October 2010. Case records were examined to determine the zone of injury. The subjects of the study were patients who experienced zone I injuries. The cases with sclera and posterior segment involvement (vitreous, choroid, retina) and the cases with intraocular foreign bodies were excluded. Posttraumatic IOP elevation was defined based on the presence of a chronically elevated IOP of al least 21 mmHg within one-year follow-up. The variables studied included age at the time of injury, baseline visual acuity, the presence of lens damage, iris damage, inflammation, and need for anterior segment reformation surgery. Stratification variables included sex (female, male), size of the repaired wound (0-3 mm, 3-6 mm, and >6 mm), and the length of time the patient remains on corticosteroids (<2 116

months, 2-6 months, >6 months). Statistical analysis Results are expressed as mean Âą standard deviation (SD). Statistical analysis was performed with SPSS software (SPSS for Windows, version 15.0, Chicago, Illinois). Conditional logistic regression analysis was used to model the relationship and account for any correlation between posttraumatic secondary glaucoma and baseline demographic characteristics, size of the wound repaired, other anterior segment structures involved in the initial injury, additional surgeries performed, and length of time on the current steroid regimen. The data were analyzed using univariate and multivariate models. A p<0.05 was considered statistically significant.

RESULTS Between January 2008 and October 2010, a total of 132 patients with open globe injuries were identified. Of these, 64 (48.5%) had a posterior segment involvement and thus were excluded. Of the remaining 68 patients with isolated anterior segment open globe injury (zone I), 17 (25%) developed IOP elevation. Demographics and other characteristics of patients with (Group I) and without (Group II) posttraumatic IOP elevation are shown in Table 1. The groups were comparable with respect to gender and baseline visual acuity, but Group I patients were significantly older compared to the Group II patients, with a mean age of 36.8Âą24.4 years in Group I and 15.7Âą15.3 years in Group II (p=0.003). The number of patients with concurrent lens damage was not significantly different between the groups. However, instances of simultaneous iris damage and postoperative inflammation were significantly greater in Group I (p<0.001 and p<0.001, respectively). In Group I, 13 of 17 patients (76.5%) had a wound size bigger than 6 mm compared to only one patient (1/51, 2%) in Group II, and the result was statistically significant (p<0.001). There was a statistically significant difference in risk of development of IOP elevation when comparing patients who had been on corticosteroids for greater than or equal to two months compared with those who had been using corticosteroids for less than two months (p=0.005). In terms of other variables studied, including the need for anterior segment reformation surgery, groups did not show significant differences (p>0.05). In the multivariate analysis incorporating all of the variables including age at the time of injury, concurrent lens damage, and inflammation, prolonged use of corticosteroids lost its statistical significance, whereas the size of wound (>6 mm) retained its statistical significance (p<0.001, odds ratio: 162.5) (Table 1). Mart - March 2013

Posttraumatic IOP elevation and associated factors in patients with zone I open globe injuries

Table 1. Demographics and other characteristics of the patients in the groups Variables Mean age (year) Gender (female / male) Baseline distance visual acuity (LogMAR)a Final corrected distance visual acuity (LogMAR) Size of the wound >6 mm Presence of lens damage Presence of iris damage Presence of inflammation Corticosteroids treatment >2 months

Group I (n=17)

Group II (n=51)

p

36.8±24.4 4 / 13 1.97±0.96 1.26±0.99 13 (76.47%) 12 (70.59%) 15 (88.23%) 15 (88.23%) 7 (41.18%)

15.7±15.3 9 / 42 1.40±0.91 0.58±0.49 1 (1.96%) 23 (45.10%) 6 (11.77%) 13 (25.50%) 41 (80.39%)

0.003 >0.05 >0.05 >0.05 <0.001 >0.05 <0.001 <0.001 0.005

OR

95% CI

1.053 1.021-1.086 1.436 0.379-5.440 1.988 1.087-3.638 4.215 1.471-12.080 162.500 16.710-1580.274 2.922 0.898-9.509 56.250 10.238-309.037 21.923 4.408-109.041 5.857 1.786-19.210

OR: Odds ratio; CI: Confidence interval; a: LogMAR: Logarithm of the minimum angle of resolution.

DISCUSSION The lifetime prevalence of ocular trauma is estimated to be 19.8% with a five-year incidence of 1.6%. [11] One of the most common causes of vision loss after trauma is a secondary glaucoma, which may occur late after the initial treatment and stabilization of other problems, but can also be present immediately after the injury.[12] Many studies report that the most frequently involved age group is under 30 (the mean age is 20.9 years in our study). The most common cause of ocular trauma in children is playground accidents, whereas sport accidents and attacks are the leading causes in adults, and home and work accidents are the most frequent cause in the elderly.[12,13] Girkin et al.[7] reported that an overall incidence of posttraumatic IOP elevation after penetrating ocular trauma was 2.67%, which is lower than the incidence found in our study (17/68, 25%). The difference between the studies may be because the current study was composed of patients with only zone I injuries, whereas in Girkin’s study, patients with zone I, II, and III injuries were included. Based on these findings, it may be postulated that after zone I injuries, more severe damage occurs in the trabecular meshwork/Schlemm’s canal (aqueous drainage system), compared to that in the ciliary body (aqueous production system); this may be the explanation for higher incidence of IOP elevation, as found in the current study. Although zone II and zone III injuries have worse prognosis than zone I injuries, it seems that zone I injuries are associated with higher risk of secondary IOP elevation. One study reported that the factors leading to better prognosis in penetrating ocular traumas are the sharp nature of the damaging object, a visual acuity better than 20/200, injuries less than 10 mm, and injuries localized to the anterior segment.[13] Any penetrating injury can initiate inflammation that eventually leads to uveitic glaucoma.[8] Inflammation must be carefully controlled and cycloplegia is usually recommended Cilt - Vol. 19 Sayı - No. 2

during the acute post-injury phase. Long-term use of corticosteroids is common in cases of penetrating trauma which can lead to elevated IOP. The rise in IOP tends to occur two to three weeks after initiation of therapy and is dose-dependent.[14] Even after cessation of corticosteroid treatment, sometimes patients require lifelong IOP control, perhaps owing to irreversible changes in the trabecular meshwork.[15] Initial IOP is usually low after open globe injury, but after wound closure, IOP elevation and subsequent glaucoma may develop. Unlike blunt trauma, the open globe injuries tend not to follow any predictable pattern, and posttraumatic IOP elevation-secondary glaucoma is often associated with multiple factors including structural alteration from injury and blockage of trabecular meshwork or secondary responses such as inflammation.[8] At least five different mechanisms of glaucoma formation are described after penetrating ocular traumas: shallow anterior chamber, inflammation, intraocular hemorrhage, lens-induced glaucoma, and epithelial or fibrous ingrowth.[13] A review of data from US Eye Injury Register found increasing age, poor baseline visual acuity, angle recession, hyphema, and lens injury to be independent risk factors for developing posttraumatic IOP elevation-glaucoma after ocular contusion. Advancing age, lens injury, baseline visual acuity below 20/200, and anterior chamber inflammation were associated with the development of post-traumatic secondary glaucoma following penetrating ocular trauma. [3,7] In these last two studies, traumatic glaucoma was recorded at any time within six months of the injury, based on the physician’s opinion alone. Despite its large numbers, traumatic glaucoma is limited by the absence of standardized criteria for diagnosis of posttraumatic secondary glaucoma. Sihota et al.[4] stated posttraumatic hyphema-secondary glaucoma were associated with ciliary body damage. These ciliary body injuries would lead to an 117

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inflammatory response not only at the site of injury, but also throughout the ciliary body and in the contiguous iris and trabecular meshwork. Uveal inflammation and injury is generally resolved using a fibroblastic response, as seen in the iris or the choroid. Such a reparative process in the ciliary body would necessarily involve the adjoining trabecular meshwork, decreasing aqueous outflow and raising IOP. In our study, we found a significant relationship between the size of wound and the development of posttraumatic IOP elevation after zone I open globe injuries. In the multivariate analysis incorporating all of the variables found significant in univariate analysis including age at the time of injury, concurrent lens damage, inflammation, and prolonged use of corticosteroids lost their statistical significance whereas the size of wound retained its significance. By the time acute symptoms and signs of trauma have subsided, patients may be unaware of a chronically elevated IOP. It is important to be able to identify eyes that have a greater risk of postrraumatic IOP elevation-secondary glaucoma and to review them carefully, so that appropriate therapy may be initiated as early as possible. As found in our study, trabecular meshwork injury, impaired aqueous drainage, and secondary intraocular pressure elevation are more frequently associated with larger wounds (defined as the wounds larger than 6 mm in the current study) than with smaller size wounds. It might, at this point, be appropriate to state that clinicians should carefully follow up the patients with zone I open globe injuries, especially those with relatively larger wound sizes with regard to the development of chronic IOP elevation. In conclusion, posttraumatic secondary glaucoma is a common and often devastating consequence of ocular injury. A thorough knowledge of the risk factors for posttraumatic IOP elevation and careful examination are required for rapid identification of affected patients, especially those who are predisposed to secondary glaucoma. Patient education, careful surveillance, and early intervention provide the posttraumatic patient with the best chance for long term vision preservation. Results of this current study may be useful in determining individuals who are most likely to develop posttraumatic IOP elevation after zone I open globe injuries. Although each case was able to match to three cases in control group, the limitation of the study was the retrospective nature and relatively small sample size. Further evaluation of patients with

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posttraumatic IOP elevation should be carried out on a larger population. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Kuhn F, Morris R, Witherspoon CD, Heimann K, Jeffers JB, Treister G. A standardized classification of ocular trauma. Ophthalmology 1996;103:240-3. 2. Rahman I, Maino A, Devadason D, Leatherbarrow B. Open globe injuries: factors predictive of poor outcome. Eye (Lond) 2006;20:1336-41. 3. Girkin CA, McGwin G Jr, Long C, Morris R, Kuhn F. Glaucoma after ocular contusion: a cohort study of the United States Eye Injury Registry. J Glaucoma 2005;14:470-3. 4. Sihota R, Kumar S, Gupta V, Dada T, Kashyap S, Insan R, et al. Early predictors of traumatic glaucoma after closed globe injury: trabecular pigmentation, widened angle recess, and higher baseline intraocular pressure. Arch Ophthalmol 2008;126:921-6. 5. De Leon-Ortega JE, Girkin CA. Ocular trauma-related glaucoma. Ophthalmol Clin North Am 2002;15:215-23. 6. Shiuey Y, Lucarelli MJ. Traumatic hyphema: outcomes of outpatient management. Ophthalmology 1998;105:851-5. 7. Girkin CA, McGwin G Jr, Morris R, Kuhn F. Glaucoma following penetrating ocular trauma: a cohort study of the United States Eye Injury Registry. Am J Ophthalmol 2005;139:100-5. 8. Milder E, Davis K. Ocular trauma and glaucoma. Int Ophthalmol Clin 2008;48:47-64. 9. Kaufman JH, Tolpin DW. Glaucoma after traumatic angle recession. A ten-year prospective study. Am J Ophthalmol 1974;78:648-54. 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. Wong TY, Klein BE, Klein R. The prevalence and 5-year incidence of ocular trauma. The Beaver Dam Eye Study. Ophthalmology 2000;107:2196-202. 12. Ozer PA, Yalvac IS, Satana B, Eksioglu U, Duman S. Incidence and risk factors in secondary glaucomas after blunt and penetrating ocular trauma. J Glaucoma 2007;16:68590. 13. Mirza GE. Non-penetrating traumas and glaucoma. In: Firat E, Atilla H, Evren O, editors. 26th National ophthalmology course textbook. Ankara: The Glaucoma-Turkish Ophthalmology Society 2006. p. 129-42. 14. Polansky JR, Weinreb RN. Steroids as anti-inflammatory agents. In: Sears ML, editor. Pharmacology of the eye. Berlin: Springer-Verlag; 1984. p. 460-538. 15. Wordinger RJ, Clark AF. Effects of glucocorticoids on the trabecular meshwork: towards a better understanding of glaucoma. Prog Retin Eye Res 1999;18:629-67.

Mart - March 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):119-122

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.21548

Hepatic hydatid disease requiring urgent treatment during pregnancy Hamilelik sırasında acil tedavi gerektiren karaciğer kist hidatiği Candaş ERÇETİN, İlgin ÖZDEN, Cem İYİBOZKURT, Koray GÜVEN, Kürşat SERİN, Orhan BİLGE, Yaman TEKANT, Aydın ALPER, Ali EMRE

BACKGROUND

AMAÇ

Pregnant women may experience an acute presentation of hepatic hydatid disease. The available literature is limited to case reports.

Karaciğer kist hidatiği hamile kadınlarda, akut gelişen tablolarla ortaya çıkabilir. Literatürdeki deneyim, olgu sunumları ile sınırlıdır.

METHODS

GEREÇ VE YÖNTEM

The charts of 7 patients who underwent urgent treatment for hepatic hydatid disease during pregnancy between 1992 and 2010 were reviewed.

1992-2010 yılları arasında, hamilelik sırasında acil tedavi uygulanması gereken karaciğer kist hidatikli yedi hastanın kayıtları değerlendirildi.

RESULTS

BULGULAR

The median patient age was 27 (range 23-39) years and median gestational age was 18 (range 13-24) weeks. The symptoms were severe abdominal pain (4), vomiting (2), jaundice (2), pruritus (2) and severe dyspepsia (1); in the asymptomatic patient, a closed intraperitoneal rupture had been detected during gynecologic ultrasonography. Surgical drainage of the cysts was performed in all cases. The two patients with frank biliary rupture underwent choledochoduodenostomy or Roux-Y hepaticojejunostomy. Four patients required postoperative tocolysis. Albendazole was not used. All mothers gave birth to healthy babies at term. The patients were followed for a median of 9 (range 4-19) years. Two patients developed recurrences at 2 and 7 years; these were treated with surgical drainage and albendazole. CONCLUSION

Ortanca (sınırlar) hasta yaşı 27 (23-39) yıl, ortanca (sınırlar) gestasyon yaşı 18 (13-24) haftaydı. Semptomlar şiddetli karın ağrısı (4), kusma (2), sarılık (2), kaşıntı (2) ve ağır dispepsiydi (1); semptomsuz hastada (1), jinekolojik ultrasonografi sırasında rastlantısal olarak, kapalı intraperitoneal yırtılma gözlendi. Bütün kistlere cerrahi drenaj uygulandı. Safra yollarına boşalma gözlenen iki hastada koledokoduodenostomi ve Roux-Y hepatikojejunostomi uygulandı. Dört hastada ameliyat sonrası tokoliz gerekti. Albendazol kullanılmadı. Annelerin hepsi, miadında sağlıklı bebekler doğurdular. Hastalar ortanca (sınırlar) 9 (419) yıl izlendi. İki hastada ikinci ve yedinci yıllarda nüksler gelişti, bunlar cerrahi drenaj ve albendazol ile tedavi edildi. SONUÇ

This entity entails the responsibility of two human beings. Although it imposes limitations on the routine diagnostic and therapeutic options due to risk of premature labor or teratogenicity, acceptable results can be obtained in collaboration with the department of obstetrics and gynecology.

Hamilelik sırasında acil tedavi gerektiren kist hidatik, aynı anda iki insanın sorumluluğunun alınmasını zorunlu kılar. Prematür doğum ve teratojenite riskleri nedeniyle rutin tanı ve tedavi yöntemlerinin kullanımı sınırlansa da, kadın hastalıkları ve doğum kliniği ile işbirliğine gidilerek, kabul edilebilir sonuçlar elde edilebilmektedir.

Key Words: Albendazole; complication; hepatic hydatidosis; liver; pregnancy; T-drainage.

Anahtar Sözcükler: Albendazol; komplikasyon; hepatik kist hidatik; karaciğer; gebelik; T-drenaj.

Department of General Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey.

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

Correspondence (İletişim): İlgin Özden, M.D. İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Fatih, Çapa, İstanbul, Turkey. Tel: +90 - 212 - 414 20 00 e-mail (e-posta): iozden@hotmail.com

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Pregnant women may experience an acute presentation of hepatic hydatid disease with pain,[1-4] vomiting,[5] pruritus,[1,6] jaundice,[5] cholangitis[7] and emergence of a mass.[8] The incidence of this rare condition is unknown. Although, a figure of 1 in 20,000-30,000 pregnancies is quoted in numerous papers, the original 1982 report from Libya (an endemic region) by Rahman et al.[9] includes only obstetric and gynecological presentations of hydatid disease; all 14 patients had pelvic hydatid disease, while 4 had a history of hepatic cysts. Authors from the Regional Hospital of Temuco, Chile (a regional reference center in an endemic region), reported an estimated figure of 0.07% for abdominal (mostly hepatic) echinococcosis during pregnancy; their series included patients diagnosed by routine prenatal abdominal ultrasonography.[10] Consequently, the reported experience on urgent treatment of hepatic disease is limited to case reports on surgery alone[1,2,7,8,11] surgery and antihelminthic chemotherapy,[3,5] antihelminthic chemotherapy alone[12] and percutaneous treatment.[13] In contrast with the situation in nonpregnant patients, this entity entails the responsibility of two human beings and unfortunately imposes limitations on the routine diagnostic and therapeutic options due to risks of premature labor or teratogenicity: these include laparotomy, computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP) and albendazole. In this paper, the experience of 7 hepatic hydatid disease patients who required urgent treatment during pregnancy is reported and recommendations on how successful maternal and fetal outcome can be achieved are made.

MATERIALS AND METHODS The charts of 7 patients treated for an acute presentation of hepatic hydatid disease during pregnancy were reviewed to identify the presenting symptoms, treatment methods and results. RESULTS Between 1992 and 2010, 7 pregnant patients were treated for hepatic hydatid disease at the Hepatopancreatobiliary Surgery Unit of the Istanbul Faculty of Medicine, Istanbul University. The median patient age was 27 (range 23-39) years and median gestational age was 18 (range 13-24) weeks. Only one patient had a past history of hydatidosis; she had undergone surgery for a brain lesion 13 years ago but was not under routine follow up. The presenting symptoms are summarized in Table 1. In the asymptomatic patient, the hepatic cyst was detected during gynecologic ultrasonography and a magnetic resonance imaging (MRI) examination was performed. Radiologic demonstration of a closed 120

Table 1. The presenting symptoms of the patients Severe abdominal pain Vomiting Jaundice Pruritus Severe dyspepsia None*

4 2 2 2 1 1

* The hepatic cyst had been detected during gynecologic ultrasonography and a magnetic resonance imaging (MRI) examination was performed. Radiologic demonstration of a closed rupture into the peritoneal cavity (Fig. 1) prompted referral to our center.

rupture into the peritoneal cavity (Fig. 1) prompted referral to our center. The diagnosis was made by ultrasonography (7 patients) and MRI (6 patients). All lesions were located in the right hemiliver. Six patients had single cysts and one patient had two cysts. Median lesion size was 122 mm (range 70-170 mm). All patients were treated in collaboration with the department of obstetrics and gynecology. None of the referred patients were considered suitable for conservative follow up and surgical drainage of the cysts was performed in all cases. Two patients had frank rupture into the biliary tree (Fig. 2); they underwent common bile duct exploration followed by choledochoduodenostomy or Roux-Y hepaticojejunostomy. Two patients had major cystobiliary communications which were sutured primarily; there was no hydatid material in the common bile duct; T-tube drainage and Y-tube (with additional side holes) drainage (due to low union of the right posterior sectional hepatic duct to the distal common bile duct) were used to keep the biliary tree pressure low and prevent a biliocystic fistula. Four patients required postoperative tocolysis. One patient had a biliocystic fistula. One patient had an unexplained episode of hepatitis which resolved spontaneously; no etiology could be determined. The T-tube

Fig. 1. Hepatic hydatid cyst (asteriks) with spontaneous closed rupture into the abdominal cavity (double asteriks). Mart - March 2013

Hepatic hydatid disease requiring urgent treatment during pregnancy

sibility that our approach may have had a role because we routinely prescribe albendazole perioperatively to all other patients. In every case, the attending physician discussed this issue with the patient and her family. All patients and families followed our recommendation to withhold albendazole in view of the unpredictable fetal risks and the generally accepted but imprecisely defined benefits in the prevention of recurrences.

Fig. 2. Multiloculated hydatid cyst (asterisk) with frank rupture into the biliary tree; cyst material obstructing the hilar confluence (arrow).

and the Y-tube were left open until delivery. Albendazole was not used due to the risk of teratogenicity. All mothers gave birth to healthy babies at term. The patients were followed for a median of 9 (range 4-19) years. Two patients developed recurrences at 2 and 7 years; these were treated with surgical drainage and albendazole.

DISCUSSION Although definite data are not available, conservative follow up of hepatic hydatid cysts diagnosed incidentally during pregnancy appeared to be the best option.[14] Cysts with acute presentation, however, require urgent treatment with judicious use of diagnostic and therapeutic options with regard to the risks of premature labor or teratogenicity. The diagnosis of hepatic hydatidosis can be made reliably by ultrasonography. Lung radiography and computed tomography, which are useful in evaluating the extent of the disease (e.g. deep intrahepatic cysts in ‘blind spots’ of ultrasonography, other intraabdominal cysts which may be missed during laparotomy, asymptomatic lung cysts which may nevertheless require urgent treatment due to the risk of severe complications such as intrabronchial rupture) should be replaced by MRI. MRI is also useful in demonstrating significant biliary involvement which was present in 4 of the 7 patients in this series. Mebendazole and albendazole are useful in the primary treatment of hepatic hydatidosis as well as prevention of postoperative recurrences in nonpregnant patients.[15] However, their use cannot be justified in pregnant women with acute complications because these drugs have been shown to be teratogenic in experimental studies.[15] We avoided the use of albendazole in all of our patients and experienced recurrences in 2 of 7 patients. Although the number of patients is too small for definite statements, we have to accept the posCilt - Vol. 19 Sayı - No. 2

ERCP is an effective method in the treatment of biliary complications of hepatic hydatid disease.[16,17] Although “nonradiation ERCP” in pregnant patients has been reported,[18,19] the experience is limited. Complete ductal clearance cannot be ascertained without a choledochoscopy, which may not be technically possible in every case.[18] Also, the inevitable increase of intra-abdominal pressure, especially during long procedures, may be detrimental to fetal circulation. Percutaneous treatment is a well-established procedure in uncomplicated hepatic cysts.[20,21] Its role in pregnant patients with an acute presentation is limited to large cysts, which cause significant pain and vomiting.[13] However, it is worth keeping in mind that such cysts have a high possibility of biliary communication which compromise the treatment and require additional procedures. In addition, although proponents argue that the risk of anaphylaxis during percutaneous treatment is similar to that of surgery,[13] there is no definitive data and the management of anaphylaxis is obviously less complicated in an intubated patient under general anesthesia. Our department prefers to conduct open surgery with prompt evacuation of the cysts, treatment of biliary involvement and management of the cavity.[22,23] Leaving the T-tube and the Y-tube open until delivery may be criticized from a quality of life point of view. These patients had normal size bile ducts and large intrahepatic cystobiliary communications. The tubes successfully prevented bile leakage to the cyst from the repaired areas. It is generally accepted that the fetal wastage rate due to elective surgery during pregnancy is lowest in the second trimester.[24,25] Although acute presentation of the patients in this series did not allow elective treatment, it was a fortunate coincidence that all were in the second trimester. The vital role of close collaboration with the obstetrics and gynecology department can not be overemphasized. All patients were monitored closely by our colleagues. Although the pelvic region was not manipulated, 4 of the 7 mothers required tocolysis. All mothers gave birth to healthy babies at term. In conclusion, hepatic hydatid disease requiring urgent treatment during pregnancy entails the responsibility of two human beings. Although it imposes 121

Ulus Travma Acil Cerrahi Derg

limitations on the routine diagnostic and therapeutic options due to risk of premature labor or teratogenicity, acceptable results can be obtained in collaboration with the department of obstetrics and gynecology. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Crow JP, Larry M, Vento EG, Prinz RA. Echinococcal disease of the liver in pregnancy. HPB Surg 1990;2:115-9. 2. Haxhimolla HZ, Crowe P. Hydatid disease of the liver in pregnancy. ANZ J Surg 2001;71:692-3. 3. Montes H, Soetkino R, Carr-Locke DL. Hydatid disease in pregnancy. Am J Gastroenterol 2002;97:1553-5. 4. Poiat C, Sivaci R, Baki E, Kosar MN, Yiimaz S, Arikan Y. Recurrent hepatic hydatid cyst in a pregnant woman. Med Sci Monit 2007;13:CS27-9. 5. Golaszewski T, Susani M, Golaszewski S, Sliutz G, Bischof G, Auer H. A large hydatid cyst of the liver in pregnancy. Arch Gynecol Obstet 1995;256:43-7. 6. Kain KC, Keystone JS. Recurrent hydatid disease during pregnancy. Am J Obstet Gynecol 1988;159:1216-7. 7. Blöchle C, Lloyd DM, Izbicki JR, Schröder S, Brölsch CE. Right-sided hemihepatectomy in echinococcosis of the liver in pregnancy. [Article in German] Chirurg 1993;64:580-3. [Abstract] 8. Can D, Oztekin O, Oztekin O, Tinar S, Sanci M. Hepatic and splenic hydatid cyst during pregnancy: a case report. Arch Gynecol Obstet 2003;268:239-40. 9. Rahman MS, Rahman J, Lysikiewicz A. Obstetric and gynaecological presentations of hydatid disease. Br J Obstet Gynaecol 1982;89:665-70. 10. Manterola C, Espinoza R, Muñoz S, Vial M, Bustos L, Losada H, et al. Abdominal echinococcosis during pregnancy: clinical aspects and management of a series of cases in Chile. Trop Doct 2004;34:171-3. 11. Sahin E, Nayki U, Sadik S, Oztekin O, Nayki C, Kizilyar A, Gungor O. Abdominal and pelvic hydatid disease during pregnancy. Arch Gynecol Obstet 2005;273:58-9. 12. van Vliet W, Scheele F, Sibinga-Mulder L, Dekker GA. Echinococcosis of the liver during pregnancy. Int J Gynaecol Obstet 1995;49:323-4.

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13. Ustünsöz B, Alemdaroğlu A, Bulakbaşi N, Uzar AI, Duru NK. Percutaneous treatment of hepatic hydatid cyst in pregnancy. Arch Gynecol Obstet 1999;262:181-4. 14. Rodrigues G, Seetharam P. Management of hydatid disease (echinococcosis) in pregnancy. Obstet Gynecol Surv 2008;63:116-23. 15. Guidelines for treatment of cystic and alveolar echinococcosis in humans. WHO Informal Working Group on Echinococcosis. Bull World Health Organ 1996;74:231-42. 16. Cicek B, Parlak E, Disibeyaz S, Oguz D, Cengiz C, Sahin B. Endoscopic therapy of hepatic hydatid cyst disease in preoperative and postoperative settings. Dig Dis Sci 2007;52:9315. 17. Tekant Y, Bilge O, Acarli K, Alper A, Emre A, Arioğul O. Endoscopic sphincterotomy in the treatment of postoperative biliary fistulas of hepatic hydatid disease. Surg Endosc 1996;10:909-11. 18. Shelton J, Linder JD, Rivera-Alsina ME, Tarnasky PR. Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos). Gastrointest Endosc 2008;67:364-8. 19. Akcakaya A, Ozkan OV, Okan I, Kocaman O, Sahin M. Endoscopic retrograde cholangiopancreatography during pregnancy without radiation. World J Gastroenterol 2009;15:3649-52. 20. Akhan O, Ozmen MN. Percutaneous treatment of liver hydatid cysts. Eur J Radiol 1999;32:76-85. 21. Giorgio A, de Stefano G, Esposito V, Liorre G, Di Sarno A, Giorgio V, et al. Long-term results of percutaneous treatment of hydatid liver cysts: a single center 17 years experience. Infection 2008;36:256-61. 22. Arioğul O, Emre A, Alper A, Uras A. Introflexion as a method of surgical treatment for hydatid disease. Surg Gynecol Obstet 1989;169:356-8. 23. Alper A, Ariogul O, Emre A, Uras A, Okten A. Choledochoduodenostomy for intrabiliary rupture of hydatid cysts of liver. Br J Surg 1987;74:243-5. 24. Jabbour N, Brenner M, Gagandeep S, Lin A, Genyk Y, Selby R, et al. Major hepatobiliary surgery during pregnancy: safety and timing. Am Surg 2005;71:354-8. 25. Giuntoli RL 2nd, Vang RS, Bristow RE. Evaluation and management of adnexal masses during pregnancy. Clin Obstet Gynecol 2006;49:492-505.

Mart - March 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):123-126

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.44442

Epidemiology of pediatric burn injuries in Istanbul, Turkey İstanbul’daki pediatrik yanıklı hastaların epidemiyolojisi Hakan ARSLAN, Baran KUL, Handan DEREBAŞINLIOĞLU, Oğuz ÇETİNKALE

BACKGROUND

AMAÇ

Many burns that occur in the first two decades of life are accidental and preventable. The aim of this study was to determine the demographic features, mortality, and other factors associated with pediatric burns in Istanbul, Turkey.

Yaşamın ilk yirmi yılında meydana gelen yanıklar önlenebilir kazalardır. Bu çalışmada İstanbul’daki pediatrik yanıklarda demografik özellikler ve mortalite oranlarının değerlendirilmesi amaçlandı.

METHODS

GEREÇ VE YÖNTEM

Our retrospective study included 375 hospitalized pediatric patients (225 male, 150 female; mean age 4.07±3.79; range 0.2 to 16 years) aged 16 years or less admitted between January 2005 and January 2009. Each child’s medical record was reviewed and demographic features, mechanism of burn, place of residence, total body surface area (TBSA), surgical treatment, duration of hospital stay and mortality rates were analyzed.

Ocak 2005 - Ocak 2009 tarihleri arasında 16 yaş ve altı hastaneye yatırılan 375 pediatrik yanıklı hasta (225 erkek, 150 kız; ort. yaş 4,07±3,79; dağılım 0.2-16 yaş) geriye dönük incelenmek üzere çalışmaya alındı. Her hastanın tıbbi kayıtları incelenerek, demografik özellikler, yanık mekanizması, hastanın yaşadığı bölge, tüm vücut yanık yüzdesi (TVYY), cerrahi tedavi, hastane yatış süresi ve mortalite oranları değerlendirildi.

RESULTS

BULGULAR

Scalding was the predominant cause among all pediatric age groups. There were no differences between the age groups with respect to mean TBSA. Length of hospital stay in infants and toddler age group was significantly lower than in other age groups (p<0.005). Sixteen (4.3%) patients died during the study period. Mortality rates associated with scalding, flame and electrical burns were 3.1%, 13.9% and 10%, respectively. Electrical burns and flame resulted in significantly higher mortality rates than scalding (p<0.05).

Tüm pediatrik yaş gruplarında haşlanma en sık yanık nedeni idi. Ortalama TVYY ve yaş grupları arasında anlamlı bir fark bulunmadı. Yenidoğan ve yürümeye başlayan çocuk yaş grubunda hastanede kalış süresi diğer yaş gruplarına göre anlamlı olarak düşüktü (p<0,005). Onaltı (%4,3) hasta çalışma dönemi sırasında öldü. Mortalite oranları sırasıyla haşlanma, alev ve elektrik yanıklarında %3,1, %13,9 ve %10 idi. Mortalite oranı elektrik ve alev yanıklarında, haşlanma yanıklarına göre istatistiksel olarak anlamlı derecede daha fazla olduğu görüldü (p<0,05).

CONCLUSION

SONUÇ

Scalding was found to be the most important cause of burns and flame-related mechanisms resulted in the highest mortality rate among children. Only a specific preventive program for changing the traditional habits of Turkish parents would reduce burn injuries among children. Key Words: Burn; children; epidemiology of pediatric burn.

Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey.

Haşlanma önlenebilir yanık kazların ensık nedeni ve alev yanığı da en fazla mortalite nedenidir. Türk ailelerde, sadece geleneksel alışkanlıkları değiştirecek eğitici programların ortaya konması, pediatrik yaş grubunda çoğu yanık kazaları önleyebilir. Anahtar Sözcükler: Çocuklar; yanıklar; yanık epidemiolojisi.

İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İstanbul.

Correspondence (İletişim): Hakan Arslan, M.D. İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi ABD, 34000 İstanbul, Turkey. Tel: +90 - 212 - 414 35 00 e-mail (e-posta): hakanarsln@yahoo.com.tr

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Many burns that occur in the first two decades of life are accidental and preventable. However, severe burn is a leading cause of morbidity and mortality in children, and burns are the major cause of injury-related death in this group.[1] Epidemiological data on burns provides information useful in designing strategies to reduce the frequency of injuries and establishing effective methods for burn management. Programs for aimed at reducing domestic accidents could prevent many of the deaths caused by burns among children.[2] The aim of this study was to provide more information regarding burn trauma in children and to determine the factors and demographic features and mortality associated with pediatric burns in Istanbul, Turkey.

MATERIALS AND METHODS This study was carried out at the Department of Plastic, Reconstructive and Aesthetic Surgery and Burn Unit, Cerrahpaşa Medical School, Istanbul University, Istanbul, Turkey. Our retrospective study included all children aged 16 years or less admitted between January 2005 and January 2009. In this period, a total of 1590 burn patients attended the outpatient burn clinic, including 975 children of whom 375 were hospitalized. All hospitalized pediatric patients were categorized into three groups: infants and toddlers (0-2 years of age), early childhood (3-6 years of age), and late childhood (7-16 years of age). Each child’s medical record was reviewed and demographic features, mechanism of burn, place of residence, total body surface area (TBSA), surgical treatment, duration of hospital stay and mortality rates were analyzed. All data were presented as mean (±) standard deviations (SD). Parametric tests were performed for data analysis. A one-way ANOVA test was performed and post-hoc multiple comparisons were done with least

significant difference (Tukey). These differences were considered significant when probability was less than 0.05.

RESULTS In this period, a total of 1590 burn patients presented to the burn clinic, including 975 (61.3%) of these were children. 375 children were admitted as inpatients. 225 (60%) male and 150 (40%) female pediatric patients were hospitalized. The mean (range) age of the patients was 4.07±3.79 (range, 0.2-16) years. The mean age of the patients with scalds was significantly lower than the age of patients with flame or electrical injury (p=0.000). The mechanisms of burn injuries were 85.6% (321 cases) scalding, 9.6% (36) flame, 2.66% (10) electric current, 1.88% (7) contact and 0.26% (1) chemical compound (Table 1). Scalding predominated in infancy. Scalding was the predominant cause among all pediatric age groups. However, the proportion of scalds decreased from 96.1% in the 0-2 years age group to 50% in the 7-16 years age group. In addition, the ratio of flame and electrical burns increased from 1.1% and 0% in the 0-2 years age group to 36.3% and 13.6% in the late childhood group, respectively. As noted, 342 (91.2%) of the 375 inpatient subjects were from urban environments while 33 (8.8%) lived in rural areas. The mean TBSA burned was 14.1%±10.4 (range 1-86%). There were no differences between the age groups with respect to mean TBSA. However, in flame injuries the mean TBSA was found significantly higher than among scalding injuries (p<0.05) and similar to electrical burns (Table 2). Length of hospital stay was 19.6±12.5 (range 1-117) days. Length of hospital stay in infants and toddler age group was significantly lower than among other age groups (p<0.005).

Table 1. The distribution of patients according to ages

Ages 0-2 (n=183)

n (%) Mean±SD

Scald Flame Electric Contact Chemical TBSA (%) Operations (n) Days in hospital Mortality

Ages 3-6 (n=126)

Ages 7-16 (n=66)

n (%)

Mean±SD

n (%)

176 (96.2) 2 (1.1) – 4 (2.2) 1 (0.5)

112 (88.9) 10 (7.9) 1 (0.8) 3 (2.4) –

33 (50.0) 24 (36.4) 9 (13.6) – –

13.96±9.8 0.74±1.26 16.8±9.3*

14.38±9.6 0.97±1.3 22.09±14.5

7 (3.9)

4 (3.3)

5 (7.6)

Mean±SD

15.6±12.9 1.04±1.03 22.7±14

TBSA: Total body surface area; * Indicates p<0.01 for 0-2 ages vs. 3-6 ages and p<0.01 for 0-2 ages vs. 7-16 ages.

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Epidemiology of pediatric burn injuries in Istanbul, Turkey

Table 2. The distribution of patients according to burn type

Scalds (n=321) Mean±SD

Flame (n=36) Mean±SD

Electric (n=10) Mean±SD

Age TBSA (%) Operations (n) Days in hospital

3.28±2.92a 13.52±8.9b 0.74±1.16c 18.83±11.6

8.91±4.68 21.41±17.29 1.8±1.68 24.5±15.6

11.9±3.5 17.6±12.98 1.8±1.75 29.7±20.5

Mortality n (%)

10 (3.1)d

5 (13.9)

1 (10)

TBSA: Total body surface area. a: Indicates p<0.001 scald vs. flame and scald vs. electric; b: Indicates p<0.05 scald vs. flame; c: Indicates p<0.01 scald vs. flame; d: Indicates p<0.05 scald vs. flame and scald vs. electric.

Conservative treatment was successful in 216 (57.6%) of cases. A total of 325 surgical interventions were carried out for 159 (42.4%) children, including 202 debridement and grafting procedures, 104 grafts later in the hospital stay, 3 amputations and 16 other procedures involving for example, escharotomies, fasciotomies or flaps. The number of surgical interventions per patient was 0.74±1.16 for scalds, 1.8±1.68 for flame burns and 1.8±1.75 for electrical burns. Although patients with flame and electrical burn required more operations than scalding patients, only patients with flame-related burns required significantly more surgical intervention than scalding patients (p<0.05). There were no statistically significant differences between age groups in mean surgical intervention number (p=0.130). Sixteen (4.3%) patients died during the study period. There were no differences between the age groups with respect to mortality rates. Ratios of these patients according to age groups were 3.8%, 3.2% and 7.6% for infants and toddlers, early childhood, and late childhood, respectively. Mortality rates associated with scalding, flame and electrical burns were 3.1%, 13.9% and 10%, respectively. Thus electrical burns and flame burns resulted in significantly higher mortality rates than scalding injuries (p<0.05).

DISCUSSION Istanbul is the biggest city in Turkey, with a greater population (more than 11 million people) than most European cities and countries. Until 2008, our burn unit was the only referral center in Istanbul. Therefore the patients presenting to this unit are generally from almost all regions of Turkey, at the crossroads between Asia and Europe. Thus, we believe that our data roughly reflect the national situation as regards burn injuries. In this study, scalding was the predominant cause of burn injury among all pediatric age groups, similar to previous reports from our country and elsewhere. [3-7] In our study, the mean age at the time of scalding was 3.2 years and scalding accounted for 85.6% of our Cilt - Vol. 19 Sayı - No. 2

pediatric inpatient group. The main source of scalding is hot liquid, especially the hot water used for making tea, a traditional practice in our country.[7] Specific to Turkey is the use of two containers with narrow bases on top of each other to make tea.[4,7] This practice is inherently unstable, and kettles have been advocated instead for increased stability. Children should not be allowed to play near fireplaces, and an elevated platform should be constructed for cooking and keeping hot pots out of reach of children in the kitchen. We believe that an effective and preventive program for the education of parents would prevent many of the scalding injuries occurring among children in our country. Children become more prone to flame and electrical burns at older ages through industrial work, in some sectors, or playing games outdoors. Even though scalding was the predominant cause of burns in all age groups, a clear shift from scalding to flame and electrical burns with increasing age was found in our data set. This has been observed similarly in developed countries.[6,8,9] Flame burn was the second most common cause of burn injuries. Childhood flame burns usually occurred outdoors, often as a result of the ignition of flammable liquids. In Turkey, public education to prevent the illegal sale of these products to children is required. Electrical burn injury is a major problem. Electrical burn injury accounts for approximately 25% of all hospitalized burn patients (both adults and children) in Turkey.[10] Electrical burns accounted for 2.4% of our inpatient group of children. Most electrical injuries in our study group occurred outdoors through contact with overhead high-voltage lines, in contrast to the international literature, in which most injuries occur in domestic environments.[11] In Turkey, due to both a rapid urbanization trend since the 1950s and differences between geographic regions, population and investments have accumulated in certain regions, while disordered and unhealthy urban areas have expanded in others. Most of the patients in our study live in these unreliable urban areas called “gecekondu”. 125

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The “gecekondu” is officially defined as a dwelling unit on land not owned by or rented to the occupant, usually built near high voltage lines without obtaining approval of the landowner and built in a way that is not approved by the general legal provisions for building and construction. Therefore to decrease the incidence of high voltage electrical burns among children in Turkey, major legislative changes are required in order to establish a more comprehensive and rational basis for the implementation of urban regeneration, rehabilitation and transformation projects. Our data also showed, that flame and electrical burns required longer hospital stays, more surgery and increased incidence of permanent complications potentially necessitating lifelong physical and psychological rehabilitation and support, in agreement with previous studies.[9,10] In our series, conservative treatment succeeded in 57.6% of the inpatient children. A total of 325 operations were carried out, involving 42.4% (159) of cases. Electrical and flame burns led to significantly more surgical interventions in comparison to scalds (p<0.05). Our results and those of others suggest electrical and flame burns cause significantly more histopathological damage which, in turn, leads to additional surgical interventions.[8,9] In our study, all the major amputations were carried out among children injured by electricity, among whom the amputation rate was 30%. Yowler et al.[12] reported that upper extremities were affected with high frequency among 51 victims of high-voltage electrical injury, similar to our results. As inaccurate diagnosis and delay in escharotomy or fasciotomy will lead to amputation, electrical and flame burns should be transferred promptly to an experienced centre where appropriate management is possible.[12] In this study, the total mortality rate was 4.3%, which could be expected.[13,14] Although electrical burn was associated with higher amputation rates and more operative interventions, flame burns had the highest associated mortality (13.9%).[7,10] In our investigation, a larger proportion of the total body surface area was affected among flame burn victims and consequently these individuals were more prone to mortal complications such as burn shock, acute renal failure and sepsis. In conclusion, burns, as one of the most devastating injuries in children, require more consideration than that given to other types of trauma. In our study, scald-

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ing was found to be the most important cause of burns and flame-related burns had the highest mortality rate in children. In our opinion, only a specific preventive program for changing the traditional habits of Turkish parents would decrease burn injuries among children. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. 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. 2. Kao CC, Garner WL. Acute burns. Plast Reconstr Surg 2000;105:2482-92; quiz 2494. 3. Anlatici R, Ozerdem OR, Dalay C, Kesiktaş E, Acartürk S, Seydaoğlu G. A retrospective analysis of 1083 Turkish patients with serious burns. Burns 2002;28:231-7. 4. Tarim A, Nursal TZ, Yildirim S, Noyan T, Moray G, Haberal M. Epidemiology of pediatric burn injuries in southern Turkey. J Burn Care Rehabil 2005;26:327-30. 5. Sakallioğlu AE, Başaran O, Tarim A, Türk E, Kut A, Haberal M. Burns in Turkish children and adolescents: nine years of experience. Burns 2007;33:46-51. 6. Thombs BD, Singh VA, Milner SM. Children under 4 years are at greater risk of mortality following acute burn injury: evidence from a national sample of 12,902 pediatric admissions. Shock 2006;26:348-52. 7. Reis E, Yasti AC, Kerimoğlu RS, Dolapçi M, Doğanay M, Kama NA. The effects of habitual negligence among families with respect to pediatric burns. Ulus Travma Acil Cerrahi Derg 2009;15:607-10. 8. Saffle JR, Davis B, Williams P. Recent outcomes in the treatment of burn injury in the United States: a report from the American Burn Association Patient Registry. J Burn Care Rehabil 1995;16:219-32; discussion 288-9. 9. Senel E, Yasti AC, Reis E, Doganay M, Karacan CD, Kama NA. Effects on mortality of changing trends in the management of burned children in Turkey: eight years’ experience. Burns 2009;35:372-7. 10. Nursal TZ, Yildirim S, Tarim A, Caliskan K, Ezer A, Noyan T. Burns in southern Turkey: electrical burns remain a major problem. J Burn Care Rehabil 2003;24:309-14. 11. D’Souza AL, Nelson NG, McKenzie LB. Pediatric burn injuries treated in US emergency departments between 1990 and 2006. Pediatrics 2009;124:1424-30. 12. Yowler CJ, Mozingo DW, Ryan JB, Pruitt BA Jr. Factors contributing to delayed extremity amputation in burn patients. J Trauma 1998;45:522-6. 13. Kut A, Basaran O, Noyan T, Arda IS, Akgün HS, Haberal M. Epidemiologic analysis of patients with burns presenting to the burn units of a University Hospital Network in Turkey. J Burn Care Res 2006;27:161-9. 14. Kai-Yang L, Zhao-Fan X, Luo-Man Z, Yi-Tao J, Tao T, Wei W, et al. Epidemiology of pediatric burns requiring hospitalization in China: a literature review of retrospective studies. Pediatrics 2008;122:132-42.

Mart - March 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):127-132

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.54782

Künt toraks travmasında mortaliteye etki eden faktörler Factors affecting mortality in blunt thoracic trauma Mustafa HASBAHÇECİ,1 Adnan ÖZPEK,1 Fatih BAŞAK,1 Müjgan ÇALIŞKAN,1 Behçet Kemal ENER,2 Orhan ALİMOĞLU1

AMAÇ

BACKGROUND

Künt toraks travması, travma hastalarında sıklıkla toraks dışı yaralanmalarla birlikte görülmekte fakat mortaliteye etkisi tam olarak bilinmemektedir.

Blunt thoracic trauma is usually associated with extrathoracic injuries, but the effect of blunt thoracic trauma on mortality is not known.

GEREÇ VE YÖNTEM

METHODS

Künt toraks travmalı hastalar, klinik özellikler ve mortaliteye etki eden faktörler açısından değerlendirildi.

Patients with blunt thoracic trauma were evaluated with regard to clinical findings and factors affecting mortality.

BULGULAR

RESULTS

Çalışma grubu 76 hastadan (37,2±15 yıl) oluştu. Trafik kazası %63 oranıyla en sık görülen travma sebebiydi. Hastalarda görülen torasik yaralanmalar pnömotoraks (%54), kot kırığı (%42), hemotoraks (%22) ve akciğer kontüzyonu (%22) olarak saptandı. Ekstremite (%46) ve karın (%40) toraks dışı travmaların en sık görüldüğü bölgeler idi. Glasgow koma skoru, yaralanma şiddet skoru ve revize edilmiş travma skoru ortalamaları sırası ile 14±2,6, 19±13 ve 7,4±1,5 olarak hesaplandı. Sadece nonoperatif yönetim 37 (%48,7) hastada yeterli olurken, 37 (%48,7) hastada tüp torakostomi ve 2 (%2,6) hastada torakotomi gerekli oldu. Toplam 8 hastada (%10,5) mortalite görüldü. İlk başvuruda 90 mmHg’nin düşük sistolik kan basıncı değeri, yüzeyel ve apneik solunum ve travma skorlama sistemi sonuçlarının mortalite üzerinde anlamlı etkisi olduğu tespit edildi (p<0,05).

There were 76 patients (37.2±15 years) in the study group. Traffic accidents (63%) were the most common cause of trauma. Pneumothorax (54%), rib fracture (42%), hemothorax (22%) and lung contusion (22%) were common thoracic injuries. Extra-thoracic injuries were most commonly seen in the extremities (46%) and abdomen (40%). Glasgow Coma, Injury Severity and Revised Trauma Scores were 14±2.6, 19±13 and 7.4±1.5, respectively. Nonoperative management was effective in 37 (48.7%) patients, tube thoracotomy and thoracotomy were performed in 37 (48.7%) and 2 (2.6%) patients, respectively. Mortality rate was 10.5%. Systolic blood pressure lower than 90 mmHg and superficial and apneic respiration at the first admission, and values of trauma scoring systems were significantly associated with mortality (p<0.05).

SONUÇ

CONCLUSION

Künt toraks travmaları toraks dışı sistem yaralanmaları ile genellikle beraber görülmektedir. Toraks patolojisinin tipi ve sayısı ile mortalite arasında bir ilişki gösterilememiştir. Yüzeyel ve apneik solunum, 90 mmHg’den düşük sistolik kan basıncı ve travma skorlama sistemi sonuçları mortalite ile yakından ilişkilidir. Nonoperatif yönetim ve tüp torakostomi tedavi açısından çoğu hastada yeterli olmaktadır.

The effect of thoracic trauma on mortality with regard to thoracic pathology is not shown, although it is usually associated with extra-thoracic injuries. There was a close relationship between the pattern of respiration, values of systolic blood pressure and trauma scoring systems, and mortality. Non-operative management and tube thoracotomy were effective in most of the cases.

Anahtar Sözcükler: Künt travma; mortalite; travma şiddet indeksleri; torasik travma.

Key Words: Blunt trauma; mortality; trauma severity indices; thoracic trauma.

Ümraniye Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, 2Göğüs Cerrahisi Kliniği, İstanbul.

Departments of 1General Surgery, 2Thoracic Surgery, Umraniye Training and Research Hospital, Istanbul, Turkey.

1

Correspondence (İletişim): Mustafa Hasbahçeci, M.D. Adem Yavuz Caddesi No: 1, 34766 Ümraniye, İstanbul, Turkey. Tel: +90 - 212 - 621 94 99 e-mail (e-posta): hasbahceci@yahoo.com

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Travma özellikle 40 yaş altı hasta grubunda en önemli ve sık görülen morbidite ve mortalite sebebidir. [1,2] Genel olarak travma olgularının %10’unda toraks travması görülmektedir. Travmaya bağlı ölümlerin ise %25’inden toraks travmaları sorumlu tutulmakta, künt toraks travmaları genellikle diğer sistem travmaları ile birlikte görülmektedir.[1-4] Toraks travmalarının en önemli sebebi trafik kazaları olmakla birlikte (%70-80), toplumların sosyal yapılarına göre farklı oranlarda diğer sebepler de yol açabilir.[1,4,5] Az gelişmiş ya da gelişmekte olan ülkelerde ateşli silahlar, delici ve kesici aletler ile oluşan penetran toraks travmaları önemli bir yer tutmaktadır. Gelişmiş ülkelerde ise, trafik kazalarının yanında özellikle yaşlı popülasyonda yürürken ya da merdivenden düşme gibi değişik mekanizmalarla gerçekleşen künt toraks travmalarına rastlanabilmektedir.[2] Künt travma ile başvuran hastaların değerlendirilmesinde, fiziksel inceleme ve direkt grafiler yanında bilgisayarlı tomografinin (BT) kullanımı son yıllarda giderek artmıştır.[6-10] Her ne kadar maliyet ve radyasyona maruz kalma gibi dezavantajları olsa da, oluşan travmanın etkilerinin daha iyi tanınması, gizli travmaların belirlenebilmesi, elde edilen bilgiler ışığında acil tedavinin yönlendirilmesi ve prognozun tahmin edilebilmesi BT’nin sağladığı genel avantajlardır.[9,10] Nonoperatif yönetim toraks travmaları ile başvuran hastalarda çoğunlukla yeterli olmaktadır. Fakat toraks travmalı bir hastada mortaliteye etki eden faktörlerin öncelikle belirlenmesi ve tedavinin buna göre şekillendirilmesi gerekmektedir.[1] Bu çalışmada künt toraks travması ile acil şartlarda başvuran hastaların, travmanın oluşum mekanizması, travmaya bağlı oluşan klinik tablo, eşlik eden diğer sistem patolojileri ve mortaliteye etki eden faktörler açısından değerlendirilmesi amaçlandı.

GEREÇ VE YÖNTEM Aralık 2008 ile Eylül 2011 döneminde Ümraniye Eğitim ve Araştırma Hastanesi Acil Servisi’ne künt toraks travması ile başvuran hastalar, travma için hazırlanmış prospektif bir veri tabanı esas alınarak değerlendirildi. Hastalara acil servis ilk başvurusunda hikaye, fiziksel inceleme ve akciğer grafilerinden elde edilen bulgularla künt toraks travması tanısı kondu. Hastalar gerektiğinde toraks travmasının detaylı analizi ya da eşlik eden diğer patolojilerin aydınlatılması amacı ile, focused assessment of sonography for trauma (FAST) ve/veya torakoabdominal BT ile değerlendirildi. FAST incelemesinden, öncelikle toraks içi ve karın içi kanamaların tespiti amacı ile yararlanıldı. BT, hemodinami128

si kararlı olan hastalarda, FAST’ye ek olarak ya da tek başına çoklu travma değerlendirmesinde kullanıldı. Tedavi yaklaşımında ileri travma hayat desteği prensiplerine göre hareket edildi. Sistolik kan basıncının 90 mmHg ve üzerinde olması ile birlikte, kalp hızının 100/dakika ve altında olması hemodinamik olarak kararlı olma ölçütü olarak kabul edildi. Hemodinamisi kararlı olan hastalara, en çok 30 dakika ara ile yakın vital bulgu takibi ve fiziksel inceleme ile nonoperatif (ameliyatsız) yönetim uygulandı. Hastaların fiziksel inceleme ve hemodinamik parametreleri ile birlikte saptanan toraks patolojileri dikkate alınarak, tanının kesinleştirilmesi ve tedavi amacı ile lokal anestezi altında tüp torakostomi kararı hastanın takibini yapan ilgili doktor tarafından verildi. Hemotoraks saptanan hastalarda ilk tüp torakostomi uygulamasında 1500 ml’den fazla ya da dört saat içinde saatte 200 ml ya da sekiz saatlik içinde saatte 100 ml’den fazla kanama olması halinde torakotomi kararı alındı. Torasik cerrahi yanında karın cerrahisi tedavi gerekliliğine, hastanın takibini yapan ilgili doktor tarafından karar verildi. Eşlik eden patolojilerin tedavisinde ilgili bölümlerin önerileri dikkate alındı. Hastaların takibi genel cerrahi servisinden taburcu olana ya da mortalite gerçekleşmesine kadar yapıldı. Çalışmaya alınan her bir hasta için Glasgow koma skoru (değer aralığı 0-15), yaralanma şiddet skoru ([ISS-Injury Severity Score] [değer aralığı 0-75]) ve revize edilmiş travma skoru ([RTS-Revised Trauma Score] [değer aralığı 0-7.8408]) değerleri hesaplandı. Hastaların acil servis değerlendirme formları ve servis yatış takipleri dikkate alındı. Hastalar yaş, cinsiyet, travmanın oluşum mekanizması, ilk başvuru anındaki vital bulgular (sistolik kan basıncı, kalp hızı, solunum hızı), toraks travmasına eşlik eden diğer sistem travmaları, toraks patolojisi, tanı amaçlı yapılan görüntüleme yöntemleri, travma skorları, uygulanan tedavi, yoğun bakım ünitesi ve genel cerrahi servisindeki yatış süreleri ve mortalite açısından değerlendirildi. Number Cruncher Statistical System (NCSS) 2007 ve Power Analysis and Sample Size (PASS) 2008 Statistical Software (Utah, USA) programları ile istatistiksel analizler gerçekleştirildi. Student-t ve MannWhitney U-testleri tanımlayıcı istatistiksel metodların (ortalama, standart sapma, medyan, frekans, oran) karşılaştırılmasında ve Mann-Whitney U-testi niceliksel verilerin karşılaştırılmasında kullanıldı. Niteliksel verilerin karşılaştırılmasında ki-kare testi ve %50’sinin beklenen değeri 5’in altında olan parametrelerin değerlendirilmesinde Fisher kesin testinden faydalanıldı. Sonuçlar %95’lik güven aralığında, anlamlılık p<0,05 düzeyinde değerlendirildi.

BULGULAR Künt toraks travması tespit edilen 62 (%82) erkek Mart - March 2013

Künt toraks travmasında mortaliteye etki eden faktörler

ve 14 (%18) kadın olmak üzere toplam 76 hasta değerlendirmeye alındı. Hastaların yaş ortalaması 37,2±15 yıl idi. Künt toraks travması değerlendirilmesinde ilk görüntüleme yöntemi olarak akciğer grafisi 50 hastada (%65,8) kullanıldı. İleri inceleme ve diğer sistem travmalarının belirlenmesi amacı ile 32 hastaya (%42) FAST, 67 hastaya (%88) bilgisayarlı tomografi, 30 (%39,5) hastaya FAST ve bilgisayarlı tomografi incelemelerinin her ikisi birlikte yapıldı. Yedi hastaya (%9) herhangi bir görüntüleme işlemi yapılmadı. Trafik kazası, hastaların 48’inde (%63) olmak üzere en sık görülen travma sebebi idi (Tablo 1). İlk başvuru esnasında ölçülen sistolik kan basıncı, 11 hastada (%14,5) 90 mmHg’nin altında idi. Kalp hızı ortalaması 93/dakika olup, 0 ile 130/dakika arası değişiyordu. Sistolik kan basıncı 90 mmHg’den düşük ve kalp hızı 100/dk’dan fazla olan 9 hasta (%12) hemodinamisi kararsız olarak değerlendirildi. Altı hastada solunum yüzeyel ve apneik idi. Diğer hastalarda ortalama solunum hızı 18/dakika (değer aralığı 16-24/ dakika) olarak tespit edildi. Hastalarda en sık görülen torasik yaralanmalar, üç hastada iki taraflı olmak üzere pnömotoraks (41 hasta [%54]) iken, diğer yaralanmalar kot kırığı (32 hasta [%42]), hemotoraks (17 hasta (%22)) ve akciğer kontüzyonu (17 hasta [%22]) idi. Pnömotoraks ve hemotoraks 9 hastada (%12) birlikte görüldü. Tek bir kot kırığı 7, iki kot kırığı 6 ve üç kot kırığı 7 hastada görülürken, 12 hastada dört ve daha fazla sayıda kot kırığı vardı. Hastalardan 5’inde (%7) klavikula kırığı dışında herhangi bir torasik patoloji tespit edilmedi. İki ya da daha fazla torasik patoloji 30 (%39,5) hastada görülürken, klavikula kırığı 11 (%14,5) ve skapula kırığı 3 (%4) hastada tespit edildi. İzole toraks travması 28 hastada (%37) görülürken, diğer 48 hastada (%63) bir ya da daha fazla toraks dışı travma varlığı tespit edildi (Tablo 2). Abdomen, ekstremiteden sonra toraks dışı travmaların en sık görüldüğü anatomik bölge idi. Travma skor sistemleri ile yapılan travma şiddet belirlemesi değerlendirmesinde Glasgow koma skoru, yaralanma şiddet skoru ve revize edilmiş travma skoru ortalamaları sırası ile 14±2,6, 19±13 ve 7,4±1,5 olarak hesaplandı. Çalışma grubunu oluşturan hastalardan 37’sine (%48,7) sadece ameliyatsız yönetim, üç hastada iki taraflı olmak üzere 37 hastaya (%48.7) tüp torakostomi ve 2 hastaya (%2.6) torakotomi işlemi uygulandı. Tüp torakostomi uygulanan 37 hastanın 28’inde, tüp torakostomi torasik patolojinin tedavisi açısından tek başına yeterli oldu (Tablo 3). Karın içi organlarda tespit edilen patolojiler için, 4 hastada packing, 4 hastada splenektomi, 1 hastada splenektomi-nefrektomi ve 1 hastada negatif laparotomi olmak üzere toplam 10 hastaya (%13) laparotomi yapıldı. Cilt - Vol. 19 Sayı - No. 2

Tablo 1. Künt toraks travması sebepleri Etyoloji

Sayı

Yüzde

Trafik kazası Araç içi Araç dışı Motorsiklet Yüksekten düşme Ağır cisim altında ezilme Darp

48 23 18 7 19 5 4

63 30 24 9 25 6,5 5

Tablo 2. Toraks dışı travmaların detaylı analizi Sistem Ekstremite Karın Pelvis Vertebra Baş-boyun Kraniyal Periferik vasküler

n (%) 35 (46) 30 (39,5) 16 (21) 13 (17) 9 (12) 8 (10,5) 2 (2,6)

Organ Dalak Böbrek Karaciğer Diğer

Sayı

15 11 10 4

Tablo 3. Hastalara yapılan tedaviler Tedavi Ameliyatsız yönetim Sadece tüp torakostomi Tüp torakostomi + laparotomi Sadece laparotomi Tüp torakostomi + torakotomi Tüp torakostomi + torakotomi + laparotomi

Sayı 37 28 7 2 1 1

Ameliyatsız yönetim ya da cerrahi sonrası yoğun bakım takibi gereken hasta sayısı 15 (%20) olup, ameliyat sonrası 0. günde mortalite ile sonuçlanan 6 hasta hariç, ortalama yatış süresi 8 gün (değer aralığı 2-21 gün) idi. Genel cerrahi servisinde gerçekleşen ortalama yatış günü 4,5 olup 1 ile 12 gün arası değişmekte idi. Genel cerrahi servis takibi sonrası 1 hastaya kulak burun ve boğaz hastalıkları bölümü tarafından mandibula kırığı için onarım ameliyatı yapıldı. On üç hastaya açık redüksiyon ve 5 hastaya kapalı redüksiyon ile internal fiksasyon ameliyatları Ortopedi bölümü tarafından gerçekleştirildi. Toplam 8 (%10,5) hastada mortalite görüldü (Tablo 4). Mortalite ile ilişkili risk faktörlerinin belirlenmesi amacı ile yapılan değerlendirmede yaş, cinsiyet, travma sebebi, ilk başvuru kalp hızı değeri, torasik patolojinin tipi ve sayısı, eşlik eden toraks dışı diğer sistem 129

Ulus Travma Acil Cerrahi Derg

Tablo 4. Mortalite sebepleri Yaralanmanın anatomik bölgesi Torakopelvik Toraks Torakoabdominal Torakopelvik Kranial, torakoabdominal Torakoabdominopelvik Kranial, torakoabdominal, periferik vasküler Torakopelvik, ekstremite, periferik vasküler

Sayı Toraks dışı organ yaralanması 1 1 1 1 1 1 1 1

Pelvik retroperiton – Karaciğer, grade 4 Pelvik retroperiton Karaciğer, grade 5 Dalak, grade 4 Dalak, grade 4; aksiller arter Pelvik retroperiton, popliteal ven

yaralanmasının tipi ve sayısının bir etkisi gösterilememiştir (p>0,05). Ancak ilk başvuruda hastanın sistolik kan basıncının 90 mmHg’den düşük ve solunumunun yüzeyel ve apneik olmasının mortalite gelişimi üzerinde istatistiksel olarak anlamlı etkisinin olduğu bulunmuştur (p<0,001). Travma skorlama sistemi değerleri ile mortalite gelişimi arasında da anlamlı bir ilişki saptanmıştır (Tablo 5).

TARTIŞMA Bu çalışmada elde edilen bulgular, künt toraks travmalarının en fazla genç erkeklerde görüldüğünü ve önemli mortalite sebeplerinden biri olduğunu göstermiştir.[1,3,5,6] Travma sebepleri incelendiğinde, genç erkeklerin etkilenmesi açıklanabilir. Fakat son yıllarda yaşlı kişilerde özellikle düşmeye bağlı künt toraks travması görülme olasılığının artması da dikkat çekici bir bulgudur.[1,4,11] Gerek gelişmiş ve gerekse gelişmekte olan ülkelerde, trafik kazaları künt toraks travmalarının en sık sebebidir.[1,3,4,6,12-14] Bu çalışmada da, gerek araç içi-dışı ve gerekse motosiklet kazaları dikkate alındığında, olguların %63’ünde trafik kazaları etyolojik sebep olarak tespit edilmiştir. Bazı çalışmalarda travma sebebi olarak darbın %28 gibi yüksek oranda bildirilmesi, bu oranların toplumlara göre değişebileceğini göstermektedir.[1] Travma neticesi oluşan torasik yaralanmalar, travmanın oluşum mekanizmalarına göre değişim göstermektedir.[3,13,15] Çalışmamızda en çok görülen toraks

Tedavi Packing Torakotomi Tüp torakostomi, packing Tüp torakostomi Tüp torakostomi, packing Torakotomi, splenektomi, packing Tüp torakostomi, splenektomi, primer onarım Tüp torakostomi, ekstremite eksternal fiksasyon, primer onarım

patolojisi pnömotoraks (%53) ve kot kırıkları (%42) olarak tespit edilmiştir. Literatürde değişik patolojiler için değişik oranlar sıklıkla bildirilmekle birlikte, özellikle pnömotoraks ve kot kırıklarının daha çok görüldüğü bildirilmektedir.[3,11,16] Travma sonrası oluşan toraks patolojilerinin tipi ve sayısı ile eşlik eden diğer yaralanmaların mortalite üzerinde etkisi olmadığı gösterilmiştir. Kot kırık sayısının mortalite üzerinde etkili olduğunu ifade eden çelişkili çalışmalar olmakla birlikte, genel kanı kırık olan kot sayısının artması ile mortalitenin artacağı yönündedir.[16,17] Fakat çalışmamızda elde ettiğimiz veriler, bunu desteklememektedir. Hasta sayısının az olmasının bu durumda etkili olduğu düşünülmüştür. Travma skorlama sistemlerinin özellikle travma şiddetinin standardize edilmesi ve prognoz tahmininde önemli olduğu bilinmektedir.[3,12,14] Bu çalışmada kullanılan Glasgow Koma Skoru, Yaralanma Şiddet Skoru ve Revize Edilmiş Travma Skoru değerlerinin, hastada var olan travmanın yaygınlığı ve şiddeti ile doğru orantılı olarak, mortalite oluşumu ile anlamlı bir ilişkisinin olduğu saptanmıştır. Bu açıdan travma hastalarının değerlendirilmesi ve beklenen prognoza göre tedavinin şekillendirilebilmesi açısından, tür skorlama sistemlerinin kullanılmasının yararlı olacağı düşünülmektedir. Her ne kadar travma skoru hesaplamalarında kan basıncı ve solunum sayısı birer parametre olarak kullanılmakla birlikte, düşük sistolik kan basıncı ve yüzeyel ve apneik solunumun da mortalite ile anlamlı bir ilişkisi gösterilmiştir. Bu yüzden skorlama sistemlerinin kullanılamama durumlarında, aynı şekilde

Tablo 5. Mortalite ile travma skorlama sistemi değerleri arasındaki ilişki Gruplar Glasgow koma skoru Yaralanma şiddet skoru Revize edilmiş travma skoru

Mortalite (n=8) Ort.±SS* 7,6±3,7 45±4,3 7,8±0,3

Yaşayan (n=64) Ort.±SS* 14,9±0,9 16,3±10 3,6±2,1

pß <0,001 <0,001 <0,001

*: Standart sapma; ß: Mann-Whitney U-testi.

130

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Künt toraks travmasında mortaliteye etki eden faktörler

prognoz tahmini ve tedavi şekillendirilmesinde sistolik kan basıncı ve solunum özellikleri kullanılabilir. Prognoz üzerinde etkili olan diğer faktörler arasında toraks travmalarına eşlik eden diğer sistem yaralanmalarının varlığı, toraks travmasının künt tipte olması ve hastanın yaşı yer almaktadır.[1,3,9,11,17] Özellikle 65 yaş ve üzeri hasta grubunda mortalite daha çok oranda görülmekle birlikte,[8] çalışma grubumuzdaki mortalite görülen 8 hastadan sadece birinin yaşı 65 üzeri idi. Toraks dışı sistem yaralanmalarının toraks travmalarının ne kadarına eşlik ettiği ve mortalite üzerinde etkili olup olmadığı tartışmalı bir diğer konudur.[1] Mortalite ile sonuçlanan olguların hepsinde eşlik eden toraks dışı yaralanmalar olmakla birlikte, toraks dışı sistem yaralanmasının tipi ve sayısı ile mortalite üzerinde istatistiksel olarak anlamlı bir ilişki gösterilememiştir. Her ne kadar çoklu sistem yaralanması, oluşan travmanın yaygınlığını göstermekle birlikte, mortaliteye büyük olasılıkla sebep olacak şiddette herhangi bir sistem yaralanmasının oluşmadığına bir işaret olarak da değerlendirilebilir. Ayrıca toraks ve toraks dışı yaralanmalarının tek başlarına ya da birlikte mortalite üzerinde herhangi bir etkileri olduğu gösterilememiştir. Fakat her bir sisteme ait yaralanma bulgularının travma skor sistemleri oluşumuna katkıda bulunmasından dolayı, indirekt olarak toraks ve toraks dışı yaralanmalarının mortalite ile ilişkili olduğu sonucuna varılabilir. Bir travma hastasının değerlendirilmesinde, travma yaygınlığı ve şiddetinin erken dönemde belirlenmesi ve buna göre gerekli müdahalelerin yapılması, prognoz açısından önemli bir konudur. Bu amaçla özellikle hemodinamik açıdan uygun hastalarda BT kullanılmasının etkin olduğu bilinmektedir.[1,6,7,18] Gizli torasik yaralanmaların tespit edilmesinde, BT’nin önemli bir üstünlüğü olduğu da gösterilmiştir.[9,10,16] Travma hastalarında son yıllarda yaygın bir şekilde kullanılan FAST’in, özellikle perikardiyal efüzyon ve karın içi serbest sıvı saptanmasında yüksek bir özgüllük oranına sahip olduğu bilinmektedir.[19] Genişletilmiş FAST ile toraks boşluğunun da değerlendirilmesi ve pnömotoraks varlığının saptanması mümkün iken, bu tür uygulamaların yaygınlık kazanması her travma merkezinde halen gerçekleşmemiştir.[19] Çoklu travmaların net olarak değerlendirilebilmesi açısından, FAST ile birlikte hemodinamik olarak uygun hastalarda (67 hasta, %88) bilgisayarlı tomografi kullanılarak, özellikle çoklu sistem değerlendirmesi açısından detaylı bilgiler elde edilmiştir. Acil servis şartlarında FAST kullanımına yeni başlanmış olması ve genişletilmiş FAST değerlendirmesinin etkin bir şekilde yerleşmemiş olmasından dolayı, FAST yapılan hastaların büyük bir kısmına aynı zamanda BT incelemesinin de istendiği gözlemlenmiştir. Sonuç olarak, çalışma grubunu oluşturan hastalarda, toraks dışı yaralanmalardan Cilt - Vol. 19 Sayı - No. 2

özellikle pelvis, vertebra, boyun ve kraniyal yaralanmaların belirlenmesi açısından BT’nin olumlu etkisi olduğu düşünülmektedir. Çalışma grubundaki hastalarda kardiyak ya da majör mediastinal vasküler yaralanmaların olmaması, bu tür travmalı hastaların hastaneye nakli öncesinde ölmeleri ile açıklanmaktadır.[3] Periferik vasküler yaralanması olan iki hasta, cerrahi tedavileri yapılmakla birlikte, mortalite ile sonuçlanmıştır. Bu durum kanamanın ilk kontrolünün, travmaya ilk müdahale yapıldığı yerde daha etkin bir şekilde yapılması gerektiğini göstermektedir. Toraks travmalarının tedavisinde ameliyatsız yaklaşımlar çoğunlukla yeterli olmaktadır.[1] Özellikle izole toraks travmalarının ameliyatsız yönetim ve gerektiğinde tüp torakostomi ile etkin bir şekilde tedavi edilmesi mümkündür.[1,5] Bu çalışmada da, ameliyatsız yönetim ve gerektiğinde tüp torakostomi uygulaması 76 hastanın 65’inde yeterli olmuştur. Fakat bu şekilde takip ve tedavi edilen hastalara, hastane ortamında yakın klinik takip ve aralıklı akciğer grafileri ile değerlendirme önemli olmaktadır.[1,13] Sonuç olarak, künt toraks travmaları sıklıkla diğer toraks dışı sistem yaralanmaları ile birlikte görülmektedir. Toraks patolojilerinin tipi ve sayısı ile mortalite arasında bir ilişki olduğu gösterilememiştir. Fakat ilk başvurudaki yüzeyel ve apneik solunum, 90 mmHg’den düşük sistolik kan basıncı ve elde edilen travma skorlama sistemi sonuçları ile mortalite arasında direkt bir ilişki söz konusudur. Tedavide ameliyatsız yönetim ve tüp torakostomi çoğu hastada yeterli olmakla birlikte, komplike travmalarda acil ileri cerrahi müdahaleler gerekebilmektedir. Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması yoktur.

KAYNAKLAR 1. Lema MK, Chalya PL, Mabula JB, Mahalu W. Pattern and outcome of chest injuries at Bugando Medical Centre in Northwestern Tanzania. J Cardiothorac Surg 2011;6:7. 2. Kidher E, Krasopoulos G, Coats T, Charitou A, Magee P, Uppal R, et al. The effect of prehospital time related variables on mortality following severe thoracic trauma. Injury 2012;43:1386-92. 3. Emircan S, Ozgüç H, Akköse Aydın S, Ozdemir F, Köksal O, Bulut M. Factors affecting mortality in patients with thorax trauma. Ulus Travma Acil Cerrahi Derg 2011;17:329-33. 4. Hanafi M, Al-Sarraf N, Sharaf H, Abdelaziz A. Pattern and presentation of blunt chest trauma among different age groups. Asian Cardiovasc Thorac Ann 2011;19:48-51. 5. Thomas MO, Ogunleye EO. Etiopathology and management challenges of blunt chest trauma in Nigeria. Asian Cardiovasc Thorac Ann 2009;17:608-11. 6. van Vugt R, Deunk J, Brink M, Dekker HM, Kool DR, van Vugt AB, et al. Influence of routine computed tomography on predicted survival from blunt thoracoabdominal trauma. Eur J Trauma Emerg Surg 2011;37:185-190. 131

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7. Gupta M, Schriger DL, Hiatt JR, Cryer HG, Tillou A, Hoffman JR, et al. Selective use of computed tomography compared with routine whole body imaging in patients with blunt trauma. Ann Emerg Med 2011;58:407-16.e15. 8. Harrington DT, Phillips B, Machan J, Zacharias N, Velmahos GC, Rosenblatt MS, et al. Factors associated with survival following blunt chest trauma in older patients: results from a large regional trauma cooperative. Arch Surg 2010;145:432-7. 9. Omar HR, Mangar D, Khetarpal S, Shapiro DH, Kolla J, Rashad R, et al. Anteroposterior chest radiograph vs. chest CT scan in early detection of pneumothorax in trauma patients. Int Arch Med 2011;4:30. 10. Lee KL, Graham CA, Yeung JH, Ahuja AT, Rainer TH. Occult pneumothorax in Chinese patients with significant blunt chest trauma: incidence and management. Injury 2010;41:492-4. 11. Lotfipour S, Kaku SK, Vaca FE, Patel C, Anderson CL, Ahmed SS, et al. Factors associated with complications in older adults with isolated blunt chest trauma. West J Emerg Med 2009;10:79-84. 12. Esme H, Solak O, Yurumez Y, Yavuz Y, Terzi Y, Sezer M, et al. The prognostic importance of trauma scoring systems for blunt thoracic trauma. Thorac Cardiovasc Surg 2007;55:190-5. 13. Karadayi S, Nadir A, Sahin E, Celik B, Arslan S, Kaptanoglu M. An analysis of 214 cases of rib fractures. Clinics (Sao Paulo) 2011;66:449-51.

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14. Costa G, Tomassini F, Tierno SM, Venturini L, Frezza B, Cancrini G, et al. The prognostic significance of thoracic and abdominal trauma in severe trauma patients (Injury severity score > 15). Ann Ital Chir 2010;81:171-6. 15. Mefire AC, Pagbe JJ, Fokou M, Nguimbous JF, Guifo ML, Bahebeck J. Analysis of epidemiology, lesions, treatment and outcome of 354 consecutive cases of blunt and penetrating trauma to the chest in an African setting. S Afr J Surg 2010;48:90-3. 16. Oâ&#x20AC;&#x2122;Connor JV, Adamski J. The diagnosis and treatment of noncardiac thoracic trauma. J R Army Med Corps 2010;156:5-14. 17. Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury 2012;43:8-17. 18. Kaiser M, Whealon M, Barrios C, Dobson S, Malinoski D, Dolich M, Lekawa M, Hoyt D, Cinat M. The clinical significance of occult thoracic injury in blunt trauma patients. Am Surg. 2010;76:1063-1066. 18. Kaiser M, Whealon M, Barrios C, Dobson S, Malinoski D, Dolich M, et al. The clinical significance of occult thoracic injury in blunt trauma patients. Am Surg 2010;76:1063-6. 19. Matsushima K, Frankel HL. Beyond focused assessment with sonography for trauma: ultrasound creep in the trauma resuscitation area and beyond. Curr Opin Crit Care 2011;17:60612.

Mart - March 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):133-139

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.58740

Dieulafoy lezyonuna bağlı akut gastrointestinal sistem kanaması nedeniyle acil servise başvuran olguların tedavi sonuçlarının değerlendirilmesi Evaluation of treatment results among patients with acute gastrointestinal bleeding due to Dieulafoy’s lesion admitted to the emergency department Yavuz BEYAZİT,1 Selçuk DİŞİBEYAZ,1 Burak SUVAK,1 Tugrul PURNAK,2 Serkan TORUN,1 Erkan PARLAK1 AMAÇ

BACKGROUND

Dieulafoy lezyonu (DL) normal mukoza ile çevrili mukozal bir yırtık alanından geniş, pulsatil bir arteryel damarın dışarıya açılımı sonucu gelişen nadir bir gastrointestinal sistem (GİS) kanaması nedenidir. Bu çalışmada, merkezimizdeki DL deneyimlerimizi, hastaların klinik özelliklerini, endoskopik tedavi yöntemleri ve sonuçlarımızı değerlendirdik.

Dieulafoy lesions (DL) are a rare cause of gastrointestinal bleeding (GIB), characterized by exteriorization of a large pulsatile arterial vessel through a minimal mucosal tear surrounded by normal mucosa. In the present study, we aimed to review the clinical experience with DL in our center, primarily focusing on clinical features and endoscopic therapeutic preferences according to clinical outcomes.

GEREÇ VE YÖNTEM

Türkiye Yüksek İhtisas Eğitim ve Araştırma Hastanesi gastrointestinal endoskopi ünitesinde GİS kanaması nedeniyle 2007 ve 2011 yılları arasında DL tanısı almış hastalar geriye dönük olarak değerlendirildi. Detaylı klinik ve endoskopik veri toplanıp özetlendi. BULGULAR

METHODS

Data from patients with upper GIB were admitted to the Turkiye Yuksek Ihtisas Training and Research Hospital gastrointestinal endoscopy unit between 2007 and 2011 and were reviewed for DL. Detailed clinical and endoscopic data were abstracted and collected.

Hastaların 27 tanesinde DL’ye bağlı gelişen kanama saptandı. Hastaların yaşları 24 ile 85 yıl arasındaydı (medyan 70 yıl). Onbeş hasta erkek, 12 hasta kadındı. Mide yerleşimli DL’nin en sıklıkla saptandığı lokalizasyon fundusdu (%59,2). Bunu korpus (%29,6) ve antrum (%11,2) izlemekte idi. Başlangıç endoskopik tedavi yaklaşımı olarak en sık uygulanan yöntem tek başına hemoklips uygulaması (%40,0) veya hemoklips+adrenalin enjeksiyonu (%33,3) şeklinde idi.

RESULTS

SONUÇ

CONCLUSION

Twenty-seven patients were identified with DL. Their ages ranged from 24 to 85 years (median age 70). Fifteen patients were male and twelve were female. Most of the DL occurred in the stomach and were most commonly localized in fundus (59.2%), followed by corpus (29.6%) and antrum (11.2%). The most common initial endoscopic therapeutic approaches were the application of hemoclips with (33.3%) or without adrenalin (40%) injection.

Çalışmamız DL’nin orta-ileri yaşlı ve erkek hasta popülasyonunda sık olduğunu gösterdi. Ek olarak endoskopik tedavi modalitelerinin güvenli, başarılı ve etkin maliyet oranına sahip olduğu gözlendi.

Our study revealed that DL occurred in relatively older patients with a male dominance. Primary hemostasis with endoscopic intervention is safe, successful and cost-effective.

Anahtar Sözcükler: Dieulafoy lezyonu; endoskopik tedavi; kanama; mide.

Key Words: Dieulafoy lesion; endoscopic treatment; bleeding; stomach.

1 Türkiye Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Gastroenteroloji Kliniği, Ankara; 2Ankara Numune Eğitim ve Araştırma Hastanesi, Hepatoloji ve Gastroenteroloji Kliniği, Ankara.

1 Department of Gastroenterology, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara; 2Department of Hepatology and Gastroenterology, Ankara Numune Training and Research Hospital, Ankara, Turkey.

Correspondence (İletişim): Yavuz Beyazit, M.D. Kızılay Sok., No: 4, Sıhhiye, Ankara, Turkey. Tel: +90 - 312 - 562 08 05 e-posta (e-mail): yavuzbeyaz@yahoo.com

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Akut gastrointestinal sistem (GİS) kanamasının insidansı yıllık 100.000’de 50-150 arasında değişmektedir.[1] Hastaların neredeyse %80’inde kanamanın nedeni peptik ülserler ve özofageal veya gastroduodenal erozyonlardır.[2] GİS kanamalarının tedavisi için uygulanan endoskopik tedavi yöntemlerindeki tüm gelişmelere rağmen GİS kanamalarına bağlı mortalite %5-10’lar düzeyindedir.[3] Mortalitenin bu kadar yüksek olmasının nedenlerinden bir tanesi de kanamanın varlığına rağmen, standart radyolojik ve endoskopik inceleme yöntemleri ile kanama yerinin saptanamamasıdır. Bunun da en sık nedenleri, kanayan yerin anatomik olarak erişilebilir olmaması, küçük olması veya görülebilir olmamasıdır. Dieulafoy lezyonu (DL) da bu açıdan değerlendirildiğinde kaynağı belli olmayan GİS kanamasına yol açabilecek ender patolojilerden bir tanesidir ve tanısı konamaz ya da geç konursa hayatı tehdit edebilecek kanamalara yol açabilmektedir. Dieulafoy lezyonu gastrointestinal sistemde submukozal damarsal genişleme ve yırtılma sonucu masif GİS kanamasına yol açarak hayatı tehdit edebilmekte ve diğer GİS kanama nedenleri ile kıyaslandığında tanısının konulmasında ciddi zorluklar yaşanmaktadır. DL nadir olarak görülür ve insidansı %0,3 - %6,7 arasında değişir.[1,4] İlk defa 1884 yılında Gallard tarafından midede miliyer bir anevrizma olarak tanımlanmışdır, ancak bu lezyonu adlandıran ve klinik karakteristiklerini ortaya koyan asıl klinisyen Georges Dieulafoy’dur.[5] Bu lezyon aberran bir submukozal arterdir ve özellikle gastroözofageal bileşkeden sonra ilk 6 cm’de yerleşimlidir. Her ne kadar endoskopik tanı yöntemlerindeki gelişmelere bağlı olarak lezyonun tanınırlılığında artışlar bildirilmiş olsa da DL’ye bağlı kanamanın mortalitesi halen yüksektir ve sıklıkla transfüzyon ihtiyacı gerektirecek masif kanama ile ilişkilidir.

Dieulafoy lezyonu tanısındaki ilk basamak GİS endoskopisidir. Ancak nisbeten küçük olan mukozal defekt ve submukozal arteryel yapı deneyimli endoskopistlerce bile gözden kaçırılabilir.[4,5] Tanıyı sağlamak için böyle durumlarda anjiyografi ve/veya endoskopik ultrasonografi kullanılabilir. Tedavide band ligasyonu, termoregülasyon, bipolar elektrokoagülasyon, fotokoagülasyon, enjeksiyon tedavisi veya endoskopik hemoklips uygulaması kullanılabilir. İnvazif olmayan tekniklerle yeterli tedavinin sağlanamadığı hastalarda cerrahi tedavi seçenekleri düşünülmelidir.[3,6,7] Bu çalışmanın amacı üst GİS kanaması nedeniyle endoskopik tanı ve tedavi uyguladığımız DL tanısı almış hastaların analizini yapmak, bu hastaların klinik ve epidemiyolojik bulgularını belirlemek, uygulanan tedavileri ve sonuçlarını geriye dönük olarak incelemektir.

GEREÇ VE YÖNTEM Üst GİS kanaması nedeniyle 2007-2011 yılları arasında Türkiye Yüksek İhtisas Hastanesi acil servisine başvuran ve bu nedenle üst GİS endoskopisi uygulanan hastalar geriye dönük olarak değerlendirildi. Bu hastaların dosya kayıtları incelenerek demografik veriler, klinik ve endoskopik bulgular, tedavi yaklaşımları ve izlem sonuçları kaydedildi. İncelenen bu hastalardan üst GİS yerleşimli DL lezyonu tanısı almış hastalar çalışmaya alındı. İncelenen tüm hastalara acil servise GİS kanama nedeniyle başvuru anından başlamak üzere intravenöz sıvı replasmanı ve proton pompa inhibitör (PPİ) tedavisi başlanmıştı. Tıbbi gereklilik durumunda kan transfüzyonu uygulanmıştı. Her hastanın kabul esnasında vital bulguları kaydedilmiş, rutin rektal tuşe ile melena/hematokezya varlığına bakılmış, aktif kanama işaretleri varlığında acil endoskopik girişim yapılmıştı. Endoskopik incelemeler, bir gastroenteroloji uzmanı, veya onun nezaretinde gastroenteroloji yan dal asistanıyla birlikte endoskopi hemşiresi varlığında yapılmıştı. Tüm hastalara ve hasta yakınlarına endoskopik girişim öncesi olası tıbbi kazançlar ve olası komplikasyonlar hakkında detaylı bilgiler verilmiş ve işlem onamları yazılı olarak alınmıştı. Dieulafoy lezyonu tanısı endoskopik olarak aşağıdaki ölçütlerden en az birinin varlığında konulmuştu; 1. Aktif arteryel kanama veya ufak bir mukozal bir defektten kaynaklanan mikropulsatil kanama, 2. Etrafı normal bir mukoza ile çevrili, ufak bir mukozal defektten kaynaklanan aktif/inaktif kanamanın eşlik ettiği protrüde bir damarın görülmesi,

Şekil 1. Gastrointestinal sistem kanamasına neden olmuş bir Dieulafoy lezyonunun endoskopik görünümü.

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Renkli şekiller derginin online sayısında görülebilir. (www.tjtes.org)

3. Ufak bir mukozal defekt veya normal görünümlü mukoza üzerine sıkıca yapışmış pıhtı. Gastrointestinal sistem kanamasına neden olmuş bir DL görülmektedir (Şekil 1). Mart - March 2013

Dieulafoy lezyonuna bağlı akut GİS kanaması nedeniyle acil servise başvuran olgular

Tablo 1. Çalışmaya alınan hastaların demografik özellikleri

Erkek (n=15) Kadın (n=12) n (%) n (%)

Yaş (yıl) Tıbbi hikaye Hipertansiyon Diabetes mellitus Kronik böbrek yetersizliği Konjestif kalp yetersizliği Koroner arter hastalığı İlaç kullanımı Proton pompa inhibitörü Aspirin Varfarin NSAİİ Klopidogrel Daha önce kanama hikayesi

70 (24-85)

77 (31-83)

2 (13,3) – – 1 (6,6) 4 (26,6)

3 (25) 1 (8,3) 2 (16,6) 2 (16,6) 1 (8,3)

3 (19,9) 2 (13,3) 1 (6,6) 1 (6,6) – 1 (6,6)

2 (16,6) 1 (8,3) 1 (8,3) 2 (16,6) – –

NSAİİ: Non-streoidal antienflamatuvar ilaçlar.

Endoskopik tedavi yöntemleri hastanın durumuna ve endoskopistin tercihine göre farklılıklar arz etmekteydi. Endoskopik band ligasyonu, hemoklips uygulaması veya enjeksiyon tercih edilen yöntemlerdi. Endoskopik işlemler önden görüşlü endoskopi cihazı (Pentax, EG-2940, EG-2985, Tokyo, Japan) kullanılarak, band ligasyonları ise tekli band (Steigmann Goffcleardye endoscopic ligator set) kullanılarak yapılmıştı. Endoskopik kanama kontrolünün sağlanması işlem başarısı olarak değerlendirildi. Birinci endoskopide kesin tanının konamadığı, yeterli girişimin yapılamadığı veya kanamanın halen devam ettiği hastalara (hemoglobin değerlerinde düşmenin devam etmesi, nabız hızında >10/dk artış olması, dirençli taşikardi, hematemezin tekrarlaması, veya nazogastrik drenajdan taze kan gelmesi gibi belirtilerin devam etmesi halinde) ikinci endoskopi işlemi takip eden günlerde yapılmıştı. Endoskopik işlem sonrası intravenöz PPI tedavisi tüm hastalarda devam ettirilmiş idi. İstatistiksel analiz Verilerin istatistiksel analizi “Statistical Package

for Social Sciences (SPSS) version 18” (SPSS Inc., Chicago, IL, United States) bilgisayar programı kullanılarak yapıldı. Sayısal değişkenlerin dağılımları Kolmogorov-Smirnov testi ile değerlendirildi ve tüm sayısal değişkenlerin normal dağılıma uymadığı saptandı. Bu nedenle sayısal değişkenlerin karşılaştırılmasında Mann-Whitney U-testi kullanıldı. Sayısal veriler “ortanca (minimum-maksimum)” olarak ifade edildi. Kategorik değişkenler için ki-kare testi kullanıldı ve çapraz tablolarda beklenen değerin beşten küçük olduğu durumlarda Fisher’in kesin testi uygulandı. P değeri 0,05’den küçük olduğunda istatistiksel olarak anlamlı kabul edildi.

BULGULAR Üst GİS kanama nedeniyle 2007-2011 yılları arasında hastanemizde 742 hastaya endoskopik işlem uygulanmıştı. Bu hastalardan DL kanaması nedeniyle endoskopi işlemi uygulanan 27 hasta (%3,6) çalışmaya alındı. Çalışmaya alınan hastaların 12’si (%44,4) kadın, 15’si (%55,6) erkek idi. Yaş ortalaması kadınlarda ve erkeklerde sırasıyla 77 (31-83) yıl ve 70 (2485) yıl idi. Hastalar eşlik eden hastalıklarına ve kullandıkları ilaçlar açısından değerlendirildiklerinde; 5 hastada hipertansiyon, 1 hastada diabetes mellitus, 5 hastada koroner arter hastalığı vardı. Üç hasta aspirin, 2 hasta varfarin kullanmakta idi (Tablo 1). Acil’e başvuru esnasında en sık ifade edilen başvuru şikayeti melena (%33,3), hematemez (%26,8) ve hematokezya (%13,3) idi. Hastalar uygulanan tedavi açısından değerlendirildiklerinde en sık uygulanan tedavinin hemoklips uygulması olduğu dikkati çekti. Dokuz (%33,3) hastaya adrenalin enjeksiyon+hemoklips, 11 hastaya (%40,7) tek başına hemoklips uygulaması, 3 (%11,1) hastaya adrenalin+heater probe uygulaması, 2 (%7,5) hastaya adrenalin enjeksiyon+heater+hemoklips uygulaması, 1 (%3,7) hastaya tek başına adrenalin enjeksiyonu yapılmıştı. Bir hastaya (%3,7) masif kanama nedeniyle endoskopik işlem uygulanamadığından dolayı acil cerrahi (gastrotomi+primer dikiş) girişim uygulanmışdı (Tablo 2). Birinci endoskopide hemoklips uygulaması yapılmış hastalarda kullanılan median hemoklips

Tablo 2. Hastalara uygulanan endoskopik tedaviler Klips Enjeksiyon + Klips Enjeksiyon + Klips + Heater Enjeksiyon + Heater Band ligasyonu

Birinci endoskopik girişim (n=27)

İkinci endoskopik girişim (n=8)

Üçüncü endoskopik girişim (n=1)

11 9 2 3 1

3 5 – – –

1 – – – –

Hastaların bir tanesine masif kanama nedeniyle cerrahi tedavi uygulandı.

Cilt - Vol. 19 Sayı - No. 2

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sayısı 4 (1-9) idi. En sık uygulanan iki tedavi yöntemi olan enjeksiyon tedavisi+hemoklips uygulaması ve tek başına hemoklips uygulaması yapılan hastaların klinik karşılaştırmaları Tablo 3’de verilmiştir. Klips+enjeksiyon uygulaması yapılan hastaların işlem öncesi ortalama hemoglobin değerleri, tek başına klips uygulanan hastalar ile kıyaslandığında anlamlı derecede düşüktü (p=0,04). Primer hemostaz 18 (%66,6) hastada sağlanmıştı. Ancak 8 (%29,6) hastada ikinci bir endoskopik girişim, 1 (%3,7) hastada ise üçüncü bir endoskopik girişim yapılmıştı. İkinci kez endoskopi işlemi uygulanan hastalar kullandıkları ilaçlar açısından değerlendirildiklerinde bu hastaların sadece 1 tanesinde varfarin kullanım hikayesi vardı. Hasta sayısı yeterli olmadığından hastaların kullandığı ilaçlarla ikinci/üçüncü endoskopik girişim ihtiyacı arasındaki ilişki değerlendirilemedi. Hastalara ortalama 2 (0-9) ünite kan transfüzyon yapılmışdı. Takip ettiğimiz hastalar içinde sadece 1 hastada kanamaya bağlı ölüm izlendi. Kanamanın şiddetli olduğunu düşündürecek klinik bulgulardan biri olan hematokezya şikayeti ile prezente olan 4 hastaya endoskopik tedavi olarak enjeksiyon

tedavisi ve/veya hemoklips uygulaması yapılmıştı. Bu hastaların 2 (%50) tanesi ikinci bir endoskopik girişime ihtiyaç duymuştu. Hastaların kabul esnasındaki medyan hemoglobin değerleri erkeklerde 9,7 (5,3-13,6) g/dl, kadınlarda 8,7 (6-10,6) g/dl idi. Ortalama hematokrit değerleri ise erkeklerde 27,2 (15,8-38,2) g/dl, kadınlarda 25,4 (1831,6) g/dl idi. Tablo 4’de hastaların kabul esnasındaki laboratuvar verileri görülmektedir. Endoskopik işlemler sonrası saptanan DL’nin yerleşim yerleri değerlendirildiğinde midede DL’nin en sık olarak kardiya-fundus’da saptandığı belirlenmiş, bunu korpus ve antrum izlemiştir. Tablo 5’de gastrik yerleşimli DL’lerin yerleşimleri ayrıntılı olarak verilmiştir.

TARTIŞMA Dieulafoy lezyonu nadir bir GİS kanama nedenidir ve özellikle orta yaşlı (ortalama 49-70) popülasyonda ve erkeklerde sıklığı daha fazladır.[1] Üst GİS kanamalarının yaklaşık %0,3-6,7’sinden sorumludur. [6-8] Genellikle hasta hikayesinde NSAİİ ilaç kullanımı

Tablo 3. Tek başına hemoklips uygulaması yapılan hastalarla hemoklips+adrenalin enjeksiyonu yapılan hastaların klinik karşılaştırmaları

Yaş (yıl) Cinsiyet (erkek / kadın) Hemoglobin (g/dl) Kan üre azotu (mg/dl) Yerleşim yeri n (%) Fundus Korpus Antrum Endoskopi sayısı Transfüzyon sayısı (ünite)

Klips (n=11)

Klips + Enjeksiyon (n=9)

p

76 (36-83) 6 / 5 9,7 (5,3-13,6) 42 (32-78) 7 (63,6) 4 (36,4) 2 (1-3) 2 (0-9)

70 (31-80) 4 / 5 8,7 (6-10,6) 38 (29-80) 5 (55,5) 1 (11,1) 3 (33,4) 1 (1-2) 1 (0-8)

0,621 0,653 0,044 0,086

0,298 0,937

Tablo 4. Çalışmaya alınan hastaların kabul esnasındaki laboratuvar değerleri Hemoglobin (g/dl) Hematokrit (%) Beyaz küre (/mm3) Trombosit (/mm3x103) International normalized ratio Kan üre azotu (mg/dl) Kreatinin (mg/dl) Alanin transaminaz (U/L) Aspartat aminotransferaz (U/L) T. bilirubin (mg/dl) Alkalin fosfataz (U/L) Gama glutamil transferaz (U/L) 136

Erkek (n=15)

Kadın (n=12)

p

9,2 (5,9-13,7) 27,8 (15,8-41,6) 7700 (4200-16500) 213 (123-347) 1,1 (0,98-2,48) 44 (36-80) 0,46 (0,2-1,2) 26 (18-50) 23 (17-48) 0,58 (0,4-1,32) 66 (38-124) 24 (12-60)

8,7 (5,3-11,1) 25,2 (16,1-34,2) 6700 (4200-34700) 211 (72-517) 1,20 (1,08-3,45) 39 (32-90) 0,63 (0,3-1,5) 25 (16-48) 25 (16-50) 0,52 (0,3-1,3) 56 (34-110) 26 (12-58)

0,368 0,345 0,233 0,451 0,280 0,431 0,364 0,523 0,531 0,439 0,418 0,532 Mart - March 2013

Dieulafoy lezyonuna bağlı akut GİS kanaması nedeniyle acil servise başvuran olgular

(%43-51), antikoagülan tedavi veya alkol kullanımı mevcuttur. Hipertansiyon, diabetes mellitus, konjestif kalp yetersizliği ve koroner arter hastalığı gibi risk faktörleri (özellikle kan akımında azalmaya neden olan) neredeyse hastaların %75’inde rapor edilmişdir.[9] Bizim olgularımızı değerlendirdiğimiz bu geriye dönük çalışmada DL tanısı alan hastalarımızın %55,6’sı erkek idi. Tüm hasta grubundaki medyan yaş 70 (24-85) idi. Bu ileri yaş ortalaması DL’de endoskopik tedavi modalitelerinin karşılaştırıldığı değişik çalışmalarla örtüşüyordu.[9,10] Hastalarımız eşlik eden hastalıklarına göre değerlendirildiklerinde büyük bir kısmında eşlik eden bir risk faktörü vardı. Her ne kadar eşlik eden bu risk faktörleri kanama miktarını, tedavi sonucunu ve transfüze edilen kan miktarı gibi değişik parametreleri etkilemiş olsa da çalışmamızda bir karşılaştırma grubu olmadığı için, eşlik eden hastalık gibi parametrelerin DL insidansı veya sağkalım üzerindeki etkisini belirtmemiz imkansız gibi gözükmektedir. Ek olarak hastaların belirli bir kısmının aspirin, varfarin gibi antiplatelet/ antikoagülan ilaç kullanım hikayesinin var olması kanamanın uzamasının ve şiddetli olmasının bir nedeni olduğunu düşündürtmektedir. Aynı zamanda hastaların neredeyse beşte birinin PPİ tedavisi aldıklarının saptanması ve buna rağmen kanamalarının olması, DL’de PPİ veya asit baskılayıcı tedavinin kanamaya karşı koruyucu olmayabileceğini düşündürtmüştür. Çalışmaya alınan hasta popülasyonunda, hastalara verilen ortalama kan transfüzyonu sayısı 2 (0-9) ünite idi. Dokuz üniteye kadar varabilen kan transfüzyon ihtiyacı bize, diğer GİS kanama nedenleri ile kıyaslandığında, DL lezyonlarında daha şiddetli kan kaybının olabildiğini göstermektedir. Çalışmamızda DL nedeniyle endoskopik tedavi uyguladığımız ve sonrasında takip ettiğimiz sadece 1 (%3.7) hastada ölüm gerçekleşmişti. Bu düşük mortalite oranının temel nedeni hastanemizin tersiyer bir referans merkezi olması ve aktif GİS kanaması gibi durumlarda 12 saat içinde endoskopik girişim şansının bulunmasıdır. Erken endoskopik girişim lezyonu tanıma ve tedavi etme noktasında gereklidir. Ancak unutulmamalıdır ki aktif kanama olmadığında bazen DL gözden kaçabilir. Bu gibi durumlarda endoskopist özellikle üst GİS kanamasının en sık nedeni olan gastrik veya duodenal ülser gibi bir patolojiyi saptayamadığı durumlarda, proksimal gastrik alanı, özellikle özofagogastrik bileşkeden sonraki ilk 6 cm’lik alanı ayrıntısıyla incelemelidir. Endoskopide kanama işaretinin olmadığı zor olgularda endosonografi ile submukoza yerleşimli geniş çaplı bir damarın izlenmesi muhtemel bir DL’ye işaret edebilir.[11] Literatürde DL tedavisi için her ne kadar çok değişik endoskopik tedavi yöntemleri bildirilmiş olsa da, bu yöntemlerin kullanım önceliğini belirten bir Cilt - Vol. 19 Sayı - No. 2

Tablo 5. Mide yerleşimli Dieulafoy lezyonlarının lokalizasyonları Lokalizasyon Fundus Korpus Antrum

n (%) 16 (59,2) 8 (29,6) 3 (11,2)

çalışma yoktur. Bu da endoskopiste, lezyonun yeri, durumu, aktif kanama varlığı veya yokluğu, elindeki mevcut aletlere ve tecrübesine dayalı olarak tedavi uygulama özgürlüğü sağlamaktadır. Enjeksiyon tedavisi, hemoklips, heater probe ve band uygulaması, lazer tedavisi gibi uygulanan değişik tedavilere bağlı olarak tedavi başarı oranı %75-98 arasındadır.[12-15] Her ne kadar bu tedavi modalitelerinin etkinliğini gösteren değişik çalışmalar mevcut olsa da, yeterli ileriye yönelik çalışma olmadığı için optimal tedavi yöntemi için bir fikir birliği bulunmamaktadır. Günümüzde endoskopistlerin çoğu birincil tedavi olarak hemoklips ve enjeksiyon yöntemlerini tercih etmektedir.[15-17] Bizim çalışmamızın da dikkat çeken en önemli sonucu DL tedavisinde endoskopik hemostaz yöntemi olarak en sık enjeksiyon ve/veya hemoklips kullanıldığını göstermiş olmamız idi. Ancak sadece bu çalışmaya bakılarak DL tedavisinde hemoklips kullanımının üstün olduğu sonucunu çıkarmak da doğru olmayacaktır. Bunun nedeni öncelikle çalışmamızın randomize kontrollü bir çalışma olmaması, geriye dönük verileri içermesi ve hasta sayısının kısıtlı olmasıdır. Ancak DL insidansındaki düşüklük, tedavi etkinliğinin karşılaştılıacağı ileriye yönelik çalışmaların en önemli kısıtlayıcı faktörüdür. Dieulafoy lezyonunda hemoklips uygulamasının başarısı değişik çalışmalarda gösterilmiş olmakla birlikte, gastrik DL’de başarılı hemoklips uygulamasını ilk kez 1988 yılında Hachisu[18] rapor etmiştir. Chung ve arkadaşları,[19] DL nedeniyle takip ettikleri 24 hastayı aldıkları tedaviye göre randomize etmiş, hastalara serum fizyolojik-epinefrin karışımı ya da endoskopik bant ligasyonu (EBL) veya hemoklips uygulamışlardır. EBL veya hemoklips uygulaması gibi endoskopik mekanik tedavi yöntemleri, başlangıç hemostazını sağlamakta, tekrarlayan kanamayı azaltma ve kalıcı hemostaz sağlamada daha başarılı bulunmuştur. Ek olarak, hemoklips uygulaması enjeksiyon terapisi ile kıyaslandığında kanama kontrolünü daha yüksek oranda sağlamıştır. Bu çalışmada saptanan başka bir bulgu da klips+enjeksiyon uygulaması yapılan hastaların işlem öncesi ortalama hemoglobin değerleri, tek başına klips uygulanan hastalar ile kıyaslandığında anlamlı derecede düşük olmasıdır. Bu da şiddetli kanama durumlarında kombine tedavi uygulamasının kanama kontrolü sağlamada bir gereklilik yarattığı ve uygun bir yaklaşım olduğunu düşündürtmektedir. Ek olarak 137

Ulus Travma Acil Cerrahi Derg

kombine tedavi uyguladığımız hastalarda ortalama endoskopi seans sayısı, tek başına klips uygulanan hastalarla kıyaslandığında her ne kadar istatistiksel anlam ifade etmese de daha düşük olarak saptanmıştı. Her ne kadar bizim hastalarımızın sadece 1’inde (%3,7) tek başına EBL uygulanmış olsa da, DL’de EBL uygulamasının en az hemoklips uygulaması kadar etkin olduğunu gösteren çok sayıda çalışma vardır.[20-23] EBL varisiyel üst GİS kanamalarında rutin uygulanan bir prosedürdür. İlk kez Brown ve arkadaşları[15] DL’de EBL ile kanama kontrolünü sağladıklarını 1994 yılında rapor etmişlerdir. Yine Valera ve arkadaşları[20] DL kanaması nedeniyle EBL uyguladıkları 4 hastalarında band ligasyonu ile başarılı hemostaz sağladıklarını rapor etmişler, hastalarının hiçbirinde tekrar kanama görülmediğini belirtmişlerdir. EBL uygulaması sonrasında 14-21 günde iyileşen sığ, temiz tabanlı, ülserler görülebilmektedir. Park ve arkadaşları[17] 26 DL hastasının tedavi sonuçlarını inceledikleri bir çalışmada, EBL veya hemoklips uygulaması yaptıkları hastaların sonuçlarını değerlendirmişlerdir. Belirtilen bu çalışmada EBL veya hemoklips uygulamasının kanayan gastrik DL’li hastalarda benzer etki ve güvenlik profillerine sahip olduğu saptanmıştır. EBL’nin başarılı olarak kullanıldığı bir diğer raporda, gastrik DL dışında EBL’nin özofageal, duodenal, jejunal ve rektal DL’de de etkin olduğu belirtilmiştir.[24-26] Belirtilen bu çalışmalara dayanılarak EBL’nin DL tedavisinde başarılı, etkili, ucuz ve kolay uygulanabilir olduğu sonucuna varılmaktadır. Bizim tek başına EBL uyguladığımız 1 hastaya ikinci bir endoskopi uygulama gerekliliği doğmamıştı. Dieulafoy lezyonu tedavisinde enjeksiyon terapisi halen güncelliğini koruyan ve sık kullanım alanı bulan bir tedavi yöntemidir. Literatürde sklerozan enjeksiyon terapisinin DL tedavisinde kullanıldığı çok sayıda çalışma vardır. Ancak bu çalışmalarda bulunan sonuçlar geniş bir spektrumu temsil etmektedir. Alis ve arkadaşlarının[6] yaptıkları bir çalışmada DL’ye bağlı kanama nedeniyle endoskopi uygulanan hastaların bir kısmına enjeksiyon tedavisi diğer gruba band ligasyonu uygulanmış. Çalışmanın sonucunda band ligasyonunun DL tedavisinde enjeksiyon tedavisine üstün olduğu belirtilmiştir. Yılmaz ve arkadaşlarının[27] yaptığı başka bir çalışmada endoskopik tedavi modalitesi olarak enjeksiyon skleroterapisi uygulanan 28 hasta geriye dönük olarak incelenmiş; endoskopik enjeksiyon skleroterapisinin DL tedavisinde güvenli ve etkili bir yöntem olduğu belirtilmiştir. Enjeksiyon skleroteapisi olarak polidekanol uygulanan 14 hastanın rapor edildiği bir başka çalışmada polidekanol skleroterapisinin etkili ve güvenli olduğu belirtilmiş, ancak bu yöntemin etkisiz kaldığı hastalarda cerrahi girişimin gerekebildiği ve buna rağmen ölüm gelişebileceği belirtilmiştir.[28] 138

Dieulafoy lezyonu tedavisinde heater uygulamasının başarısı biliniyor olmakla birlikte, geniş hasta serilerini içeren randomize kontrollü çalışmalara halen ihtiyaç vardır. Bizim çalışmamızda DL nedeniyle primer hemostaz yöntemi olarak heater uyguladığımız 3 (%11,1) hasta vardı. Hasta sayısının düşük olması, heater uygulamasının diğer tedaviler ile kıyas edilebilmesini zorlaştırmaktaydı. Cheng ve arkadaşları[13] 29 DL hastasında uyguladıkları endoskopik tedavi yöntemlerini geriye dönük olarak karşılaştırmışlar ve sonuçta epinefrin ile heater prob koagülasyonun birlikte kullanımının tek başına epinefrin kullanımı ile kıyaslandığında hemostaz sağlamadaki başarısının daha yüksek olduğunu belirtmişlerdir. Lin ve arkadaşları[10] tek başına heater probe uygulanan 6 hastada %100 başarılı endoskopik müdahele rapor etmişlerdir. Parra-Blanco ve arkadaşları[29] her ne kadar bir miktar düşük başarı oranı rapor etmişler ise de, tedavi başarısı sağladıkları 6 hastanın 4 tanesinde tekrar kanama izlenmemiştir. Heater probun başarısız olduğu iki hastanın birine hemoklips uygulaması, diğerine ise öncelikle ethanol enjeksiyonu sonrasında hemoklips uygulaması yapılarak kanamanın durduğu rapor edilmiştir. Hastalarımız DL lokalizasyon yeri olarak değerlendirildiklerinde en sık yerleşim yerinin fundus olduğu saptandı. Bunu korpus ve antrum takip etmekde idi. Şiddetli kanama işaretleri taşıyan hastalar DL lokalizasyon yeri açısından değerlendirildiklerinde aralarında anlamlı bir ilişki saptanamadı. Bu da kanama şiddetinin, DL lokalizasyonundan bağımsız olduğunu düşündürmektedir. Dieulafoy lezyonu cerrahi tedavi oranları, endoskopik tedavi yöntemlerinin ve başarı şansının zaman içinde artması nedeniyle belirgin azalmışdır. Günümüzde cerrahi tedavinin hastaların ancak %4-8’inde gerektiğini gösteren çalışmalar mevcuttur. Bizim çalışmamızda sadece 1 (%3,7) hastaya cerrahi ihtiyacı doğmuş ve cerrahi olarak gastrotomi ve primer sütur işlemi uygulanmıştı. Sonuç olarak, DL karakteristik morfolojik ve klinik özellikler içeren, ancak tanı konması bazı durumlarda zor olan, hayatı tehdit edecek boyutta kanamaya neden olabilecek nadir bir üst GİS kanama nedenidir. Tanı konmazsa yüksek morbidite ve mortalite ile seyredebilir. En sık olarak midede yerleşmekle birlikte, sindirim sisteminin herhangi bir segmentinde gözlenebilir. Üst GİS kanaması nedeniyle acil endoskopik girişim uygulanan her hastada bu tanı akla gelmeli, kardiya ve çevre bölgenin dikkatli incelemesi mutlaka yapılmalıdır. Tedavide tek başına hemoklips uygulaması veya hemoklips ile birlikte adrenalin enjeksiyonu etkili bir yöntem gibi gözükmektedir. EBL uygulamasının etkinliği değişik çalışmalarda gösterilmiştir. Cerrahi tedavi öncesi mutlaka endoskopik tedavi yöntemlerinin denenmiş olması gereklidir. DL tedavisinde Mart - March 2013

Dieulafoy lezyonuna bağlı akut GİS kanaması nedeniyle acil servise başvuran olgular

endoskopik tedavi yöntemleri etkili, uygulaması kolay, ucuz ve güvenilirdir. Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması yoktur.

KAYNAKLAR 1. Baxter M, Aly EH. Dieulafoy’s lesion: current trends in diagnosis and management. Ann R Coll Surg Engl 2010;92:54854. 2. Bingener J, Gostout CJ. Management of nonvariceal upper gastrointestinal bleeding. Gastrointest Endosc Clin N Am 2011;21:721-30. 3. Sostres C, Lanas A. Epidemiology and demographics of upper gastrointestinal bleeding: prevalence, incidence, and mortality. Gastrointest Endosc Clin N Am 2011;21:567-81. 4. British Society of Gastroenterology Endoscopy Committee. Non-variceal upper gastrointestinal haemorrhage: guidelines. Gut 2002;51 Suppl 4:iv1-6. 5. Peumery JJ. Georges Dieulafoy (1839-1911) and the teaching of medicine in Paris at the hinge of the Second Empire and the Third Republic. [Article in French] Vesalius 2004;10:747. [Abstract] 6. Alis H, Oner OZ, Kalayci MU, Dolay K, Kapan S, Soylu A, et al. Is endoscopic band ligation superior to injection therapy for Dieulafoy lesion? Surg Endosc 2009;23:1465-9. 7. Marek TA. Gastrointestinal bleeding. Endoscopy 2007;39:998-1004. 8. Norton ID, Petersen BT, Sorbi D, Balm RK, Alexander GL, Gostout CJ. Management and long-term prognosis of Dieulafoy lesion. Gastrointest Endosc 1999;50:762-7. 9. Schmulewitz N, Baillie J. Dieulafoy lesions: a review of 6 years of experience at a tertiary referral center. Am J Gastroenterol 2001;96:1688-94. 10. Lin HJ, Lee FY, Tsai YT, Lee SD, Lee CH, Kang WM. Therapeutic endoscopy for Dieulafoy’s disease. J Clin Gastroenterol 1989;11:507-10. 11. Levy MJ, Wong Kee Song LM, Farnell MB, Misra S, Sarr MG, Gostout CJ. Endoscopic ultrasound (EUS)-guided angiotherapy of refractory gastrointestinal bleeding. Am J Gastroenterol 2008;103:352-9. 12. Adler DG, Leighton JA, Davila RE, Hirota WK, Jacobson BC, Qureshi WA, et al. ASGE guideline: The role of endoscopy in acute non-variceal upper-GI hemorrhage. Gastrointest Endosc 2004;60:497-504. 13. Cheng CL, Liu NJ, Lee CS, Chen PC, Ho YP, Tang JH, et al. Endoscopic management of Dieulafoy lesions in acute nonvariceal upper gastrointestinal bleeding. Dig Dis Sci 2004;49:1139-44. 14. Yanar H, Dolay K, Ertekin C, Taviloglu K, Ozcinar B, Guloglu R, et al. An infrequent cause of upper gastrointestinal

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tract bleeding: “Dieulafoy’s lesion”. Hepatogastroenterology 2007;54:1013-7. 15. Brown GR, Harford WV, Jones WF. Endoscopic band ligation of an actively bleeding Dieulafoy lesion. Gastrointest Endosc 1994;40:501-3. 16. Lara LF, Sreenarasimhaiah J, Tang SJ, Afonso BB, Rockey DC. Dieulafoy lesions of the GI tract: localization and therapeutic outcomes. Dig Dis Sci 2010;55:3436-41. 17. Park CH, Joo YE, Kim HS, Choi SK, Rew JS, Kim SJ. A prospective, randomized trial of endoscopic band ligation versus endoscopic hemoclip placement for bleeding gastric Dieulafoy’s lesions. Endoscopy 2004;36:677-81. 18. Hachisu T. Evaluation of endoscopic hemostasis using an improved clipping apparatus. Surg Endosc 1988;2:13-7. 19. Chung IK, Kim EJ, Lee MS, Kim HS, Park SH, Lee MH, et al. Bleeding Dieulafoy’s lesions and the choice of endoscopic method: comparing the hemostatic efficacy of mechanical and injection methods. Gastrointest Endosc 2000;52:721-4. 20. Valera JM, Pino RQ, Poniachik J, Gil LC, O’Brien M, Sáenz R, et al. Endoscopic band ligation of bleeding dieulafoy lesions: the best therapeutic strategy. Endoscopy 2006;38:1934. 21. Yen HH, Chen YY. Endoscopic band ligation for Dieulafoy lesions: disadvantages and risks. Endoscopy 2006;38:651. 22. Xavier S. Band ligation of Dieulafoy lesions. Indian J Gastroenterol 2005;24:114-5. 23. Mumtaz R, Shaukat M, Ramirez FC. Outcomes of endoscopic treatment of gastroduodenal Dieulafoy’s lesion with rubber band ligation and thermal/injection therapy. J Clin Gastroenterol 2003;36:310-4. 24. Al-Kawas FH, O’Keefe J. Nd:YAG laser treatment of a bleeding Dieulafoy’s lesion. Gastrointest Endosc 1987;33:38-9. 25. Hurlstone DP. Successful endoscopic band ligation of duodenal Dieulafoy’s lesions. Further large controlled studies are required. Scand J Gastroenterol 2002;37:620. 26. Murray KF, Jennings RW, Fox VL. Endoscopic band ligation of a Dieulafoy lesion in the small intestine of a child. Gastrointest Endosc 1996;44:336-9. 27. Yilmaz M, Ozütemiz O, Karasu Z, Ersöz G, Günsar F, Batur Y, et al. Endoscopic injection therapy of bleeding Dieulafoy lesion of the stomach. Hepatogastroenterology 2005;52:1622-5. 28. Ortuño-Cortés JA, Quintana-Tomás L, García-García A. Endoscopic sclerotherapy is useful in Dieulafoy’s disease. [Article in Spanish] Gastroenterol Hepatol 1996;19:47-51. [Abstract] 29. Parra-Blanco A, Takahashi H, Méndez Jerez PV, Kojima T, Aksoz K, Kirihara K, et al. Endoscopic management of Dieulafoy lesions of the stomach: a case study of 26 patients. Endoscopy 1997;29:834-9.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):140-144

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.06888

Pediatrik travma skorunun yüksek kinetik enerjiye sahip parça etkili yaralanmalardaki analizi: İlk müdahale merkezi sonuçları Analysis of the pediatric trauma score in patients wounded with shrapnel; the effect of explosives with high kinetic energy: results of the first intervention center Hüseyin TAŞ,1 Ayhan MESCİ,2 Suzi DEMİRBAĞ,3 Mehmet ERYILMAZ,4 Taner YİĞİT,2 Yusuf PEKER2 AMAÇ

BACKGROUND

Parça etkili patlayıcılar ile gerçekleşen pediatrik travma olgularının epidemiyolojik ve klinik verileri ışığında pediatrik travma skorunun analizi amaçlandı.

We aimed to assess the pediatric trauma score analysis in pediatric trauma cases due to shrapnel effect of explosives material with high kinetic energy.

GEREÇ VE YÖNTEM

METHODS

Şubat 2002 ve Ağustos 2005 tarihleri arasında başvuran 17 pediatrik travma olgusunun verileri geriye dönük olarak incelendi. Yaş, cinsiyet, travma-hastane aralığı, travma mekanizması, yaralanan organlar, pediatrik Glaskow koma skoru (PGKS), pediatrik travma skoru (PTS), hemodinamik parametreler, kan transfüzyonu ve yapılan müdahaleler ile hastanede kalış süresine (HKS) ait bilgiler araştırıldı.

The data of 17 pediatric injuries were reviewed retrospectively between February 2002 and August 2005. The information about age, gender, trauma-hospital interval, trauma mechanism, the injured organs, pediatric Glasgow coma score (PGCS), pediatric trauma score (PTS), hemodynamic parameters, blood transfusion, interventions and length of hospital stay (LHS) were investigated.

BULGULAR

RESULTS

Olguların tamamında ekstremite travması varken 4 olguda travmatik alt ekstremite ampütasyonu vardı. Transport süresi, olguların %35’inde ≤1 saat iken %65’inde ise >1 saat idi. Olguların %35,3’ünde (n=6) PTS ≤8 olarak hesaplanırken %64,7’sinde (n=11) skor >8 olarak bulundu. PTS ≤8 olan olgularda nabız ortancası 94/dk, PTS >8 olanlarda bu değer 70/dk olarak bulundu (p=0,007). PTS ≤8 olan olgularda morbidite oranı %29,4 (n=5), PTS >8 olanlarda ise %5,9 (n=1) idi (p=0,026). PTS ≤8 olan olgularda HKS’nin 22,8 gün, PTS >8 olan olgulardaki HKS’nin ise 4 gün olduğu görüldü. HKS arasındaki bu farkta istatistiksel olarak anlamlıydı (p=0,001).

While all patients suffered from trauma to the extremities, only four patients had traumatic lower-limb amputation. Transportation time was ≤1 hour in 35% of cases, and >1 hour in 65% of cases. While PTS was found as ≤8 in 35.3% of cases (n=6), the score was found to be higher than 8 in 64.7% of them (n=11). Median heart rate in patients with PTS ≤8 was 94 beats/min. This value was 70 beats/min in those with PTS >8 (p=0.007). Morbidity rates of PTS ≤8 cases and PTS >8 cases were 29.4% and 5.9%, respectively (p=0.026). While LHS was 22.8 days in PTS ≤8 cases, LHS was found to be only 4 days in PTS >8 cases. This difference was found to be statistically significant (p=0.001).

SONUÇ

CONCLUSION

PTS parça etkili patlayıcı yaralanmalarında travmanın değerlendirilmesinde oldukça etkin ve zaman kazandırıcıdır. PTS ≤8 olan olgularda nabız ortancası, morbidite ve HKS belirgin olarak artmaktadır.

PTS is very efficient and a time-saving procedure to assess the severity of trauma caused by the shrapnel effect. The median heart rate, morbidity, and LHS increased significantly in patients with PTS ≤8.

Anahtar Sözcükler: Parça etkili patlayıcılar; pediatrik; pediatrik travma skoru; travma; yüksek kinetik enerji.

Key Words: Shrapnel effect of explosives material; pediatric; pediatric trauma score; trauma; high kinetic energy.

1 Şırnak Askeri Hastanesi, Genel Cerrahi Kliniği, Şırnak; Gülhane Askeri Tıp Akademisi, 2Genel Cerrahi Anabilim Dalı, 3 Çocuk Cerrahisi Anabilim Dalı, 4Acil Tıp Anabilim Dalı, Ankara.

1 Department of General Surgery, Şırnak Military Hospital, Şırnak; Departments of 2General Surgery, 3Pediatrik Surgery, 4Emergency Surgery, Gülhane Military Medical Academy, Ankara, Turkey.

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

140

Pediatrik travma skorunun yüksek kinetik enerjiye sahip parça etkili yaralanmalardaki analizi

Travma, pediatrik ve adölesan yaş grubunun hem tanı hem de tedavi alanlarındaki yeniliklere rağmen halen en sık mortalite nedenidir.[1] Travma merkezlerine ve acil servislere başvuran pediatrik popülasyondaki travma olgularının yaklaşık %10’unu penetran yaralanmalar oluştururken ateşli silah yaralanmaları bu tür yaralanmaların en önemli nedenidir.[2] Çatışma bölgelerinde terörist gruplar tarafından gerçekleştirilen ateşli silah yaralanmalarının sivil ortamdaki yaralanmalardan en önemli farkı yaralanma mekanizması ve yarattığı tahribatın büyüklüğüdür. Bu tahribat, yüksek kinetik enerji taşıyan mermi ve parça etkili patlayıcıların dokuda ilerlerken blast etkisine (geçici kavite) bağlı olarak etraf dokulara da zarar vermesi nedeniyle düşük kinetik enerjili yaralanmalardan daha ciddidir.[3] Penetran pediatrik travma olgularında yaralanma mekanizmasına bakılmaksızın en sık mortaliteye hemoraji neden olmaktadır.[2] Travmaya uğrayan çocukların yaşam oranlarının yükseltilmesi için triyaj işleminin önemi büyüktür. Bu amaçla çeşitli travma değerlendirme yöntemleri geliştirilmiştir. Pediatrik Glasgow koma skalası (PGKS), yaralanma şiddet derecesi skoru (Injury Severity Score - ISS) ve pediatrik travma skoru (PTS) gibi skalalar travmaya uğramış çocukları değerlendirmek amacıyla geliştirilmiş skorlama sistemleridir. Bunların içerisinde pediatrik olgularda travmanın ciddiyetini belirten PTS kliniklerde yoğun olarak kullanıma girmiştir (Tablo 1). PTS ≤8 olan olgularda morbidite ve mortalitenin PTS >8 olan olgulara göre daha yüksek olduğu belirtilmektedir.[4] Bu çalışmada, ilk müdahale merkezi olan hastanemizde yüksek kinetik enerjiye sahip parça etkili patlayıcılar ile gerçekleşen pediatrik travma olgularının epidemiyolojik ve klinik verileri ışığında PTS’nin analizi amaçlandı.

GEREÇ VE YÖNTEM İlk müdahale yeri olan bölge hastanesine Şubat 2002 ve Ağustos 2005 tarihleri arasında parça tesirli patlayıcı

ile oluşan yaralanma nedeniyle başvuran 17 pediatrik olgunun verileri geriye dönük olarak incelendi. Olgulara acil servise geldiklerinde hızlı ve etkili bir sistemik fiziksel inceleme yapıldı. Vital bulguları değerlendirilip damar yolu açıldıktan sonra laboratuvar incelemeleri ve kan grubu tayini için kan örneği alındı. Tüm olguların anal bölge incelemesi ve üretral kataterizasyonu yapıldı. İlk girişim ardından tüm olgulara profilaktik tetanoz aşısı, üçlü antibiyotik sağaltımı (I. kuşak sefalosporin, metranidazol ve aminoglikozit) ile intravenöz izotonik solüsyonu verilerek monitörize edildiler. Merkezimiz ilk müdahale hastanesi olması nedeniyle şok tablosundaki olgulara ameliyattan önce uygulanan transfüzyonda hasta başı cross-match ile tam kan kullanıldı. Her hastanın yaş, cinsiyet, travma-hastane aralığı, travma mekanizması, yaralanan organlar, PGKS, PTS, hemodinamik parametreler, kan transfüzyonu ve yapılan müdahaleler ile hastanede kalış süresine (HKS) ait bilgiler kayıt altına alındı. Olgulara ilişkin tanımlayıcı istatistiklerin gösteriminde median (IQR, interquatile range - çeyreklikler arası sapma) değerleri kullanıldı. Interval ve PTS skorlarına göre karşılaştırmalar yapmak için MannWhitney U-testi uygulandı. İstatistiksel analiz ve hesaplamalar; MS-Excel 2003 ve “SPSS for Windows Ver. 15.0” (SPSS Inc., Chicago, IL., USA) paket programları ile yapıldı. İstatistiksel kararlarda p<0,05 seviyesi anlamlı farklılığın göstergesi olarak kabul edildi.

BULGULAR Bu çalışmada, sadece yüksek kinetik enerjiye sahip parça tesirli patlayıcıya bağlı olarak gelişmiş yaşları 1 ile 15 arasında değişen, 10’u kız, 7’si erkek toplam 17 pediatrik travma olgusunun verileri geriye dönük olarak incelendi. Olguların yaşları daha çok 6-10 yaşları arasında yoğunlaşmakla birlikte yaş ortalamaları 8 yaş idi (Şekil 1). Olguların ortalama sistolik/diyastolik kan basınçları 100/60 mmHg, nabızları 80/dk, Hb’leri 12 mg/dl, Htc’leri %36,4 idi. HKS’leri ise ortalama 7 gün idi (Şekil 2).

Tablo 1. Pediatrik travma skoru Değişkenler

+2

+1

-1

Hava yolu Bilinç durumu Vücut ağırlığı Sistolik sasınç Açık yara İskelet sistemi travması

Normal Uyanık >20 kg >90 mmHg Yok Yok

Hava yolu açıklığı sürdürülebilir Donuklaşma veya bilinç düzeyinde azalma 10-20 kg 50-90 mmHg Minör Kapalı kırık var

Hava yolu açıklığı sürdürülemez veya entübasyon gerekir Koma

<10 kg <50 mmHg Majör Açık kırık veya çoklu kırıklar

Skor -6 ile +12 arasında değişir. <8 puan potansiyel olarak önemli bir travmayı ifade eder.

Cilt - Vol. 19 Sayı - No. 2

141

Ulus Travma Acil Cerrahi Derg 10 9 8 7 6 5 4 3 2 1 0

50,00

Hematokrit

45,00

Hemoglobin

40,00 35,00 30,00 25,00 20,00 0-5 yaş

6-10 yaş Erkek

11-15 yaş

15,00

>15 yaş

Kız

10,00

Şekil 1. Yaşlara göre hasta dağılımı.

5,00

İlk değerlendirmede olguların tamamında ekstremite travması varken 2 olguda karın, 2 olguda toraks ve karaniyal yaralanma ek olarak vardı. Dört olguda travmatik alt ekstremite ampütasyonu olduğu görüldü. Bu olgular kanama kontrolünü takiben acil ameliyata alındı.

0,00

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Şekil 2. Hastaların hemoglobin ve hematokrit değerlerinin dağılımı.

Olguların %35’i travma sonrası bir saat içerisinde ilk müdahale merkezine transport edilebilirken

Tablo 2. Hastaneye geliş süresine göre karşılaştırma sonuçları

İnterval (saat)

n

Medyan

IQR

Z

p

≤1 >1 ≤1 >1 ≤1 >1 ≤1 >1 ≤1 >1 ≤1 >1 ≤1 >1 ≤1 >1 ≤1 >1

6 11 6 11 6 11 6 11 6 11 6 11 6 11 6 11 6 11

9,0 8,0 100,0 100,0 60,0 70,0 91,0 72,0 14,5 14,0 37,2 33,0 11,9 12,0 7,5 9,0 17,5 4,0

9,0 4,0 17,5 10,0 17,5 10,0 20,5 28,0 2,0 1,0 15,0 7,8 6,2 1,6 3,3 3,0 18,5 11,0

0,454 1,125 0,480 1,814 0,614 0,252 0,403 1,021 1,721

0,660

Yaş SKB DKB Nabız PGKS Hematokrit Hemoglobin PTS Hospitalizasyon süresi

0,301 0,660 0,078 0,591 0,808 0,733 0,404 0,098

SKB: Sistolik kan basıncı; DKB: Diastolik kan basıncı; PGKS: Pediatrik Glaskow koma skoru; PTS: Pediatrik travma skoru.

Tablo 3. Pediatrik travma skoruna göre karşılaştırma sonuçları PTS ≤8 a(6) >8 (11) ≤0

Yaş (yıl)

Nabız (dk)

PGKS

Hb (mg/dl)

Hematokrit (%)

Morbidite n (%)

OHKS (gün)

10 8

94 70 –

14 14 –

11,5 12,5 –

34,7 37,8

5 (29,4) 1 (5,9) –

22,8 4,0 –

PGKS: Pediatrik Glaskow koma skoru; OHKS: Ortalama hastanede kalış süresi; PTS: Pediatrik travma skoru. a: p=0.301, p=0.007, p=0.301, p=0.06, p=0.35, p=0.026, p=0.001 vs PTS >8.

142

Mart - March 2013

Pediatrik travma skorunun yüksek kinetik enerjiye sahip parça etkili yaralanmalardaki analizi

%65’inin transportu bir saatten daha uzun sürdü. Hastaneye geliş sürelerine göre karşılaştırma sonuçları Tablo 2’de verildi. Hastaneye geliş süresi değişkenlerin hiçbiri üzerinde istatistiksel bir fark oluşturmadı (Tablo 2). Olguların %35,3’ünde (n=6) PTS ≤8 olarak hesaplanırken %64,7’sinde (n=11) skor >8 olarak bulundu. PTS değerinin, nabız, morbidite ve HKS dışında hiçbir değişken üzerinde istatistiksel olarak anlamlı bir etkisi bulunmadı (Tablo 3). PTS ≤8 olan olguların nabız ortancası 94/dk iken PTS >8 olan olgularda bu değer 70/dk olarak tespit edildi. Bu fark istatistiksel olarak anlamlı bulundu (p=0,007). PTS ≤8 olan olgularda morbidite oranı %29,4, PTS >8 olanlarda ise %5,9 idi. İki grup arasındaki bu fark istatistiksel olarak anlamlıydı (p=0.026). Çalışmamızda bölge hastanesine transportu sağlanmış ve çalışmaya alınan hiçbir olguda mortaliteye rastlanmadı. PTS ≤8 olan olgularda HKS’nin 22,8 gün, PTS >8 olan olgulardaki HKS’nin ise 4 gün olduğu görüldü. HKS arasındaki bu fark istatistiksel olarak anlamlıydı (p=0.001).

TARTIŞMA Travmalı pediatrik olguların tedavisinde morbidite ve mortalite oranlarının azaltılması amacıyla oluşturulmuş çeşitli travma skorlama sistemleri vardır. Bunların bir kısmı erişkin skorlama sistemlerinden uyarlanmıştır. Ancak, erişkinlerle çocuklar arasında anatomik ve fizyolojik farkların olması özgün yaklaşımları gerektirmiştir.[4,5] Parça etkili patlayıcılar ile gerçekleşen ateşli silah yaralanmaları çatışma ortamları dışında günümüzde kitleleri hedef seçen terör olayların artması nedeni ile sivil ortamlarda da görülmektedir. Bununla birlikte pediatrik olgularda bu tür yaralanmalar oldukça nadirdir. Bu tür yaralanmaların değerlendirilmesinde kullanılan travma şiddet derecelendirme skorları farklı mekanizmalarla gelişen travma türlerindekinden değişiklikler göstermektedir. Bostancı ve ark. çalışmalarında travma-hastane aralığı ile HKS arasında anlamlı bir ilişki olduğunu ortaya koymuşlardır. İlk bir saatte hastaneye ulaştırılan pediatrik travmalı olgularda HKS, transport süresi bir saatten fazla olan hastalara göre anlamlı derecede düşük bulunmuştur.[6] Bizim çalışmamızda bu ilişki gösterilememiş olmakla birlikte travma-hastane aralığı bir saatten fazla olan hastalarda ortalama HKS’nin daha kısa olduğu saptanmıştır. Bu sonucu ilk müdahale yerinde yapılan triyaj sonucu travma ciddiyeti fazla olan olguların ambulans helikopterleri ile ilk müdahaCilt - Vol. 19 Sayı - No. 2

le merkezine taşınmış olmasına bağlamaktayız. Yapılan çalışmalarda kritik değer olarak belirtilen PTS >8 olması durumunda mortalite oranının %9 olduğu, PTS değerinin ≤8 olması durumunda mortalite oranının ters orantılı olarak arttığı ve ortalama HKS’nin de buna bağlı olarak uzadığı bildirilmektedir.[5,7] Çalışmamızda, PTS ≤8 olan olgulardaki HKS anlamlı derecede yüksek bulunması morbidite oranlarıyla doğrudan ilişkili olduğunu düşünmekteyiz. Ayrıca PTS >8 ve ≤8 olan olgularımızdaki nabız farkının istatistiksel olarak anlamlı bulunmasını skor hesaplanırken kriterler içerisinde sistolik tansiyonun bir parametre olarak kullanılmasıyla ile ilişkilendirdik. Nabız ve sistolik tansiyon değerleri travmanın ciddiyeti ile değişim göstermektedir. PTS hesaplanırken düşük sistolik tansiyon kullanılan bir parametre olması yanında nabızda bununla orantılı olarak artmaktadır. [8] Çalışmamızdaki PTS ≤8 olan olgulardaki nabız ortancasının istatistiksel olarak anlamlı derecede yüksek bulunması diğer çalışma sonuçlarını desteklemektedir. Travma şiddetinin artması morbidite ile beraber mortalite oranını da artırmaktadır. Buna bağlı olarak PTS ≤8 olan olgularda morbidite ve mortalitenin PTS >8 olan ogulara göre daha yüksek olduğu bildirilmektedir.[4,8] Serimizde mortalite olmamasına rağmen özellikle travma ciddiyeti yüksek PTS ≤8 olan olgulardaki morbidite oranı literatüre uygun şekilde istatistiksel olarak anlamlı derecede yüksek bulundu. HKS, travma ciddiyeti ve buna bağlı olarak gelişebilecek artmış komplikasyon oranları nedeni ile uzamaktadır. Çalışmamızda PTS ≤8 olan olgularda tespit edilen yüksek HKS, bu olgulardaki travmanın ciddiyeti nedeniyle belirgin olarak artmıştır. Serimize ait bu veriler diğer çalışmalara ait sonuçlar ile uyumludur. [4,5,7,8]

Sonuç olarak, PTS parça etkili patlayıcı yaralanmalarında travmanın değerlendirilmesinde oldukça etkin ve zaman kazandırıcıdır. PTS ile değerlendirilmiş yüksek kinetik enerjiye sahip parça etkili yaralanmalar analiz edildiğinde, PTS ≤8 olan olgularda nabız ortancası, morbidite ve HKS belirgin olarak artmaktadır. Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması yoktur.

KAYNAKLAR 1. Mikrogianakis A. Penetrating abdominal trauma in children. Clinical Pediatric Emergency Medicine 2010;11:217-24. 2. Snyder AK, Chen LE, Foglia RP, Dillon PA, Minkes RK. An analysis of pediatric gunshot wounds treated at a Level I pediatric trauma center. J Trauma 2003;54:1102-6. 3. Mesci A, Arıcı C. Travma kinematiği. Travma resüsitasyon Kitabı; 2008. 4. Inan M, Ceylan T, Ayvaz S, Aksu B, Pul M. Diagnostic value of pediatric trauma score in blunt abdominal injuries. Ulus 143

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Travma Acil Cerrahi Derg 2005;11:238-41. 5. Jandric S. Injury severity and functional outcome following paediatric trauma in war conditions. Pediatr Rehabil 2001;4:169-75. 6. Bostancı İ, Sarıoğlu A, Cinbiş M, Bedir E, Herek O, Akşit M. Çocuk acil servise kabul edilen travma olgularının epidemiyolojik değerlendirilmesi. Ulus Travma Acil Cerrahi Derg 1998;4:261-4.

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7. Diamond IR, Parkin PC, Wales PW, Bohn D, Kreller MA, Dykes EH, et al. Pediatric blunt and penetrating trauma deaths in Ontario: a population-based study. J Pediatr Surg 2009;44:981-6. 8. Soyer T, Deniz T, Akman H, Hançerlioğullari O, Türkmen F, Cesur O, et al. The impact of Pediatric Trauma Score on burden of trauma in emergency room care. Turk J Pediatr 2009;51:367-70.

Mart - March 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):145-151

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.75301

Mid-term results of calcaneal plating for displaced intraarticular calcaneus fractures Eklemiçi kalkaneus kırıklarında cerrahi tedavi yöntemimizin orta dönem sonuçları Deniz GÜLABİ,1 Ferdi SARI,1 Cengiz ŞEN,2 Cem Coşkun AVCI,1 Fevzi SAĞLAM,1 Mehmet ERDEM,1 Güven BULUT1

BACKGROUND

AMAÇ

The radiological and functional results of surgical treatment in intraarticular calcaneal fractures are presented in this study.

Kalkaneus kırıklarında cerrahi tedavi sonuçlarımız radyolojik ve fonksiyonel açıdan değerlendirildi.

METHODS

Kasım 2003 - Mayıs 2009 tarihleri arasında kliniğimizde deplase intraartiküler kırığı olan 26 hastanın 27 ayağı çalışmaya alındı. Hastaların 21’i erkek (%81), 5’i kadın (%19) ve ameliyat olduklarında ortalama yaşları 29,2 (18-61) idi. Kalkaneus plağı kullanılarak açık redüksiyon ve internal tespit kullanıldı.

27 feet of 26 patients with displaced intraarticular fractures were treated surgically in our clinic between November 2003 and May 2009. Twenty-one patients were male (81%), and 5 were female (19%). The average age was 29.2 (range, 18-61 years) at the time of the surgical treatment. Open reduction internal fixation was performed by using a calcaneal plate. RESULTS

The results were evaluated according to the Maryland foot scores and Creighton-Nebraska scores. The mean follow-up period was 34.4 months (range, 19-85 months). The radiological evaluation was made according to the mean value changes of Böhler and Gissane angles after injury and at the last follow-up. Except for 3 patients with Sanders type 4 fractures, good results were obtained with surgical treatment. CONCLUSION

We conclude that open reduction and internal fixation methods yield a reasonable outcome, even in patients with Sanders type 4 intraarticular fractures of the calcaneus.

GEREÇ VE YÖNTEM

BULGULAR

Hastalar Maryland ve Creighton-Nebraska ayak değerlendirme skorlarına göre değerlendirildi. Radyolojik değerlendirme Böhler ve Gissane açılarındaki değişikliklere göre yapıldı. Hastalar ortalama 34,4 ay (dağılım, 6-79 ay) takip edildi. Üç hasta dışında diğer hastalarda iyi ve çok iyi sonuç elde edildi. SONUÇ

Sanders tip 4 kırığı olan hastalarda tatmin edici sonuçlar elde ettiğimiz için, bu tip kırıklarda bile açık redüksiyon internal tespit uygulamasının makul bir seçenek olduğu kanısındayız.

Key Words: Calcaneal plating; calcaneus fracture; intraarticular fracture; Sanders classification.

Anahtar Sözcükler: Kalkaneus plakları; kalkaneus kırıkları; eklemiçi kırıklar; Sanders sınıflaması.

Department of Orthopaedic and Traumatology, Dr. Lutfi Kırdar Kartal Training and Research Hospital, Istanbul; 2 Department of Orthopaedic and Traumatology, Bezmi Alem University Faculty of Medicine, Istanbul, Turkey.

Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul; Bezmi Alem Üniversitesi Tıp Fakültesi Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul.

1

1

2

Correspondence (İletişim): Deniz Gülabi, M.D. Caferağa Mah. Hacı Şükrü Sok., Hür Apt. No: 38/10, 34710 Kadıköy, İstanbul, Turkey. Tel: +90 - 216 - 449 27 24 e-mail (e-posta): dgulabi@yahoo.com

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Ulus Travma Acil Cerrahi Derg

Calcaneus fractures occur due to high-energy traumas such as falls from height and traffic accidents. These fractures are very important in socioeconomic terms as well, as they deprive 20% of the patients from returning to their jobs completely for up to three to five years following injury.[1-3] Calcaneus fractures comprise 2% of all the fractures, and they are the most common fractures among the tarsal bone fractures. Intraarticular calcaneus fractures comprise 75% of all the calcaneus fractures.[3,4] Another important point to note is that the forces that cause the calcaneus fracture also injure the surrounding tissues to some extent. While some authors suggest that the best results are obtained by surgical methods (open reduction and internal fixation, subtalar arthrodesis or percutaneous screw fixation), others advocate a conservative treatment method.[2,5-9] In this study, we present the midterm results of open reduction internal fixation for the treatment of intraarticular calcaneal fracture. Our aim is to determine the success rate of our open reduction and internal fixation for intraarticular calcaneus fractures according to Maryland and Creighton-Nebraska foot scores.[10]

MATERIALS AND METHODS Twenty-six patients with 38 displaced fractures were surgically treated between November 2003 and May 2009. Ten were excluded due to lack of followup, which left the study group of 26 patients with 27 displaced intraarticular calcaneus fractures. Twentyone patients were male (81%), and five patients were female (19%), and their average age was 29.2 years (18-61 years) when they were operated. Nineteen patients had isolated left, six patients had isolated right, and one patient had bilateral intraarticular calcaneus fractures. The reason for injury was fall from height in all patients. Nine patients displayed accompanying injuries: Thoracic vertebral compression fractures in two patients, and radial head, glenoid, cuboid, second metatarsal, pilon tibia, lumbar burst, occipital, subtrochanteric, tibial plateau, sacrum, lateral mallolar, and pubic rami fracture in one patient each. Additionally, six patients exhibited contralateral calcaneal fractures without articular displacement, which were treated conservatively. Anteroposterior, lateral, and tangential radiographs and computed tomography were obtained in all patients prior to surgical treatment. Decision-making and planning of the surgical treatment of the patients were undertaken according to the Sanders classification during evaluation of the computed tomography (Table 1). 146

The time interval from trauma to surgery was eight days on average (4-22 days). One patient, who was operated late on the 22nd day, had been followed up by the brain surgery clinic for 17 days due to head trauma and was then referred to our clinic. A plaster brace and immobilization and elevation were applied until the operation date. Twenty-seven calcanei of 26 patients were operated, and extended lateral incision was used in all patients. Sherman reconstruction plates were used in 18 patients and Sanders anatomic calcaneus plates in 9 calcanei. Bone grafting was performed in all patients (autogenous iliac bone grafts in 18 and allografts in 8) (Table 1). Surgical technique The patient was placed on a radiolucent table in the lateral decubitis position so that the fractured extremity would face upwards. In patients who consented to autogenous iliac grafting, the ipsilateral iliac wing was also prepared sterile. The extended lateral incision was used in all patients. The fractured lateral wall was lifted with the help of an osteotome, followed by reduction of the sustencalum calcanei, anterior process, tuberosity and then the posterior facet. Once the correction was checked with the c-arm and found to be accurate, bone grafting was utilized into the defect in the calcaneal body and then internal fixation was performed using a plate (Figs. 1a to d, Figs. 2a to c). Active ankle and foot range-of-motion exercises were initiated on day 2. The same day, patients were mobilized with crutches if not contraindicated due to an associated injury, without weight-bearing. At 15 days postoperatively, the sutures were removed and the posterior splint was discharged. The patients were allowed to bear weight by an average of 10.4 weeks (9-13 weeks) after the surgical treatment. All patients were evaluated according to the Maryland foot score and Creighton-Nebraska score on their last follow-up day.

RESULTS The average follow-up time was 34.4 months (19-85 months). Twelve fractures were Sanders type 2 (44.5%), 10 were type 3 (37%) and 5 were type 4 (18.5%). According to Maryland foot score, very good results were obtained in 6 patients (22.2%) and good results in 4 patients (14.9%) in Sanders type 2 fractures; good results were obtained in 9 patients (33.3%) and average results in 3 feet of 2 patients (11.1%) in Sanders type 3 fractures; good results were obtained in 2 patients (7.4%) and average results in 3 patients (11.1%) in Sanders type 4 fractures. The patientsâ&#x20AC;&#x2122; scores were obtained at the last follow-up. According to the Creighton-Nebraska score, very good results were obtained in 7 patients (26%) and good results in 3 patients (11%) in Sanders type 2 Mart - March 2013

Mid-term results of calcaneal plating for displaced intraarticular calcaneus fractures

Table 1. Patients characteristics No

Fracture type

Graft type

Maryland score

Creighton-Nebraska score

Böhler injury

Böhler last follow-up

Gissane injury

Gissane last follow-up

Plate type

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

2A 2A 2A 2A 2A 2A 2B 2B 2B 2C 2C 2C 3AB 3AB 3AB 3AB 3AC 3AC 3BC 3BC 3BC 3BC 4 4 4 4 4

CA CA CA CA CA CA CA CA IC IC IC IC ICC ICC ICC ICC ICC ICC ICC ICC ICC ICC ICC ICC ICC ICC ICC

Very good Very good Very good Very good Very good Very good Good Good Good Good Intermediate Intermediate Good Good Good Good Good Good Good Good Good Intermediate Good Good Intermediate Intermediate Intermediate

Very good Very good Very good Very good Very good Very good Good Very good Good Good Good Good Good Good Good Good Good Good Good Intermediate Intermediate Intermediate Intermediate Intermediate Intermediate Intermediate Bad

11.32 6.2 11.13 15 10.22 10.07 6.7 10.1 9.2 8 5 10.1 9.2 8.4 9.2 10 6.8 7.4 8.2 3 7.1 6.3 4 3.7 2.3 1.5 0

28.6 29.4 27.2 30 29.4 29.2 18 28.7 27 28 26.54 27 24.4 23.8 24.2 24.2 27 23.3 24.8 22 24.3 19 14 19 12 13 12

130.32 129.25 128.42 131 126.12 124.4 120.22 127.8 119 121.48 120 125.35 125.6 131 133 132.5 125 134.2 133.4 140 131.3 129.7 141.2 140.6 140.2 138 145

104.2 103.4 104.1 105 103.1 102.2 100.1 99.2 99.4 99.1 99 101.72 99 103.2 98 99.2 110 102.5 99.1 102.6 99 105.9 116 97 111 106 118

Sanders Scherman Scherman Sanders Scherman Scherman Sanders Scherman Scherman Sanders Scherman Scherman Scherman Sanders Scherman Scherman Scherman Scherman Sanders Scherman Scherman Sanders Scherman Scherman Sanders Sanders Scherman

CA: Cancalleous allograft; IC: Iliaca cancalleous; ICC: Ilaca corticocancalleous.

fractures; good results were obtained in 7 patients (26%) and average results in 5 feet of 4 patients (18%) in Sanders type 3 fractures; average results were obtained in 4 patients (15%) and poor results in 1 patient (4%) in Sanders type 4 fractures (Table 1). The change in Böhler and Gissane angles is shown in Table 1. At the last follow-up, the mean Böhler angle was improved 15.9° with Sanders plate, 19.05° with Sherman plates and Gissane angle was improved 23.65° with Sanders plate, 23.27° with Sherman plates in Sanders type 2 fractures; Böhler angle was improved 14.9° with Sanders plate, 16.7° with Sherman plates, and Gissane angle was improved 28.63° with Sanders plate, 30.13° with Sherman plates in Sanders type 3 fractures; Böhler angle was improved 10.6° with Sanders plate, 12.5° with Sherman plates, and Gissane angle was improved 30.6° with Sanders plate, 31.93° with Sherman plates in Sanders type 4 fractures. Four patients developed superficial soft tissue infection during the postoperative period, which responded to oral antibiotic treatment and wound care. Small skin necrosis was encountered in two patients, which resolved completely with local wound care without the need for a reconstructive procedure. Cilt - Vol. 19 Sayı - No. 2

DISCUSSION Calcaneus fractures comprise 2% of all fractures, and 60-75% of these fractures are intraarticular. Ten percent of the patients with calcaneus fractures have accompanying spine fractures and other extremity injuries. Similar proportions were found in our study as well. Ninety percent of the calcaneus fractures occur in males employed in industry aged between 21 and 45 years, which demonstrates that these fractures have important economic impacts.[11] Calcaneus fractures are generally due to high-energy traumas such as a fall from height and traffic accidents. We used Sanders classification based on computed tomography for our patients; however, no classification system has proved adequate.[12] Twelve of the 27 calcaneus fractures comprising our task group were found to be type 2, 10 were type 3, and 5 were type 4. The options for treating intraarticular calcaneus fractures may be evaluated in four groups[1,13,14] as: Conservative treatment, closed reduction percutaneous fixation, open reduction internal fixation and primary subtalar arthrodesis, and mini open approaches with percutaneous fixation.[15-17] 147

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(a)

(b)

(c)

(d)

Fig. 1. (a) Right foot lateral radiography shows a displaced intraarticular calcaneal fracture in a 34-year-old man injured in a fall. (b) Preoperative CT scan shows Sanders type 3AB fracture. (c) Reduction obtained through lateral extended incision. (d) Postoperative lateral radiography at 1-year follow-up.

Kitoaka et al.[8] reviewed the results of the walking analyses of 16 of 27 patients, who were not subjected to reduction and were treated with plaster. Many patients in their study showed differences in walking especially on uneven grounds, which showed that conservative treatment of displaced calcaneus fractures results in permanent functional disorders, at least to some extent. Oâ&#x20AC;&#x2122;Farrel et al.[18] treated 12 patients with surgical methods and 12 patients with conservative methods. They concluded that the surgical treatment was superior. Similarly, Leung et al.[19] compared 44 patients treated by surgical methods with 19 patients treated conservatively according to the results of three-year follow-up on average. Comparing pain, ease of movement, return to job, and swallowed back of the foot, they found that the results of the group treated surgically were significantly better. 148

For patients who are to undergo surgical treatment, the timing of the operation is very important. While many authors suggest that the surgical intervention take place after the excessive edema in the foot has regressed, there are also authors suggesting it take place within the first 24 hours. Surgical intervention should preferably take place after regression of the excessive edema and should not be delayed beyond two weeks, as it will be difficult to provide anatomic reduction. [1,20,21] The period between injury and operation was eight days on average in our cases. One patient was operated on day 22, as the patient was admitted and followed up by the brain surgery clinic. We agree that the surgical intervention should take place once the edema in the foot has regressed. Many of the studies published recently about the surgical treatment of calcaneus fractures use the lateral approach, in which the reduction of the calcaneus body Mart - March 2013

Mid-term results of calcaneal plating for displaced intraarticular calcaneus fractures

and calcaneus height, length and width can be regained regardless of the disintegration level.[12,22] Extended lateral incision was used for 26 ankles out of 27 operated (96%), and medial incision was used for 1 (4%). When the literature is reviewed, good and perfect results were obtained only for displaced intraarticular calcaneus fractures for which the lateral approach was used. [12,22-25] It is preferred by many surgeons at present, as it provides wide lateral incision, and whole lateral wall, subtalar joint and calcaneocuboid joint visualization, and leads to nearly no peroneal tendon or sural nerve damage, but poses high skin necrosis risk.[26] Extended lateral incision was used for all our patients.

In cases with no ensured anatomic reduction, heel and calcaneofibular impingement pain is common during the early period, while arthritic complaints are common in the late period. In 4 (80%) of our 5 patients operated due to Sanders type 4 fracture and 2 (16.6%) of our 12 patients operated due to Sanders type 3 fracture, we determined subtalar arthritic changes. We suggested shoe modifications and made some other suggestions to these patients in the late follow-up period. The modificatation of the shoes were as follows: the posterior heel of the shoes is designed in the equinus posture with soft sole plate to decrease the pressure at the subtalar joint. After the modification of the shoes,

The osteosynthesis material should be selected to provide a stable fixation and should allow early movement of the ankle and subtalar joint.[25,27] We used Sherman plates in 18 patients and Sanders calcaneus plate in 9 patients. Sherman plates were preferred at first, and Sanders plates later. We did not observe any reduction loss in the early or late period due to osteosynthesis material. Therefore, it is our opinion that osteosynthesis by plate screw is very important in receiving good functional results by both protecting the anatomic reduction and enabling early movement. Use of bone grafting remains controversial for the treatment of calcaneus fractures. While many authors suggest that the calcaneus with cancellous structure will recover fast and there is thus no need to use bone grafting, there are also authors suggesting that bone grafting should absolutely be used in order to protect joint reduction, and also that the bone graft can add mechanical strength and stimulate fracture healing. [1,28-30] We used autografting in 18 cases and allografting in 8 cases in order to preserve calcaneus integrity and to support subtalar joint reduction due to bone defects. We did not face any problems with these patients and indeed obtained good results. It is our opinion that it is beneficial to use bone grafting in order to preserve joint reduction for displaced intraarticular calcaneus fractures as bone defect develops following reduction. There is no consensus regarding surgical maintenance and rehabilitation of the intraarticular fractures, just as there is no such consensus about their treatment. [31,32] There are those who prefer fixation by plaster for two to three weeks following surgery, while others have the patient start on early active movements on day 2.[14] We had our patients start active ankle and foot movements after receiving the drain on day 2. We introduced the patients to partial weight-bearing in weeks 7-8 and introduced full weight-bearing in weeks 9-12. We recommend starting active motion during the early period, on day 2, if stable osteosynthesis is ensured. The key to success in the surgical treatment of intraarticular calcaneus fractures is ensuring reduction. Cilt - Vol. 19 Say覺 - No. 2

(a)

(b)

(c) Fig. 2. (a) Right foot lateral radiography shows a displaced intraarticular calcaneal fracture in a 61-year-old man injured in a fall. (b) Preoperative CT scan shows Sanders type 2 fracture. (c) Postoperative lateral radiography at the 6-month follow-up. 149

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our patients were pleased, but there was no significant recovery in their Maryland and Creighton-Nebraska foot scores; they are all scheduled for an arthrodesis procedure in the future. The inversion and evertion motion of these patients were decreased. In our study, we obtained very good results in 6 patients and good results in 15 patients according to the Maryland foot score, which yields a proportion of 77% for good and very good results. Anatomic reduction and stable osteosynthesis are very important to achieve good functional results in the early period and to enable the patients to return to their former jobs. Twenty-four of our patients returned to their former employment in an average period of 6.3 months. Some authors suggest trying anatomic reduction for type 4 fractures, while others suggest subtalar arthrodesis directly.[1,2,21] It is our opinion that efforts should be made to enable reconstruction of the subtalar joint. In our study, 4 of 5 patients with type 4 fractures were working. Three of these patients (75%) returned to their jobs in 10 months on average. We did not apply subtalar arthrodesis to our patients. The most common complication faced following calcaneus fracture is related to wound healing.[26,33,34] Risk factors for wound problems include smoking, diabetes, open fractures, high body mass index, and enclosing the skin in a single layer. Most of the scars heal eventually. In case of a wound problem, movement exercises are delayed in order to prevent any further disintegration. Plaster may be applied on the extremity by leaving a window over the scar and wet-to-dry dressing changes, or other granulation-stimulant scar agents may be started.[12,15] In our study, 4 patients had a superficial wound infection that responded to oral antibiotics according to culture and sensitivity. The organism was Staphyloccocus epidermidis in all and it was sensitive to Bactrim. Two patients (8%) with skin necrosis were treated with daily wound care with no need for secondary intervention. The implants of one patient were removed due to plate irritation one year after the surgery. The most common neurological complication following the treatment of calcaneal fractures is iatrogenic nerve injuries. The sural nerve is the nerve most affected, due to frequent use of lateral incision, and may be observed in up to 15% of the cases. In our study, temporary sural nerve hypoesthesia was observed in only one patient in the early period. In light of both the knowledge available in the literature and our own experience, we conclude that open reduction and a stable fixation method yield more satisfactory results when compared to the conservative treatment methods in the treatment of displaced intraarticular calcaneus fractures.[34] 150

None of the authors received any kind of support related to this study.

REFERENCES 1. Sanders R. Fractures and fracture-dislocations of the calcaneus. In: Coughlin MJ, Mann RA, editors. Surgery of the foot and ankle. Vol. 2, 7th ed. St. Louis: Mosby; 1999. p. 1422-64. 2. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-50. 3. Potter MQ, Nunley JA. Long-term functional outcomes after operative treatment for intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2009;91:1854-60. 4. Sayed-Noor AS, Agren PH, Wretenberg P. Interobserver reliability and intraobserver reproducibility of three radiological classification systems for intra-articular calcaneal fractures. Foot Ankle Int 2011;32:861-6. 5. Giachino AA, Uhthoff HK. Intra-articular fractures of the calcaneus. J Bone Joint Surg [Am] 1989;71:784-7. 6. Howard JL, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, et al. Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 2003;17:241-9. 7. Barnard L, Odegard JK. Conservative approach in the treatment of fractures of the calcaneus. J Bone Joint Surg [Am] 1955;37-A:1231-6. 8. Kitaoka HB, Schaap EJ, Chao EY, An KN. Displaced intraarticular fractures of the calcaneus treated non-operatively. Clinical results and analysis of motion and ground-reaction and temporal forces. J Bone Joint Surg [Am] 1994;76:153140. 9. Pozo JL, Kirwan EO, Jackson AM. The long-term results of conservative management of severely displaced fractures of the calcaneus. J Bone Joint Surg [Br] 1984;66:386-90. 10. Schepers T, Heetveld MJ, Mulder PG, Patka P. Clinical outcome scoring of intra-articular calcaneal fractures. J Foot Ankle Surg 2008;47:213-8. 11. de Souza LJ, Rutledge E. Grouping of intraarticular calcaneal fractures relative to treatment options. Clin Orthop Relat Res 2004;420:261-7. 12. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;290:87-95. 13. Aitken AP. Fractures of the os calcis-treatment by closed reduction. Clin Orthop Relat Res 1963;30:67-75. 14. Fractures and dislocations of the calcaneus. In: Rockwood Jr. CA, Green DP, Bucholz RW, Heckman JD, Fitzgibbons TC, McMullen ST, Mormino MA, editors. Fractures in adults. 5th ed. Vol. 2, Lippincott-Raven; 2001. p. 2133-79. 15. Frank MA, Berberian W, Liporace F. Calcaneal fractures: surgical exposure and fixation technique update. Current Orthopaedic Practice 2011;22:4-11 16. Weber M, Lehmann O, Sägesser D, Krause F. Limited open reduction and internal fixation of displaced intraarticular fractures of the calcaneum. J Bone Joint Surg Br 2008;90:1608-16. 17. Simpson RB. Fractures of the calcaneus. Curr Opin Orthop 2007;18:124-7. 18. O’Farrell DA, O’Byrne JM, McCabe JP, Stephens MM. Fractures of the os calcis: improved results with internal fixation. Injury 1993;24:263-5. 19. Leung KS, Yuen KM, Chan WS. Operative treatment of disMart - March 2013

Mid-term results of calcaneal plating for displaced intraarticular calcaneus fractures

placed intra-articular fractures of the calcaneum. Mediumterm results. J Bone Joint Surg Br 1993;75:196-201. 20. Zwipp H, Rammelt S, Gavlik JM. Calcaneus fractures. In: Surgical techniques in orthopaedics and traumatology. Paris: Elsevier SAS; 2000. p. 55-650-B, 7. 21. Sanders R, Gregory P. Operative treatment of intra-articular fractures of the calcaneus. Orthop Clin North Am 1995;26:203-14. 22. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;290:87-95. 23. Bèzes H, Massart P, Delvaux D, Fourquet JP, Tazi F. The operative treatment of intraarticular calcaneal fractures. Indications, technique, and results in 257 cases. Clin Orthop Relat Res 1993;290:55-9. 24. Johnson EE, Gebhardt JS. Surgical management of calcaneal fractures using bilateral incisions and minimal internal fixation. Clin Orthop Relat Res 1993;290:117-24. 25. Letournel E. Open treatment of acute calcaneal fractures. Clin Orthop Relat Res 1993;290:60-7. 26. Tomesen T, Biert J, Frölke JP. Treatment of displaced intraarticular calcaneal fractures with closed reduction and percutaneous screw fixation. J Bone Joint Surg Am 2011;9310:9208.

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27. Aşik M, Sen C. Surgical management of intraarticular fractures of the calcaneus. Arch Orthop Trauma Surg 2002;122:354-9. 28. Banerjee R, Nickisch F, Easley ME, Digiovanni CW. Foot injures. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, Kretek C, editors. Skeletal trauma. Vol. 2, 4th ed. Philadelphia: Saunders; 2009. p. 2626-64. 29. Squires B, Allen PE, Livingstone J, Atkins RM. Fractures of the tuberosity of the calcaneus. J Bone Joint Surg [Br] 2001;83:55-61. 30. Clare MP, Lee WE 3rd, Sanders RW. Intermediate to longterm results of a treatment protocol for calcaneal fracture malunions. J Bone Joint Surg Am 2005;87:963-73. 31. Gaskill T, Schweitzer K, Nunley J. Comparison of surgical outcomes of intra-articular calcaneal fractures by age. J Bone Joint Surg [Am] 2010;92:2884-9. 32. Kwon JY, Diwan A, Susarla S. Effect of surgeon training, fracture, and patient variables on calcaneal fracture management. Foot Ankle Int 2011;32:262-71. 33. Emara KM, Allam MF. Management of calcaneal fracture using the Ilizarov technique. Clin Orthop Relat Res 2005;439:215-20. 34. Jiang SD, Jiang LS, Dai LY. Surgical treatment of calcaneal fractures with use of beta-tricalcium phosphate ceramic grafting. Foot Ankle Int 2008;29:1015-9.

151

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):152-156

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.43966

An analysis of 45 patients with pure nasal fractures İzole nazal fraktürü olan 45 hastanın değerlendirilmesi Yakup ÇİL,1 Erkan KAHRAMAN2

BACKGROUND

AMAÇ

Nasal fracture is generally encountered alone or in combination with other serious injuries. The objective of this study was to analyze patients who had pure nasal fracture.

Nazal kemik kırıkları izole olarak görülebileceği gibi diğer ciddi travmalar ile birlikte de görülür. Bu çalışmanın amacı izole nazal kemik kırığı olan hastaları analiz etmektir.

METHODS

GEREÇ VE YÖNTEM

Forty-five records from patients with pure nasal fracture treated in the hospital between 7 October 2005 and 14 December 2011 were included. The following nasal fracture criteria were evaluated: age at the time of nasal trauma, gender, accident type, use of alcohol, findings of the physical examination, treatment time after the nasal fracture, and year and seasonal distribution.

Bu çalışmada, izole nazal kemik kırığı nedeniyle 7 Ekim 2005 ile 14 Aralık 2011 arasında hastanede tedavi edilen 45 hastanın bilgileri incelendi. Hastalar çalışma kapsamı içerisinde; nazal travmanın olduğu zamandaki yaş, maruz kalınan travmanın tipi, alkol kullanımı, fiziksel inceleme bulguları, nazal kırık sonrası hastaneye başvuru zamanı ve tedavi zamanı ile nazal kırığın oluş zamanının yıllık ve mevsimsel dağılımları incelendi.

RESULTS

BULGULAR

The age ranged from 6-32 years, with a mean age of 21 years. The most frequent reasons of the injury were violence 60% (27 cases) followed by falling 31% (14 cases), accidents 4.5% (2 cases) and sport injuries 4.5% (2 cases). The most frequent findings were tenderness in 71.1% (32 cases), followed by swelling in 51.1% (23 cases), nasal deviation in 42.2% (19 cases), and epistaxis in 15.6% (7 cases). Nasal bone fracture was diagnosed exactly by standard X-ray films in 91.1% (41 cases).

Hastaların yaşları 6 ile 32 arasında değişiyordu ve ortalama yaş 21 idi. En çok travma nedeni olarak kavga olaylarını %60 (27 olgu), yüksekten düşme 31 (14 olgu), kaza %4,5 (2 olgu) ve sportif olaylar %4,5 (2 olgu) takip ediyordu. En sık bulgu olan hassasiyeti %71 (32 olgu), şişme %51,1 (23 olgu), burun eğriliği %42,2 (19 olgu), burun kanaması %15,6 (7 olgu) takip ediyordu. Nazal kemik kırıklarının kesin tanısı 41 olguda (%91,1) düz grafi ile konuldu.

CONCLUSION

SONUÇ

In this study; pure nasal bone fractures occurred primarily among men under 25 years of age, and fights were found to be the main etiologic factor.

Çalışmada izole nazal kemik kırıkları öncelikli olarak 25 yaş altı genç erkeklerde görülmüş olup temel etyolojik faktör olarak kavga bulunmuştur.

Key Words: Analysis; etiology; fracture; injury; nose.

Anahtar Sözcükler: Analiz; burun; etyoloji; kırık; yaralanma.

The etiology of the nasal fractures differs from one country to another due to social, cultural, and environmental factors. The main etiologies of nasal fractures worldwide are falls, violence, traffic accidents, and sport injuries.[1] Interpretation of these surveys was dif-

ficult because there was also variation in the classification of injuries.[2,3] The continuous communication of data associated with nasal trauma epidemiology is extremely important in order to provide the necessary information for preventive action aimed at reducing the

Departments of 1Plastic Surgery, 2Otolaryngology, Head & Neck Surgery, Eskişehir Military Hospital, Eskisehir, Turkey.

Eskişehir Asker Hastanesi, 1Plastik Cerrahi Kliniği, 2KBB Kliniği, Eskişehir.

Correspondence (İletişim): Yakup Çil, M.D. Eskişehir Asker Hastanesi, Plastik Cerrahi Kliniği, 26020 Eskişehir, Turkey. Tel: +90 - 222 - 220 45 30 / 4219 e-mail (e-posta): yakupcil@yahoo.com

152

An analysis of 45 patients with pure nasal fractures

incidence of nasal injuries. The objective of this study was to verify the age, sex, and the most frequent causes of nasal fractures treated in the hospital.

Table 1. Demographic data of the patients No

Year / Age

Sex

Etiology

Season

MATERIALS AND METHODS The records of patients with pure nasal fracture diagnosis during the period from 7 October 2005 through 14 December 2011 were retrospectively evaluated. The diagnosis was based on the nasal bone radiography. 76 patients who had presented with nasal trauma associated with other maxillofacial bone fracture that had been confirmed with radiography were excluded. Nasal cavities were examined using anterior rhinoscopy and the presence of epistaxis and localization of the hemorrhage were recorded. All patients were treated with closed reduction by specialist. Closed reduction was performed under local anesthesia. Nasal packing and nasal splint were also applied in all patients. The packing and the nasal splint were removed at the 3rd and 7th days, respectively. The following criteria were evaluated: age at the time of nasal trauma, gender, accident type (interpersonal violence, car accident, fall, bicycle, motorcycle, sport, or occupational accident), use of alcohol (found through information from the patient and/or physical exam), findings of the physical examination, and treatment time after the nasal fracture, and year and seasonal distribution of the nasal fractures.

2005 / 21 2005 / 27 2005 / 20 2006 / 21 2006 / 22 2006 / 20 2006 / 21 2006 / 20 2007 / 21 2007 / 21 2007 / 7 2007 / 23 2007 / 21 2007 / 20 2007 / 20 2008 / 22 2008 / 21 2008 / 21 2008 / 27 2008 / 21 2008 / 32 2008 / 20 2008 / 21 2009 / 20 2009 / 20 2009 / 20 2009 / 21 2010 / 21 2010 / 21 2010 / 25 2010 / 21 2010 / 6 2010 / 21 2010 / 20 2010 / 21 2010 / 20 2011 / 24 2011 / 21 2011 / 21 2011 / 25 2011 / 20 2011 / 20 2011 / 21 2011 / 22 2011 / 21

Male Male Male Female Male Male Male Male Female Male Male Male Male Male Female Male Male Male Female Male Male Male Male Male Male Male Male Male Male Male Male Female Male Male Male Male Male Male Male Male Female Male Male Male Male

Fall Fall Accident Fall Violence Violence Violence Sport Fall Violence Fall Violence Violence Violence Violence Violence Violence Violence Fall Fall Sport Violence Fall Violence Fall Violence Violence Fall Fall Violence Violence Accident Violence Violence Violence Violence Violence Fall Violence Violence Fall Violence Violence Violence Fall

Spring Spring Autumn Spring Summer Spring Autumn Winter Winter Spring Spring Summer Spring Autumn Autumn Winter Autumn Spring Spring Autumn Spring Summer Summer Summer Spring Spring Autumn Winter Winter Spring Spring Spring Summer Summer Autumn Autumn Spring Spring Summer Summer Spring Autumn Autumn Spring Winter

RESULTS A total of 45 patients, 39 men (86.7%) and 6 women (13.3%), were included in the study (Table 1). The age ranged from 6-32 years, with a mean of 21. Postoperative follow-up period was 6 months, ranging from 3-9 months. The most frequent reason for nasal fracture was violence in 60% (27 cases) followed by falling in 31% (14 cases), accident in 4.5% (2 cases) and sport injuries in 4.5% (2 cases) (Fig. 1). The most frequent findings were tenderness in 71.1% (32 cases) followed by swelling in 51.1% (23 cases), nasal deviation in 42.2% (19 cases), and epiAccident Sport (2); 4.5% (2); 4.5%

Fall down (14); 31% Violence (27); 60%

Accident Sport Violence Fall down

Etiology

Fig. 1. Distribution of the nasal fractures according to related etiology. Cilt - Vol. 19 Say覺 - No. 2

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

staxis in 15.6% of cases (7 cases) (Fig. 2). Nasal-septal hemorrhages were drained in four patients (8.8%). Most of the cases were admitted to hospital on the same day of injury (average 0.8 days) and reduction of the nasal bone was typically carried out on the same day (Fig. 3). 153

Ulus Travma Acil Cerrahi Derg

Diagnosis of nasal bone fracture was made positively by standard X-ray films in 91.1% of cases (41 cases). 8.9% of cases (4 cases) were suspicious for fracture and the exact diagnosis of the fracture was made by computerized tomography (Fig. 4). Among three patients (6.7%), physical examination showed that they had consumed alcohol.

(b)

Patient distribution in the years of 2005-2011 was not different according to year (Fig. 5). Seasonal evaluation indicated slightly higher incidence in the spring (Fig. 6).

DISCUSSION The nose is located prominently in the face, and it is possible to analyze the pure nasal trauma etiology separately. Patients who had only pure nasal fractures without other maxillofacial bone fractures were analyzed in this study. The most common cause of the nasal fracture in our series was physical aggression. Other studies indicated that vehicle accidents were the main cause of facial fracture.[4-6] In this study we suggested the cause of pure nasal fractures was different from complex facial fractures as previous nasal fracture reports.[7,8] A nasal injury might be associated with another 35

32 (71.1%) 23 (51.1%)

25 20

7 (15.6%)

Tenderness

Swelling

Nasal deviation

9

9

2010

2011

8 7

Epistaxis

5

5

4

4 3

3

2 1

Fig. 2. Findings of the nasal fractures.

0

2005

2006

2007

2008

2009

Fig. 5. Annual distributions of the nasal fractures. 27

24 Winter, 6; 13%

18

20 15

4

5 The same day Admitted time

Summer, 9; 20%

Spring, 19; 43%

10

10

First day

3

Second day

Winter Summer Autumn Spring

Autumn, 11; 24%

Reduction time

Fig. 3. Time interval between hospital consultations for the nasal fracture treatment time (day). 154

head and neck trauma. Physicians must consider the possibility of an associated facial fracture.[9] If the patients have nasal trauma, all facial lacerations, swellings and deformities should be noted. The objective

6

5

0

available at www.tjtes.org).

7

19 (42.2%)

10

25

Fig. 4. (a) A 21-year-old patient with nasal fracture after falling down. (b) X-ray (arrow) and (c) further evaluation with computerized tomography was needed (arrow). (Color figures can be viewed in the online issue, which is

8

15

30

(c)

9

30

0

(a)

Fig. 6. Seasonal distributions of the nasal fractures. Mart - March 2013

An analysis of 45 patients with pure nasal fractures

of this study was to analyze pure nasal fractures. Tenderness (71.1%) was the most frequent finding in this study. The association of alcohol consumption and facial fractures was well documented. Shapiro et al.[10] describe a relationship in up to 45.0% of the cases. Interpersonal violence has become one of the major problems in many areas and the increase of these rates has been associated with alcohol consumption. A law increasing the age for permitting alcohol consumption that is rigorously upheld, and a larger social alert about the morbidity related to alcohol may reduce such traumas resulting from usage. Three patients’ (6.7%) examinations showed they had consumed alcohol. Diagnosis of nasal fracture is based on the physical examination and radiographic evaluation. Simple radiographs of the nasal bone are important to show fractures and for medicolegal reasons. Computerized tomography is also useful for differential diagnosis of nasal bone fracture because the reliability of plain film is not 100%.[11,12] Nasal fractures were diagnosed by nasal X-ray examination in 41 (91.1%) of our patients, and further evaluation with computerized tomography was needed in four of the patients (8.9%). Incidence of trauma in pediatric and adolescent population was lower than the adult population. Many factors make this age group (0 to 18 years) different, such as: bone elasticity, relatively small facial size, and growth processes in young bone.[13] There was only one pediatric patient in our series (Patient-32). The peak age incidence of nasal fractures was difficult to compare, since the available studies have used different upper and lower age limits for their cases. In this study, the peak incidence was at age 21. Another study showed similar mean age.[14] It was speculated that subjects in this age peak were becoming more involved in the same activities. We also observed physical aggression was encountered more between 20 and 30 years. Annual distribution of nasal fracture was almost equal during the study period. Seasonal incidence was slightly higher in the spring. This finding may be explained with the increase of outdoor physical activity in the spring. Male patients were mostly affected by facial injuries by a ratio of approximately 4:1; this ratio was within the range described in the literature, which varied between 6:1 and 11.8:1.[15-17] Our series included six female (8.7:1.3) patients. This high vulnerability of men to most types of trauma may be associated with the fact that in our society men have more freedom in outdoor activities and are more involved in high-risk jobs, thus being more vulnerable to accidents. Cilt - Vol. 19 Sayı - No. 2

Many studies reported on the etiology of facial fractures in various areas,[17-19] but not many on pure nasal bone fractures. The primary objective of this study was to verify the age, sex, and the most frequent causes of the pure nasal fractures treated in the hospital. Pure nasal bone fractures were encountered most frequently in young adult men due to interpersonal violence. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Scariot R, de Oliveira IA, Passeri LA, Rebellato NL, Müller PR. Maxillofacial injuries in a group of Brazilian subjects under 18 years of age. J Appl Oral Sci 2009;17:195-8. 2. Leong SC, Abdelkader M, White PS. Changes in nasal aesthetics following nasal bone manipulation. J Laryngol Otol 2008;122:38-41. 3. Rocchi G, Fadda MT, Marianetti TM, Reale G, Iannetti G. Craniofacial trauma in adolescents: incidence, etiology, and prevention. J Trauma 2007;62:404-9. 4. Scherer M, Sullivan WG, Smith DJ Jr, Phillips LG, Robson MC. An analysis of 1,423 facial fractures in 788 patients at an urban trauma center. J Trauma 1989;29:388-90. 5. Haug RH, Prather J, Indresano AT. An epidemiologic survey of facial fractures and concomitant injuries. J Oral Maxillofac Surg 1990;48:926-32. 6. Sargent LA, Fernandez JG. Incidence and management of zygomatic fractures at a level I trauma center. Ann Plast Surg 2012;68:472-6. 7. Kucik CJ, Clenney T, Phelan J. Management of acute nasal fractures. Am Fam Physician 2004;70:1315-20. 8. Fornazieri MA, Yamaguti HY, Moreira JH, Navarro PL, Hesbiki RE, Takemoto LE. Fracture of nasal bones: An epidemiologic analysis. Intl Arch Otorhinolaryngol Sao Paulo 2008;12:498-501. 9. Ellis E 3rd, Scott K. Assessment of patients with facial fractures. Emerg Med Clin North Am 2000;18:411-48, vi. 10. Shapiro AJ, Johnson RM, Miller SF, McCarthy MC. Facial fractures in a level I trauma centre: the importance of protective devices and alcohol abuse. Injury 2001;32:353-6. 11. Oluwasanmi AF, Pinto AL. Management of nasal trauma-widespread misuse of radiographs. Clin Perform Qual Health Care 2000;8:83-5. 12. Smith H, Peek-Asa C, Nesheim D, Nish A, Normandin P, Sahr S. Etiology, diagnosis, and characteristics of facial fracture at a midwestern level I trauma center. J Trauma Nurs 2012;19:57-65. 13. Oji C. Fractures of the facial skeleton in children: a survey of patients under the age of 11 years. J Craniomaxillofac Surg 1998;26:322-5. 14. Hwang K, You SH, Kim SG, Lee SI. Analysis of nasal bone fractures; a six-year study of 503 patients. J Craniofac Surg 2006;17:261-4. 15. Hächl O, Tuli T, Schwabegger A, Gassner R. Maxillofacial trauma due to work-related accidents. Int J Oral Maxillofac Surg 2002;31:90-3. 16. Pombo M, Luaces-Rey R, Pértega S, Arenaz J, Crespo JL, García-Rozado A, et al. Review of 793 facial fractures treated from 2001 to 2008 in a coruña university hospital: types and 155

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etiology. Craniomaxillofac Trauma Reconstr 2010;3:49-54. 17. Naveen Shankar A, Naveen Shankar V, Hegde N, Sharma, Prasad R. The pattern of the maxillofacial fractures - A multicentre retrospective study. J Craniomaxillofac Surg 2012;40:675-9. 18. Klenk G, Kovacs A. Etiology and patterns of facial fractures

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in the United Arab Emirates. J Craniofac Surg 2003;14:7884. 19. Smith H, Peek-Asa C, Nesheim D, Nish A, Normandin P, Sahr S. Etiology, diagnosis, and characteristics of facial fracture at a midwestern level I trauma center. J Trauma Nurs 2012;19:57-65.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):157-163

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.56957

Distribution of occult fractures detected in emergency orthopedic patient trauma with computerized tomography Acil ortopedik travma hastalarında bilgisayarlı tomografi ile tanınan gizli kırıkların dağılımı Ahmet İMERCİ,1 Umut CANBEK,2 Ahmet KAYA,3 Levent SÜRER,4 Ahmet SAVRAN3

BACKGROUND

AMAÇ

Computerized tomography (CT) is a very useful diagnostic method in orthopedic emergency cases where fractures are suspected but cannot be detected through direct radiography, or when the fracture is detected in direct radiography but better evaluation of the anatomical structure is necessary. In this study, we analyzed occurrences of missed fractures in radiographs that were subsequently diagnosed in CT scans.

Bilgisayarlı tomografi (BT) acil ortopedik travma hastalarında kırıktan şüphelendiğimizde, direkt grafi ile tanınamayan veya direkt grafi ile tanınan ama anatomik yapılar hakkında daha iyi değerlendirme imkanı sağlayan çok yararlı bir tanı yöntemidir. Bu çalışmada radyografi ile atlanmış sonrasında BT ile tanı almış kırıklar ile ilgili deneyimlerimizi sunduk.

METHODS

GEREÇ VE YÖNTEM

This was a retrospective study. We examined the medical records of all orthopedic trauma patients who visited our hospital’s emergency room due to orthopedic trauma between January 2010 and January 2011 and whose spine, pelvis and extremity CTs were taken.

Bu geriye dönük çalışmada, Ocak 2010 ile Ocak 2011 tarihleri arasında ortopedik travma nedeniyle hastanemiz acil servisine başvuran, omurga, pelvis ve ekstremite BT’si çekilen bütün ortopedik travmalı hastaların tıbbi kayıtları gözden geçirildi.

RESULTS

BULGULAR

Occult fractures were detected using CT in 12 (6.6%) of the children and 102 (6.8%) of the adults. We detected cervical vertebra fractures in 23 patients, femoral neck fractures in 6 patients, and tibia plato fractures in 5 patients, which can cause complications unless immediately acted upon in the emergency room. CONCLUSION

Sonuç olarak erişkinde 102 (%6,8) ve çocuklarda 12 hastada (%6,6) BT kullanılarak gizli kırık saptandı. Acil serviste müdahale edilmediği takdirde komplikasyonlara neden olan ve kötü prognoza sahip servikal vertebra kırığı 23, femur boyun kırığı 6 ve tibia plato kırığı 5 hastada saptandı. SONUÇ

CT revealed most missed diagnoses and proved that direct radiography is less capable of detecting fractures of some critical regions. Where there is clinical suspicion, we recommend that before conservative treatment of patients, especially in cases of possible cervical spine and pelvic region fractures, CT should be requested, even if the radiography is normal.

Ortopedik travması olan hastalarda, atlanmış tanıların ortaya çıkarılması seyrektir. BT atlanmış tanıların çoğunu ortaya çıkarmış ve radyografinin bazı önemli bölgelerin kırıkların saptanmasında düşük bir yeteneğe sahip olduğunu ortaya koymuştur. Klinik şüphenin olduğu durumlarda, radyografi normal olsa bile, özellikle servikal omurga ve pelvik bölge travmalı hastaların konservatif tedavisinden önce BT çekilmesini öneriyoruz.

Key Words: Computed tomography; emergency orthopedic trauma; missed diagnosis; occult fracture; radiography.

Anahtar Sözcükler: Bilgisayarlı tomografi; acil ortopedik travma; atlanmış tanılar; gizli kırık; radyografi.

1 Department of Orthopedics and Traumatology, Erzurum Palandoken State Hospital, Erzurum; 2Department of Orthopedics and Traumatology, Mugla Sıtkı Kocman University Faculty of Medicine, Mugla; 3Department of Orthopedics and Traumatology, Izmir Tepecik Training and Research Hospital, Izmir; 4Department of Orthopedics and Traumatology, Erzurum Regional Training and Research Hospital, Erzurum, Turkey.

Erzurum Palandöken Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Erzurum; 2Muğla Sıtkı Kocman Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Kliniği, Muğla; 3İzmir Tepecik Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İzmir; 4 Erzurum Bölge Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Erzurum. 1

Correspondence (İletişim): Ahmet İmerci, M.D. Erzurum Palandöken Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, 25000 Erzurum, Turkey. Tel: +90 - 442 - 235 50 80 e-mail (e-posta): ahmet_dr81@hotmail.com

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Direct radiography has a key role in detecting fractures and dislocation in extremity and pelvis traumas. Radiography is still one of the most frequently used examinations in emergency departments (EDs) despite many new generation imaging methods because of its accessibility, relative cheapness, and high potential to help diagnosis. Of all patients examined in EDs, 35-61% were subjected to radiological evaluation.[1] Optimum benefit from radiography depends on technically proper imaging and accurate evaluation. Computerized tomography (CT) is one of the imaging methods used in EDs.[2] CT is not only used to better understand the fracture anatomy and make a surgical plan for both adult and child patients, but also to investigate the occult pelvis, extremity, and vertebral fractures for which direct radiography revealed negative results.[2,3] CT should be considered for patients with suspected spine, knee, pelvis, and hip traumas which can cause catastrophical consequences if not detected early because direct radiography is inadequate.[2,4-10] Trauma surgeons need to understand the types of injuries that might be missed by direct radiography, and whether these missed diagnoses might influence the management and the prognosis of the patients. The missed diagnoses could be discovered using a CT scan or other diagnostic tools. Accordingly, we conducted a retrospective study to determine the frequency and character of missed diagnoses after radiography in orthopedic trauma patients.

MATERIALS AND METHODS The number of patients examined in the adult and child ED of our hospital between January 1, 2010 January 1, 2011 was 183.552 and 171.450 respectively. The records for the application of CT on children (aged 0-14) and adults (aged 14+) visiting the emergency trauma section in 2010 were analyzed. During this analysis, we used emergency examination cards, computer-based hospital registration system, and preCT direct radiographies and CT images taken from computer archive (PACS). The analyses were done by one orthopedist and one radiologist. The reasons for demanding a tomography and findings of the physical examination were recorded. Occult fractures, injuries that have no radiographic indicators that occur following trauma or without any trauma, are characterized by pain and detected by CT. Those fractures, which appear normal in direct radiography but can be detected by CT, were evaluated as occult fractures. The CTs were grouped as extremity, pelvic, cervical, thoracic, and lumbar spine. Iliac bone, sacrum, acetabulum, and hip joint CTs were classified as pelvis CT in general. All data were also classified as child (aged 0-14) and adult (aged 14+). All patients in this study were ex158

amined and had CTs requested by the same team of doctors. The data were analyzed using SPSS version 15.00 pack program. Chi-square and two sided analyses were used where appropriate and the alpha value was accepted as 0.05.

RESULTS Out of 32.685 patients examined in child and adult emergency trauma units over one year, 1.664 were asked for an extremity, pelvis, and spine CT (7.02%). The mean age of the patients was 38.6 (2-94). Occult fractures were detected in 37 of the 493 extremity CTs of adults, and in 2 of the 56 extremity CTs of children. Occult fractures were detected in 14 of the 169 adult pelvis CTs and 2 of the 6 child pelvis CTs. Occult fractures were detected in 16 of the 504 adult cervical CTs and 7 of the 107 child pelvis CTs. Occult fractures were detected in 3 of the 44 adult thoracic vertebra CTs and 1 of the 4 child thoracic vertebra CTs. Occult fractures were detected in 32 of the 273 adult lumbar vertebra CTs and none of the 8 children lumber vertebra CTs (Table 1). The most frequent occult spine fractures were detected as lamina fracture in 12 cases, transverse process fractures in 8 cases, and spinosis process fractures in 7 cases (Table 2). A total of 12 (6.6%) occult fractures were detected in children, and 102 (6.8%) in adults. We also observed that there was a significant difference in favor of children between two groups in detecting occult fractures (p<0.004). However, significantly more occult fractures were seen in the cervical area of children (p=0.033). In adults, significantly more occult fractures were seen in the lumbar area (p<0.001), and occult fractures were seen the least in the cervical area (p<0.001). No significant difference was found in detecting the fractures in all areas in total (p=0.427). DISCUSSION An analysis of the rates of occult fracture detection as a result of the retrospective analysis of CT examinations requested by trauma units in child and adult EDs revealed that CTs can change treatment significantly. Table 1. The distribution of occult fractures detected in emergency trauma patients with computerized tomography Occult fracture Extremity CT Pelvis CT Cervical CT Thoracic CT Lumbar CT Total CT

Adults (%)

Child (%)

Total (%)

37 (7.5) 14 (8.2) 16 (3.1) 3 (6.8) 32 (11.7) 102 (6.8)

2 (3.5) 2 (33.3) 7 (6.5) 1 (25) â&#x20AC;&#x201C; 12 (6.6)

39 16 23 4 32 114 (6.8)

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Distribution of occult fractures detected in emergency orthopedic patient trauma with CT

Table 2. The distribution of occult fractures detected in extremity and pelvis patients with computerized tomography Upper extremity

n

Lower extremity

n

Scapula fracture Proximal humerus fracture Radial head fracture Coronoid proces fracture Radius distal fissure Scaphoid fracture Capitatum fracture Lunatum fracture

2 2 6 1 1 2 1 1

Sacrum fracture Pubic rami fracture Collum femoris fracture Patella fracture Tibia plato fracture Fibular head fissure Posterior malleolus fracture Tuber calcanei fracture Fibular sesamoid fracture Navicular fissure

7 1 6 4 5 1 3 6 1 1

The frequent locations of these fractures include collum femoris, spine, pelvis, scaphoid, sacrum, coccyx, sternum, tarsometatarsal region, patella, and sesamoid bone.[11] In case the occult fractures in these bones are unclear, further examination is needed in patients whose direct radiographies are normal.[2,12-14] In the present study the most common occult fractures observed were sacrum fractures (n=7), collum femoris fractures (n=6), and radius head fractures (n=6). Emergency and orthopedic doctors should apply radiographic requests based on a plan that utilizes resources wisely.[2] CT is a reliable, noninvasive, painless, easy-to-apply examination method and quite sensitive in detecting the pathologies in bone structure. It is especially important to request CTs based on true justifications and to minimize dosage while obtaining the diagnostic information using the due examination method.[15,16] Cervical In the ED, physical examination of the cervical spine is difficult because movement of this area in patients with possible spinal injury is prohibited, and the ability of the physician to predict such injury on the basis of history and physical examination is poor. [17-19] Conventional radiography remains an excellent screening test when the probability of injury is high and the consequences of missing a fracture could be catastrophic.[20-22] Conventional tomography has advantages when nondisplaced dens fractures or facet fractures are being evaluated. CT is particularly useful in assessing fractures of the occipital condyles, Jefferson fractures, atlantoaxial rotatory dislocations, burst fractures with retropulsed fragments, and injuries to the cervicothoracic junction.[20,23-25] Acheson et al.[11] revealed that though radiographs suggested fractures in vertebrae, most so-called occult fractures (i.e., fractures detected on CT scans but not on conventional radiographs) were located in different parts of the vertebrae, such as in the pedicle, than Cilt - Vol. 19 SayÄą - No. 2

those found in radiographs. Fractures of the occipital condyles are difficult to diagnose because findings on plain radiographs are frequently normal.[20] In 1996, NuĂąez et al.[15] reported that nearly 40% of cervical spine fractures are missed on conventional radiography but are later revealed on CT. Delays in diagnoses of clinically significant cervical spine injuries have been reported in approximately 5% to 23% of patients in various series, most of which used plain radiography as the initial screening modality. Neurologic deterioration (possibly secondary to mismanagement) occurred in 10% to 50% of these patients.[26,27] In contrast, development of a secondary neurologic deficit occurred in only 1.4% of patients whose injuries were detected on initial screening in Reid and coworkersâ&#x20AC;&#x2122; cohort.[28] Generally, it has been accepted that 10-20% of all significant cervical spine injuries are missed by standard radiographs.[18,22] Of note, all the cervical spine injuries missed by plain films required some form of treatment, and 13 of these were unstable injuries requiring surgical stabilization.[5] A total of 23 cervical occult fractures were detected in our study. Six of the 16 occult fractures detected in adults were surgically stabilized, and 7 occult fractures detected in children were traced conservatively (Fig. 1a-c). Thoracic and lumbar spine The options for thoracic and lumbar spine radiographs are far less complicated than those for the cervical spine.[26,27] AP and lateral films are adequate to rule out thoracic or lumbar spine injuries in most cases. As stated previously, the upper thoracic spine can be difficult to visualize with plain films and should be included as part of a cervical CT scan if indicated. Obscuring soft-tissue shadows in obese patients can make interpretation of plain radiographs difficult; this may prompt CT evaluation for spinal clearance. A CT also should be obtained in those patients with continued pain and tenderness or a neurologic deficit despite negative plain radiographs.[21,29] In most cases, 159

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(a)

(b)

(c)

Fig. 1. (a) The normal appearance of the lateral cervical radiography. (b) The normal appearance of the AP cervical radiography. (c) Lamina fracture of third cervical vertebra in axial CT.

a CT is obtained to evaluate an injury identified by plain radiographs. Incidental injuries, such as spinous process and transverse process fractures, often are coincidentally detected on chest or abdominal CT scans obtained for non-spine reasons.[21,26] Sacrum Dedicated sacral images are usually not a routine component of the spine evaluation and in fact lie more within the auspices of pelvic fracture evaluation. However, dedicated pelvic views should be obtained in patients with fractures or dislocations of the lumbosacral junction. This includes an AP pelvis (which is usually obtained as part of the initial trauma series) and pelvic inlet and outlet views. Pelvic ring fractures that include the sacrum are routinely evaluated by CT.[21,30] In our study occult sacrum fractures were detected in 7 patients, and 2 patients had neurological deficiency. If the sacrum fracture is not immobilized, it causes or deteriorates the neurological damage. While this is a medicolegal threat for the doctor who relies solely on direct radiography, it means destruction for the patient. As neurological damage can develop in sacral area fractures, routine pelvis CT is quite useful in early diagnosis. Extremity and pelvis Occult scaphoid fracture: If no fracture is visible on radiographs six weeks after trauma, it is considered safe to discontinue immobilization. This strategy, however, includes weeks-long unnecessary immobilization in some patients, which results in both a reduction in the quality of life and an increase in health care costs.[31] In cases of negative or equivocal findings, additional projections (i.e., scaphoid views and/ or magnification views) have been reported to increase sensitivity.[31,32] However, immediately after injury, up to 65% of scaphoid fractures remain radiographically occult.[32] In our study occult scaphoid fractures were 160

detected in two patients, and such patients should be subjected to CT alternatively as most scaphoid fractures are missed in direct radiographies. Occult hip and pelvic fracture: The challenge for emergency physicians is to diagnose this subset of patients at the point of care, because significant morbidity can result when a patient ambulates on an unrecognized hip fracture.[8] Surprisingly, there are limited data as to the overall incidence of hip fracture that is not radiographically apparent on plain radiographs, particularly with respect to patients presenting to the ED with hip injury.[8,10,33] Of the pelvic and hip fractures, 8% were not identified by plain radiograph as compared with 6.8% in their population.[10] Dominguez et al.[10] found that the most common fractures identified by magnetic resonance imaging after negative plain radiographs included the pubic rami (34.5%), the sacrum (27.6%), the femoral neck (13.8%), and the intertrochanteric region (6.9%). We found that 4.4% of the ED patients with hip pain who had negative plain radiographs were subsequently diagnosed as having fractures.[33] Further studies are warranted to identify characteristics of patients requiring advanced hip imaging studies. Immediate in situ nailing was used in six patients with detected femoral neck fracture (Fig. 2a, b). Occult posterior pelvic ring fractures are easily missed in geriatric patients with pubic rami fractures following a simple fall.[8] Occult pubic rami fracture was detected in one of our patients. In our study occult plateau fractures were detected in five patients. Three of them were schatzker type 1; two were type 2 (Fig. 3a-c). If these fractures, which are treated conservatively, cannot be detected early and the patient applies load early, the collapse in the joint accelerates and requires surgical treatment. In a similar vein, the early diagnosis of the patellar fractures and immobilization of the knee in the early phase is important. During the flexion of the immobilized Mart - March 2013

Distribution of occult fractures detected in emergency orthopedic patient trauma with CT

(a)

(b)

Fig. 2. (a) The normal appearance of the Pelvic AP radiograph. (b) Left collum femoris fracture (black sign) in pelvic CT (black arrow).

knee, the fracture line is separated and causes tendons to stick to the patella, which may need surgical treatment.[7] In our study we found transverse patellar fractures in three patients and vertical patellar fracture in one patient, which healed with conservative treatment. A large number of patients from almost all age groups were involved in this study. The results are significant when considering patients whose radiographies revealed no fractures after proper anamnesis and regular physical examination in the orthopedical emergencies but who revealed occult factures in the following CTs and were treated starting from the first day. The occult fractures missed in the CT imaging become more complicated to treat, cost more, and the rates of disability increase. Therefore, detecting these occult fractures CTs is a very useful diagnostic tool. Child The term â&#x20AC;&#x2DC;occult fractureâ&#x20AC;&#x2122; is used for a fracture that is either radiographically undetectable or demonstrating subtle abnormalities that were missed on the initial

(a)

(b)

prospective interpretation, even if the fracture is visualized retrospectively or confirmed by other imaging tests.[9,14] Injuries to the physis can occur at any age before physeal closure, but are most common during periods of rapid skeletal growth. Although problems after injury to the physis are uncommon, missed injuries to this area can lead to premature closure with resultant focal bone growth arrest. Fortunately, fractures across the physis usually occur in a predictable pattern. Knowledge of these patterns is key for the emergency physician to avoid this potential orthopedic pitfall.[9,34,35] The incidence of pediatric cases of occult fractures occurs in about 2-18% of reviewed cases.[3,9] In our study occult fractures were detected using CT in 12 (6.6%) of the children. The absence of early management in these children may increase the complication rate. Thus, immobilization is critical for improving healing time, preventing potential growth arrest and fracture deformity, and to avoid discomfort.[3,13] However, the major limitation of this strategy is the undesirable overtreatment, resulting

(c)

Fig. 3. (a) The normal appearance of the AP knee radiography. (b) The normal appearance of the lateral knee radiography. (c) Occult tibia plateau fracture in knee axial CT. Cilt - Vol. 19 SayÄą - No. 2

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in unnecessary limitation of extremity motion, and a 1-2 week follow-up that is imposed on children without a fracture, as well as unnecessary visits for parents or guardians. As a result, about half of the children without fractures can be over treated, and nearly one-third of children with a fracture can be undertreated.[9,13] The limitation of our study is in its retrospective design. The second limitation was our failure to classify fracture types and to evaluate the trauma mechanism because we were concerned about the presence of an occult fracture. In conclusion, missing the diagnosis of patients with femoral neck fractures, which need immediate surgical treatment, and vertebral fracture, which can cause neurological damage, means destruction for patient and a medicolegal threat for the doctor who relies only on physical examination and direct radiography. As orthopedic surgeons, we should train ourselves about destructive outcomes caused by the risk of missing occult fractures not seen in direct radiography and delay diagnosis, act based on proofed protocols, and request for proper examinations immediately when necessary. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Reisdorf E, Schwartz T. Introduction to emergency radiology. In: Schwartz T, Reisdorf E, editors. Emergency radiology. 1th ed. New York: McGraw-Hill; 2000. p. 1-10. 2. Freed HA, Shields NN. Most frequently overlooked radiographically apparent fractures in a teaching hospital emergency department. Ann Emerg Med 1984;13:900-4. 3. Naranja RJ Jr, Gregg JR, Dormans JP, Drummond DS, Davidson RS, Hahn M. Pediatric fracture without radiographic abnormality. Description and significance. Clin Orthop Relat Res 1997;342:141-6. 4. Germann CA, Perron AD. Risk management and avoiding legal pitfalls in the emergency treatment of high-risk orthopedic injuries. Emerg Med Clin North Am 2010;28:969-96. 5. Vandemark RM. Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficiency and communication. AJR Am J Roentgenol 1990;155:465-72. 6. Korres DS, Papagelopoulos PJ, Petrou HG, Tzagarakis GP, Triantafyllidis PG, Tsarouchas J, et al. Occult fracture-dislocation of the cervical spine. Eur J Orthop Surg Traumatol 1999;9:195-9. 7. Capps GW, Hayes CW. Easily missed injuries around the knee. Radiographics 1994;14:1191-210. 8. Lau TW, Leung F. Occult posterior pelvic ring fractures in elderly patients with osteoporotic pubic rami fractures. J Orthop Surg (Hong Kong) 2010;18:153-7. 9. Cho KH, Lee SM, Lee YH, Suh KJ. Ultrasound diagnosis of either an occult or missed fracture of an extremity in pediatric-aged children. Korean J Radiol 2010;11:84-94. 10. Dominguez S, Liu P, Roberts C, Mandell M, Richman PB. Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial standard ra162

diographs--a study of emergency department patients. Acad Emerg Med 2005;12:366-9. 11. Acheson MB, Livingston RR, Richardson ML, Stimac GK. High-resolution CT scanning in the evaluation of cervical spine fractures: comparison with plain film examinations. AJR Am J Roentgenol 1987;148:1179-85. 12. Gangopadhyay S, Akra GA and Nanu AM. Occult hip fractures in the elderly: a protocol for management. Eur J Orthop Traumatol 2007;17:153-6. 13. Berger PE, Ofstein RA, Jackson DW, Morrison DS, Silvino N, Amador R. MRI demonstration of radiographically occult fractures: what have we been missing? Radiographics 1989;9:407-36. 14. Kan JH, Estrada C, Hasan U, Bracikowski A, Shyr Y, Shakhtour B, et al. Management of occult fractures in the skeletally immature patient: cost analysis of implementing a limited trauma magnetic resonance imaging protocol. Pediatr Emerg Care 2009;25:226-30. 15. Nu単ez DB Jr, Zuluaga A, Fuentes-Bernardo DA, Rivas LA, Becerra JL. Cervical spine trauma: how much more do we learn by routinely using helical CT? Radiographics 1996;16:1307-21. 16. Grogan EL, Morris JA Jr, Dittus RS, Moore DE, Poulose BK, Diaz JJ, et al. Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan. J Am Coll Surg 2005;200:160-5. 17. Freemyer B, Knopp R, Piche J, Wales L, Williams J. Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma. Ann Emerg Med 1989;18:818-21. 18. MacDonald RL, Schwartz ML, Mirich D, Sharkey PW, Nelson WR. Diagnosis of cervical spine injury in motor vehicle crash victims: how many X-rays are enough? J Trauma 1990;30:392-7. 19. Berlin L. CT versus radiography for initial evaluation of cervical spine trauma: what is the standard of care? AJR Am J Roentgenol 2003;180:911-5. 20. el-Khoury GY, Kathol MH, Daniel WW. Imaging of acute injuries of the cervical spine: value of plain radiography, CT, and MR imaging. AJR Am J Roentgenol 1995;164:43-50. 21. France JC, Bono CM, Vaccaro AR. Initial radiographic evaluation of the spine after trauma: when, what, where, and how to image the acutely traumatized spine. J Orthop Trauma 2005;19:640-9. 22. Diaz JJ Jr, Gillman C, Morris JA Jr, May AK, Carrillo YM, Guy J. Are five-view plain films of the cervical spine unreliable? A prospective evaluation in blunt trauma patients with altered mental status. J Trauma 2003;55:658-64. 23. Bachulis BL, Long WB, Hynes GD, Johnson MC. Clinical indications for cervical spine radiographs in the traumatized patient. Am J Surg 1987;153:473-8. 24. Blacksin MF, Lee HJ. Frequency and significance of fractures of the upper cervical spine detected by CT in patients with severe neck trauma. AJR Am J Roentgenol 1995;165:1201-4. 25. Jelly LM, Evans DR, Easty MJ, Coats TJ, Chan O. Radiography versus spiral CT in the evaluation of cervicothoracic junction injuries in polytrauma patients who have undergone intubation. Radiographics 2000;20:251-62. 26. Bagley LJ. Imaging of spinal trauma. Radiol Clin North Am 2006;44:1-12. 27. Poonnoose PM, Ravichandran G, McClelland MR. Missed and mismanaged injuries of the spinal cord. J Trauma 2002;53:314-20. Mart - March 2013

Distribution of occult fractures detected in emergency orthopedic patient trauma with CT

28. Reid DC, Henderson R, Saboe L, Miller JD. Etiology and clinical course of missed spine fractures. J Trauma 1987;27:980-6. 29. Hauser CJ, Visvikis G, Hinrichs C, Eber CD, Cho K, Lavery RF, et al. Prospective validation of computed tomographic screening of the thoracolumbar spine in trauma. J Trauma 2003;55:228-35. 30. White JH, Hague C, Nicolaou S, Gee R, Marchinkow LO, Munk PL. Imaging of sacral fractures. Clin Radiol 2003;58:914-21. 31. Perron AD, Brady WJ, Keats TE, Hersh RE. Orthopedic pitfalls in the ED: scaphoid fracture. Am J Emerg Med

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2001;19:310-6. 32. Breitenseher MJ, Gaebler C. Trauma of the wrist. Eur J Radiol 1997;25:129-39. 33. Perron AD, Miller MD, Brady WJ. Orthopedic pitfalls in the ED: radiographically occult hip fracture. Am J Emerg Med 2002;20:234-7. 34. Perron AD, Miller MD, Brady WJ. Orthopedic pitfalls in the ED: pediatric growth plate injuries. Am J Emerg Med 2002;20:50-4. 35. Della-Giustina K, Della-Giustina DA. Emergency department evaluation and treatment of pediatric orthopedic injuries. Emerg Med Clin North Am 1999;17:895-922.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):164-166

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.25902

A rare complication of aortobifemoral bypass operation: internal herniation Aortobifemoral baypas ameliyatının nadir bir komplikasyonu: İnternal herniasyon Bülent ÇİTGEZ, Gürkan YETKİN, Mehmet ULUDAĞ, İsmail AKGÜN, Uğur EKİCİ, Abdulcabbar KARTAL

Intestinal brids are most common cause of postoperative ileus although there are various cause of ileus after abdominal operation. On the other hand internal herniation is a rare cause of ileus after abdominal operations. Diagnosis of this hernias are important because of strangulation and necrosis of its content due to circulatory disturbance. In this case report, we publish a patient with ileus due to a greft which has been used in a previous abdominal surgery for abdominal aort aneurysm.

Karın operasyonları sonrası çeşitli nedenler dolayısıyla olmakla beraber, en sık intestinal yapışıklıklara bağlı mekanik intestinal tıkanıklık (MİT) görülebilmektedir. İnternal herniasyonlar ise karın operasyonları sonrası nadir bir MİT nedenidir. Bu hernilerde içeriğin boğulma ve nekroza kadar giden dolaşım bozukluğu nedeniyle doğru tanı konabilmesi önemlidir. Bu yazıda, karın aort anevrizma ameliyatı sonrası kullanılan greftin neden olduğu internal herniasyon sonucu oluşan MİT sunuldu.

Key Words: Aortobifemoral bypass; internal herniation/complication.

Anahtar Sözcükler: Aortobifemoral baypas; internal herniasyon/ komplikasyon.

Internal herniation is a rare cause of intestinal occlusion. Internal herniation, either congenital or acquired, is responsible for 0.6-5.8% of all intestinal occlusions.[1]

We aimed to present a case that presented to our emergency surgical clinic one week after the aortobifemoral by-pass surgery with a complaint of the ileus.

CASE REPORT A 56-year-old male patient presented to our emergency unit with complaints of abdominal pain and inability to pass gas or move his bowels that was ongoing for 2 days. A midline incision was identified during his abdominal examination, and he explained that he had an operation for AAA in another healthcare institution one week prior. Abdominal distention was present and the patient described malodorous vomiting once before his presentation to the emergency unit. Bowel sounds were hypoactive. There was tenderness in the four abdominal quadrants. Formed stool was identified in the rectal touch. Air-fluid levels were observed on X-ray. Fecaloid content came out from the case after placement of the catheter for decompression. The computed tomography (CT) was unremarkable for the ileus. The patient was urgently admitted for surgery due to deterioration of his general condition and acute abdominal findings. Exploratory laparotomy revealed

Department of General Surgery, Sisli Etfal Training and Research Hospital, Istanbul, Turkey.

Şişli Etfal Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul.

Abdominal aortic aneurism (AAA) is a frequently encountered pathology with a prevalence of 1-4% of the entire population and is observed in 5-9% of men older than 65 years.[2] Currently, treatment for AAA is the interposition of vascular prosthesis by surgically reaching the aneurysmatic section of the aorta specifically through the abdomen.[2] Gastrointestinal complications such as ischemic colitis, mechanical ileus and aortoduodenal fistula incidence is 20% in the post-operative period and 16% to 67% of these complications may be mortal.[3]

Correspondence (İletişim): Bülent Çitgez, M.D. Şişli Etfal Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, 34377 İstanbul, Turkey. Tel: +90 - 212 - 373 50 00 e-mail (e-posta): bcitgez@yahoo.com

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an opened retroperitoneum due to aortobifemoral by-pass and jejunal loop adhered to the graft, which caused the ileus by preventing the passage of intestinal content jejunum since it was not peritonised. Intestinal loops entered the open area and were struck due to adhesions (Fig. 1a). The retroperitoneum was peritonized after the adherences were removed (Fig. 1b). There was no other pathology and the procedure was terminated. The post-operative period was uneventful and the patient was discharged in stable condition.

tors, they identified perforation secondary to internal herniation in 4 patients (10%). In treatment, intestinal loops stuck in the hernia sac are removed. If the patient develops strangulation or perforation, segmentary intestinal resection and end-to-end anastomosis should be performed.[8] In our case, intestinal loops were herniated towards the non-peritonized area and compression occurred due to adhesions in that region; however, no additional intervention was considered necessary since perfusion was not impaired.

DISCUSSION Herniation of the intestinal loops and mesentery to openings in the visceral peritoneum or recesses are rare causes of intestinal obstructions, which stand for 1% of all cases. Symptoms include localized sensitivity, epigastric mass and increased peristaltic motion.[4] Severe forms may manifest with dehydration and leucocytosis.[4,5] Abdominal X-ray may show dilated intestinal loops and air-fluid levels.[5] Abdominal X-ray can only show obstruction.[5] Abdominal CT shows displaced, tensed, dilated and overlapping intestinal segments. Displacements of the mesenteric vascular structures perfusing these intestinal segments can also be observed. CT is the most important non-invasive radiological method that facilitates an absolute diagnosis.[5] In our case, abdominal X-ray revealed air-fluid levels; however, the CT was unremarkable. Complaints may deteriorate if the patient develops incarceration or strangulation. Pathology may progress and may cause perforation if no definitive diagnosis can not be reached and patient is usually admitted for surgery with the presumptive diagnosis of acute abdomen.[6,7] In a study by Aky覺ld覺z et al.,[6] which excluded perforations secondary to trauma, colorectal tumor, adhesions, mesenteric ischemia and iatrogenic fac-

Aortobifemoral bypass with prosthetic graft is commonly used in aorto iliac occlusive vascular diseases and AAA as well as the lesions effecting the iliac segments.[9] There is no ideal material for production of vascular prosthesis and datron and polytetrafluoroethylene (PTFE) are the most commonly used materials. PTFE was identified to be superior to dacron graft in the femoropopliteal bypass grafting. However, there is no exact consensus on the superiority of each treatment for aortobifemoral bypass. Cintora et al.[10] did not find any statistical difference between PTFE and dacron graft in 312 aortofemoral cases, but they noted that the rate of complications were higher in the Dacron group. Abdominal adhesions are a dynamic, fibro-proliferative and inflammatory defense mechanism occurring as a response to trauma to the peritoneum. Intraperitoneal adhesion develop due to ischemia on the peritoneal surface and trauma and continues with extravasation and inflammation at the cellular level. The features of a prosthetic material are as follows: it must not physically interact with tissue fluids, must be chemically inert, must not lead to inflammation or foreign object reaction, must not be carcinogenic, must not cause allergy or hypersensitivity and be resistant to mechanical stress.[11] Dacron graft was used in our case, and the omentum adhered to the graft as a result of the interac-

(a)

(b)

Fig. 1. (a) Jejunal loop adhesed to the graft since it was not peritonized, blocked the bowel passage and caused to ileus. (b) The retroperitoneum was peritonized after the adhesion was opened.

(Color figures can be viewed in the online issue, which is available at www.tjtes.org).

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tion between the omentum and graft, which caused the ileus due to suppression on the jejunum. The vascular grafting process is either retroperitoneal (RP) or transperitoneal (TP). There are several studies discussing the superiority of the RP or TP approaches in the surgical treatment of aorto-iliac occlusive vascular disease.[12] In a study with two groups of 55 cases, Başel et al.[12] did not find a significant difference between TP and RP, although they reported gastrointestinal problems to be more common in TP. In our study, the transperitoneal approach was preferred and as a result of the unclosed retroperitoneum, interaction of the omentum and the graft led to an internal herniation. Aortobifemoral bypass with prosthetic graft is commonly used in aorto iliac occlusive vascular diseases and abdominal aortic aneurism as well as the lesions effecting the iliac segments. Complications may develop related to the graft due to an unclosed peritoneum. It should be noted that the ileus in AAA cases may be secondary to adhesions due to the graft used in surgery. Conflict-of-interest issues regarding the authorship or article: None declared. REFERENCES 1. Newsom BD, Kukora JS. Congenital and acquired internal hernias: unusual causes of small bowel obstruction. Am J Surg 1986;152:279-85. 2. García-Madrid C, Josa M, Riambau V, Mestres CA, Muntaña J, Mulet J. Endovascular versus open surgical repair of abdominal aortic aneurysm: a comparison of early and intermediate results in patients suitable for both techniques. Eur J

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Vasc Endovasc Surg 2004;28:365-72. 3. Huddy SP, Joyce WP, Pepper JR. Gastrointestinal complications in 4473 patients who underwent cardiopulmonary bypass surgery. Br J Surg 1991;78:293-6. 4. Tekin A, Şahin M, Küçükkartallar T, Kaynak A. Nadir bir ileus nedeni: Paradoudenal hernia. Genel Tıp Derg 2007;17:111-4. 5. Ulusan Ş, Koç Z. İnternal herniasyonun radyolojik bulguları. Turkiye Klinikleri J Med Sci 2007;27:311-2. 6. Akyildiz HY, Akcan AC, Sözüer E, Küçük C, Yilmaz N, Artiş T. Unusual causes of intestinal perforation and their surgical treatment. Ulus Travma Acil Cerrahi Derg 2009;15:579-83. 7. Akcakaya A, Sahin M, Coskun A, Demiray S. Comparison of mechanical bowel obstruction cases of intra-abdominal tumor and non-tumoral origin. World J Surg 2006;30:12959. 8. Ozkan E, Fersahoğlu MM, Dulundu E, Ozel Y, Yıldız MK, Topaloğlu U. Factors affecting mortality and morbidity in emergency abdominal surgery in geriatric patients. Ulus Travma Acil Cerrahi Derg 2010;16:439-44. 9. Türköz R, Deniz B, Kestelli M, Özbek C, Akçay A, Tonguç E ve ark. Aortobifemoral bypass olgularında Dakron ve politetrafloroetilen greftin karşılaştırılması. Türk Göğüs Kalp Damar Cerrahisi Dergisi 1997;5:212-7. 10. Cintora I, Pearce DE, Cannon JA. A clinical survey of aortobifemoral bypass using two inherently different graft types. Ann Surg 1988;208:625-30. 11. Alimoglu O, Akcakaya A, Sahin M, Unlu Y, Ozkan OV, Sanli E, et al. Prevention of adhesion formations following repair of abdominal wall defects with prosthetic materials (an experimental study). Hepatogastroenterology 2003;50:725-8. 12. Başel H, Aydın Ü, Kutlu H, Özsoy SD, Dostbil A, Taşdemir M ve ark. Aortoiliyak tıkayıcı arter hastalıklarının cerrahi tedavisinde retroperitoneal ve transperitoneal yaklaşımların karşılaştırılması. Türk Göğüs Kalp Damar Cerrahisi Dergisi 2009;17:249-53.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):167-172

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.22567

Use of radiofrequency ablation for controlling liver hemorrhage in the emergency setting; report of two cases and review of the literature Acil ortamlarda karaciğer kanamasının kontrolünde radyofrekans ablasyonun kullanılması: İki olgu sunumu ve literatürün gözden geçirilmesi Ioannis MAROULIS,1 Charalambos SPYROPOULOS,1 Christina KALOGEROPOULOU,2 Dimitrios KARAVIAS1

Active liver hemorrhage with hemodynamic instability is a serious situation often requiring surgical intervention. The most common causes of hepatic bleeding are trauma and tumors of the liver parenchyma: mainly hepatocellular carcinoma and adenoma. Liver hemorrhage from blunt trauma or spontaneous tumor rupture is sometimes difficult to control with traditional methods and postoperative complications are frequent. Recently, the radiofrequency ablation system (RF) has been used for obtaining haemostasis of ruptured hepatic tumors or for controlling hemorrhage due to liver trauma in experimental models. We report two cases where the radiofrequency ablation system (RF) has been efficiently used during emergency laparotomy in humans in order to control massive hemorrhage from spontaneous rupture of a liver metastatic testicular germ cell tumor and from a Grade IV blunt liver trauma. RF ablation system combined with traditional techniques was effective in controlling liver bleeding during laparotomy in both cases. No recurrence of the hemorrhage or any side effects associated with the RF system were recorded postoperatively. RF system is an effective strategy for achieving hemostasis in patients with active liver hemorrhage. In cases of bleeding liver tumors, RFA could also be helpful in synchronous tumor elimination, maximizing the chances of longer term survival.

Hemodinamik instabiliteyle birlikte aktif karaciğer kanaması sıklıkla cerrahi girişimi gerektiren ciddi bir durumdur. Karaciğer kanamasının en sık görülen nedenleri travma, başlıca hepatoselüler karsinom ve adenom olmak üzere karaciğer parankimi tümörleridir. Künt travma veya spontane tümör rüptürünü bazen klasik yöntemlerle kontrol altına almak zorlaşmakta ve sık sık ameliyat sonrası komplikasyonlar görülmektedir. Son zamanlarda rüptüre karaciğer tümörlerinde hemostazı sağlamak veya deneysel modellerde karaciğer travmasına bağlı kanamayı kontrol altına almak için radyofrekans ablasyon (RFA) sistemi kullanılmaktadır. İnsanlarda karaciğerde metastatik testis germ hücreli tümörün spontane rüptürüne ve grade IV künt karaciğer travmasına bağlı masif kanamanın kontrol altına alınması için acil laparatomi sırasında RFA sisteminin etkinlikle kullanılmış olduğu iki olgu sunuyoruz. Klasik tekniklerle kombine edilmiş RFA sistemi her iki olguda da laparotomi sırasında karaciğer kanamasını kontrol altına almada etkili olmuştur. Ameliyat sonrası dönemde RFA sistemiyle ilişkili herhangi bir kanama nüksü veya yan etki kaydedilmedi. Aktif karaciğer kanaması olan hastalarda hemostazı sağlama açısından RFA sistemi etkili bir stratejidir. Kanayan karaciğer tümörlerinde RFA aynı zamanda eş zamanlı olarak tümörün ortadan kaldırılmasına yardımcı olarak daha uzun sağkalım şansını en üst düzeye çıkartabilir.

Key Words: Hemorrhage; liver; radio frequency ablation.

Anahtar Sözcükler: Kanama; karaciğer; radyofrekans ablasyon.

Departments of 1Surgery, 2Radiology, University Hospital of Patras Rion, Patras, Greece.

Patras Rion Üniversite Hastanesi 1Cerrahi Kliniği, 2Radyoloji Bölümü, Patras, Yunanistan.

Correspondence (İletişim): Charalambos Spyropoulos, M.D. 59, Vitsentzou Kornarou Street 26442 Patras, Greece. Tel: +0030 - 2610 - 454958 e-mail (e-posta): xspiropupatras@gmail.com

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The liver is the most frequently injured abdominal organ. Management of liver injuries has evolved significantly over the last two decades, with significant improvement in outcomes. Road traffic accidents and antisocial, violent behavior account for the majority of liver injuries. In the absence of trauma or anticoagulant therapy, hepatic hemorrhage may be due to underlying liver disease. The most common causes of non-traumatic hepatic hemorrhage are hepatocellular carcinoma (HCC) and adenoma but such hemorrhage can also occur in patients with other liver tumors, such as focal nodular hyperplasia and hemangioma. In contrast, hemoperitoneum due to rupture of liver metastases is quite rare while the cases of bleeding metastatic testicular tumors are quite exceptional.[1-3] In the case of massive hemorrhage with hemodynamic destabilization, surgical intervention is required. There are a variety of methods to control liver bleeding; radiofrequency ablation (RFA) system has been recently used in the emergency setting for obtaining haemostasis of ruptured HCCs[4,5] or for controlling traumatic liver bleeding[6] at the experimental level. In the present study, we report two cases where RFA was successfully applied during emergency laparotomy in humans in order to control hepatic hemorrhage, not managed by conventional techniques. The first case is a spontaneous rupture of a liver metastasis from a testicular germ cell tumor and the second case is a Grade IV liver trauma after blunt abdominal injury due to a traffic accident. We also report a review of the current literature as to our knowledge there is no current report on the efficacy of this technique in humans, when applied in the emergency setting.

CASE REPORTS Case 1â&#x20AC;&#x201C; A 30-year-old male patient was admitted to the emergency department of our hospital reporting fatigue, abdominal pain and vomiting. His medical record included reports of prior surgical operation for undescended testicle at the age of four and heroin use in the preceding six months. Clinical examination re-

(a)

(b)

vealed sensitivity at the palpation of the abdomen with tenderness and presence of rebound, without any clinical signs of hemorrhagic shock. Laboratory examinations indicated a hemoglobin level of 6.8 g/dl without any coagulation disorders or associated thrombocytopenia, elevated liver enzymes with ALT=290 g/dl and AST=133 g/dl and moderate elevation of ÎłGT, ALP and amylase levels. A computed tomography scan (CT) was undertaken revealing multiple hepatic metastases, free quantity of endoperitoneal blood and the presence of a blood clot in the left hepatic lobe, without any active contrast extravasation (Fig. 1). Considering the patientâ&#x20AC;&#x2122;s medical history and the findings of the CT scan, the possibility of hepatic metastases from a testicular tumor was suspected. Ultrasound (US) scan of the testes was subsequently performed revealing the presence of a single lesion on the right testicle of 1.5 cm in diameter with multiple calcifications. The patient was transferred to the clinic for hemodynamic monitoring and support, and planning was made to perform the selected embolization of the left hepatic artery afterwards. Upon transfer and despite rigorous resuscitation with crystalloid, colloid and blood transfusion, clinical signs of serious hemorrhagic shock emerged with hemodynamic destabilization. An emergency exploratory laparotomy was deemed necessary to perform liver packing and possibly subsequent embolization postoperatively. During surgery, as would be expected, massive intrabdominal blood clots were found and multiple hepatic metastases were detected with the largest ranging about 4 cm in diameter, located in the left hepatic lobe. The rupture was visible on the surface of the metastatic lesions accompanied by both massive blood clots around them and active bleeding. Temporary packing of the hemorrhagic lesions was performed with successful temporary stabilization of the patient. Bearing in mind recent reports of hemorrhage control via RFA in experimental conditions, particularly in liver trauma, and estimating the extent of the underlying

(c)

Fig. 1. Pre (a) and post contrast scans (b, c) reveal hemoperitoneum and multiple hypervascular liver metastases. A large metastasis in segment II is adjacent to the liver surface producing contour abnormality and discontinuity, surrounded by sentinel thrombus. 168

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Use of radiofrequency ablation for controlling liver hemorrhage in the emergency setting

(a)

(b)

Fig. 2. Pre (a) and post contrast scan (b), 10 days post surgery. There is marked hypovascularity of the ruptured metastasis in the left lobe and hyper dense material within it, corresponding to intralesional thrombus.

damage as well as our experience with RFA-assisted hepatic resection, it was decided that RFA was a viable alternative for the specific patient. To this end we employed the Cool-tipTM RF system (Valley Lab, Boulder, CO®) utilizing the system’s “manual mode”. Operating at a generator power output of 180-200W and using a single probe, we performed various applications directly inside the rupture as well as to the surrounding area, effectively creating an occlusive barrier of dried tissue within the liver parenchyma, ranging ~3 cm in diameter. The time length of each application varied between 3-5 minutes and it was carried out at every site until the impedance readings exceeded 300 Ω and the tissue had assumed a characteristic dehydrated, brownish appearance. After completion of the RFA sessions, hemorrhage was completely controlled with hemodynamic stabilization of the patient and he was admitted to the intensive care unit for 48 hours. Lesion biopsy was indicative of metastatic testicular choriocarcinoma. The diagnosis was also supported by the pre-operative values of chorionic gonadotropin which were 25.000 mIU/mL. The patient remained hospitalized for a period of 12 days (two days in the intensive care unit) without any postoperative complications, as indicated by a new CT scan during followup (Fig. 2), before being transferred to the oncology department for commencing chemotherapy sessions. The patient is still alive at present and doing well. Case 2– A 28-year-old male patient, victim of a road traffic accident, who had been initially managed in a secondary general hospital, was transferred intubated to the emergency department of our hospital for further evaluation and management. His medical record included heroin use and chronic hepatitis C. The patient had initially undergone an exploratory damage control Cilt - Vol. 19 Sayı - No. 2

laparotomy due to hemodynamic instability where a Grade IV hepatic trauma was revealed with right lobar destruction and active bleeding. Furthermore there was a rupture in the prepyloric area of the stomach and also a laceration at the body of the pancreas with the presence of extended peripancreatic hematoma. Damage control management consisted of peri-hepatic packing, partial suturing of the prepyloric injury and positioning of a drainage tube throughout the gastric rupture. During initial assessment at our hospital the patient was hemodynamically stable and he was transferred to the radiology department where a CT scan was performed (Fig. 3). Computed tomography findings indicated additional thoracic injuries (right pneumothorax) and minor injuries at the right kidney. The patient was admitted to the ICU where he remained hemodynamically stable receiving transfusions of concentrated red blood cells and fresh frozen plasma. After 24 hours, he was transferred to the angiography suite where selective embolization of the right hepatic artery was performed due to continuous low volume bleeding from branches of the right hepatic artery. Forty-eight hours after the accident, a second-look laparotomy was performed where unpacking revealed extended injuries at the right hepatic lobe (segments IV, V, VI and VIII) with areas of active bleeding. Bearing in mind recent effective hemorrhage control via RFA in our patient of case 1, recent reports of hemorrhage control via RFA in experimental conditions for liver trauma, and estimating the extent of the damage it was decided to use the RFA system as an adjunct for achieving liver haemostasis. The Cool-tipTM RF system (Valley Lab, Boulder, CO®) was applied performing ablative applications at maximum power (180-200 W) and for time-lengths/periods long enough to de169

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syndrome and central venous catheter related infections, all managed successfully. On the 22nd postoperative day he was transferred to our clinic where he remained for a period of 39 days without any further complications, as confirmed in repetitive CT scans (Fig. 5).

Fig. 3. Grade IV hepatic injury. Contrast-enhanced CT scan shows multiple hepatic lacerations in the right hepatic lobe, resulting in parenchymal disruption of about 50% of the lobe. Pneumoperitoneum and gauze pads in the liver surface are also present, due to prior laparotomy (packing).

hydrate/cauterize thick pieces of liver tissue to cease hemorrhage at all sites, as described above (Fig. 4a). Applications again did not exceed 3 minutes at every site, while the 300 立 impedance reading and tissue discoloration criteria were applied once more for every hemorrhagic site. The application of RFA was effective and prevented any further blood loss (Fig. 4b). All other intra-abdominal injuries were systematically reviewed and were properly managed. Drainage tubes were positioned at the site of the liver injury and the peripancreatic hematoma. The patient was transferred to the intensive care unit for 24 days. On the second postoperative day, minor pancreatic leakage was detected leading to the formation of a low-volume pancreatic fistula. The patient also developed abstinence

(a)

DISCUSSION Spontaneous rupture of liver tumors is infrequent and it is usually caused by HCCs while rupture of hepatic metastasis is quite exceptional.[7] In a series of 70 cases of spontaneous liver hemorrhage reported by Chen et al, the cause was HCC rupture in 60 patients, cirrhosis without underlying tumor existence in three, hemangioma in two, hepatocellular adenoma in four and a bleeding metastatic lesion in only one patient.[8] These hypervascular tumors can usually be revealed after accidents which involve liver trauma and thus about 10% of HCC would present in such a way, responsible for the deaths of 3% of patients with HCC in a large Swedish series.[9] Massive hemorrhage related to ruptured liver metastases is quite exceptional and less than 50 cases are reported in the literature.[7] Spontaneous rupture of an HCC may be explained by bleeding disorders, the intense vascularity of the tumor, the rapid tumor growth and probably by the coexistence of peritumoral venous dilatation due to portal hypertension. In the context of metastatic disease several factors may be invoked to explain sudden rupture such as rapid tumor growth, the peripheral vascularity and the intense central necrosis. Metastatic tumors are usually fibrotic, less vascular and invasive, and penetrate the liver capsule less frequently than HCC. The usual treatment of hemoperitoneum caused by ruptured benign or malignant liver lesions is based on hepatic artery embolization which in most cases is highly effective.[10] Surgical intervention is deemed

(b)

Fig. 4. The application of the RF system on major hepatic injury (a) prevented any further blood loss (b). (Color figures can be viewed in the online issue, which is available at www.tjtes.org). 170

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Use of radiofrequency ablation for controlling liver hemorrhage in the emergency setting

necessary only in cases of hemodynamic instability despite conservative treatment with main goals to attain hemostasis and to preserve enough functional liver parenchyma. Various surgical procedures, including perihepatic packing, suture application of ruptured tumors, injection of alcohol, ligation of the hepatic artery and rarely emergency liver resection, have been reported to be effective in achieving hemostasis but they are associated with extremely high morbidity and mortality rates.[10] The liver is also the most commonly injured organ in patients with blunt abdominal trauma. Non-operative management of grade I and II hepatic injuries is state of the art but this technique has also been supported for high-grade injuries;[11] nonetheless, embolization through digital selective angiography offers an effective way to control hepatic hemorrhage in these cases, although 24% of patients managed non-operatively are expected to require additional treatment secondary to complications.[12,13] In the case of uncontrolled hepatic bleeding despite conservative techniques, surgical intervention is necessary. During emergency laparotomy, wide exposure of the injured liver is essential and temporary perihepatic packing with swabs and sponges is particularly useful. Packing can be freed gradually in theater 48 to 72 hours later, according to the patient’s condition. Hepatic resection is indicated only in patients with severe multiple contusions and injuries in bile ducts, hepatic veins, and the inferior vena cava in combination with extensive parenchymal damage.[14] RFA is a therapeutic approach exhibiting substantial progress in the last decade.[4] In recent years, the effectiveness of this method for achieving hepatic hemostasis has become greatly appreciated in the treatment of liver trauma, as shown in animal models, as well as in cases of ruptured liver tumors.[4,6] RFA system uses pulsed radiofrequency current to quickly heat and ablate large volumes of tissue[15] and is mainly used for thermal destruction of unrespectable liver tumors. Alternating current through the tissue creates friction on a molecular level. Increased intracellular temperature generates localized interstitial heating. At temperatures above 60 °C, cellular proteins rapidly denature and coagulate.[15] The unique ability of radiofrequency to irreversibly denature sub-cellular protein structures and to coagulate tissues leaving them dry and essentially free of any circulating blood is in fact responsible for its hemostatic effect. The dried tissue, which can be several millimeters thick, acts as a permanent occlusive barrier on the endings of severed and ruptured vessels thereby rendering subsequent bleeding from the coagulated site impossible. In cases of emergency surgical planning, the apCilt - Vol. 19 Sayı - No. 2

Fig. 5. Post contrast follow up scan. Haemostatic elements have been removed from the liver surface. Embolic agents (coils) are present in the RT hepatic artery.

plication of RFA provides valuable time for determining final surgical manipulations, an alternative to perihepatic packing and subsequent unpacking operations. The application of this system should always be evaluated in the operating room, and if deemed commendable it should be performed in the appropriate cases. Based on successful results from the use of RFA in hepatic resections, this technique could be extremely helpful as an efficient alternative in cases of emergency laparotomic exploration for liver bleeding, when other traditional methods cannot be applied due to specific conditions and underlying limitations. In both cases reported in the current study, the RFA protocol involved our system’s manual mode of function. In this mode, no inherent algorithm is at work and the result is more dependent on the operator’s experience. By applying the single Cool-tipTM probe (Valley Lab, Boulder, CO) at the site of hemorrhage and monitoring the system’s impedance readings, it is possible to control blood loss at that site by dehydrating the parenchyma as well as by forming occlusive blood clots within small nearby vessels. The occlusive barrier is essentially formed in columns of 1 cm in diameter and 3 cm in length (the length of the probe’s active tip), which can be created within 1-2 mins at a generator output of 200 W. Then, by applying the probe at successive sites, the occlusive barrier can be shaped according to the operator’s needs. The barrier can be concentrated at one site to terminate blood loss or spread along a path forming a dehydrated wall within the parenchyma that can be cut bloodlessly. Throughout every application, the impedance elevation above the 300 Ω threshold, the characteristic discoloration 171

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of the tissue and of course blood leakage cessation are the criteria that dictate the system’s operation. RFA is an effective strategy for achieving hemostasis in patients with liver hemorrhage in the emergency setting when the appropriate infrastructure is present. In addition to controlling active liver bleeding caused by ruptured tumors, RFA could also be helpful in synchronous tumor elimination, maximizing survival. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Fidas-Kamini A, Busuttil A. Fatal haemoperitoneum from ruptured hepatic metastases from testicular teratomas. Br J Urol 1987;60:80-1. 2. Erb RE, Gibler WB. Massive hemoperitoneum following rupture of hepatic metastases from unsuspected choriocarcinoma. Am J Emerg Med 1989;7:196-8. 3. Leseur J, Trivin F, Dupont-Bière E, Boucher E, Kerbrat P, Raoul JL. Hemoperitoneum secondary to spontaneous rupture of metastatic liver of a testicular germ cell tumor. [Article in French] Gastroenterol Clin Biol 2007;31:1150-2. [Abstract] 4. Lau WY, Lai EC. The current role of radiofrequency ablation in the management of hepatocellular carcinoma: a systematic review. Ann Surg 2009;249:20-5. 5. Manikam J, Mahadeva S, Goh KL, Abdullah BJ. Percutaneous, non-operative radio frequency ablation for haemostasis of ruptured hepatocellular carcinoma. Hepatogastroenterology 2009;56:227-30. 6. Felekouras E, Kontos M, Pissanou T, Drakos E, Pikoulis E,

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Papalois A, et al. Radio-frequency tissue ablation in liver trauma: an experimental study. Am Surg 2004;70:989-93. 7. Tung CF, Chang CS, Chow WK, Peng YC, Hwang JI, Wen MC. Hemoperitoneum secondary to spontaneous rupture of metastatic epidermoid carcinoma of liver: case report and review of the literature. Hepatogastroenterology 2002;49:14157. 8. Chen ZY, Qi QH, Dong ZL. Etiology and management of hemmorrhage in spontaneous liver rupture: a report of 70 cases. World J Gastroenterol 2002;8:1063-6. 9. Kaczynski J, Hansson G, Wallerstedt S. Clinical features in hepatocellular carcinoma and the impact of autopsy on diagnosis. A study of 530 cases from a low-endemicity area. Hepatogastroenterology 2005;52:1798-802. 10. Chen WK, Chang YT, Chung YT, Yang HR. Outcomes of emergency treatment in ruptured hepatocellular carcinoma in the ED. Am J Emerg Med 2005;23:730-6. 11. Christmas AB, Wilson AK, Manning B, Franklin GA, Miller FB, Richardson JD, et al. Selective management of blunt hepatic injuries including nonoperative management is a safe and effective strategy. Surgery 2005;138:606-11. 12. Velmahos GC, Toutouzas KG, Vassiliu P, Sarkisyan G, Chan LS, Hanks SH, et al. A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma 2002;53:303-8. 13. Carrillo EH, Spain DA, Wohltmann CD, Schmieg RE, Boaz PW, Miller FB, et al. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma 1999;46:619-24. 14. Strong RW, Lynch SV, Wall DR, Liu CL. Anatomic resection for severe liver trauma. Surgery 1998;123:251-7. 15. Cool-tip™ RF Ablation System. [Online] http://www.cooltiprf.com.

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Turkish Journal of Trauma & Emergency Surgery Case Report

Ulus Travma Acil Cerrahi Derg 2013;19 (2):173-176 Olgu Sunumu doi: 10.5505/tjtes.2013.29291

Management of acute myocardial infarction after a blunt chest trauma Künt göğüs travması sonrası gelişen akut miyokart enfarktüsünün tedavisi Öner ÖZDOĞAN,1 Mustafa KARAÇELİK,2 Cenk EKMEKÇİ,1 Cengiz ÖZBEK2

Coronary artery dissection is a rare complication after blunt chest trauma. Patients usually present with sudden death and the diagnosis is frequently missed. In this report, we present a case of a 46-year-old with a hyperacute anterior wall myocardial infarction after blunt chest trauma. Diagnostic coronary angiography showed total occlusion of the left anterior descending coronary artery (LAD) starting at the takeoff of the vessel from the left main coronary artery (LMCA). A bare-metal stent was immediately deployed at the proximal LAD and TIMI 3 flow was achieved; however post-procedural images revealed no satisfactory results. A proximal dissection and intraluminal thrombus extending to the LMCA was observed. Because of the proximity of the lesion to the LMCA, re-intervention was considered to be risky and urgent coronary artery bypass grafting (CABG) was planned. Coronary artery stenting is the advised treatment modality for coronary occlusion after blunt chest trauma. However, post-traumatic percutaneous coronary intervention was sometimes considered to be risky because of the anatomic features of the lesion. Timing is cardinal in achieving early reperfusion in the course of myocardial infarction after blunt chest trauma and CABG should be the preferred procedure for initial reperfusion treatment especially in proximal LAD dissections with subsequent thrombus formation leading to total occlusion of the artery.

Künt göğüs travması sonrası koroner arter diseksiyonu nadir bir komplikasyondur. Hastalar genellikle ani ölüm ile gelirler ve tanı çoğu zaman atlanmaktadır. Bu yazıda künt göğüs travması sonrası hiperakut önyüz miyokart enfarktüsü gelişen 46 yaşında bir olgu sunuldu. Tanısal koroner anjiyografi sol ana koroner arter çıkışından başlayan sol ön inen arterin (LAD) total oklüzyonunu göstermekteydi. Koroner anjiyografi sonrası hızlıca proksimal LAD’ye çıplak stent yerleştirildi ve TIMI 3 akım elde edildi; fakat işlem sonrası görüntüler tatminkâr sonuçlar göstermedi. Proksimal bir diseksiyon ve sol ana koronere yayılan intraluminal trombüs gözlendi. Lezyonun sol ana koroner artere yakınlığından dolayı tekrar girişim riskli bulundu ve acil koroner arter baypas greftleme (CABG) planlandı. Koroner arter stentleme, künt göğüs travması sonrası gelişen koroner tıkanıklıkta tavsiye edilen tedavi yöntemidir. Fakat lezyonun anatomik özelliklerine bağlı olarak perkütan koroner girişim bazen riskli olarak kabul edilmektedir. Künt göğüs travması sonrası miyokart enfarktüsü durumunda erken reperfüzyonun sağlanmasında zamanlama önemlidir ve CABG özellikle damarın total oklüzyonuna yol açan trombüs oluşumu ile birlikte olan proksimal LAD diseksiyonlarında başlangıç reperfüzyon tedavisi için tercih edilen yöntem olmalıdır.

Key Words: Chest trauma; coronary artery dissection; percutaneous coronary intervention.

Anahtar Sözcükler: Göğüs travması; koroner arter diseksiyonu; perkutan koroner girişim.

Coronary artery dissection is a rare complication after blunt chest trauma.[1,2] The diagnosis is frequently missed or delayed and since many of the patients present with sudden death, it is an unusual consequence of blunt chest trauma.

injury to the heart and coronary vessels should be suspected.

In patients who present with chest pain or dyspnea, Department of 1Cardiology, 2Cardiovascular Surgery, Izmir Tepecik Training and Research Hospital, Izmir, Turkey.

In this report, we present a case of a 46-year-old with a hyperacute anterior wall myocardial infarction (MI) after blunt chest trauma. We discussed the treatment procedures after the coronary artery dissection. İzmir Tepecik Eğitim ve Araştırma Hastanesi, 1Kardiyoloji Kliniği, 2 Kalp ve Damar Cerrahisi Kliniği, İzmir.

Correspondence (İletişim): Öner Özdoğan, M.D. İzmir Tepecik Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, İzmir, Turkey. Tel: +90 - 232 - 469 69 69 e-mail (e-posta): onerozdogan@yahoo.com

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CASE REPORT A 46-year-old, otherwise healthy man was admitted to our hospital with severe sternal and left chest pain. The pain was started 30 minutes after a blunt chest trauma due to a crash by a massive glass block. He described his pain as tightening and it was disproportionately severe to the level of apparent musculoskeletal injury. The patient was in good health and family history was noncontributory. The patient reported no medications or allergies. Initial physical examination revealed no pathological findings; the patient appeared in no apparent distress. Examination upon arrival revealed a heart rate of 98 beats/min, blood pressure at 130/80 mmHg, respiratory rate at 20 breaths/min, and overt chest wall trauma. Lungs were clear to auscultation. Cardiac examination was normal without murmurs, rubs or gallops. Chest examination revealed external signs of injury to the chest and 6-8 costal fractures on the left side were observed on chest radiography (Fig. 1). Abdominal examination was unremarkable. Initial electrocardiography (ECG) did not reveal any diagnostic abnormalities. During follow up, the patient demonstrated ongoing symptoms and a subsequent ECG featured a hyperacute anterior wall MI (Fig. 2). Transthoracic echocardiography showed moderate hypokinesis of the septum and the anterior wall. Right ventricular and valvular functions appeared normal. No pericardial effusion was observed. A decision was made for an urgent diagnostic coronary angiography. Diagnostic coronary angiography showed total occlusion of the left anterior descending coronary artery (LAD) starting at the takeoff of the vessel from the left main (Fig. 3). Other coronary arteries were free of coronary artery disease, without significant stenosis. After coronary angiography, a bare-metal stent was immediately deployed at the proximal LAD and TIMI 3 flow was achieved; however post-procedural (Fig. 4a, b) images revealed no satisfactory results. A proximal

Fig. 1. Left costal fractures at posterior-anterior chest radiography.

dissection and intraluminal thrombus extending to left main coronary artery was observed. Because of the proximity of the lesion to the left main coronary artery, re-intervention was considered to be risky and urgent coronary artery bypass grafting was planned. At surgery he underwent a single bypass graft as follows: left internal mammary artery to LAD. The operative course was uneventful. Respiratory support was required for 42 days after the operation due to the contusion.

DISCUSSION In patients who present with chest pain or dyspnea after a blunt chest trauma, injury to the heart and coronary vessels should be suspected. The LAD is involved in the majority of the reported cases.[3,4] Intimal tearing caused by shearing forces and the compression of the artery between the heart and the sternum lead to coronary artery dissection. Impairment of the coronary flow by the dissection flap and accompanying intraluminal thrombosis can induce MI as was seen in our patient.

Fig. 2. Electrocardiography after ongoing chest pain. Precordial derivations featuring hyperacute anterior wall infarction. 174

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Fig. 3. Right anterior oblique caudal view during the diagnostic coronary angiography showing the proximal total occlusion of left anterior descending artery.

The earliest feature of coronary occlusion is the development of ST/T wave changes observed by ECG. Echocardiography can identify cardiac tamponade, aortic dissection, valvular injury, and wall motion abnormalities. Delayed revascularization results with increased myocardial damage and sudden death. Furthermore, since it is an acute coronary artery occlusion, ventricular impairment, clinical heart failure, and a worse long-term prognosis should also be taken into account in cases without specific treatments. Treatment pro-

(a)

cedures include angiography with stenting, thrombolytics, and surgical revascularization.[5-7] However, thrombolytic agents are usually not recommended because of the increased risk of bleeding from associated injuries. On the other hand, since MI could be the result of intimal tear or dissection, thrombolytic therapy may worsen the prognosis itself. Therefore, if coronary artery dissection is suspected, urgent diagnostic cardiac catheterization must be performed. Coronary artery stenting is the advised treatment modality most often reported in previous data.[1] Although it requires aggressive anti-platelet treatment, it is still an important procedure in the setting of acute trauma and is minimally invasive. On the other hand, the use of adjunctive anti-platelet drugs must be individualized depending on the risk of stent thrombosis versus the bleeding threat from associated injuries. Coronary artery bypass surgery is especially recommended in cases with associated valvular disruption. As reported in our case percutaneous intervention after post-traumatic coronary dissection was sometimes considered to be high risk because of the anatomic features of the lesion. Coronary angioplasty in the proximal LAD usually does not reveal satisfactory results due to the proximity of the lesion to the left main coronary artery and the nature of the lesion. In conclusion, the possibility of severe injury of the heart after blunt chest trauma indicates close follow-up of the patient. The diagnosis should be confirmed by urgent coronary angiography. Although coronary artery dissection is a rare complication after blunt chest trauma, it could lead to MI and sudden death and the diagnosis is frequently missed or delayed. Surgery should

(b)

Fig. 4. (a) Right anterior oblique caudal view after bare metal stenting. (b) Left anterior oblique caudal view after coronary bare metal stenting showing intraluminal thrombus and proximal dissection of the left anterior descending artery extending into the left main coronary artery. Cilt - Vol. 19 Say覺 - No. 2

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be considered when percutaneous intervention is not appropriate due to the nature of the lesion and when there is associated valvular disruption. As we all know, timing is cardinal in achieving early reperfusion in the course of MI and it could be stated that coronary artery bypass surgery should be the preferred procedure for initial reperfusion treatment especially in proximal LAD dissections with subsequent thrombus formation leading to total occlusion of the artery after blunt chest trauma. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Moreno R, PĂŠrez del Todo J, Nieto M, Alba F, Alfonso F, Garcia-Rubira JC, et al. Primary stenting in acute myocardial infarction secondary to right coronary artery dissection following blunt chest trauma. Usefulness of intracoronary ultrasound. Int J Cardiol 2005;103:209-11.

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2. Hobelmann A, Pham JC, Hsu EB. Case of the month: Right coronary artery dissection following sports-related blunt trauma. Emerg Med J 2006;23:580-1. 3. Hazeleger R, van der Wieken R, Slagboom T, Landsaat P. Coronary dissection and occlusion due to sports injury. Circulation 2001;103:1174-5. 4. James MM, Verhofste M, Franklin C, Beilman G, Goldman C. Dissection of the left main coronary artery after blunt thoracic trauma: Case report and literature review. World J Emerg Surg 2010;5:21. 5. Boland J, Limet R, Trotteur G, Legrand V, Kulbertus H. Left main coronary dissection after mild chest trauma. Favorable evolution with fibrinolytic and surgical therapies. Chest 1988;93:213-4. 6. Ginzburg E, Dygert J, Parra-Davila E, Lynn M, Almeida J, Mayor M. Coronary artery stenting for occlusive dissection after blunt chest trauma. J Trauma 1998;45:157-61. 7. Shah P, Dzavik V, Cusimano RJ, Sermer M, Okun N, Ross J. Spontaneous dissection of the left main coronary artery. Can J Cardiol 2004;20:815-8.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):177-179

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.26779

Multiple magnet ingestion resulting in small bowel perforation: a case report Çoklu mıknatıs yutulmasına bağlı bağırsak perforasyonu: Olgu sunumu Feryal GÜN, Tansel GÜNENDİ, Başak KILIÇ, Alaaddin ÇELİK

Foreign body ingestion is a common clinical situation that is primarily diagnosed by emergency clinicians. Most foreign bodies can be evacuated without difficulty. Although rare, magnets that reach the lower intestinal tract may cause complications such as intestinal fistula formation, perforation, volvulus or appendicitis. We report herein a two-yearold girl who was admitted to our department 3 days ago with abdominal pain and non-bilious vomiting. Upon admission direct abdominal roentgenogram revealed a foreign body consisting of multiple spheric parts bound together forming a circle in the lower quadrants of the abdomen. Her family, unaware of this ingestion, stated that a magnetic toy matching the object present on the plain radiograph was lost several days ago. Surgical intervention showed a magnetic toy in the proximal part of the ileum causing multiple perforations in the intestinal wall and the neighboring mesentery. The ileal portion containing the magnet toy was seen folded over itself forming a blind loop. The patient was discharged uneventfully in the 7th postoperative day. Our case highlights a well known fact that foreign body ingestion in children may not have eye witnesses and should be taken into consideration when evaluating children with abdominal pain. Key Words: Ingested magnets in children; ingested foreign body.

Yabancı cisim yutulması sıklıkla acil hekimlerinin karşılaştığı bir klinik durumdur. Çoğu yabancı cisim kendiliğinden çıkar. Ancak nadiren de olsa, distal intestinal sisteme ulaşabilen yabancı cisimler fistül, perforasyon, volvulus veya apandisit gibi komplikasyonlara yol açabilir. Bu yazıda, kliniğimize üç günlük karın ağrısı ve safrasız kusma şikayeti ile başvuran iki yaşındaki kız hasta sunuldu. Başvuru esnasında çekilen ayakta direkt karın grafisinde, karın sağ alt kadranda halka yapısında birbirine bağlı birden fazla sayıda yabancı cisim izlendi. Aile yabancı cisim yutulması ile ilgili herhangi bir öykü vermedi ancak karın grafisinde izlenen yabancı cisme benzer bir oyuncak mıknatısın birkaç gün önce evde kaybolduğunu belirttiler. Cerrahi girişimde proksimal ileumda bağırsak duvarında ve komşu mezenterde çoğul bağırsak delinmesine yol açan halka şeklinde mıknatıslı oyuncak izlendi. Bu yabancı cismin yer aldığı ileal parça yabancı cismin şeklini alarak kendi üstüne katlanmış ve o da halka şeklini almıştı. Hasta ameliyat sonrası yedinci günde sorunsuz olarak taburcu edildi. Bu olgu ile çocuklarda yabancı cisim yutulmasında herhangi bir şahitin olmayabileceği ve karın ağrılarının değerlendirilmesinde bu durumun da hatırlanması gerektiğinin bir kere daha altı çizilmelidir. Anahtar Sözcükler: Çocuklarda yutulmuş mıknatıs; yutulan yabancı cisimler.

Foreign body ingestion is a problem commonly encountered in children, particularly in those aged between 6 months and 3 years. Ingested foreign bodies including coins, batteries, and pins reaching the stomach pass through the gastrointestinal tract spontaneously. On the other hand, multiple magnet ingestion may result in complications such as entero-enteric fistula or intestinal obstruction. Therefore, we report

a very rare case of intestinal obstruction by enteroenteric fistula after the ingestion multiple magnets.

Department of Pediatric Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey.

İstanbul Üniversitesi İstanbul Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, İstanbul.

CASE REPORT A two-year-old girl was admitted to our department with abdominal pain and non-bilious vomiting. Intravenous fluids and antibiotics were administered for three days however bilious vomiting developed afterwards.

Correspondence (İletişim): Feryal Gün, M.D. Talatpaşa Cad. Hareket Ordusu Sok. Işıl Apt., No: 12 / 17, Bahçelievler, 34180 İstanbul, Turkey. Tel: +90 - 212 - 555 79 46 e-mail (e-posta): gunferyal@yahoo.com

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pain started again and this time bilious vomiting developed. The patient was taken to the operation room and laparotomy was performed via an infraumblical midline incision. Upon exploration, foreign body was visualized in the proximal ileum causing perforation in the intestinal wall and the neighboring mesentery by forming a circle and leading to entero-enteric fistula.

Fig. 1. Abdominal roentgenogram demonstrating a foreign body in the region of the lower quadrants.

On physical examination she looked dehydrated, and there was abdominal pain with diffuse tenderness in all quadrants, laboratory values were white blood cell: 16.100 mm3, C-reactive protein: 40.1 mg/L, sodium:133 mEq/L, respectively. Abdominal roentgenogram showed a foreign body which consists of multiple spheric parts in a circular fashion (Fig. 1). Her parents admitted that a magnetic toy looking exactly the same as the roentgenogram disappeared several days ago. The patient was hospitalized, oral intake was stopped, intravenous isotonic crystalloid fluids and antibiotic (sefazoline 100 mg/kg) were administered. Serial abdominal X-rays were taken daily in which the magnets seemed to change place in each radiogram. On the 2nd day fluid resuscitation and antibiotic therapy seemed to improve the patientâ&#x20AC;&#x2122;s clinical characteristics as she was mobilized and a slight relief in the abdominal pain was noted. On the 3rd day abdominal

(a)

It can be speculated that the patient had swallowed these magnetic pieces one by one and that the first and the very last piece of magnet opposed each other in the ileal segment closing the line and forming the circle. (Fig. 2). The foreign body was removed and the perforations were oversewn. She was discharged on the 7th day postoperatively without any further complications.

DISCUSSION Foreign body ingestion is usually detected in children between 6 months and 3 years of age and 80% of cases will have spontaneous passage of the foreign body, 10-20% require endoscopic removal, and 1% require surgical intervention.[1] In some cases children swallow foreign bodies without an eyewitness and may not develop any symptoms at all. In a retrospective review, only 50% of children with confirmed foreign body ingestion were symptomatic.[2] Once these swallowed objects pass the esophagus they will leave the gastrointestinal tract without difficulty and very few will necessitate surgical treatment. Foreign bodies that reach the stomach should be observed by serial abdominal radiograms.[3] One magnet may not cause any clinical problem but things get complicated if multiple magnets are swallowed, resulting in gastrointestinal complica-

(b)

Fig. 2. (a) Illustration of foreign body on the original photo. (b) Note the pinched tissues between magnets.

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(Color figures can be viewed in the online issue, which is available at www.tjtes.org).

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Multiple magnet ingestion resulting in small bowel perforation

tions, including intestinal fistula formation, leading to intestinal obstruction or perforation.[4,5] A delay in the diagnosis facilitates necrosis of the intervening tissue, which will eventually lead to perforation and/or entero-enteric fistula formation and/ or bowel obstruction secondary to kinking, inflammatory reaction, and/ or internal herniation.[6,7] In our case enteroenteric fistula was detected peroperatively. Ingestion of multiple magnets in children may cause intestinal perforation in the early period. These cases should be monitored by close follow-up by repeated Xrays, and surgical intervention should not be delayed.[8] Foreign bodies pass through children’s gastrointestinal tract without their parents awareness before symptoms arise. Clinicians should be aware of risks associated with multiple magnet ingestion. When a child with a history of a foreign body ingestion is seen by a physician, a thorough history should be taken for a possible magnet ingestion. Upon appropriate medical support for deteriorated clinical condition, X-ray studies should be undertaken to determine the route of the magnet. If signs of bowel obstruction are present, a surgical approach is warranted to avoid further complications.

Cilt - Vol. 19 Sayı - No. 2

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Brown DJ. Small bowel perforation caused by multiple magnet ingestion. J Emerg Med 2010;39:497-8. 2. Nguyen LT. Foreign bodies. In: Puri P, Höllwarth ME, editors. Pediatric surgery. Berlin, Heidelberg: Springer; 2009. p. 206. 3. Butterworth J, Feltis B. Toy magnet ingestion in children: revising the algorithm. J Pediatr Surg 2007;42:e3-5. 4. Robinson AJ, Bingham J, Thompson RL. Magnet induced perforated appendicitis and ileo-caecal fistula formation. Ulster Med J 2009;78:4-6. 5. Nui A, Hirama T, Katsuramaki T, Maeda T, Meguro M, Nagayama M, et al. An intestinal volvulus caused by multiple magnet ingestion: an unexpected risk in children. J Pediatr Surg 2005;40:e9-11. 6. Fenton SJ, Torgenson M, Holsti M, Black RE. Magnetic attraction leading to a small bowel obstruction in a child. Pediatr Surg Int 2007;23:1245-7. 7. Alzahem AM, Soundappan SS, Jefferies H, Cass DT. Ingested magnets and gastrointestinal complications. J Paediatr Child Health 2007;43:497-8. 8. Sahin C, Alver D, Gulcin N, Kurt G, Celayir AC. A rare cause of intestinal perforation: ingestion of magnet. World J Pediatr 2010;6:369-71.

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Ulus Travma Acil Cerrahi Derg 2013;19 (2):180-182

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.58159

Isolated unilateral vagus nerve palsy secondary to trauma Travmaya sekonder izole tek taraflı nervus vagus yaralanması Dursun AYGÜN,1 Ethem ACAR2

A 41-year-old man presented to emergency service with loss of consciousness lasting 20 minutes after a piece of wood struck the right side of his face. Shortly after admission, he developed difficulty swallowing. On admission, he was alert and had normal vital findings. There was no motor, sensorial, or cerebellar deficit. Deviation of the uvula to the left side and pharyngeal reflex loss on the right side was obvious. The right vocal cord was paralyzed. Other cranial nerves were intact on examination. The patient’s cranial computed tomography (CT), CT-angiogram, cranial and neck magnetic resonance (MR) imaging, MR-angiogram, and cervical and lung X-ray were normal. We evaluated this case with isolated unilateral vagus nerve palsy (VNP) secondary to trauma at the emergency department. Our case illustrated that trauma can cause isolated VNP with the absence of abnormal findings on imaging modalities.

Yüzünün sağ tarafına tahta parçası çarptıktan sonra 20 dakika bilinç kaybı gelişen 41 yaşında erkek hasta acil servise başvurdu. Kabulden kısa bir süre sonra hastada yutma güçlüğü gelişti. Kabülde hasta alertti ve vital bulguları normaldi, motor, sensoriyal ve serebeller defisiti yoktu. Uvula sola deviyeydi ve sağ tarafta belirgin farenjeal refleks kaybı vardı. Sağ vokal kortlarda paralizi vardı. Diğer kraniyal sinir muayeneleri intaktı. Hastanın beyin tomografisi (BT), BT anjiyogramı, beyin ve boyun manyetik rezonans (MR) bulguları, MR anjiyogramı, servikal ve akciğer grafileri normaldi. Bu yazıda, acil serviste travmaya bağlı izole tek taraflı nervus vagus yarlanmalı olgu değerlendirildi. Bu olgu görüntüleme tekniklerinde patolojik bulgu olmadan da izole nervus vagus yaralanması olabileceğini göstermektedir.

Key Words: Emergency department; isolated vagus nerve palsy; trauma evaluation.

Anahtar Sözcükler: Acil servis; izole nervus vagus yaralanması; travma değerlendirilmesi.

Vagus nerve palsy (VNP) may be due to trauma, surgery, tumor, internal carotid artery dissection, infection, or inflammation and may be idiopathic.[1-6] Trauma induced VNP is often associated with other cranial nerve involvements (such as IX, XI) and also associated with cranial or facial fractures.[7-8] Urculo et al.[7] reported a case of glossopharyngeal and vagal nerve paralysis following an occipital condyle fracture. Alberio et al.[8] reported a case with isolated glossopharyngeal and vagal nerve palsies due to trauma. However, they established a fracture involving the jugular foramen on cranial computed tomography (CT). It has been reported that in cases with non-traumatic causes of isolated VNP, a lesion may also be established.[1,3,5]

Thus, the importance of neuroimaging studies in patients with isolated VNP is clear. In contrast to previous cases, we could not find any associated lesion on imaging modalities although there was a presence of trauma in our case. The patients with trauma have been evaluated firstly at emergency departments. We evaluated a case with isolated unilateral VNP due to trauma and could not find any associated lesion on the patient’s imaging modalities.

Department of Neurology, Ondokuz Mayıs University Faculty of Medicine, Samsun; 2Department of Emergency Service, Erzurum Training and Research Hospital, Erzurum, Turkey.

1

In this paper, we would like to emphasize that VNP may happen without any associated injury to the neck, skull or brain. VNP should be thought in trauma patients who present with nistagmus and difficulty in swallowing and speaking. Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Nöroloji Anabilim Dalı, Samsun; 2 Erzurum Bölge Eğitim ve Araştırma Hastanesi, Acil Servis, Erzurum.

1

Correspondence (İletişim): Ethem Acar, M.D. Erzurum Bölge Eğitim ve Araştırma Hastanesi Acil Servis, 25070 Erzurum, Turkey. Tel: +90 - 442 - 232 55 55 e-mail (e-posta): ethem.acar@mynet.com

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Isolated unilateral vagus nerve palsy secondary to trauma

CASE REPORT A 41 year old, right handed man presented to emergency service with loss of consciousness. There was no significant disease in the past medical history. It was known that loss of consciousness continued for about 20 minutes and developed after he was struck with a piece of wood on the right side of his face and shortly after admission he developed difficulty in swallowing. On admission, he was alert and had normal vital findings. There was no motor or sensorial deficit. He described vertigo shortly after presentation. Cerebellar tests were normal. However, horizontal nistagmus with rotator component and left beat were observed during vertigo. Deviation of the uvula to left side with pharyngeal reflex loss on the right side were also present. The right vocal cord was paralyzed, with saliva pooling and the rima was 3-4 mm during phonation. Other cranial nerves were intact on examination. The patient’s cranial CT, CT-angiogram, cranial and neck magnetic resonance (MR) imaging, MR-angiogram, and cervical and lung X-ray were all normal. Schemer test was normal in both eyes. The patient was fed entirely via nasogastric tube (NGT) for 10 days due to inability to swallow. He was discharged on the 10th day of admission. Since he could eat semi-solid foods, the NGT was removed after 11 days of discharge. The information from the patient was obtained by telephone after two weeks and showed that his swallowing was gradually getting better. He was able to speak normally (i.e., no voice problem). The present case and previous cases with isolated VNP are shown in Table 1. DISCUSSION Tang et al. reported a case with isolated VNP due to Herpes simplex virus infection. The neck MRI of their case revealed a focal lesion in the sub-glottis region. Nusbaum et al.[3] reported a case with isolated VNP that showed a dissection of the extra cranial internal carotid artery on imaging. Nakagawa et al.[5] reported a case with isolated VNP caused by Varicella zoster virus reactivation, which revealed lesions on the laryngeal mucosa. In the present patient, isolated VNP was due to trauma; however, there was no lesion on the cranial CT, CT-angiogram, cranial and neck MR imaging, MR-angiogram, or cervical and lung Xray of the patient. It has been reported that the majority [1]

of isolated unilateral recurrent laryngeal nerve palsies are idiopathic in nature and are associated with diabetes mellitus where palatopharyngeal and articulatory functions are usually normal.[4,8] Our case not only had vocal cord paralysis but also palatopharyngeal involvement. Furthermore, if the lesion is below the origin of the pharyngeal branches, palatal weakness and pharyngeal or palatal sensory loss are also seen. [9] Our case had both palatal weakness and pharyngeal and palatal sensory loss. In our patient, we think that the vagus nerve damage was located at the exit site of the vagus nerve in the base of skull at the point where it runs into the carotid sheath in the neck. This was reasoned because if the vagus nerve is damaged before emerging from the jugular foramen, the other cranial nerves such as IX, XI, and XII would also be involved at these locations.[2] In the present case, the probable mechanisms of the vagus nerve injury included: (1) excessive rotation and/or lateral flexion of the neck which may cause distraction or stretching of the vagus nerve; and (2) in the upper-cervical area, direct compression to the trunk of the vagus nerve arising from muscular spasm due to trauma or direct trauma to the neck, causing fascicular damage.[2] Due to these mechanisms, trauma may be caused as Sunderland’s grade II injury (mild axonotmesis).[10] In this type of injury, complete recovery is more likely than with severe axonotmesis. Our patient could swallow liquid foods and speak normally (i.e., no voice problem) at the 21st day of admission, followed by swallowing semi-solid foods on the 25th day of admission. The patient can now more easily swallow solid/semisolid foods. We expect complete recovery of swallowing in the present case. In conclusion, our case illustrated that trauma can cause isolated VNP with the absence of abnormal findings on imaging modalities. This does not mean that the emergency physician should not evaluate the cases with isolated unilateral VNP at the emergency department, as isolated VNP may be associated with extra cranial internal carotid artery dissection. VNP should be thought of in trauma patients who present with nistagmus and difficulty in swallowing and speaking. Conflict-of-interest issues regarding the authorship or article: None declared.

Table 1. Previous reports with isolated vagal nerve palsy with present case References

Case (Years / Sex)

Etiology

Lesion localization

Nusbaum et al.[3] Tang et al.[1] Nakagawa et al.[5] The present case

40 / Male 29 / Male 55 / Female 41 / Male

Trauma HSV-infection VZV-infection Trauma

ICA dissection The sub-glottis region The larynx mucosa No associated lesion

ICA: Internal carotid artery; HSV: Herpes simplex virus; VZV: Varicella-zoster virus.

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REFERENCES 1. Tang SC, Jeng JS, Liu HM, Yip PK. Isolated vagus nerve palsy probably associated with herpes simplex virus infection. Acta Neurol Scand 2001;104:174-7. 2. Brazis PW, Masdeu JC, Biller J. Localization in clinical neurology. 3rd ed. Boston: Little, Brown & Co.; 1996. 3. Nusbaum AO, Som PM, Dubois P, Silvers AR. Isolated vagal nerve palsy associated with a dissection of the extracranial internal carotid artery. AJNR Am J Neuroradiol 1998;19:18457. 4. Berry H, Blair RL. Isolated vagus nerve palsy and vagal mononeuritis. Arch Otolaryngol 1980;106:333-8. 5. Nakagawa H, Satoh M, Kusuyama T, Fukuda H, Ogawa K. Isolated vagus nerve paralysis caused by varicella zoster virus reactivation. Otolaryngol Head Neck Surg 2005;133:460-1. 6. Vaile JH, Davis P. Isolated unilateral vagus nerve palsy in

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systemic lupus erythematosus. J Rheumatol 1998;25:2287-8. 7. Urculo E, Arrazola M, Arrazola M Jr, Riu I, Moyua A. Delayed glossopharyngeal and vagus nerve paralysis following occipital condyle fracture. Case report. J Neurosurg 1996;84:522-5. 8. Alberio N, Cultrera F, Antonelli V, Servadei F. Isolated glossopharyngeal and vagus nerves palsy due to fracture involving the left jugular foramen. Acta Neurochir (Wien) 2005;147:791-4. 9. Victor M, Ropper AH. Diseases of the cranial nerves. In: Victor M, Ropper AH, editors. Adams and Victorâ&#x20AC;&#x2122;s principles of neurology. 7th ed. New York: McGraw-Hill; 2001. p. 144663. 10. Murray B. Peripheral nerve trauma. In: Bradley, WG, Daroff RB, Fenichel GM, Jankovic J, editors. Neurology in clinical practice. Philadelphia: Butterworth & Heinemann; 2004. p. 1179-95.

Mart - March 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):183-185

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.80269

Intestinal stenosis from mesenteric injury after blunt abdominal trauma in children: case reports Çocuklarda künt karın travması sonrası oluşan mezenterik yaralanmadan kaynaklanan bağırsak darlığı: Olgu sunumları Mustafa İMAMOĞLU, Haluk SARIHAN

The incidence of mesenteric injury after blunt abdominal trauma (BAT) has increased in recent years; however, relatively little attention has been paid to instances of its sequelae, especially in childhood. We present three children who had post-traumatic intestinal stenosis (PIS). A history of BAT was obtained in all. They had abdominal pain, bilious vomiting and peritoneal signs. The time intervals, the duration from the initial trauma to the onset of symptoms, ranged from 23 to 62 days. Stenotic segments were parallel to the location of the previously recognized mesenteric hematoma (MH), and resection with primary anastomosis was performed. Pathological examinations of specimens confirmed mucosal and mural ischemia and full-thickness fibrosis of the intestinal wall. In our opinion, large MH may pose an increasing risk of narrowing in the adjacent intestine at different time points. Therefore, if there is a large MH at laparotomy after BAT, it should be evacuated and the bleeding halted. For the differential diagnosis, typical BAT should be investigated carefully in cases presenting with intermittent colic abdominal pain and/or partial intestinal obstruction findings.

Künt karın travmasından kaynaklanan mezenterik yaralanmalar son yıllarda artış göstermesine rağmen, özellikle çocukluk yaş grubunda, oluşabilecek sekellerine yeterince dikkat verilmemiştir. Bu yazıda, künt travma sonrası bağırsak darlığı gelişen üç olgu sunuldu. Olgularda künt karın travma öyküsü vardı, karın ağrısı, safralı kusma ve akut karın bulguları da vardı. Travma ile şikayetlerin başlaması arasındaki zaman aralığı 23-62 gündü. Dar segmentler daha önceden tanımlanan mezenterik hematoma paraleldi ve rezeksiyon-anastomoz yapıldı. Patolojilerinde mukozal ve mural iskemi ile bağırsak duvarının tam kat fibrozisi görüldü. Büyük mezenterik hematomların komşu bağırsakta farklı süreler sonrasında darlık oluşturma riski olduğunu düşünmekteyiz. Bu nedenle, eğer künt karın travması sonrası laparotomide büyük bir mezenterik hematom varsa, bu boşaltılmalı ve kanama durdurulmalıdır. Tipik karın travması geçirmişlerde karın ağrısı ve/veya kısmi barsak tıkanıklığı bulguları oluştuğunda ayırıcı tanı dikkatli yapılmalıdır.

Key Words: Blunt abdominal trauma; children; mesenteric injury; intestinal stricture.

Anahtar Sözcükler: Künt karın travması; çocuklar; mezenter yaralanması; bağırsak darlığı.

The incidence of blunt mesenteric injury has increased in recent years due to high levels of blunt abdominal trauma (BAT). Alsayali et al.[1] recently reported that out of 1.553 consecutive patients with BAT, 278 were admitted to their department for treatment of blunt mesenteric injury. Their operative findings showed that the small or large bowel mesentery was injured in 54% (n=120) and 9% (n=19) of patients, respectively. However, relatively little attention

has been paid to instances of its sequelae, especially in childhood. One reported late sequela following BAT is post-traumatic intestinal stenosis (PIS). When seatbelt injuries are excluded, only a few pediatric PIS cases have been reported in the literature.[2-4] Our three children with BAT-associated PIS were examined retrospectively in order to produce new suggestions for both the mechanism involved in PIS and mesenteric hematoma (MH) treatment strategies in such cases.

Department of Pediatric Surgery, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey.

Karadeniz Teknik Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Trabzon.

Correspondence (İletişim): Mustafa İmamoğlu, M.D. Karadeniz Teknik Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, 61080 Trabzon, Turkey. Tel: +90 - 462 - 377 55 35 e-mail (e-posta): mimamoglu61@yahoo.com

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CASE REPORTS Case 1â&#x20AC;&#x201C; A five-year-old boy was admitted to our clinic as a victim of physical abuse. He had bilious vomiting with abdominal pain. Abdominal examination revealed severe abdominal distension and tenderness. Blood pressure was less than 50 mmHg and hemoglobin (Hb) was 5.9 g/dl. Appropriate fluid resuscitation and blood transfusion were started. A Foley catheter was inserted in the bladder and gross hematuria was noted. Plain film of the abdomen demonstrated severe free intraperitoneal air, and immediate surgical exploration was performed. At laparotomy, a large gastric perforation located along the greater curvature and a splenic laceration were noted. Furthermore, large mesenteric and retroperitoneal hematomas were present, but there was no localized serosal injury or ischemic change in the wall of the adjacent intestine. Primary repair of the stomach and splenorrhaphy were performed. Oral feeding was started and was well tolerated seven days after surgery. Twenty-three days later, a colic-type abdominal pain associated with bile-stained vomiting developed. Physical examination revealed diffuse tenderness in the upper abdomen, but no fever or palpable mass was present. At this time, Hb level was 9.7 g/dl and white blood cell (WBC) count 15.000/mm3. Abdominal radiographs showed a partial small bowel obstruction. Nasogastric suction, antibiotics, and parenteral nutrition were initiated for postoperative adhesions, and he was observed carefully. After two days with no apparent clinical or laboratory improvement, surgery was considered. At laparotomy, an excessive fibrosis with disruption in the location of the previously recognized distal jejunal MH and a thick-walled stenosis (10 cm) in the adjacent intestine with proximal dilatation were encountered. There were no obstructive adhesions. The stenotic segment was resected and an anastomosis performed. Histopathological examination revealed mucosal and submucosal ischemia and full-thickness fibrosis. The patient had an uneventful postoperative course. Case 2â&#x20AC;&#x201C; A 13-year-old boy was referred to our unit with anorexia, nausea, intermittent bilious vomiting, and subsequent weight loss over the previous three weeks. The day before, he had severe abdominal pain and vomited feculent material, and passed no flatus. He had been kicked in the right side of the abdomen by a friend while playing football 62 days before. For two days after the trauma, he had a low-grade abdominal pain and vomiting, but then felt well again. Abdominal examination revealed a mass in the right quadrant with peritoneal signs. Laboratory examination showed a Hb level of 10.5 g/dl and WBC count of 19.500/mm3, with normal amylase and urinalysis results. Abdominal X-ray films showed air-fluid levels in the small intestine. An emergency laparotomy was performed and a resolved ileal MH with excessive fibrosis and 184

disruption were observed. A stenotic ileal segment (10 cm) parallel to that location was diagnosed, and resection-anastomosis was performed. Pathological findings confirmed a severe full-thickness fibrosis of the intestinal wall. Case 3â&#x20AC;&#x201C; A five-year-old girl was referred to our unit after sustaining a major lower abdomen injury due to a collapsing heating radiator. Examination revealed tenderness and distension of the lower abdomen. Vaginal bleeding was also noted due to a large anterior vaginal laceration. A skeletal survey demonstrated a disruption of the right sacroiliac joint and pubic diastasis. Systolic blood pressure was 50 mmHg. Laboratory examination revealed a Hb level of 6.5 g/ dl. Despite massive fluid replacement, shock findings continued. Seven hours following injury, an emergency laparotomy was performed. Abdominal exploration demonstrated a large diameter MH in the ileum. There were no mesenteric defects, localized intestinal injury or ischemic changes in the adjacent intestine. Pelvic exploration revealed an anterior bladder laceration extending through the bladder neck and 2 cm into the proximal urethra. Bladder, bladder neck and proximal urethral injuries were repaired, and vaginal reconstruction was performed subsequently. By the ninth postoperative day, oral feeding was started and well tolerated. Two weeks later, abdominal pain, mild distension and vomiting developed. Abdominal radiographs demonstrated a partial intestinal obstruction. A PIS was initially suspected because of our experiences with the previous cases, and surgical intervention was decided. At laparotomy, there were excessive fibrosis and disruption in the location of the previously recognized ileal MH and a tight fibrotic stricture (5 cm) in the adjacent ileum. No adhesions were determined. Resection-anastomosis was performed. Pathological examination revealed full-thickness intestinal fibrosis. She was discharged on the sixth postoperative day.

DISCUSSION The exact cause of PIS due to MH after BAT is still in question. However, three mechanisms may be involved in its development: (1) direct disruption or occlusion of large arteries, (2) partial arterial obstruction due to compression due to a mass effect of a large MH, and (3) disruption or occlusion of large arteries secondary to resolved MH with excessive fibrosis.[4-6] In two of our patients, large hematomas were noted during the initial laparotomy in the mesentery without macroscopically adjacent bowel wall injury or localized ischemic changes. At their second laparotomies, an excessive fibrosis and disruption in the location of the previously recognized MH were present. Stenotic segments were parallel to these locations. Therefore, we postulated that resolution begins after the acute large volume of blood extravasations into the mesenMart - March 2013

Intestinal stenosis from mesenteric injury after blunt abdominal trauma in children

tery. During this period, fibroblast reorganization of the scar collagen leads to wound volume reduction and contraction. Contracture and tissue distortion may cause compression of some mesenteric arterial branches, leading to a partial obstruction. Latent poor blood perfusion may thus result in full-thickness ischemia and fibrosis of this bowel wall at different time points. In agreement with these results, pathological examinations of resected specimens from our subjects confirmed mucosal and mural ischemia and full-thickness fibrosis of the intestinal wall. Although both small and large intestinal stenoses have been reported, stenosis developed in the small intestine in all our cases.[7] In addition, our patients had a single stenotic segment, although multiple stenotic segments have also been reported.[5] Delayed presentations of mesenteric injuries following traffic accidents and attributed to seatbelt use have been documented in children. However, other causes of BAT may also lead to PIS through similar mechanisms. A specific history of bicycle handlebar injury, child abuse or a direct blow to the abdomen should heighten suspicion of mesentery injury.[5] A history of similar BAT was elicited in all our cases. In such cases, the reported time range between BAT and the onset of PIS symptoms ranges from 10 days to 26 years. The interval ranged from 23 to 62 days in our patients. Because of the tendency for late presentations, preoperative diagnosis of PIS is frequently difficult.[5,8] Furthermore, the clinical manifestations and radiographic features of PIS are mimicked by various intestinal diseases, and are characterized by obstructive symptoms. Few adult cases have been reported in the literature, these being diagnosed preoperatively with small or large bowel barium investigation.[9,10] In children, however, contrast studies are of limited value since the lesion is usually limited to the small bowel. Therefore, investigation of the type of injury is the first step in the preoperative diagnosis of PIS. Any child who suffers a possible BAT, including bicycle handlebar injury, child abuse or a direct blow to the anterior abdomen, and in whom abdominal pain, bilious vomiting and/or peritoneal signs develop even months or years later, may be suspected of having PIS. In appropriate cases, preoperative diagnosis may be performed using contrast intestinal passage computed tomography. It is unclear what percentage of MH results in PIS. In our experience, however, intraoperative manage-

Cilt - Vol. 19 Say覺 - No. 2

ment of MH found at laparotomy depends on whether the hematoma is small or large. Small MH can be treated conservatively without late sequelae. However, in our opinion, large MH may pose an increasing risk of narrowing in the adjacent intestine at different time points. Therefore, if there is a large MH at laparotomy after BAT, it should be evacuated and the bleeding halted. In this way, we predict that less scar collagen will be deposited, and excessive mesenteric fibrosis can be prevented. Consequently, the patient is now probably not at risk for PIS. On the other hand, because of the high frequency of BAT in childhood, a history of unrecognized, typical BAT should be carefully investigated in cases presenting with intermittent colic abdominal pain and/or partial intestinal obstruction findings. If present, PIS should be considered and investigated. Primary treatment is partial resection of the stenotic segment and then anastomosis, as performed in our cases. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Alsayali MM, Atkin C, Winnett J, Rahim R, Niggemeyer LE, Kossmann T. Management of blunt bowel and mesenteric injuries: experience at the Alfred Hospital. Eur J Trauma Emerg Surg 2009;35:482-8. 2. Chi T, Shin SL. Delayed intestinal stenosis after blunt abdominal trauma: report of a case. Kaohsiung J Med Sci 1998;14:734-7. 3. Shah P, Applegate KE, Buonomo C. Stricture of the duodenum and jejunum in an abused child. Pediatr Radiol 1997;27:281-3. 4. Jones VS, Soundappan SV, Cohen RC, Pitkin J, La Hei ER, Martin HC, et al. Posttraumatic small bowel obstruction in children. J Pediatr Surg 2007;42:1386-8. 5. Lynch JM, Albanese CT, Meza MP, Wiener ES. Intestinal stricture following seat belt injury in children. J Pediatr Surg 1996;31:1354-7. 6. Bryner UM, Longerbeam JK, Reeves CD. Posttraumatic ischemic stenosis of the small bowel. Arch Surg 1980;115:103941. 7. Balupuri S, Stock SE. Post traumatic large bowel stricture. Injury 1999;30:68-9. 8. Vanderschot PM, Broos PL, Gruwez JA. Stenosis of the small bowel after blunt abdominal trauma. Unfallchirurg 1992;95:71-3. 9. Lee-Elliott C, Landells W, Keane A. Using CT to reveal traumatic ischemic stricture of the terminal ileum. AJR Am J Roentgenol 2002;178:403-4. 10. De Backer AI, De Schepper AM, Vaneerdeweg W, Pelckmans P. Intestinal stenosis from mesenteric injury after blunt abdominal trauma. Eur Radiol 1999;9:1429-31.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (2):186-188

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.92332

Bilateral isolated cut of sensory branch of radial nerve Radial sinir duyusal dalının iki taraflı izole kesisi Nuray AKKAYA,1 Hakan Ramazan ÖZCAN,2 İnci GÖKALAN KARA,2 Füsun ŞAHİN1

Bilateral injuries of the sensory branch of the radial nerve (SBRN) usually occur as a result of tight-handcuff neuropathy. In this case we aimed to present bilateral isolated cut of SBRN resulting an injury mechanism that has not been reported in the literature previously. A male twentyfour years old, a worker in a glass factory, presented to our clinic. The dorsolateral skin of his wrists were cut by breaking of the glass as a result of occupational accident and was primarily sutured in a healthcare center. The patient sought additional care after a month because of lingering numbness and pain, and surgery was planned. During surgery, scar tissue and neuroma at the cut ends of SBRN were excised, and bilateral SBRN cuts were repaired. Four weeks after operation, mild sensory deficit on the dorsal side of bilateral thumbs, and left first web space and flexion limitation on the right wrist were detected. At the 3rd month postoperative, right wrist joint range of motion was full, and sensory deficits, and hyperesthesia were decreased. The SBRN elicits the sensory innervation of the thumb dorsum and its injury does not cause important functional deficit. However because of susceptibility of SBRN to develop painful neuroma, diagnosis, treatment and follow up of isolated SBRN injury would be worthwhile for prevention of possible painful neuropathy disturbing quality of life.

Radial sinir duyusal dalının (RSDD) iki taraflı yaralanmaları genellikle sıkı takılmış kelepçe nöropatisi sonucunda oluşur. Bu yazıda daha önce literatürde bildirilmemiş yaralanma mekanizması ile oluşan iki taraflı izole RSDD kesisinin sunulması amaçlandı. Yirmi dört yaşında cam fabrikasında işçi erkek hasta sunuldu. İş kazası sonucu cam kırılması ile el bilekleri dorsolateralinde oluşan cilt kesisi, başvurduğu sağlık merkezinde primer dikilmiş. Hasta 1 ay sonra geçmeyen hissizlik ve ağrı nedeniyle plastik ve rekonstrüktif cerrahi bölümüne başvurdu ve cerrahi planlandı. Cerrahi sırasında gözlenen skar doku ve RSDD kesik uçlarında oluşan nöroma temizlendi ve iki taraflı RSDD kesisi tamir edildi. Hastanın fizik tedavi ve rehabilitasyon bölümündeki fiziksel incelemesinde, iki taraflı başparmak dorsal yüzünde ve sol 1. web aralığında hafif duyusal kayıp ve sağ el bileği fleksiyonunda kısıtlılık olduğu saptandı. Ameliyat sonrası 3. ay incelemede sağ el bileği eklem hareket açıklığı tam, duyusal defisitler ve hiperestezi azalmıştı. RSDD başparmak dorsalinin duyusunu sağlar, o nedenle yaralanması önemli fonksiyonel kayıba neden olmaz. Ancak, RSDD’nin ağrılı nöroma gelişimine yatkınlığı nedeniyle, izole RSDD yaralanmasının tanı, tedavi ve takibinin yapılması yaşam kalitesini bozan olası ağrılı nöropatinin önlemesi için faydalı olacaktır.

Key Words: Nerve injury of forearm; neuroma; sensory branch of radial nerve.

Anahtar Sözcükler: Önkol sinir yaralanması; nöroma; radial sinir duyusal dalı.

The superficial branch of the radial nerve (SBRN) is a peripheral nerve which is commonly injured along with the common peroneal and spinal accessory nerves, and can be easily repaired.[1] SBRN injury may be caused by fractures, lacerations or iatrogenic mechanisms.[2-4] It was reported that SBRN divides into 3 branches on the dorsolateral aspect of the wrist in 90% of explored cadavers. SBNR1 extends over the dor-

sal side of the index finger, SBNR2 extends over the dorsal side of the first web space and SBRN3 extends over the dorsolateral side of the thumb.[5] SBRN injury typically results in numbness, paresthesia on the dorsal side of first web space and thumb, and the formation of painful neuroma.[1] In the literature, unilateral SBRN injuries were reported due to fractures, compression of mass or iatrogenic causes[2-4] bilateral SBRN injuries

Departments of 1Physical Medicine and Rehabilitation, 2Plastic and Reconstructive Surgery, Pamukkale University Faculty of Medicine, Denizli, Turkey.

Pamukkale Üniversitesi Tıp Fakültesi, 1Fizik Tedavi ve Rehabilitasyon Anabilim Dalı, 2Plastik ve Rekonstrüktif Cerrahi Anabilim Dalı, Denizli.

Correspondence (İletişim): Nuray Akkaya, M.D. Pamukkale Üniv. Tıp Fakültesi, Fizik Tedavi ve Rehabilitasyon Anabilim Dalı, Kınıklı, 20070 Denizli, Turkey. Tel: +90 - 258 - 444 07 28 e-mail (e-posta): nrakkaya@gmail.com

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Bilateral isolated cut of sensory branch of radial nerve

Fig. 1. Scars on wrist anterolateral.

(Color figures can be viewed in the online issue, which is available at www.tjtes.org).

were reported due to application of tight handcuffs.[6,7] In this case we aimed to present bilateral isolated cut of the SBRN by an injury mechanism that has not been reported in the literature previously. The patient has signed an informed consent form.

CASE REPORT A 24-year-old, male patient who was a worker in a glass factory for 10 years presented to our clinic. Skin cuts on the dorsolateral side of bilateral forearms occurred due to breaking of glass while he was carrying a large glass block. Primary suture was completed for his skin cut at a healthcare center. Patient was not wearing gloves or any other protective materials at the time of injury. The patient did not report alcohol or narcotic substances usage. The patient consulted to the Department of Plastic and Reconstructive Surgery after a month due to lingering numbness and pain on the dorsal side of bilateral thumbs and left first web space, and surgery was planned. At the time of surgery it was observed that the ends of bilateral SBRNs had been healed with scar tissue and had formed neuroma. Following excision of scar tissue and neuroma, bilateral SBRN cuts were repaired by the end-to-end epineural repair technique during surgery. After bilateral forearms were encased in a plastersplint, the patient was referred to our Department of Physical Therapy and Rehabilitation for follow up examinations and rehabilitation.

pect (Fig. 1). His bilateral wrist extension was 55°, right wrist flexion was 40°, left wrist flexion was 70°. The reason behind the limitation of right wrist flexion range of motion may be an immobilization process. For this limitation, the patient was given a physical therapy program including infrarogue, therapeutic ultrasound and exercises postoperatively. Mild sensory deficits were detected on the dorsal side of bilateral thumbs and the left first web space. Motor or sensory deficits in other nerves or in other fingers were not determined. When sensory deficits were evaluated with Semmes-Weinstein Monofilament test, and the dorsal side of bilateral thumbs prior to rehabilitation varied between 3.61-4.31, and the left hand first web space prior to rehabilitation varied between 4.56-6.65 (Fig. 2a). He was also taken into a desensitization program. According to the preoperative evaluation of nerve and sensory tests, it was thought that the SBRN3 was injured on the right side, and SBRN2, and SBRN3 were injured in the left side of the patient. On his postoperative follow up at 3rd month, wrist range of motion was full and when sensory deficits were evaluated with Semmes-Weinstein Monofilament test, bilateral thumb dorsal sensory again varied between 3.61-4.31, and left first web space varied between 4.31-4.56 (Fig. 2b). Hyperesthesia was decreased but still continued.

DISCUSSION The radial nerve divides into deep and superficial branches after reaching the forearm. The sensory branch of radial nerve superficially lies on the radial side of the forearm. This superficial course of the nerve makes the SBRN a frequently injured nerve. Patients who are not treated may experience lifetime sensory problems depending on the degree of injury.[8] The reported reasons for unilateral injury of SBRN are: trauma, lipoma or compression of ganglion cyst, radius fracture, damage due to Kirschner wiring of radial fracture, injury by the cannulation of peripheral vein prior to anesthesia, arthroscopy of wrist or due to De Quervain’s disease.[2,4,8-10]

At his physical examination, 5 cm of injury and sur(b) gery scars were seen on both (a) the distal one third of fore- Fig. 2. (a) Semmes-Weinstein monofilament test before treatment. (b) Semmes-Weinstein arms on the dorsolateral asmonofilament test after treatment. Cilt - Vol. 19 Sayı - No. 2

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Bilateral radial nerve paralysis is a rare incident. It has been reported that median, ulnar or multiple nerves could be damaged by tight handcuffs, however the SBRN is the most commonly injured nerve following application of tight handcuffs.[12] These SBNR injury cases often occur under the influence of alcohol or narcotic substances.[7] SBRN becomes prone to injury by compression of tight handcuffs at the distal lateral radius.[3] In this case, however, the patient had an occupational injury independent of the effects of alcohol or narcotic substances. [11]

Nerve injuries in the upper limb are usually combined injuries with arterial or tendon damage and occur mostly at distal forearm or wrist.[13] In our patient, the injury was dorsolateral of the wrists. However in this case the injury resulted in isolated SBRN cut because of the anatomic features of the SBRN and the injury mechanism. While the SBRN lies laterally to the radial artery in the middle third of the forearm at the radial side, it is distanced from the radial artery in the lower third of forearm.[5] Although the SBRN is adjacent to the radial artery in the middle part of the forearm, in this case the injury was on the lower part of forearm, which led to isolated SBRN cut. Thus the patient may have been saved from the probable concomitant radial artery injury. Moreover, the presence of only SBRN3 cut on the right wrist, and only SBRN2 and SBRN3 cut on the left wrist were interesting, with the SBRN1 intact bilaterally. In this case, injuries occurred at approximately below the distribution of the SBRN, resulting in this type of cut in the SBRN branches. Dellon et al.[14] reported that because of an anatomic mechanism, SBRN is more prone to develop neuroma than the palmar cutaneous branch of the median nerve and dorsal cutaneous branch of ulnar nerve. Ciaramitaro et al.[15] determined that traumatic neuropathies are usually seen in males and on upper limbs, and 72% of traumatic neuropathies were painful. In addition, a strong correlation was found between the severity of neuropathic pain and quality of life.[15] In our case, the skin cut was primarily sutured following the injury. Because of the continuation of pain and paresthesia, the patient consulted again. When the patient had the surgery for SBRN injury diagnosis, the presence of neuroma between cut ends of SBRN was observed. His pain passed and paresthesia decreased after surgery. On his postoperative follow up, it was determined that his left first web space sensory also improved. Injury of SBRN does not cause direct negative effects to hand function because it is purely a sensory branch. However sensory deficits because of inadequate healing of the nerve following laceration of SBRN may have negative effects on hand functions, 188

making the hand more prone to injury. Furthermore, probable development of painful neuroma decreases the quality of life. Early diagnosis, treatment and good follow up may be effective for prevention of these complications. It should be emphasized that persons handling incisory-poignant, searing subjects, as seen in our case, must take precautions to reduce hand injuries. In conclusion, even though peripheral sensory nerve injury does not cause motor deficits, diagnosis of SBRN cut is important because of the probable development of painful neuroma. Therefore injuries of SBRN should be diagnosed early, and properly treated to avoid negative effects of injury on quality of life. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Robson AJ, See MS, Ellis H. Applied anatomy of the superficial branch of the radial nerve. Clin Anat 2008;21:38-45. 2. Tosun N, Tuncay I, Akpinar F. Entrapment of the sensory branch of the radial nerve (Wartenberg’s syndrome): an unusual cause. Tohoku J Exp Med 2001;193:251-4. 3. Grant AC, Cook AA. A prospective study of handcuff neuropathies. Muscle Nerve 2000;23:933-8. 4. Singh S, Trikha P, Twyman R. Superficial radial nerve damage due to Kirschner wiring of the radius. Injury 2005;36:330-2. 5. Ikiz ZA, Uçerler H. Anatomic characteristics and clinical importance of the superficial branch of the radial nerve. Surg Radiol Anat 2004;26:453-8. 6. Dellon AL, Mackinnon SE. Radial sensory nerve entrapment in the forearm. J Hand Surg Am 1986;11:199-205. 7. Haddad FS, Goddard NJ, Kanvinde RN, Burke F. Complaints of pain after use of handcuffs should not be dismissed. BMJ 1999;318:55. 8. Boeson MB, Hranchook A, Stoller J. Peripheral nerve injury from intravenous cannulation: a case report. AANA J 2000;68:53-7. 9. Jou IM, Wang HN, Wang PH, Yong IS, Su WR. Compression of the radial nerve at the elbow by a ganglion: two case reports. J Med Case Rep 2009;3:7258. 10. Amar MF, Benjelloun H, Ammoumri O, Marzouki A, Mernissi FZ, Boutayeb F. Anatomical snuffbox lipoma causing nervous compression. A case report. [Article in French] Ann Chir Plast Esthet 2012;57:409-11. [Abstract] 11. Sturzenegger M, Rutz M. Bilateral radial nerve paralysis. Diagnostic and differential diagnostic aspects. Schweiz Med Wochenschr 1990;120:1325-34. [Abstract] 12. Levin RA, Felsenthal G. Handcuff neuropathy: two unusual cases. Arch Phys Med Rehabil 1984;65:41-3. 13. Ozdemir HM, Biber E, Oğün T. The results of nerve repair in combined nerve-tendon injuries of the forearm. Ulus Travma Acil Cerrahi Derg 2004;10:51-6. 14. Dellon AL, Mackinnon SE. Susceptibility of the superficial sensory branch of the radial nerve to form painful neuromas. J Hand Surg Br 1984;9:42-5. 15. Ciaramitaro P, Mondelli M, Logullo F, Grimaldi S, Battiston B, Sard A, et al. Traumatic peripheral nerve injuries: epidemiological findings, neuropathic pain and quality of life in 158 patients. J Peripher Nerv Syst 2010;15:120-7. Mart - March 2013

Değerli Meslektaşlarım, Sizleri 19-23 Nisan 2013 tarihleri arasında Antalya’da gerçekleşecek olan 9. Ulusal Travma ve Acil Cerrahi Kongresi’ne davet etmekten mutluluk duyuyoruz.   Bu kongrede, Travma ve Acil Cerrahi konusunda en üst düzeyde bilgi birikimi ve yoğun deneyimle elde edilebilecek, tanı, tedavi, organizasyon ve hasta bakımı alanındaki tüm gelişmeler bilgilerinize sunulacaktır.   Kongre programı kongre öncesi kursları, uzman oturumları, video sunumları, interaktif paneller, tartışma oturumları, uzlaşma toplantıları, konferanslar ve uzmanlık alanındaki yenilikleri içermektedir. Hedefimiz değerli görüşlerinizle bilimsel programımızı zenginleştirip, herkesin birbirinden bir şeyler öğrenebileceği bilimsel bir platform gerçekleştirmektir.   Antalya tarih boyunca kültürün, sanatın, mimarinin ve mitolojinin merkezi olmuştur. Muhteşem doğası, açık maviden laciverte uzanan denizi, şelaleleri, Toros dağları ve palmiye ağaçları ile bu gölgenin büyüsüne kapılacaksınız. Bu özellikleri ile de Antalya, Travma ve Acil Cerrahideki son gelişmeleri tartışabileceğimiz en uygun yer.   Sizi Antalya’da ağırlamaktan büyük memnuniyet duyacağız. Saygılarımızla, Recep Güloğlu Salih Pekmezci Ulusal Travma ve Acil Cerrahi Derneği Başkanı Kongre Başkanı

DÜZENLEME KURULU Kongre Başkanı Salih PEKMEZCİ Kongre Eş Başkanı Tayfun YÜCEL Genel Sekreter M. Mahir ÖZMEN Bilimsel Sekreterya Kaya SARIBEYOĞLU Hakan YANAR Üyeler Ediz ALTINLI Acar AREN Gürhan ÇELİK Cemalettin ERTEKIN Recep GÜLOĞLU Ahmet Nuray TURHAN


TRAVMA 2013-2