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Cilt - Volume 19

Sayı - Number 3

Mayıs - May 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 Sakarya 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 İstanbul 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): Nisan (April) 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.

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

SAYI - NUMBER 3 MAYIS - MAY 2013

İçindekiler - Contents

Deneysel Çalışma - Experimental Study 189-194 Effect of antibiotic lavage in adhesion prevention in bacterial peritonitis Bakteriyel peritonitte antibiyotikle lavajın adezyonu önlemede etkisi Kayaoğlu HA, Özkan N, Yenidoğan E, Köseoğlu RD 195-199 The hemostatic effect of calcium alginate in experimental splenic injury model Deneysel dalak yaralanma modelinde kalsiyum alginatın hemostatik etkinliği Taşkın AK, Yaşar M, Özaydın İ, Kaya B, Bat O, Ankaralı S, Yıldırım Ü, Aydın M

Klinik Çalışma - Original Articles 200-204 Comparison of open and laparoscopic appendectomy in uncomplicated appendicitis: a prospective randomized clinical trial Komplike olmayan apandisitlerde açık ve laparoskopik apendektominin karşılaştırılması: Bir prospektif randomize klinik çalışma Kocataş A, Gönenç M, Bozkurt MA, Karabulut M, Gemici E, Alış H 205-214 A model of complaint based for overcrowding emergency department: Five-Level Hacettepe Emergency Triage System Aşırı kalabalık aciller için şikayet temelli bir model: Beş-Düzeyli Hacettepe Acil Triyaj Sistemi Özüçelik DN, Kunt MM, Karaca MA, Erbil B, Sivri B, Şahin A, Çetinkaya Şardan Y, Özmen MM, Güçiz Doğan B 215-218 2-octyl-cyanoacrylate glue for fixation of STSG in genitourinary tissue defects due to Fournier gangrene: a preliminary trial Fournier gangrenine bağlı genitoüriner doku defektlerinde STSG fiksasyonu için 2-oktil-siyanoakrilat doku yapıştırıcının kullanımı: Bir ön çalışma Sivrioğlu N, İrkören S, Ceylan E, Sonel AM, Copçu E 219-222 Soccer ball related posterior segment closed-globe injuries in outdoor amateur players Amatör oyuncularda futbol topu ile oluşan arka segment kapalı göz yaralanmaları Gökçe G, Ceylan OM, Erdurman FC, Durukan AH, Sobacı G 223-228 The management of mesenteric vein thrombosis: a single institution’s experience Mezenter ven trombozuna yaklaşım: Tek merkez deneyimi Yanar F, Ağcaoğlu O, Gök AFK, Sarıcı İŞ, Özçınar B, Aksakal N, Aksoy M, Özkurt E, Kurtoğlu M 229-234 Çocuklarda ve erişkinlerde özofagus yabancı cisimleri: 20 yıllık deneyim Esophageal foreign bodies in children and adults: 20 years experience Çelik S, Aydemir B, Tanrıkılı H, Okay T, Doğusoy I 235-240 Ateşli silah yaralanmasına bağlı periferik sinir lezyonlarında cerrahi tedavi sonuçlarımız: 28 olgunun değerlendirilmesi Surgical treatment outcomes ın peripheral nerve lesions due to gunshot injuries: assessment of 28 cases Topuz AK, Eroğlu A, Atabey C, Çetinkal A Cilt - Vol. 19 Sayı - No. 3

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SAYI - NUMBER 3 MAYIS - MAY 2013

İçindekiler - Contents 241-245 The role of bedside ultrasonography for occult scaphoid fractures in the emergency department Acil serviste gizli skafoid kırıkları için yatakbaşı ultrasonografinin rolü Yıldırım A, Ünlüer EE, Vandenberk N, Karagöz A 246-250 Predominant causes and types of orofacial injury in children seen in the emergency department Acil servise başvuran çocuk hastalarda gözlenen orafasiyel yaralanma tipleri ve sık karşılaşılan nedenleri Aren G, Sepet E, Pınar Erdem A, Tolgay CG, Kuru S, Ertekin C, Güloğlu R, Aren A 251-255 Analysis of burn cases observed after the 2011 Van earthquake Van’da yaşanan 2011 depremi sonrası gözlenen yanık olgularının analizi Dursun R, Karadaş S, Görmeli G, Işık Y, Çakır C, Görmeli CA 256-260 Ocular injuries caused by metal caps of carbonated mineral water bottles Soda şişelerinin metal kapaklarının neden olduğu göz yaralanmaları Erdurman FC, Ceylan OM, Hürmeriç V, Pellumbi A, Durukan AH, Sobacı G

Olgu Sunumu - Case Reports 261-266 Abusive head trauma: report of 3 cases İstismara bağlı kafa travması: 3 olgu sunumu Demirli Çaylan N, Yılmaz G, Oral R, Karacan CD, Zorlu P 267-270 Human immunodeficiency virus ile enfekte bir hastada gelişen iki taraflı epidural hematom: Olgu sunumu Bilateral epidural hematoma in a patient with human immunodeficiency virus infection: a case report Kelten B, Karaoğlan A, Çal MA, Akdemir O, Karancı T 271-273 Larynx, hypopharynx and mandible injury due to external penetrating neck injury Eksternal penetran boyun yaralanmasına bağlı gelişen larinks, hipofarinks ve mandibula yaralanması Özbilen Acar G, Tekin M, Çam OH, Kaytancı E 274-276 Velpeau bandajı sonrası nadir bir komplikasyon: Hemopnömotoraks A rare complication after Velpeau bandage: hemopneumothorax Yeginsu A, Ergin M, Gürlek K 277-281 Total skalp, alın, sol kulak, kaşlar ve üst gözkapakları amputasyonunun başarılı replantasyonu ve 6 yıllık takip sonuçları A successful replantation of total scalp, forehead, left ear, eyebrows and upper eyelids amputation and 6-year follow-up results Özkan Ö, Bektaş G, Cinpolat A, Özkan Ö 282-284 Künt travma sonucu gelişen izole hiyoid kırığı: Olgu sunumu Isolated hyoid bone fracture due to blunt trauma: case report Erdoğan MÖ, Koşargelir M, Yorulmaz R, Meriç K, Erdoğan B

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):189-194

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2013.63444

Effect of antibiotic lavage in adhesion prevention in bacterial peritonitis Bakteriyel peritonitte antibiyotikle lavajın adezyonu önlemede etkisi Hüseyin Ayhan KAYAOĞLU,1 Namık ÖZKAN,1 Erdinç YENİDOĞAN,1 Reşid Doğan KÖSEOĞLU2 BACKGROUND

AMAÇ

Intra-abdominal adhesions remain a major clinical problem. Previously, rifamycin lavage was used to prevent adhesion formation in the septic abdomen. The aim of our study was to test the effectiveness of intraperitoneal application of alternate antibiotics in an abdominal sepsis model.

Karıniçi yapışıklıklar halen ciddi bir problemdir. Geçmişte septik karında adezyon formasyonunu önlemek için sadece rifamisin lavajı denenmiştir. Bu çalışmanın amacı karın sepsis modelinde farklı antibiyotiklerin periton içine uygulamasının etkinliğini değerlendirmektir.

METHODS

GEREÇ VE YÖNTEM

Sixty Wistar-albino rats were randomly divided into 6 equal groups. Bacterial peritonitis was induced using caecal ligation and puncture model in all groups. Group 1 was an untreated control. The peritoneum was lavaged with isotonic saline in Group 2, with imipenem in Group 3, with ceftriaxone in Group 4, with cefazolin in group 5 and with metronidazole in group 6. Four weeks after the surgery, intra-abdominal adhesions were graded, tensile strength of the adhesions was measured and histopathological examinations were performed. RESULTS

Imipenem, ceftriaxone and cefazolin significantly reduced adhesion formation (p<0.001) with significantly reduced fibrosis scores (p=0.013). Adhesion formation was greatest in the metronidazole treatment group. The breaking force of adhesions was significantly reduced in Groups 4 and 5 (p<0.001). Although, the inflammation scores were similar between groups (p=0.058), grade 3 inflammation scores were only seen in control, saline and metronidazoletreatment groups.

Altmış adet Wistar-albino sıçan rastgele olacak şekilde 6 eşit gruba ayrıldı. Tüm gruplara çekal ligasyon ve puncture modeli uygulanarak bakteriyel peritonit oluşturuldu. Grup 1 kontrol grubuydu. Grup 2’ye izotonik salinle, grup 3’e imipenemle, grup 4’e seftriaksonla, grup 5’e sefazolinle ve grup 6’ya metronidazolle periton lavajı yapıldı. Cerrahiden 4 hafta sonra karıniçi yapışıklık değerlendirildi, yapışıklıkların gerginlik kuvveti ölçüldü ve histopatolojik değerlendirme yapıldı. BULGULAR

İmipenem, seftriakson ve sefazolin ile yapışıklık formasyonu anlamlı derecede azaldı (p<0,001) ve fibrozis skorları anlamlı derecede düşük olarak bulundu (p=0,013). En kötü yapışıklık metronidazol grubunda izlendi. Yapışıklık kopma kuvveti grup 4 ve 5’te anlamlı olarak düşüktü (p<0,001). Enflamasyon dağılım skorları benzer olmasına rağmen (p=0,058) grade 3 enflamasyon skorları sadece kontrol, salin ve metronidazol grubunda gözlemlendi. SONUÇ

According to these data, cephalosporins may be effective in preventing adhesion formation in septic abdomens. These antibiotics need to be evaluated in a clinical trial.

Bu veriler ışığında septik karında sefalosporinle peritoneal lavajın yapışıklığı önlenmede etkin olduğu ve sonuçların bir klinik çalışmada değerlendirilmesi gerektiği söylenebilir.

Key Words: Antibiotic; cefazolin; ceftriaxone; imipenem; intraabdominal adhesion; metronidazole; peritoneal lavage.

Anahtar Sözcükler: Antibiyotik; sefazolin; seftriakson; imipenem; karıniçi yapışıklık; metronidazol; peritoneal lavaj.

CONCLUSION

Departments of 1General Surgery, 2Pathology, Gaziosmanpasa University, Faculty of Medicine, Tokat, Turkey.

Gaziosmanpaşa Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, 2Patoloji Anabilim Dalı, Tokat.

1

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

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Intra-abdominal adhesions occur in approximately 95% of patients following abdominal surgery. Adhesions cause serious problems including chronic abdominal pain, intestinal obstructions, and female infertility. Certain conditions, such as intra-abdominal infections, aggravate this condition. Infectious conditions are associated with fibrin deposits, which may cause clinically significant adhesion and abscess formation with mortality rates as high as 17 to 38%. [1-4] Gram negative and anaerobic bacteria occur frequently in intra-abdominal infections and abscesses. Previously, systemic or local use of antibiotics have been evaluated for adhesion prevention properties.[5-8] However, only rifamisin has been studied in experimental sepsis model.[9] The aim of our study was to test the effectiveness of intraperitoneal application of various antibiotics in an experimental intra-abdominal sepsis model created by cecal ligation and puncture.

MATERIALS AND METHODS Subjects and surgery After the approval of the institutional ethical committee (approval code 03-GEKTIP-007), 60 adult, male, Wistar-albino rats (250-300 g) provided by the Experimental Research Laboratory of the University under standard husbandry conditions, were randomly divided into 6 equal groups. Animals were operated on at a room temperature of 20°C under 75 mg/kg ketamine hydrochloride with 5 mg/kg xylazine anesthesia was injected intramuscularly. After cleaning the skin, the anterior abdominal wall was shaved, treated with 10% povidon iodine, and a 3-cm median laparotomy was performed. Bacterial peritonitis was induced using a caecal ligation and puncture (CLP) model in all groups.[10] The cecum was punctured on the antimesenteric border with an 18-gauge needle after ligation below the ileocecal valve. Six hours later, following repeat laparotomy, the caecum was resected and the peritoneum was lavaged with isotonic saline (Mediflex; Eczacibasi-Baxter Hastane Urunleri, Ayazaga, Istanbul, Turkey) in Group 2, with 50mg/kg imipenem (Tienam 500 mg IV Flakon, Merck Sharp & Dohme Ilac, Esentepe, Istanbul, Turkey) in Group 3, with 100 mg/kg ceftriaxone (Forsef Flakon; Bilim Ilac, Gebze, Kocaeli, Turkey) in Group 4, with 50 mg/kg cefazolin (Cefamezin Flakon; Eczacibasi Ilac, Luleburgaz, Kırklareli, Turkey) in Group 5 and with 40 mg/kg metronidazole (Flagyl enjektabl solusyon 0.5%; Eczacibasi Ilac, Luleburgaz, Kırklareli, Turkey) in Group 6. These doses were chosen based on the manufacturer’s recommendation using the appropriate surface area-dosage conversion factor of seven from man to rat. Group 1 served as control and peritoneal lavage was not performed in this group. All animals were resuscitated with 10 ml saline subcutaneously in divided doses. 190

Rats were sacrificed by high dose pentothal injection four weeks after the surgery. After performing a U-type incision to the anterior abdominal wall, the adhesions were evaluated. A numerical score described by Knightly et al.[11] was used to determine the adhesion grading by a surgeon unaware of the study groups (Table 1). After the grading of adhesions, the tensile strength of adhesions between abdominal organs was measured by the help of tensile testing equipment (Mark-10 Corporation, NY, USA), in which the test material was placed between a moveable arm over a stationary and a fixed arm connected to the balance with metal clips, by the same independent surgeon. By stretching the moveable arm gradually at speed of 10 mm/min, strength was applied and breaking force values at the time of disruption were detected in Newtons (N). Histopathology Histopathological evaluations were performed by light microscopy with a magnification power of 100x and 400x. The resected adherent tissues were fixed in formaldehyde, embedded in paraffin blocks, and 4 µm sections were stained with haematoxylin and eosin (H&E). A pathologist, who was blind to the groups, graded the extent of fibrosis and inflammation in each specimen with a semi-quantitative scoring system (Tables 2 and 3).[12] Table 1. Adhesion grading scale[11] Score

Adhesion

No adhesions Filmy adhesions Definite localized adhesions Dense multiple visceral adhesions Dense adhesions extending to abdominal wall

0 1 2 3 4

Table 2. Fibrosis grading scale[12] Score

Amount of fibrosis

None Minimal, loose Moderate Florid, dense

0 1 2 3

Table 3. Inflammation grading scale[12] Score

Amount of inflammation

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

0 1 2 3

Mayıs - May 2013


Effect of antibiotic lavage in adhesion prevention in bacterial peritonitis

6

Knightly 1.00 2.00 3.00 4.00

5

Count

4 3 2 1 0

Control

Isotonic Imipenem Ceftriaxone Cefazolin metronidazole

Fig. 1. Peritoneal lavage with imipenem, ceftriaxone and cefazolin significantly reduced adhesion formation by comparison to the other groups. Control and isotonic saline groups showed similar distributions. The most adhesions were present in the metronidazole treatment group (p<0.001).

Statistical evaluation Chi-square tests (likelihood ratios) were used to assess differences in mortality, adhesion, fibrosis, and inflammation grades. One-way ANOVA following Tukeyâ&#x20AC;&#x2122;s test was used for evaluation of tensile strength of the adhesions. Differences with a value of p<0.05 were accepted as significant.

RESULTS Ten rats from Groups 1, 3, 4, 5, and 6 died (n=1, 2, 1, 2, 4, respectively) on the postoperative first and second days. Autopsy was compatible with peritonitis including findings of dilated bowel loops and large volumes of peritoneal fluid in all animals. Although the highest mortality was seen in Group 6, the differences did not reach statistical significance (p=0.180). These

mortalities were excluded while performing other statistical analyses. Distribution of adhesion grading scores among groups was significantly different (p<0.001, Fig. 1). Peritoneal lavage with imipenem, ceftriaxone, and cefazolin significantly reduced adhesion formation compared to the other groups. Control and isotonic saline groups exhibited similar rates of adhesion formation. The most severe adhesions were observed in the metronidazole group (Fig. 2). Mean and standard deviation values for the breaking force of adhesions between organs of the study groups are shown in Table 4. The differences were statistically significant (p<0.001). In paired comparisons of the groups, Groups 4 and 5 were significantly different from groups 1, 2 and 6 (p=0.037, 0.026, and <0.001, respectively, compared with Group 4 and p=0.025, 0.018, and <0.001, respectively, compared with Group 5). Although imipenem treatment did not result in significant improvement compared with the control and saline groups, the improvement was significant when compared to metronidazole. Fibrosis and inflammation grading scores among groups are shown in Figures 3 and 4. Fibrosis scores were statistically different between groups (p=0.013). Significantly decreased fibrosis scores were observed in the imipenem, ceftriaxone, and cefazolin groups. The highest fibrosis scores were seen in the control and metronidazole groups. Although the distribution of the inflammation scores were similar (p=0.058), grade 3 inflammation scores were only seen in the control, saline, and metronidazole groups. Imipenem, ceftriaxone and cefazolin groups showed no inflammation or moderate inflammation scores (Fig. 5).

DISCUSSION Adhesions remain a major clinical challenge with serious complications including chronic pain, bowel 8

Fibrosis .00 1.00 2.00 3.00

Count

6

4

2

0

Fig. 2. Dense adhesions between abdominal organs and abdominal wall in an animal in Group 6. Cilt - Vol. 19 SayÄą - No. 3

Control

Isotonic Imipenem Ceftriaxone Cefazolin Metronidazole saline

Fig. 3. Significantly reduced fibrosis scores were observed in imipenem, ceftriaxone and cefazolin groups. Highest scores were seen in control and metronidazole groups (p=0.013). 191


Ulus Travma Acil Cerrahi Derg

obstruction, or infertility. Some patients require repeat surgeries to address these complications. The duration of surgery, previous surgical history, peritonitis, bowel perforations, and emergency surgery increase complication incidence. Surgeries of the colon and rectum are associated with increased risk of adhesion-related problems relative to surgeries of the small bowel, appendix, or gallbladder. Intra-abdominal infections and subsequent peritonitis are associated with fibrin deposits, which may cause clinically significant adhesion and abscess formation.[13,14] We used the CLP model to simulate this clinical situation. No systemic antibiotic was administrated in our study in order to specifically evaluate the local effects of the antibiotics.

Inflammatory response occurs simultaneously with the activation of the coagulation cascade. This activation results in thrombin formation, which is necessary for the conversion of fibrinogen to fibrin.[15,16] Fibrin fulfills a temporary role in tissue repair. Resolution of the fibrin deposits is essential for proper restoration of preoperative, non-inflamed conditions. When fibrin deposit persist, fibrin provides a matrix for invading fibroblasts and new blood vessels, and the deposited fibrin becomes organized, permanent adhesions, characterized by the deposition of collagen and vascular ingrowth. The degradation of fibrin is regulated by the fibrinolytic system. Inflammatory mediators play an important role in this period. Several different cell types, cytokines, coagulation factors and proteases interact in biochemical events and control the adhesion formation process.[17] Early fibrinolysis, within 5 days of surgery, decreases adhesion formation. If early fibrinolysis does not occur, the temporary fibrin matrix persists and gradually becomes more organized as collagen-secreting fibroblasts, leading to adhesion formation.[18,19] Intra-abdominal infections severely disrupt fibrinolysis, as evidenced by the high levels of plasminogen activator inhibitor in peritoneal tissue and fluid.[20] Peritoneal injury caused by bacteria results in accumulation of an inflammatory exudate that leads to fibrin deposition, resulting in fibrinous adhesions between adjacent organs.[21] In addition, invasion of fibroblasts at infection sites leads to deposition of collagen and subsequent formation of permanent fibrous adhesions.[22]

Adhesions are formed when the peritoneum is damaged and the basal membrane of the mesothelial layer is exposed to the surrounding tissues. This injury to the peritoneum causes a local inflammatory response, which leads to the formation of a serosanguineous, fibrin-rich exudate as part of the haemostatic process.

Peritoneal lavage in the treatment of intra-abdominal infections is widely studied but its benefits are unclear. Although lavage is generally considered a safe procedure, there are some objections to its use. Ability of removing bacteria from the peritoneal cavity and serving as adjuvant substance of peritoneal

Table 4. Breaking force of adhesions between organs according to study group Group

ontrol C Isotonic saline Imipenem Ceftriaxone Cefazolin Metronidazole Total

n

Mean±SD

9 10 8 9 8 6 50

0.2222±0.0565 0.2250±0.1136 0.1838±0.1185 0.0778±0.0417* 0.0663±0.0443* 0.3583±0.1801 0.1820±0.1321

p<0.001; Cefazolin and ceftriaxone significantly reduced tensile strength of adhesions when compared to control, isotonic saline and metronidazole groups. Although, imipenem did not show significant improvement relative to control and saline treatment groups, the decrease was significant when compared to metronidazole.

4

Inflammation .00 1.00 2.00 3.00

Count

3

2

1

Control

Isotonic saline

Imipenem Ceftriaxone Cefazolin Metronidazole

Group

Fig. 4. Although, the distribution was similar between groups (p=0.058), grade 3 inflammation scores were only seen in control, saline and metronidazole treatment groups. 192

Fig. 5. Florid fibrosis and grade 2 inflammation with giant cell formation in an animal in the metronidazole treated group. Mayıs - May 2013


Effect of antibiotic lavage in adhesion prevention in bacterial peritonitis

fluid itself for defense mechanisms are the major origins of the objections. The ideal peritoneal lavage solution should be highly effective, with no mortality, and result in low incidence of adhesion formation. [23-25] To date, there is no universally accepted method for peritoneal lavage. Some researchers have demonstrated that peritoneal lavage with saline, antibiotics, or fibrinolytic agent solutions does not influence outcome following laparotomies for peritonitis. Other reports indicate that peritoneal lavage promotes adhesion formation, as opposed to reports that suggested a preventive role for peritoneal lavages in adhesion formation.[26-28] Antibiotics can exert their anti-adhesive effects by inhibition of synthesis or expression of adhesins on the bacterial cell surface, or modify bacterial protein expression in such a way as to interfere with the ability of the microorganisms to approach receptors on animal cell surface.[29] Sortini et al.[5] compared the efficacy of peritoneal lavage with chloramphenicol, clindamycin, piperacillin, tobramycin, ceftriaxone and imipenem-cilastatin to saline, with adhesion formation increased in study groups. Jallouli et al.[9] used rifamycin for peritoneal lavage in a peritonitis model and demonstrated significantly reduced adhesion formation and higher survival rate. On the other hand, in the study by Rappaport et al.,[23] cefazolin and tetracycline irrigation increased peritoneal adhesion formation in the non-septic abdomen. We evaluated cefazolin, ceftriaxone, imipenem and metronidazole for peritoneal lavage in a peritonitis model. These antibiotics have clinical efficacy against a wide variety of organisms, including gram-positive aerobic cocci, gram-negative aerobes and most penicillin-susceptible anaerobes. Ceftriaxone has enhanced activity against Enterobacteriaceae associated with hospital-acquired infections. Imipenem is particularly important for its activity against Pseudomonas aeruginosa and the Enterococcus species. Metronidazole is a nitroimidazole antibiotic used against anaerobic bacteria and protozoa. These compounds have wide area of usage in daily general surgical practice for both prophylaxis and treatment, with a low side-effect profile.[30-32] Peritoneal lavage with imipenem, ceftriaxone and cefazolin significantly reduced the adhesion formation relative to the other groups. In addition, adhesions were weak in cefazolin and ceftriaxone groups, with significantly reduced adhesion breaking force by comparison to other groups with the exception of imipenem. Fibrosis scores were also significantly reduced in the same groups. Although the inflammation scores were statistically similar, control, saline and metronidazole treatment groups exhibited the highest scores. Cahill et al.[33] demonstrated that enteric bacteria and their antigens stimulated subsequent adhesion formation after laparotomy. Differing from epithelial restoration, mesothelial regeneration after injury represents a form Cilt - Vol. 19 SayÄą - No. 3

of secondary wound healing, and such reparative processes are markedly influenced by bacterial contamination. Gut-associated microbes and their antigens (in particular endotoxin/lipopolysaccharide) may directly induce a peritoneal inflammatory reaction through activation of resident peritoneal cells. Cephalosporins and imipenem induce cell wall synthesis disorders in bacteria, fimbria loss and a decrease in the expression of elements responsible for adhesion on the surface of bacterial cells.[34] Adhesion is considered to be the first step in the sequence of events leading to colonization, and is an important determinant of virulence and subsequent infection. The effect of antibiotics on adhesion may be strain specific and various antibiotics may have varying effects on bacterial adhesion properties. [35] We hypothesize that the higher adhesion rate in the group treated with metronidazole was the result of the overgrowth of aerobic bacteria, especially gram negatives, rather than a direct effect of metronidazole itself. In conclusion, according to these data, metronidazole should not be recommended for peritoneal lavage. Cephalosporins seem to be effective in preventing adhesion formation in septic abdomens and should be evaluated in a clinical trial. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Ellis H, Moran BJ, Thompson JN, Parker MC, Wilson MS, Menzies D, et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet 1999;353:1476-80. 2. Jeekel H. Cost implications of adhesions as highlighted in a European study. Eur J Surg Suppl 1997;579:43-5. 3. Tito WA, Sorr MG. Intestinal obstructions. In: Zuidema GD, Nyhus LM, editors. Shakelfordâ&#x20AC;&#x2122;s surgery of alimentary tract. 5th ed. Philadelphia: Saunders; 1996. p. 375-416. 4. Christou NV, Barie PS, Dellinger EP, Waymack JP, Stone HH. Surgical Infection Society intra-abdominal infection study. Prospective evaluation of management techniques and outcome. Arch Surg 1993;128:193-9. 5. Sortini D, Feo CV, Maravegias K, Carcoforo P, Pozza E, Liboni A, et al. Role of peritoneal lavage in adhesion formation and survival rate in rats: an experimental study. J Invest Surg 2006;19:291-7. 6. Cohen BM, Heyman T, Mast D. Use of intraperitoneal solutions for preventing pelvic adhesions in the rat. J Reprod Med 1983;28:649-53. 7. Phillips RK, Dudley HA. The effect of tetracycline lavage and trauma on visceral and parietal peritoneal ultrastructure and adhesion formation. Br J Surg 1984;71:537-9. 8. Oncel M, Kurt N, Remzi FH, Sensu SS, Vural S, Gezen CF, et al. The effectiveness of systemic antibiotics in preventing postoperative, intraabdominal adhesions in an animal model. J Surg Res 2001;101:52-5. 9. Jallouli M, Hakim A, Znazen A, Sahnoun Z, Kallel H, Zghal K, et al. Rifamycin lavage in the treatment of experimental intra-abdominal infection. J Surg Res 2009;155:191-4. 10. Wichterman KA, Baue AE, Chaudry IH. Sepsis and septic 193


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shock--a review of laboratory models and a proposal. J Surg Res 1980;29:189-201. 11. Knightly JJ, Agostino D, Cliffton EE. The effect of fibrinolysin and heparin on the formation of peritoneal adhesions. Surgery 1962;52:250-8. 12. Hooker GD, Taylor BM, Driman DK. Prevention of adhesion formation with use of sodium hyaluronate-based bioresorbable membrane in a rat model of ventral hernia repair with polypropylene mesh--a randomized, controlled study. Surgery 1999;125:211-6. 13. Blacker CM, Diamond MP. Pelvic adhesions and infertility. In: Seibel MM editor. Infertility: a comprehensive text. 2nd ed. Stamford, CT: Appleton & Lange; 1997. p. 655-68. 14. Cheong YC, Laird SM, Li TC, Shelton JB, Ledger WL, Cooke ID. Peritoneal healing and adhesion formation/reformation. Hum Reprod Update 2001;7:556-66. 15. Holmdahl L, Ivarsson ML. The role of cytokines, coagulation, and fibrinolysis in peritoneal tissue repair. Eur J Surg 1999;165:1012-9. 16. Reed KL, Fruin AB, Bishop-Bartolomei KK, Gower AC, Nicolaou M, Stucchi AF, et al. Neurokinin-1 receptor and substance P messenger RNA levels increase during intraabdominal adhesion formation. J Surg Res 2002;108:165-72. 17. Hellebrekers BW, Kooistra T. Pathogenesis of postoperative adhesion formation. Br J Surg 2011;98:1503-16. 18. Reijnen MM, Bleichrodt RP, van Goor H. Pathophysiology of intra-abdominal adhesion and abscess formation, and the effect of hyaluronan. Br J Surg 2003;90:533-41. 19. Sulaiman H, Dawson L, Laurent GJ, Bellingan GJ, Herrick SE. Role of plasminogen activators in peritoneal adhesion formation. Biochem Soc Trans 2002;30:126-31. 20. van Goor H, de Graaf JS, Grond J, Sluiter WJ, van der Meer J, Bom VJ, et al. Fibrinolytic activity in the abdominal cavity of rats with faecal peritonitis. Br J Surg 1994;81:1046-9. 21. van Goor H, Bom VJ, van der Meer J, Sluiter WJ, Bleichrodt RP. Coagulation and fibrinolytic responses of human peritoneal fluid and plasma to bacterial peritonitis. Br J Surg 1996;83:1133-5. 22. Thompson JN, Whawell SA. Pathogenesis and prevention of adhesion formation. Br J Surg 1995;82:3-5. 23. Rappaport WD, Holcomb M, Valente J, Chvapil M. Antibiotic irrigation and the formation of intraabdominal adhesions.

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Am J Surg 1989;158:435-7. 24. Reijnen MM, Meis JF, Postma VA, van Goor H. Prevention of intra-abdominal abscesses and adhesions using a hyaluronic acid solution in a rat peritonitis model. Arch Surg 1999;134:997-1001. 25. el-Ghoul W. The effects of combined liquid and membrane barriers in prevention of post-operative intra-abdominal adhesions after experimental jejunal anastomosis in dogs. Dtsch Tierarztl Wochenschr 2005;112:3-10. 26. Kayaoglu HA, Ozkan N, Hazinedaroglu SM, Ersoy OF, Koseoglu RD. An assessment of the effects of two types of bioresorbable barriers to prevent postoperative intra-abdominal adhesions in rats. Surg Today 2005;35:946-50. 27. Kirdak T, Uysal E, Korun N. Assessment of effectiveness of different doses of methylprednisolone on intraabdominal adhesion prevention. Ulus Travma Acil Cerrahi Derg 2008;14:188-91. 28. Günaydın M, Güvenc D, Yıldız L, Aksoy A, Tander B, Bicakci U, et al. Comparison of substances used for prevention of intra-abdominal adhesions: an experimental study in rats. Türkiye Klinikleri J Med Sci 2012;32:337-45. 29. Lorian V, Ernst J. Effects of antibiotics on bacterial structure and their pathogenicity. Pathol Biol (Paris) 1987;35:1370-6. 30. Ikawa K, Morikawa N, Sakamoto K, Ikeda K, Ohge H, Takesue Y, et al. Pharmacokinetics and pharmacodynamic assessment of imipenem in the intraperitoneal fluid of abdominal surgery patients. Chemotherapy 2008;54:131-9. 31. Abad CL, Kumar A, Safdar N. Antimicrobial therapy of sepsis and septic shock--when are two drugs better than one? Crit Care Clin 2011;27:1-27. 32. Weigelt JA. Empiric treatment options in the management of complicated intra-abdominal infections. Cleve Clin J Med 2007;74:29-37. 33. Cahill RA, Wang JH, Redmond HP. Enteric bacteria and their antigens may stimulate postoperative peritoneal adhesion formation. Surgery 2007;141:403-10. 34. Zalas-Wiecek P, Gospodarek E, Piecyk K. Influence of subinhibitory concentrations of cefotaxime, imipenem and ciprofloxacin on adhesion of Escherichia coli strains to polystyrene. Pol J Microbiol 2011;60:345-9. 35. Shibl AM. Effect of antibiotics on adherence of microorganisms to epithelial cell surfaces. Rev Infect Dis 1985;7:51-65.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):195-199

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2013.30676

The hemostatic effect of calcium alginate in experimental splenic injury model Deneysel dalak yaralanma modelinde kalsiyum alginatın hemostatik etkinliği Ali Kemal TAŞKIN,1 Mehmet YAŞAR,1 İsmet ÖZAYDIN,1 Bülent KAYA,2 Orhan BAT,2 Seyit ANKARALI,3 Ümran YILDIRIM,4 Metin AYDIN1 BACKGROUND

AMAÇ

We evaluated the effect of calcium alginate as a hemostatic agent in a splenic injury model.

Kalsiyum alginatın deneysel dalak yaralanma modelinde etkinliği araştırıldı.

METHODS

GEREÇ VE YÖNTEM

Experimental rats (Wistar albino) were divided into four groups. Group I: Laparotomy was not performed. Group II: After laparotomy, the abdomen was closed without any splenic injury. Group III: After laparotomy, splenic injury about 0.5 cm in depth and 0.3 cm in length was created by standard Rochester pean forceps. Physiological serum treated gauze dressing, about 2x2 cm in size, was applied to the injured splenic tissue for 3 minutes. Group IV: After laparotomy, standard splenic injury about 0.5 cm in length and 0.3 cm in depth was created. Calcium alginate wound dressing, 1x1 cm in size, was applied to the splenic wound. In all groups, blood samples for bleeding time and hemogram were taken. Peroperative blood loss, pre- and post-operative hemoglobin and hematocrit values were calculated.

Deney hayvanları (Wistar albino sıçanlar) dört gruba ayrıldı. Grup I: Laparotomi uygulanmadı. Sadece kan örneklemesi yapılarak kanama zamanı ve hemogram incelemesi çalışıldı. Grup II: Laparotomi yapıldı. Herhangi bir dalak yaralanması oluşturmaksızın karın kapatıldı. Grup III: Laparotomi yapıldıktan sonra 0,5 cm derinlik ve 0,3 cm uzunluğunda dalak yaralanması oluşturuldu. Yaklaşık 2x2 cm ebadında serum fizyolojikli gazlar dalaktaki yaralanma bölgesine uygulandı. Grup IV: Laparatomi sonrası standart 0,5 cm derinlik ve 0,3 cm uzunluğundaki dalak yaralanması bu grupta da uygulandı. 1x1 cm ebadındaki kalsiyum alginat yara örtüsü yaralanma bölgesine kondu. Ameliyat sırasında kan kaybı, ameliyat öncesi ve sonrası hemoglobin ve hemotokrit değerleri ölçüldü.

RESULTS

BULGULAR

Comparing hematocrit values and peroperative bleeding in Groups III and IV, Group IV had a lower decline in hematocrit values and lower peroperative bleeding. CONCLUSION

Calcium alginate has hemostatic capacity. It may be used in splenic injuries, especially for Grades I and II.

Grup III ve Grup IV hematokrit değerleri ve ameliyat sırasında kanama miktarı açısından karşılaştırıldığında Grup IV’deki düşüş miktarı daha azdı. SONUÇ

Kalsiyum alginatın hemostatik kapasitesi vardır. Grade I ve grade II dalak yaralanmalarında kullanılabilir.

Key Words: Calcium alginate; hemostasis; splenic injury.

Anahtar Sözcükler: Kalsiyum alginat; hemostaz; dalak yaralanması.

Alginate dressings are hydrophilic products which are formed by alginic acids (mannuronic and guluronic) extracted from seaweed species.[1] They are highly absorbent, gel-forming materials with haemostatic

capacity. Alginate dressings were first presented as wound care and haemostatic products. Alginate dressings have been used to treat different wound types, as they absorb any fluid collection inside a wound and

Departments of 1General Surgery, 3Physiology, 4Pathology, Duzce University Faculty of Medicine, Duzce; 2 Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey.

Düzce Üniversitesi Tıp Fakültesi 1Genel Cerrahi Anabilim Dalı, 3 Fizyoloji Anabilim Dalı, 4Patoloji Anabilim Dalı, Düzce; 2 Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi Genel Cerrahi Kliniği, İstanbul.

Correspondence (İletişim): Bülent Kaya, M.D. Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey. Tel: +90 - 216 - 578 30 00 e-mail (e-posta): drbkaya@yahoo.com

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favour debridement. Thus, they promote wound healing and epidermal regeneration. When alginate is combined with calcium or sodium it gains hemostatic properties. Calcium alginate dressings form a gel when in contact with body fluids. In dentistry, alginate products are used widely to control bleeding in tooth sockets.[2] The availability of calcium ions at the injury site helps to support the normal clotting process, and this has been shown to significantly reduce clotting times, in some cases up to 54% compared to controls.[2] Calcium alginate dressing is tailored as a textile product. It is designed for cavity wounds such as pilonidal sinus cavity or tooth cavity after extraction process. There are also flat-non-woven pad models for application to open wounds. In this experimantal study, we evaluated the effect of calcium alginate as a hemostatic agent in a splenic injury model. Intraabdominal adhesion formation with calcium alginate usage was also studied.

MATERIALS AND METHODS This study was conducted in Duzce University Medical Faculty Research Center.The experimental protocol was approved by the animal studies and ethical committee of Abant Izzet Baysal University

(a)

(c)

Medical Faculty. Thirty-two male Wistar albino rats weighting 250-300 g (mean age: 6 months) were used. The rats were fed with standard rat chow diet. Experimental rats were divided into four groups: Group I (Control group): Laparotomy was not performed; Group II (Sham group): After laparotomy, the abdomen was closed without any splenic injury; Group III (Splenic injury treated by gauze dressing with serum physiologic): After laparotomy, splenic injury about 0.5 cm in depth and 0.3 cm in length was created by standard Rochester pean forceps. Physiological serum treated gauze dressing, about 2x2 cm in size, was applied to the injured splenic tissue for 3 minutes (Fig. 1a). Gauze was taken out after 3 minutes; Group IV (Splenic injury treated with calcium alginate): after laparotomy, standard splenic injury about 0.5 cm in length and 0.3 cm in depth was created. Calsium alginate wound dressing 1x1 cm in size was applied to the splenic wound (Fig. 1b). During the surgical procedure, the rats were under general anaesthesia using an intramuscular injection of 20 mg/kg ketamin hydrocholoride (Ketalar®, Parke Davis, Levent-İstanbul, Turkey) and 2 mg/kg xylasin (Rhompun®, Bayer Türk Kimya, Şişli-İstanbul, Turkey). After cleaning the abdominal region of rats with poidon iot solution, a 3 cm median laparotomy was performed in all groups except Group I (controls). Be-

(b)

(d)

Fig. 1. (a) Polyester bag was placed for collecting accumulated blood after splenic injury. (b) Gauze dressing with 0.9% NaCl applied to splenic injury. (c) Calcium alginate dressing (Sorbalgon) 1x1 cm applied to splenic injury. (d) Stage 3 adhesion in rats treated with Ca-alginate dressing. (Color figures can be viewed in the online issue, which is available at www.tjtes.org). 196

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The hemostatic effect of calcium alginate in experimental splenic injury model

Table 1. Comparison of postoperative laboratory values in four groups

Sham group (n=8)

Postoperative

Mean±SD

Wbc Rbc Hb

Gauze dressing with 0.9% NaCl (n=8)

Min.-Max.

Mean±SD

Min.-Max.

8.22±4.68

3-14

7.47±3.54

8.27±1.31 13.93±1.81

5.9-9.7 10.6-15.6

8.41±.35 13.07±1.18

Hct

64.53±2.72

60.3-67.9

BT

11.0±.707

10-12

Plt Perop. bleeding

937.5±136.99 675-1050 .35±.104 .20-.50

Ca-alginate dressing (n=8)

Mean±SD

Min.-Max.

4.43-15.20

8.59±.418

4.07-13.60

0.87

6.70-8.78 13.5-16.2

8.51±.409 14.33±.663

7.85-8.96 13.20-15.10

0.79 0.05

61.38±3.37

56.7-65.6

65.43±2.95

60.3-67.9

0.0005

10.87±.51

10.5-12

11.18±.703

10-12

0.79

789.37±139.704 –

560-950 –

0.16 0.0004

Mean±SD

Min.-Max.

3.3-13.50

9.41±4.26

8-8.8 10.9-14.4

8.16±.777 14.74±1.08

55.05±2.98

50.2-58.7

11.00±.755

10-12

918.28±246.02 600-1240 1.80±.130 1.6-2

p

Control group (n=8)

747.0±199.696 420-1080 .95±.169 .70-1.2

BT: Bleeding time.

fore splenic injury, a funnel shape polyster bag was placed under the spleen (Fig. 1c). Approximately 10 minutes after laparatomy and splenic injury, accumulated blood was taken from polyester bag by injector and peroperative blood loss was calculated. The polyester bag was removed from the abdominal cavity and the abdomen was closed with 3/0 silk sutures. Re-laparatomy was performed seven days after the first operation for histopathological examination. Adhesion scoring was performed with adhesion scoring system. After adhesion evaluation, splenectomy was performed. Inflammatory cell amount, vascularization, and fibroblast number were evaluated and scored as (-), (+), (++), (+++).

hemoglobin values were significantly lower in gauze dressing with 0.9% NaCl group (Table 1). When comparing the decline in hematorit values and peroperative bleeding amount between Group III and Group IV, Group IV had a lower decline in hematocrit values and less peroperative bleeding (Tables 2 and 3).

RESULTS Preoperative mean values for WBC, RBC, hemoglobin, hematocrit, and thrombocyte count were measured. There were no statistically significant differences between the 4 groups (p>0.05).

Several hemostatic agents have been used in the treatment of solid organ hemorrhages.[3-5] They work by different mechanisms. Some stimulate fibrin formation or inhibit fibrinolysis. Some hemostatics are a preparation of a procoagulant agent combined with a transporter molecule such as collagen matrix. All have effects on hemostasis mechanisms.

Postoperative values including WBC, RBC, hemoglobin, hematocrit and amount of bleeding are shown in Table 1. When comparing postoperative hemoglobin, hematocrit values and amount of bleeding, there were statistically significant differences between groups (p<0.05). Postoperative hematocrit and

Pathological results and adhesion scores are shown in Table 4. There were statistically significant differences between Group III and Group IV in inflammation, vascularization and fibrosis (p<0.05). The highest adhesion score was detected in Group IV (Fig. 1d).

DISCUSSION

Alginate is formed by Alpha-L-Glucuronic acid and Beta-D-Mannuroic acid monomers. When two molecules of calcium combine with alginate, calcium alginate is formed. Calcium alginate has been used as

Table 2. Decline in hematocrit values in Gauze dressing and Ca-alginate dressing Differance in Htc values (preop-postop)

Gauze dressing with 0.9% NaCl

Ca-alginate dressing

Mean±SD

Mean±SD

9.3±2.22

3.81±0.67

p 0.001

Table 3. Comparison of bleeding amount in Gauze dressing and Ca-alginate dressing Peroperative Bleeding (ml) Cilt - Vol. 19 Sayı - No. 3

Gauze dressing with 0.9% NaCl

Ca-alginate dressing

Mean±SD

Mean±SD

1.80±1.30

0.95±0.169

p 0.001

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Table 4. Patological results in four groups including adhesion scores

Sham group

Gauze dressing with 0.9% NaCl

Ca-alginate dressing

Control group

Pathological findings

n

%

n

%

n

%

n

%

Inflammation Vascularization Fibrosis Necrosis Adhesion

0 1 2 0 1 2 0 1 2 3 0 0 1 2 3 4

8 0 0 8 0 0 8 0 0 0 0 4 4 0 0 0

100 0 0 100 0 0 100 0 0 0 100 50 50 0 0 0

0 8 0 1 7 0 0 5 3 0 0 1 6 1 0 0

0 100 0 12.5 87.5 0 0 62.5 37.5 0 100 12.5 75 12.5 0 0

0 4 4 0 4 4 0 0 6 2 0 0 5 2 1 0

0 50 50 0 50 50 0 0 75 25 100 0 62.5 25 12.5 0

8 0 0 8 0 0 8 0 0 0 0 8 0 0 0 0

100 0 0 100 0 0 100 0 0 0 100 100 0 0 0 0

a local hemostatic agent and wound dressing in recent years.[6,7] When calcium alginate contacts tissue, calcium and sodium ions are exchanged. Calcium has an important role in hemostasis. It is known as factor IV in the hemostasis cascade. It causes secretion of hemostatic mediators from thrombocytes by the help of calcium ions.[8-11] It activates thrombocytes, Factor VII-IX and X in hemostasis. In this experimental study, a spleen laceration model was established and the hemostatic effect of calcium alginate was evaluated. It was demonstrated that calcium alginate was able to decrease the intraoperative bleeding after splenic injury. It was also associated with a lesser decrease in hemoglobin and hemotocrit levels in the postoperative period when compared to 0.9% NaCl treated gauze dressing. Henderson et al.[12] used calcium alginate as a hemostatic agent in children after tooth extraction. They compared the cotton swab with alginate swab for hemostasis. They concluded that calcium alginate swabs did not have any clinical or statistical advantage over traditional cotton swabs. Ingram et al.[13] used calcium alginate (Sorbsan) and standard gauze packing following haemorrhoidectomy. Although calcium alginate dressing effectively decreased the postoperative pain compared to standard gauze packing, there were no differences in postoperative hemorrhage. Calcium alginate was also used as a hemostatic swab in hip fracture surgery, where alginate swabs significantly decreased intra-operative blood loss and post-operative suction drainage loss.[14] Mlekusch et al.[15] used 198

p

0.0001

0.0001

0.0001

1.000 0.003

calcium alginate pads for access site management after peripheral percutaneous transluminal procedures. Calcium alginate pad were compared with conventional comprasion.They concluded that, although calcium alginate pads reduced the time to hemostasis, the risk of access site complications was not significantly different. Although it was not main objective of this study, development of intraabdominal adhesions after calcium alginate usage was also evaluated. El-Kamel et al.[16] used sodium alginate in formulation of vaginal tablets as a bioadhesive molecule. Calcium-alginate was placed on to the lacerated spleen. It did not dissolve, and adhesions around the lacerated spleen were detected. When compared to 0.9% NaCl gauze and sham groups, inflammation, vascularization and fibrosis were statistically higher in calcium alginate group (p<0.05). The adhesion score was also higher in calcium alginate group. These results were associated with higher incidence of adhesion formation in calcium alginate group. Higher inflammation and vascularization in calcium alginate group may be associated with rapid wound healing. In conclucion, calcium alginate has hemostatic capacity. It may be used in splenic injuries specially for Grade I and II, but it may be associated with intraabdominal adhesion formation. Conflict-of-interest issues regarding the authorship or article: None declared. May覺s - May 2013


The hemostatic effect of calcium alginate in experimental splenic injury model

REFERENCES 1. Timmons J. Alginates and hydrofibre dressings. Prof Nurse 1999;14:496-9, 501, 503. 2. Kaneda K, Kuroda S, Goto N, Sato D, Ohya K, Kasugai S. Is sodium alginate an alternative haemostatic material in the tooth extraction socket? J Oral Tissue Engin 2008;5:127-33. 3. Bilgili H, Kosar A, Kurt M, Onal IK, Goker H, Captug O, et al. Hemostatic efficacy of Ankaferd Blood Stopper in a swine bleeding model. Med Princ Pract 2009;18:165-9. 4. Schwaitzberg SD, Chan MW, Cole DJ, Read M, Nichols T, Bellinger D, et al. Comparison of poly-N-acetyl glucosamine with commercially available topical hemostats for achieving hemostasis in coagulopathic models of splenic hemorrhage. J Trauma 2004;57:S29-32. 5. Chan MW, Schwaitzberg SD, Demcheva M, Vournakis J, Finkielsztein S, Connolly RJ. Comparison of poly-N-acetyl glucosamine (P-GlcNAc) with absorbable collagen (Actifoam), and fibrin sealant (Bolheal) for achieving hemostasis in a swine model of splenic hemorrhage. J Trauma 2000;48:454-8. 6. Qin Y. Absorption characteristics of alginate wound dressings. J Appl Polym Sci 2004;91:953-7. 7. Gilchrist T, Martin AM. Wound treatment with Sorbsan-an alginate fibre dressing. Biomaterials 1983;4:317-20. 8. Biggs G, Hafron J, Feliciano J, Hoenig DM. Treatment of splenic injury during laparoscopic nephrectomy with BioGlue, a surgical adhesive. Urology 2005;66:882. 9. Berrevoet F, de Hemptinne B. Clinical application of topi-

Cilt - Vol. 19 Say覺 - No. 3

cal sealants in liver surgery: does it work? Acta Chir Belg 2007;107:504-7. 10. Demirel AH, Basar OT, Ongoren AU, Bayram E, Kisakurek M. Effects of primary suture and fibrin sealant on hemostasis and liver regeneration in an experimental liver injury. World J Gastroenterol 2008;14:81-4. 11. Schwartz M, Madariaga J, Hirose R, Shaver TR, Sher L, Chari R, et al. Comparison of a new fibrin sealant with standard topical hemostatic agents. Arch Surg 2004;139:1148-54. 12. Henderson NJ, Crawford PJ, Reeves BC. A randomised trial of calcium alginate swabs to control blood loss in 3-5-yearold children. Br Dent J 1998;184:187-90. 13. Ingram M, Wright TA, Ingoldby CJ. A prospective randomized study of calcium alginate (Sorbsan) versus standard gauze packing following haemorrhoidectomy. J R Coll Surg Edinb 1998;43:308-9. 14. Davies MS, Flannery MC, McCollum CN. Calcium alginate as haemostatic swabs in hip fracture surgery. J R Coll Surg Edinb 1997;42:31-2. 15. Mlekusch W, Dick P, Haumer M, Sabeti S, Minar E, Schillinger M. Arterial puncture site management after percutaneous transluminal procedures using a hemostatic wound dressing (Clo-Sur P.A.D.) versus conventional manual compression: a randomized controlled trial. J Endovasc Ther 2006;13:23-31. 16. El-Kamel A, Sokar M, Naggar V, Al Gamal S. Chitosan and sodium alginate-based bioadhesive vaginal tablets. AAPS PharmSci 2002;4:E44.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):200-204

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.58234

Comparison of open and laparoscopic appendectomy in uncomplicated appendicitis: a prospective randomized clinical trial Komplike olmayan apandisitlerde açık ve laparoskopik apendektominin karşılaştırılması: Bir prospektif randomize klinik çalışma Ali KOCATAŞ,1 Murat GÖNENÇ,1 Mehmet Abdussamet BOZKURT,2 Mehmet KARABULUT,1 Eyup GEMİCİ,1 Halil ALIŞ1 BACKGROUND

AMAÇ

In the treatment of a subset of patients with uncomplicated appendicitis, no surgical method has been clearly established as superior.

Komplike olmayan apandisitle başvuran hastalarda herhangi bir cerrahi yöntemin diğerine üstünlüğü henüz açıkça belirlenmemiştir.

METHODS

GEREÇ VE YÖNTEM

The present study was a prospective randomized clinical trial. Patients diagnosed with acute appendicitis were recruited for the study. Patients with a preoperative diagnosis of complicated appendicitis were excluded. The patients were randomly divided into two groups: a laparoscopic appendectomy group and an open appendectomy group. The primary outcome measure was the rate of postoperative septic complications. Secondary outcome measures were the length of hospital stay, postoperative pain score, and quality of life score.

Çalışma, ileriye yönelik randomize bir klinik çalışmaydı. Akut apandisit tanısı konulan hastalar çalışmaya alındı. Ameliyat öncesi olarak komplike apandisit tanısı alan hastalar çalışmanın dışında tutuldu. Hastalar iki gruba ayrıldı: Laparoskopik apendektomi grubu ve açık apendektomi grubu. Birincil sonuç ölçütü ameliyat sonrası septik komplikasyon oranıydı. İkincil sonuç ölçütleri hastanede kalış süresi, ameliyat sonrası ağrı skoru ve yaşam kalitesi skoruydu.

RESULTS

BULGULAR

Ninety-six patients were included in the study, 50 in the laparoscopic appendectomy group and 46 in the open appendectomy group. There were no significant differences between the two groups in terms of the rates of postoperative septic complications, hospital stay lengths, postoperative pain scores, or quality of life scores.

Çalışmaya alınan 96 hastanın 50’si laparoskopik apendektomi grubu, 46’sı ise açık apendektomi grubu olarak ayrıldı. Ameliyat sonrası septik komplikasyonların oranı, hastanede kalış süresi, ameliyat sonrası ağrı skoru ve yaşam kalitesi skoru açısından iki grup arasında anlamlı bir fark saptanmadı.

CONCLUSION

SONUÇ

The laparoscopic approach to appendectomy in patients with uncomplicated appendicitis does not offer a significant advantage over the open approach in terms of length of hospital stay, postoperative pain score, or quality of life, which are considered the major advantages of minimally invasive surgery.

Komplike olmayan apandisit olgularında laparoskopik yaklaşım, minimal invasif cerrahinin önemli avantajları olduğu kabul edilen hastanede kalış süresi, ameliyat sonrası ağrı skoru ve yaşam kalitesi açısından açık yaklaşıma göre önemli bir avantaj sağlamamaktadır.

Key Words: Appendicitis; laparoscopic appendectomy; open appendectomy; pain score; uncomplicated appendicitis; quality of life.

Anahtar Sözcükler: Açık apendektomi; ağrı skoru; apandisit; komplike olmayan apandisit; laparoskopik apendektomi; yaşam kalitesi.

Department of General Surgery, Dr. Sadi Konuk Training and Research Hospital, Istanbul; 2 Department of General Surgery, Pervari Public Hospital, Siirt, Turkey.

Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul; 2 Pervari Devlet Hastanesi, Genel Cerrahi Kliniği, Siirt.

1

1

Correspondence (İletişim): Murat Gönenç, M.D. Tevfik Sağlam Caddesi, No: 11, Zuhuratbaba, 34147 Bakırköy, İstanbul, Turkey. Tel: +90 - 212 - 414 71 71 e-mail (e-posta): gonencmd@hotmail.com

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Comparison of open and laparoscopic appendectomy in uncomplicated appendicitis

The gold standard treatment for acute appendicitis has been open appendectomy (OA) due to its efficient outcomes.[1] In 1983, however, Semm introduced laparoscopic appendectomy (LA), which has since become increasingly popular.[2] SAGES strongly recommends LA only for female patients of child-bearing age because the advantages of minimal invasive surgery, such as shorter length of hospital stay, better cosmetic appearance, faster recovery and return to normal activities, and less postoperative pain, are considered to be relative for appendectomy, in patients with uncomplicated appendicitis in particular.[1,3-6] LA is not favored because of longer operative times, greater hospital costs, and most importantly, increased incidence of postoperative abscess formation. [7] However, operative times have dramatically decreased with increasing experience. Furthermore, the use of reusable laparoscopic instruments has led to a significant reduction in hospital charges. Nonetheless, increased incidence of postoperative abscess formation continues to be a major concern in spite of many studies reporting contradictory results.[6-9] In the treatment of a subset of patients with uncomplicated appendicitis, no surgical method has been clearly established as superior. Thus, we conducted a prospective randomized clinical trial comparing OA and LA in the treatment of uncomplicated appendicitis.

MATERIALS AND METHODS The study was designed as a prospective randomized clinical trial and was initiated after approval by the institutional review board. The inclusion criterion was preoperative diagnosis of acute appendicitis. All of the patients underwent combined clinical, radiological, and biochemical evaluations for acute appendicitis. The diagnosis was determined and the final decision for surgical treatment was made by the attending surgeon. All of the patients were given detailed information about the study and provided signed informed consent forms. The patients were divided into two randomized groups: Group 1 underwent laparoscopic appendectomy, whereas Group 2 underwent OA. Randomization was performed using a lottery method. A resident, who had no knowledge of the preoperative data and would not be involved in the operations, was chosen to select lottery cards. Exclusion criteria were as follows: unwillingness to participate; inability to provide informed consent (mental disabilities); age younger than 15 years; pregnancy; severe sepsis or septic shock on admission; contraindication for laparoscopy; ASA III or IV; conversion to open procedure; and complicated appendicitis. All of the operations were performed under general anesthesia. Prophylactic antibiotherapy with a single Cilt - Vol. 19 Sayı - No. 3

shot of cefazolin (1 g, intravenous) was administered on a routine basis during the induction of anesthesia. All of the operations were performed by residents who were at least within their second year under supervision of the chief resident or the attending surgeon. In the laparoscopic approach, a temporary Foley catheter and an orogastric tube were inserted after the induction of general anesthesia to prevent visceral injury; both were withdrawn prior to recovery from anesthesia. The patient was positioned in a 30° Trendelenburg position and a 15° left tilt. A Verres needle was used to create pneumoperitoneum in all patients except those who had undergone previous abdominal surgery; Hasson technique was used on the latter patients instead. A 10-mm optic trocar was inserted through an infraumbilical incision, and a 30° scope was utilized in all cases. Under direct vision, a 10-mm and a 5-mm trocar were introduced in the left lower quadrant and suprapubic region, respectively. The dissection of the mesoappendix was performed using a 5-mm or a 10-mm vessel sealing device (The LigaSureTM Vessel Sealing System, Valleylab, Boulder, CO, USA). The dissection was kept as close to the appendix as possible to reduce the bulk of the specimen so as to avoid specimen delivery problems. The appendiceal base was secured using intracorporeal knotting with 2/0 silk. Either one or two knots were used based on the experience of the operating surgeon. The standard knot type used was a square knot with two turns in the first throw and one turn in the last two throws. A metal endoclip was applied to the specimen’s side to prevent contamination. Following the appendectomy, the specimen was extracted from the trocar in the left lower quadrant and placed in a specimen bag. A “suction only” policy was preferred over irrigation unless there was localized pus accumulation in the pelvis. Drainage was avoided in all cases. In the open procedure, a Rockey-Davis or McBurney incision was used for the laparotomy. The anterolateral abdominal muscles were split, and the peritoneum was incised. The mesoappendix was ligated with 2/0 silk and divided. The base of the appendix was ligated with 2/0 silk. A hemostat was applied to the distal side of the specimen, and the appendix was transected. The incision was closed in an anatomic fashion. Again, a “suction only” policy was preferred over irrigation unless there was localized pus accumulation in the pelvis. Drainage was similarly avoided in all cases. All of the patients, except those who experienced nausea or vomiting, were allowed to start oral intake at the 4th postoperative hour. Tramadol (100 mg as needed, intravenous) was administered for the management of postoperative pain and was replaced by peroral naproxen sodium (550 mg twice a day) after the initiation of oral intake. 201


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The patients were followed for 30 days after surgery. All of the findings among those admitted for dressing changes and stitch removal and those readmitted for postoperative complications were recorded. A visual analog pain scale was used to compare postoperative pain at the 4th postoperative hour and at the time of discharge. All of the patients were asked to complete to a quality of life questionnaire, specifically, the Nottingham Health Profile, at the 15th postoperative day. The Nottingham Health Profile is a validated tool that consists of 38 health-related questions which represent six dimensions of subjective health: physical mobility, pain, sleep, energy, emotional reactions, and social isolation.[10-12] The primary outcome measure was postoperative complications, including readmissions, rehospitalizations, and reoperations. The secondary outcome measures were length of hospital stay, visual analog pain scores, and quality of life scores. Statistical analysis was performed using NCSS 2007 Software (NCSS, Kaysville, UT, USA). Descriptive data were expressed as mean values and standard deviations. Student’s t-test and Fisher’s exact test were used to evaluate proportional data and qualitative data, respectively, for intergroup differences. A p value less than 0.05 was considered statistically significant.

RESULTS One hundred and twenty-one patients were assessed for eligibility for the study. Twenty-two patients were excluded, and three patients were lost to followup. Therefore, a total of 96 patients were randomly divided into two groups: 50 patients in Group 1, and 46 patients in Group 2. The mean ages of the patients in Groups 1 and 2 were 27.4±18.5 years (range: 16-54 years) and 28.2±21.2 years (range: 15-71 years), re-

spectively. The female-to-male ratios in Groups 1 and 2 were 0.9 (23/27) and 0.09 (4/44), respectively. The results and the comparison of outcome measures are presented in Table 1. The mean hospital stay lengths were similar for both groups (p=0.618). In Group 1, an iatrogenic ileal injury occurred in one patient. The injury was overlooked during the procedure, and the patient underwent reoperation on the second post-operative day, prior to discharge, due to signs of peritonitis. During diagnostic laparoscopy, a 1 cm perforation was found on the antimesenteric side of the terminal ileum. The perforated ileal segment was exteriorized because of the presence of diffuse peritonitis. The patient was discharged on the eighth day without any further complications and was scheduled for stoma closure. In Group 1, massive bleeding occurred after the insertion of the suprapubic trocar in one patient. The bleeding could not be controlled by direct compression, so the incision was enlarged, and the bleeding vessel was exposed and ligated. Four patients, one in Group 1 and three in Group 2, who developed wound infections were managed using regular wound care in the outpatient setting. Two patients, one in Group 1 and one in Group 2, with intraabdominal abscess were immediately rehospitalized. In both cases, parenteral antibiotherapy with piperacilline-tazobactam (13.5 g/day, intravenous) was started, and a percutaneous drainage catheter was inserted under sonographic guidance by an interventional radiologist. Three patients in group one presented with paralytic ileus. Of the three, one patient was managed via enema application in the outpatient setting. However, the other two were rehospitalized and received conser-

Table 1. Results of outcome measures

Group 1 (n=50)

Postoperative complications Wound infection Intraabdominal abscess Bleeding Paralytic ileus Purulent peritonitis Length of hospital stay (hours) Readmission Rehospitalization Reoperation Visual analog pain score Postoperative 4th hour At discharge Quality of life score 202

p

Group 2 (n=46)

%

n

Mean±SD

%

n

Mean±SD

2.1 2.1 – 6.5 2.1 – 13 6.5 2.1

1 1 – 3 1 12-192 6 3 1

– – – – – 20.3±14.3 – – –

6 2 – – – – 8 6 –

3 1 – – – 8-120 4 3 –

– – – – – 21.12±18.56 – – –

0.618 0.999 – 0.106 0.479 0.618 0.513 0.999 0.479

– – –

9-9 4-5 8-9

8.78±1.27 4.74±0.8 8.64±0.94

– – –

9-9 5-5 8-9

9±0.54 4.86±0.81 8.64±0.94

0.537 0.327 0.888

Mayıs - May 2013


Comparison of open and laparoscopic appendectomy in uncomplicated appendicitis

vative treatment, including nasogastric decompression and bowel rest. Both patients were discharged on the second day. There were no mortalities in either of the groups.

DISCUSSION Previous studies have consistently found that the overall rate of postoperative complications, including intraabdominal abscess formation, wound infection, and paralytic ileus, is higher in complicated appendicitis, irrespective of the method used for appendectomy.[13] Thus, the major determinant of postoperative complications seems to be related to advanced disease rather than the method of appendectomy in complicated appendicitis. Therefore, the present study focused on cases with uncomplicated appendicitis. Early studies comparing LA and OA reported higher rates of postoperative septic complications in LA.[7-9] However, numerous recent studies comparing LA and OA have reported contradictory results,[8,9] although most of the studies included a heterogeneous group of acute appendicitis cases, including all types of complicated appendicitis. Unfortunately, currently available data comparing LA and OA in uncomplicated appendicitis are limited and originate from either studies specifically focused on uncomplicated appendicitis patients or subgroup analyses from studies of patients with all types of appendicitis. Therefore, only a few studies could be used for comparison of results in the present study.[14-17] The rates of postoperative complications in both groups were similar and were comparable to those of the previous studies. Although shorter length of hospital stay is a wellknown advantage of minimally invasive surgery, in the present study, no hospital stay length advantage was associated with either uncomplicated appendicitis group. Moreover, regardless of the appendectomy technique, early discharge within the first 24 hours after appendectomy for uncomplicated appendicitis does not seem to lead to a significant increase in the rate of postoperative complications when compared to the results of similar studies.[7,9] We found that postoperative pain and quality of life in both groups were similar. This conflicts with two other important advantages of minimally invasive surgery, namely, less postoperative pain and faster return to daily activities. However, it also conflicts with previous studies comparing LA and OA in terms of quality of life in both the short-term and the long-term in which better quality of life has been associated with LA.[18-20] Preference for the laparoscopic approach over the open approach in uncomplicated appendicitis is still justified because of the important role of laparoscopic appendectomy in surgical training and patient preference for minimally invasive surgery. Cilt - Vol. 19 Say覺 - No. 3

In conclusion, the laparoscopic approach to appendectomy in patients with uncomplicated appendicitis does not offer a significant advantage over the open approach, in terms of length of hospital stay, postoperative pain scores, or quality of life, which are considered the major advantages of minimally invasive surgery. However, it should also be noted that concerns about increased postoperative septic complications with the laparoscopic approach in uncomplicated appendicitis seem to be unfounded. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Fingerhut A, Millat B, Borrie F. Laparoscopic versus open appendectomy: time to decide. World J Surg 1999;23:835-45. 2. Semm K. Endoscopic appendectomy. Endoscopy 1983;15:5964. 3. Laine S, Rantala A, Gullichsen R, Ovaska J. Laparoscopic appendectomy-is it worthwhile? A prospective, randomized study in young women. Surg Endosc 1997;11:95-7. 4. Fogli L, Brulatti M, Boschi S, Di Domenico M, Papa V, Patrizi P, et al. Laparoscopic appendectomy for acute and recurrent appendicitis: retrospective analysis of a singlegroup 5-year experience. J Laparoendosc Adv Surg Tech A 2002;12:107-10. 5. Ortega AE, Hunter JG, Peters JH, Swanstrom LL, Schirmer B. A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy. Laparoscopic Appendectomy Study Group. Am J Surg 1995;169:208-13. 6. McCall JL, Sharples K, Jadallah F. Systematic review of randomized controlled trials comparing laparoscopic with open appendicectomy. Br J Surg 1997;84:1045-50. 7. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010;10:CD001546. 8. Asarias JR, Schlussel AT, Cafasso DE, Carlson TL, Kasprenski MC, Washington EN, et al. Incidence of postoperative intraabdominal abscesses in open versus laparoscopic appendectomies. Surg Endosc 2011;25:2678-83. 9. Liu Z, Zhang P, Ma Y, Chen H, Zhou Y, Zhang M, et al. Laparoscopy or not: a meta-analysis of the surgical effects of laparoscopic versus open appendicectomy. Surg Laparosc Endosc Percutan Tech 2010;20:362-70. 10. http://www.atsqol.org/sections/instruments/ko/pages/nott. html. American Thoracic Society. Nottingham Health Profile. 11. Hunt SM, McEwen J, McKenna SP. Measuring health status: a new tool for clinicians and epidemiologists. J R Coll Gen Pract 1985;35:185-8. 12. McEwan J. The Nottingham health profile. In: Walker SJ, Rosser RM, editors. Quality of life assessment: key issues in the 1990s. 2nd ed. New York, NY: Springer; 1993. 13. Gonenc M, Gemici E, Kalayci MU, Karabulut M, Turhan AN, Alis H. Intracorporeal knotting versus metal endoclip application for the closure of the appendiceal stump during laparoscopic appendectomy in uncomplicated appendicitis. J Laparoendosc Adv Surg Tech A 2012;22:231-5. 14. Sahm M, Kube R, Schmidt S, Ritter C, Pross M, Lippert H. Current analysis of endoloops in appendiceal stump closure. Surg Endosc 2011;25:124-9. 203


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15. Amortegui JD, Restrepo H. Knot security in laparoscopic surgery. A comparative study with conventional knots. Surg Endosc 2002;16:1598-602. 16. Beldi G, Vorburger SA, Bruegger LE, Kocher T, Inderbitzin D, Candinas D. Analysis of stapling versus endoloops in appendiceal stump closure. Br J Surg 2006;93:1390-3. 17. Wu HS, Lai HW, Kuo SJ, Lee YT, Chen DR, Chi CW, et al. Competitive edge of laparoscopic appendectomy versus open appendectomy: a subgroup comparison analysis. J Laparoendosc Adv Surg Tech A 2011;21:197-202.

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18. Katkhouda N, Mason RJ, Towfigh S, Gevorgyan A, Essani R. Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg 2005;242:439-50. 19. Kaplan M, Salman B, Yilmaz TU, Oguz M. A quality of life comparison of laparoscopic and open approaches in acute appendicitis: a randomised prospective study. Acta Chir Belg 2009;109:356-63. 20. Kapischke M, Friedrich F, Hedderich J, Schulz T, Caliebe A. Laparoscopic versus open appendectomy-quality of life 7 years after surgery. Langenbecks Arch Surg 2011;396:69-75.

May覺s - May 2013


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):205-214

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.44789

A model of complaint based for overcrowding emergency department: Five-Level Hacettepe Emergency Triage System Aşırı kalabalık aciller için şikayet temelli bir model: Beş-Düzeyli Hacettepe Acil Triyaj Sistemi Doğaç Niyazi ÖZÜÇELİK,1 Mehmet Mahir KUNT,1 Mehmet Ali KARACA,1 Bülent ERBİL,1 Bülent SİVRİ,1 Ahmet ŞAHİN,1 Yeşim ÇETİNKAYA ŞARDAN,1 Mehmet Mahir ÖZMEN,1 Bahar GÜÇİZ DOĞAN2 BACKGROUND

AMAÇ

To compare ESI Five-Level Triage System with 5-Level Hacettepe Emergency Triage System (HETS), which was developed for Overcrowded EDs in our country.

Ülkemizdeki kalabalık aciller için geliştirdiğimiz şikayet temelli 5-düzeyli Hacettepe Acil Triyaj Sistemi’ni (HATS) ESI 5-düzeyli triyaj sistemiyle karşılaştırmaktır.

METHODS

GEREÇ VE YÖNTEM

Over a period of six days, patients were assessed by a different ED staff everyday using HETS, then re-evaluated blindly by an emergency physician using HETS. Then patients were evaluated blindly for a third time by an independent, ESI-using emergency physician.

Altı gün süresince hergün başka bir görevli tarafından HATS ile değerlendirilen hastalar, bir acil tıp uzmanı tarafından HATS ile kör olarak tekrar değerlendirildiler. Her iki değerlendirme kararını bilmeyen ve ESI konusunda uzman olan başka bir acil tıp uzmanı tarafından bağımsız ve kör olarak ESI ile değerlendirildiler.

RESULTS

Of the patients in the study, 133 were men, 175 were women and the average age was 44.41±18.033. Inter-rater agreement was 97.40% (Kappa=0.963) between HETS and HETS-Blind, 74.35% (Kappa=0.646) between HETS and ESI-Blind, 74.67% (Kappa=0.652) between HETSBlind and ESI-Blind. Inter-observer agreement between the second emergency physician performing HETS-Blind and the first emergency physician, resident, or nurse was very good (Kappa=1.0). Intern doctor, non-medical secretary and paramedic were found to have almost very good agreement (Kappa=0.971; 0.935; 0.864, respectively). An overtriage of 7.25% and undertriage of 1.08% were found in HETS. CONCLUSION

Complaint-based HEST developed for overcrowded EDs is a triage system with a very good agreement between observations and observers. low undertriage and overtriage ratios, and easy application by all staff from a non-medical secretary to the emergency physician. Key Words: Complaint-based triage system; emergency medicinedepartment; emergency severity index; Hacettepe emergency triage system; triage. Departments of 1Emergency Medicine, 2Public Health, Hacettepe University, Faculty of Medicine, Ankara, Turkey.

BULGULAR

Araştırmadaki 308 hastanın 133’ü erkek, 175’i kadın ve yaş ortalaması 44,41±18,033 bulundu. HATS ile HATS-Kör karşılaştırıldığında gözlemler arası tutarlılık %97,40 (Kappa=0,963), ESI-Kör ile karşılaştırıldığında gözlemler arası tutarlılık %74,35 (Kappa=0,646) saptandı. HATS-Kör ile ESI-Kör karşılaştırıldığında gözlemler arası tutarlılık %74,67 (Kappa=0,652) saptandı. Birinci acil tıp uzmanı, acil tıp asistanı ve acil hemşiresi ile HATS-Kör uygulayan ikinci acil tıp uzmanı arasındaki tutarlılığın en yüksek olduğu (Kappa=1,0), intern doktor, tıbbi olmayan acil sekreteri ve paramedikin de çok iyi olduğu (sırasıyla, Kappa=0,971; 0,935; 0,864) saptandı. HATS ile değerlendirilen hastalarda %7,25 yanlış yüksek triyaj, %1,08 yanlış düşük triyaj bulundu. SONUÇ

Aşırı kalabalık acil servisler için geliştirilmiş olan şikayet temelli HATS, gözlemler ve gözlemciler arası tutarlığı yüksek, yanlış triyaj oranları düşük, tıbbi olmayan sekreterden acil tıp uzmanına kadar herkesin kolaylıkla uygulayabileceği bir triyaj sistemidir. Anahtar Sözcükler: şikayet temelli triaj sistem; acil servis; acil tıp; acil şiddet indeksi; Hacettepe acil triyaj sistemi; triyaj. Hacettepe Üniversitesi Tıp Fakültesi, 1Acil Tıp Anabilim Dalı, 2 Halk Sağlığı Anabilim Dalı, Ankara.

Correspondence (İletişim): Doğaç Niyazi Özüçelik, M.D. Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, İstanbul, Turkey. Tel: +90 - 212 - 414 71 02 e-mail (e-posta): dogacniyazi@gmail.com

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Overcrowded emergency departments, dedicated to providing a continuous medical service 24 hours per day, 7 days per week, are becoming an ever-increasing problem in developing countries, such as Turkey, in terms of emergency medical services. Different strategies of administration and triage have been developed to notice urgent and critical patients in overcrowded emergency departments and not to cause an increased rate of morbidity and mortality.[1-9] Inappropriate care areas and long durations for care in overcrowded emergency departments cause problems between patients and health care providers.[10-14] Different triage systems (2-Level, 3-Level, 4-Level and 5-Level) have been applied to determine the priority and management of health care for emergent patients in emergency departments.[15-19] A survey carried out in US in 4897 hospitals showed that there is no triage system in 0.7% of emergency departments, a 2-level triage system in 0.3%, a 3-level triage system in 25.2%, a 4-level triage system in 9.6%, a 5-level ESI triage system in 56.9%, another 5-level triage system in 6.3%, and other triage system in 0.1% of emergency departments.[20] It was also shown that the triage level application has changed according to the number of incoming patients; while 5-level ESI triage system applied in 78.3% of crowded emergency departments having more than 100.000 or more annual urgent patients, 3-level triage system has been applied in 60.2% of the emergency departments having less than 1.000 annual urgent patients.[20,21] As suggested in the statement published in 2009 by the Ministry of Health of Turkish Government, the 3-level triage system has been commonly used in Turkey. In 3-level triage system, patients are categorized as emergent (red), urgent (yellow) and non-urgent (green).[22] 5-level triage systems such as Australasian or National Triage Scale (ATS-NTS), Canadian Triage and Acuity Scale (CTAS), Manchester Triage System (MTS), and the Emergency Severity Index (ESI) have been widely used in emergency departments of developed countries in terms of emergency medical services.[23-28] Validity and reliability of 5-level triage system were found to be greater than 3-level systems.[15,29-31] There are various studies about accuracy, reliability and validity of acute patient triage in ATS-NTS, MTS, CTAS and ESI 5-level systems.[21,32-37] ESI 5-level triage system which is widely used and has high value in US has been developed by emergency physicians, Richard Wuerz and David Eitel. In this 206

system, patients are categorized from triage level 1-2 (life-threatening and critical conditions) to triage level 3-5 (diseases according to the necessities for expected sources usage).[38,39] With respect to the characteristics of the hospitals, the triage mission is accomplished by different health care providers such as the emergency physicians, nurses or paramedics in emergency departments. Studies about which of these health workers perform more accurate triage are insufficient.[40-45] Although ESI 5-level triage system has higher reliability and validity, it is unlikely to be routinely applied in the emergency departments of our country since it requires experience and education and, it is difficult to find a triage expert. Evaluation time is long in triage area and violent actions are made by patients who do not tolerate waits in overcrowded emergency departments (1.000 or more patients/day). For overcrowded emergency departments, an emergency triage system is needed that can be applied quickly, does not require any education or experience and is determined based on the priority for care according to the chief complaints, prediagnosis or symptoms of the patients. To address this need, a complaint-based 5-level Hacettepe Emergency Triage System (HETS) has been developed for overcrowded emergency departments in our country. The aim of this study is to compare ESI 5-level triage system which has been tested for its world-wide validity and reliability and HETS 5-level triage system and to test its consistency and validity for emergency triage applications.

MATERIALS AND METHODS This methodological study was carried out with 308 patients in the emergency department of Hacettepe University Faculty of Medicine, which had an annual patient number of approximately 35.000 between 08/08/2008 and 08/15/2008. The study was approved by the Ethical Committee. In the first stage of the study, 5-level triage systems were examined and evaluated. Secondly, patient triage application complaints from the Emergency Department of Medical Faculty of Hacettepe University over a one-year period were collected and evaluated. Third, 120 chief complaints, which were mostly applied reasons, were sorted into 5 triage levels according to the priority of the condition. These complaints were then listed alphabetically according to triage levels determined by the users. If there is a condition with a new complaint not written in algorithm, May覺s - May 2013


A model of complaint based for overcrowding emergency department

Emergency Patients (n=308) 1. Day Triage (n=51)

2. Day Triage (n=52)

3. Day Triage (n=51)

4. Day Triage (n=51)

5. Day Triage (n=51)

6. Day Triage (n=52)

HETS-1 EN

HETS-1 Secretary

HETS-1 Paramedic

HETS-1 ER

HETS-1 3. EP

HETS-1 Intern doctor

HETS-Blind 1. EP

HETS-Blind 1. EP

HETS-Blind 1. EP

HETS-Blind 1. EP

HETS-Blind 1. EP

HETS-Blind 1. EP

ESI-Blind 2. EP

ESI-Blind 2. EP

ESI-Blind 2. EP

ESI-Blind 2. EP

ESI-Blind 2. EP

ESI-Blind 2. EP

Fig. 1. The study diagram of HATS study.

HETS: Hacettepe Emergency Triage System; ESI: Emergency Severity Index; EN: Emergency Nurse; EP: Emergency Physician; ER: Emergency Resident.

‘Ask to Doctor’ is written on the last line of every triage levels of complaint category. “Hacettepe Emergency Triage System (HETS)’’ cards with columns listing the complaint with triage levels of the patients (T1: Critical-Red, T2: EmergentOrange, T3: Urgent-Yellow, T4: Less Urgent-Green, T5: Non Urgent-Blue), evaluation time (T1: 0 minute, T2: 5-15 min, T3: 30-60 min, T4: 1-2 hours, T5: 3-4 hours) and re-evaluation time (T1: Always, T2: In every 15 min, T3: Once in 60 min, T4: Once in 60 min, T5: Once in 120 min) were hung on the triage table. In the fourth stage, patients arriving at the Emergency Department were evaluated between 8:00 and

18:00 over a period of six days by different Emergency Department staff (non-medical emergency secretary, emergency nurse, paramedic, emergency intern doctor-last medical student, emergency resident and emergency physician) according to HETS (recorded as HETS-1) (Figure 1). Patients were also evaluated by an emergency physician who did not know the decision of the first triage staff (the same person over six days) again according to HETS (recorded as HETS-blind). After the patient’s triage levels, care areas and priorities treatment were determined, an emergency physician who did not know the previous two decisions

Table 1. Vitals signs and demographical information of patients in triage Gender Age (Mean.±SD) Min/Max SBP (Mean.±SD) Min/Max DBP (Mean.±SD) Min/Max Puls (Mean.±SD) Min/Max RR (Mean.±SD) Minn/Max PO (Mean.±SD) Min/Max Fever (Mean.±SD) Min/Max

(N=308)

Nurse (n=51)

Secretary (n=52)

Paramedic (n=51)

ER (n=51)

EP (n=51)

Intern (n=52)

Male=133 Male=16 Male=21 Male=21 Male=25 Male=22 Male=27 Female=175 Female=35 Female=31 Female=30 Female=25 Female=29 Female=25 44.41±18.03 44.98±18.20 42.90±19.44 44.00±18.30 46.61±16.22 47.35±18.00 40.67±17.88 16/84 18/78 16/82 17/84 17/83 18/80 20/82 115.5±22.43 119.61±17.34 115.77±19.73 116.86±21.60 116.47±25.83 114.92±28.79 109.62±19.09 0/220 80/155 80/200 80/180 0/180 80/220 60/175 72.6±12.99 75±11.24 75.10±12.81 71.18±11.68 73.53±15.20 70.63±14.18 70.19±12.08 0/110 50/101 50/110 45/90 0/100 50/110 40/100 88.6±16.62 90.9± 16.21 88.52±16.81 85.53±15.17 87.96±20.78 89.51±15.79 89.19±14.61 0/162 60/145 56/140 58/130 0/162 55/137 56/132 17.3±3.27 19.59±3.10 17.73±1.75 17.04±1.87 17.18±4.20 16.71±4.53 15.54±1.40 0/36 16/34 15/24 14/22 0/28 12/36 14/20 96.2±6.37 95.57±4.83 96.60±2.80 96.61±1.88 95.37±13.69 96.22±3.92 96.81±3.08 0/99 75/99 80/99 87/99 0/99 75/99 77/99 36.49±21.16 36.55±0.61 36.55±0.63 36.76±0.61 35.88±5.16 36.51±0.14 36.66±0.60 0/39.6 35.8/38.9 35.8/39.6 35.9/39.6 0/38.9 35.8/38.1 35.7/38.8

SD: Standart deviation; Min: Minimum; Max: Maximum; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; RR: Respiratory rate; PO: Pulse oximetry.

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Table 2. Comparison between HETS-1, HETS-Blind and ESI-Blind in all patients Triage system

HETS-1 T1 T2 T3 T4 T5 n

HETS-Blind T1 T2 T3

T4 T5

24 1 – – – 1 44 – – – – 3 136 – – – – 2 82 – – – – 1 14 25 48 138 83 14 Kappa=0.963 Agreement=97.40%

ESI-Blind n

T1 T2

25 45 139 84 15 308

1 – – – – 1

T3

T4

T5

22 25 6 1 – 54

2 – – 19 1 – 127 6 – 4 65 14 – 4 11 152 76 25 Kappa=0.646 Agreement=74.35%

n 25 45 139 84 15 308

HETS: Hacettepe Emergency Triage System; ESI: Emergency Severity Index.

and specialized in ESI independently and blindly reevaluated the patients (the same person over six days).

T5 sensitivity was 44% and specificity was 98.58% (Table 2).

Triage and demographical information of patients evaluated as HETS-1, HETS-blind and independent ESI were statistically analyzed with SPSS program for Windows. Inter- and intra-observer agreement was calculated by Kappa statistics.

When 308 patients were evaluated by the first emergency physician according to HETS (HETS-blind) and re-evaluated blindly by second emergency physician according to ESI , agreement between triage decisions was 74.67% in all triage levels (Kappa=0.652).

RESULTS Of the patients in the study, 133 were men, 175 were women and the average age was 44.41±18.33 years old (median=44, minimum=16, maximum=84). The numbers and vitals of patients in the study were found to be randomly close to each other (Table 1).

According to triage levels, T1 sensitivity was 100% and specificity was 92.18%; T2 sensitivity was 51.85% and specificity was 93.30%; T3 sensitivity was 83.55% and specificity was 92.94%; T4 sensitivity was 84.21% and specificity was 91.81%; and T5 sensitivity was 40% and specificity was 98.58% (Table 3).

When 308 patients were evaluated by six different emergency department staff with HETS-1 and reevaluated blindly by the first emergency physician according to HETS (HETS-blind) , agreement between triage decisions was 97.40% in all triage levels (Kappa=0.963).

When 51 patients were evaluated by the emergency nurse according to HETS (HETS-1) and re-evaluated blindly by the first emergency physician according to HETS on the first day, agreement between triage decisions was 100% in all triage levels (Kappa=1.0). When these same patients were re-evaluated blindly

According to triage levels, T1 sensitivity was 96% and specificity was 99.64%; T2 sensitivity was 91.66% and specificity was 99.61%; T3 sensitivity was 98.55% and specificity was 98.23%; T4 sensitivity was 98.79% and specificity was 99.11%; and T5 sensitivity was 100% and specificity was 99.65% (Table 2). When 308 patients were evaluated by six different emergency department staff with HETS-1 and reevaluated blindly by the second emergency physician according to ESI, agreement between triage decisions was 74.35% in all triage levels (Kappa=0.646). According to triage levels, T1 sensitivity was 100% and specificity was 92.18%; T2 sensitivity was 46.29% and specificity was 92.12%; T3 sensitivity was 83.55% and specificity was 92.30%; T4 sensitivity was 85.52% and specificity was 91.81%; and 208

Table 3. Comparison between HETS-1 and ESI-Blind in all patients Triage system

HETS-Blind T1 T2 T3 T4 T5 n

ESI-Blind T1

T2

1 – – – – 1

21 28 4 1 – 54

T3

T4

T5

3 – – 19 1 – 127 7 – 3 64 15 – 4 10 152 76 25 Kappa=0.652 Agreement=74.67%

n 25 45 138 83 14 308

HETS: Hacettepe Emergency Triage System; ESI: Emergency Severity Index.

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by the second emergency physician according to ESI on the second day, agreement between triage decisions was 78.43% in all triage levels. The evaluations by the first emergency physician according to HETS (HETSblind) and the second emergency physician according to ESI on the first day, had 78.43% agreement between triage decisions in all triage levels (Table 4). When 52 patients were evaluated by the non-medical emergency secretary according to HETS (HETS-1) and re-evaluated blindly by the first emergency physician according to HETS on the second day, agreement between triage decisions was 96.15% in all triage levels (Kappa=0.935). When these same patients were reevaluated blindly by the second emergency physician according to ESI on the second day, agreement between triage decisions was 82.69% in all triage levels. The evaluations by the first emergency physician according to HETS (HETS-blind) and the second emergency

physician according to ESI had 86.53% agreement between triage decisions in all triage levels (Table 5). When 51 patients were evaluated by the paramedic according to HETS (HETS-1) and re-evaluated blindly by the first emergency physician according to HETS on the third day, agreement between triage decisions was 90.19% in all triage levels (Kappa=0.864). When these same patients were re-evaluated blindly by the second emergency physician according to HETS on the third day, agreement between triage decisions was 66.66% in all triage levels. The evaluations by the first emergency physician according to HETS (HETSblind) and the second emergency physician according to ESI had 66.66% agreement between triage decisions in all triage levels (Table 6). When 51 patients were evaluated by the emergency resident according to HETS (HETS-1) and re-evaluated blindly by the first emergency physician according

Table 4. Comparison between HETS-Blind and ESI-Blind in patients evaluated by the emergency nurse Nurse triage

HETS-1 T1 T2 T3 T4 T5 n

HETS-Blind T1 T2 T3

T4 T5

7 – – – – – 7 – – – – – 25 – – – – – 10 – – – – – 2 7 7 25 10 2 Kappa=1.000 Agreement=100%

ESI-Blind n 7 7 25 10 2 51

T1 T2

T3

T4

T5

n

– – – – – –

7 – – – 7 6 1 – – 7 – 24 1 – 25 – – 8 2 10 – – – 2 2 13 25 9 4 51 Kappa could not calculated because of T1 column is empty Agrrement=78.43%

HETS: Hacettepe Emergency Triage System; ESI: Emergency Severity Index.

Table 5. Comparison between HETS-Blind and ESI-Blind in patients evaluated by the non-medical secretary Sekretary triage

HETS-1 T1 T2 T3 T4 T5 n

HETS-Blind T1 T2 T3

T4 T5

ESI-Blind n

2 1 – – – 3 – 3 – – – 3 – 1 30 – – 31 – – – 12 – 12 – – – – 3 3 2 5 30 12 3 52 Kappa=0.935 Agreement=96.15%

T1 T2

T3

T4

T5

n

– – – – – –

3 – – – 3 2 1 – – 3 1 29 1 – 31 – – 10 2 12 – – 1 2 3 6 30 12 4 52 Kappa could not calculated because of T1 column is empty Agreement=82.69%

HETS: Hacettepe Emergency Triage System; ESI: Emergency Severity Index.

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Table 6. Comparison between HETS-Blind and ESI-Blind in patients evaluated by the paramedic Paramedic triage

HETS-1 T1 T2 T3 T4 T5 n

HETS-Blind T1 T2 T3

T4 T5

3 – – – – 1 9 – – – – 2 17 – – – – 1 15 – – – – 1 2 4 11 18 16 2 Kappa=0.864 Agreement=90.19%

ESI-Blind n 3 10 19 16 3 51

T1 T2

T3

T4

T5

n

– – – – – –

3 – – – 3 4 6 – – 10 3 15 1 – 19 – 2 13 1 16 – – 1 2 3 10 23 15 3 51 Kappa could not calculated because of T1 column is empty Agreement=66.66%

HETS: Hacettepe Emergency Triage System; ESI: Emergency Severity Index.

Table 7. Comparison between HETS-Blind and ESI-Blind in patients evaluated by the emergency resident Resident triage

HETS-1 T1 T2 T3 T4 T5 n

HETS-Blind T1 T2 T3

T4 T5

4 – – – – – 6 – – – – – 20 – – – – – 16 – – – – – 5 4 6 20 16 5 Kappa=1.000 Agreement=100%

ESI-Blind n 4 6 20 16 5 51

T1 T2 1 – – – – 1

T5

n

– – – 1 1 – 20 – – – 12 4 – 1 4 21 14 8 Kappa=0.727 Agreement=80.39%

4 6 20 16 5 51

3 4 – – – 7

T3

T4

HETS: Hacettepe Emergency Triage System; ESI: Emergency Severity Index.

to HETS on the fourth day, agreement between triage decisions was 100% in all triage levels (Kappa=1.0). When these same patients were re-evaluated blindly by the second emergency physician according to ESI on the fourth day, agreement between triage decisions was 80.39% in all triage levels (Kappa=0.727). The evaluations by the first emergency physician according to HETS (HETS-blind) and the second emergency physician according to ESI had 80.39% agreement between triage in all triage levels (Kappa=0.727) (Table 7). When 51 patients were evaluated by the third emergency physician according to HETS (HETS-1) and reevaluated blindly by the first emergency physician according to HETS on the fifth day, agreement between triage decisions was determined as 100% in all triage levels (Kappa=1.0). When these same patients were re-evaluated blindly by the second emergency physician according to ESI on the fifth day, agreement between triage decisions was determined as 68.62% in all triage levels. The evaluations by the first emer210

gency physician according to HETS (HETS-blind) and the second emergency physician according to ESI had 68.62% agreement between triage decisions in all triage levels (Table 8). When 52 patients were evaluated by intern doctor according to HETS (HETS-1) and re-evaluated blindly by the first emergency physician according to HETS on the sixth day, agreement between triage decisions was determined as 98.07% in all triage levels (Kappa=0.971). When these same patients were re-evaluated blindly by the second Emergency Physician according to ESI on the sixth day, agreement between triage decisions was determined as 78.84% in all triage levels. The evaluations by the first emergency physician according to HETS (HETS-blind) and the second emergency physician according to ESI had 76.92% agreement between triage decisions in all triage levels (Table 9). Of all 308 patients evaluated by six different emergency triage staff as HETS-1, HETS-blind and ESIMayıs - May 2013


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Table 8. Comparison between HETS-Blind and ESI-Blind in patients evaluated by the emergency physician Physician triage

HETS-1 T1 T2 T3 T4 T5 n

HETS-Blind T1 T2 T3

T4 T5

3 – – – – – 14 – – – – – 19 – – – – – 15 – – – – – – 3 14 19 15 – Kappa=1.000 Agreement=100%

ESI-Blind n 3 14 19 15 – 51

T1 T2

T3

T4

T5

n

– – – – – -

2 1 – – 3 6 8 – – 14 – 16 3 – 19 – – 13 2 15 – – – – – 8 25 16 2 51 Kappa could not calculated because of T1 column is empty Agreement=68.62%

HETS: Hacettepe Emergency Triage System; ESI: Emergency Severity Index.

Table 9. Comparison between HETS-Blind and ESI-Blind in patients evaluated by the intern doctor Intern

HETS-1 T1 T2 T3 T4 T5 n

HETS-Blind T1 T2 T3

T4 T5

5 – – – – – 5 – – – – – 25 – – – – 1 14 – – – – – 2 5 5 26 14 2 Kappa=0.971 Agreement=98.07%

ESI-Blind n 5 5 25 15 2 52

T1 T2

T3

T4

T5

n

– – – – – –

4 1 – – 5 3 2 – – 5 – 25 – – 25 – 1 11 3 15 – – – 2 2 7 29 11 5 52 Kappa could not calculated because of T1 column is empty Agreement=78.84%

HETS: Hacettepe Emergency Triage System; ESI: Emergency Severity Index.

blind over six days, a total of 77 (8.33%) showed an inconsistency with respect to their triage levels. While HETS triage level in 12.98% of all patients was lower than the ESI triage level (incorrect undertriage), HETS triage level in 87.02% of all patients was higher than ESI triage level (incorrect overtriage). Of the undertriaged, four patients were categorized in HETS T3 instead of ESI T2; three were HAT T4 instead of ESI T3; and three were HETS T5 instead of ESI T4. The greatest inconsistency at 31.16% was shown in Triage 1. Twenty-two patients evaluated as Triage 1 according to HETS were evaluated as Triage 2 according to ESI.

DISCUSSION Due to the problems that arise from overcrowded emergency departments, different emergency triage systems and solutions have been tested around the world, including in Turkey.[1-12] Cilt - Vol. 19 Sayı - No. 3

Five-level triage systems have been commonly used in emergency departments of countries where emergency medical services have been developed.[23-28] In the United States, ESI has emerged as a new triage system in which education and experience are needed; it is the most widely used and is the most valuable of emergency triage systems.[38,39] There are different studies about the accuracy, reliability and validity of 5-level triage systems for the acute patient triage.[21,32-37] In an observational study including 486 patients by Worster et al.,[36] there was no statistical difference between ESI and CTAS triage systems. In a study including 900 patients conducted by eight educated triage nurses, in which Storm-Versloot et al.[33] used MTS and ESI without using a triage algorithm, it was reported that ESI had a lower triage score than MTS (11% to 20%). In this study, all three systems were found to have a low sensitivity. In a theoretical scenario study by Storm-Versloot et 211


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al.,[46] including comparison of MTS and ESI systems, inter-observer Kappa was found as 0.76 for MTS, 0.46 for ESI; intra-observation Kappa was found as 0.84 for MTS and as 0.65 for ESI. In a study by Burstr繹m et al.,[43] a comparison between triages of physicians and nurses between 8:00 and 21:00 was made; the team led by the physician had a greater advantage than the others in terms of activity and quality indications. In a study by Chi et al.,[47] including 3171 patients and comparing Taiwan Triage System (TTS) and ESI, ESI was found to be more accurate than TTS in terms of determining acute patients. When patients determined at 1-level Triage by TTS were evaluated by ESI, their ESI levels were found as ESI 1 in 21.1% of patients, as ESI 2 in 68.1%, as ESI 3 in 7.4%, as ESI 4 in 3.4% and as ESI 5 in 0%. When patients determined at 3-level Triage by TTS were evaluated by ESI, their ESI levels were found as ESI 1 in 0.1% of them, as ESI 2 in 26.2%, as ESI 3 in 39.5%, as ESI 4 in 27.5% and as ESI 5 in 6.8%.[47] In a study by Durand et al.,[41] including evaluations of decisions distinguishing patients between urgent and not urgent by doctors and nurses in France, there was a high level of agreement between the two groups in terms of cranial injury, gynecologic and toxicologic indications while there was a low level of agreement between the two groups in terms of urinary system and hospitalization. Doctors had higher sensitivity (94% to 43.1%) and specificity (89.5% to 30.9%) than nurses in terms of hospitalization of urgent and non-urgent patients.[41] In a study by Kahveci et al.,[45] comparing emergency residents and paramedics, there was agreement between two groups in 47% of 3-level triage decisions (Kappa=0.47) and 45% of 5-level ATS triage decisions (Kappa=0.45). Kahveci et al.[45] emphasized that there has to be a new and simple triage scale that can be easily applied by uneducated personnel in all emergency services. In a reliability study by Tanabe et al.,[32] including retroactive examination of triage records in terms of the triage accuracy of nurses who have taken ESI education, a better consistency between nurses was found (Kappa=0.89). In a study by Buschhorn et al.[48] examining the reliability of ESI among EMS personnel, the level of agreement between EMS personnel and emergency triage nurses was found to be medium (Kappa=0.409). In a randomized controlled study by Worster et al.,[37] comparing 5-level ESI and CTAS triage, there was no difference between triage nurses applying ESI and CTAS (Kappa=0.91, Kappa=0.89). In our study, HETS was found to have high level 212

of agreement when applied by different observers and compared to a different triage system. In our study, when all patients evaluated by emergency department staff using HETS were re-evaluated blindly using HETS, there was a 97.40% agreement between observations (Kappa value was 0.963). When they were re-evaluated blindly using ESI, there was 74.35% agreement between observations (Kappa value was 0.646). When all patients evaluated by the first emergency physician according to HETS were re-evaluated blindly by the second emergency physician according to ESI, there was 74.67% agreement between observations (Kappa was 0.652). When analyzing the agreement between observers in application of HETS in our study, a very good agreement was detected between the first emergency physician, emergency resident, emergency nurse and the second emergency physician applying HETSBlind (Kappa=1.0); a very good agreement was also detected between intern doctor, non-medical emergency secretary and paramedic (Kappa levels were 0.971, 0.935 and 0.864, respectively). Our study showed that the best emergency triage could be applied by emergency physician, emergency resident and emergency nurse who were serving on the subject of emergency medical diseases; a developed and simplified triage system suitable for countries and hospitals according to their patient profiles could be correctly applied even by a non-medical secretary. The biggest problem in evaluation of emergency triage is to evaluate life-threatening critical or emergent patients as less urgent or non-urgent patients. These incorrectly undertriaged patients could be kept waiting in incorrect areas of emergency departments for a long time; thus the mortality and morbidity ratios could be increased. Another problem is to evaluate less urgent or nonurgent patients as emergent or urgent patients. These incorrectly overtriaged patients could unnecessarily occupy emergency departments and emergency department staff and could cause the real urgent patients to be overlooked. In some of the studies, incorrect overtriage ratios were reported as between 16-62% and incorrect undertriage ratio was reported as 16-61%.[49-51] In our study, incorrect overtriage ratio was found as 7.25% and incorrect undertriage ratio was found as 1.08% in evaluation of all patients. There were no life-threatening cases in the patients with incorrect undertriage ratio. The difference in T1 triage evaluations between HETS and ESI caused the incorrect overtriage of 22 patients. While life-threatMay覺s - May 2013


A model of complaint based for overcrowding emergency department

ening cases such as arrest appeared in Triage 1 category of ESI, all unstable patients appeared in Triage 1 category of HETS. Complaint-based 5-level Hacettepe Emergency Triage System developed for overcrowded emergency departments is a triage system which has “a very good agreement” between observations and observers, low undertriage and overtriage ratios, and easy application by all staff from the non-medical secretary to the emergency physician. Conflict-of-interest issues regarding the authorship or article: None declared.

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33. Storm-Versloot MN, Ubbink DT, Kappelhof J, Luitse JS. Comparison of an informally structured triage system, the emergency severity index, and the manchester triage system to distinguish patient priority in the emergency department. Acad Emerg Med 2011;18:822-9. 34. Beveridge R, Ducharme J, Janes L, Beaulieu S, Walter S. Reliability of the Canadian emergency department triage and acuity scale: interrater agreement. Ann Emerg Med 1999;34:155-9. 35. Jelinek GA, Little M. Inter-rater reliability of the National Triage Scale of 11,500 simulated occasions of triage. Emerg Med 1996;8:226-30. 36. Worster A, Fernandes CM, Eva K, Upadhye S. Predictive validity comparison of two five-level triage acuity scales. Eur J Emerg Med 2007;14:188-92. 37. Worster A, Gilboy N, Fernandes CM, Eitel D, Eva K, Geisler R, et al. Assessment of inter-observer reliability of two fivelevel triage and acuity scales: a randomized controlled trial. CJEM 2004;6:240-5. 38. Gilboy N, Travers D, Wuerz R. Re-evaluating triage in the new millennium: A comprehensive look at the need for standardization and quality. J Emerg Nurs 1999;25:468-73. 39. Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N. Reliability and validity of a new five-level triage instrument. Acad Emerg Med 2000;7:236-42. 40. Choi YF, Wong TW, Lau CC. Triage rapid initial assessment by doctor (TRIAD) improves waiting time and processing time of the emergency department. Emerg Med J 2006;23:262-5. 41. Durand AC, Gentile S, Gerbeaux P, Alazia M, Kiegel P, Luigi S, et al. Be careful with triage in emergency departments: interobserver agreement on 1,578 patients in France. BMC Emerg Med 2011;11:19. 42. Johansen MB, Forberg JL. Nurses’ evaluation of a new for-

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malized triage system in the emergency department - a qualitative study. Dan Med Bull 2011;58:A4311. 43. Burström L, Nordberg M, Ornung G, Castrén M, Wiklund T, Engström ML, et al. Physician-led team triage based on lean principles may be superior for efficiency and quality? A comparison of three emergency departments with different triage models. Scand J Trauma Resusc Emerg Med 2012;20:57. 44. Rowe BH, Villa-Roel C, Guo X, Bullard MJ, Ospina M, Vandermeer B, et al. The role of triage nurse ordering on mitigating overcrowding in emergency departments: a systematic review. Acad Emerg Med 2011;18:1349-57. 45. Kahveci FO, Demircan A, Keles A, Bildik F, Aygencel SG. Efficacy of triage by paramedics: a real-time comparison study. J Emerg Nurs 2012;38:344-9. 46. Storm-Versloot MN, Ubbink DT, Chin a Choi V, Luitse JS. Observer agreement of the Manchester Triage System and the Emergency Severity Index: a simulation study. Emerg Med J 2009;26:556-60. 47. Chi CH, Huang CM. Comparison of the Emergency Severity Index (ESI) and the Taiwan Triage System in predicting resource utilization. J Formos Med Assoc 2006;105:617-25. 48. Buschhorn HM, Strout TD, Sholl JM, Baumann MR. Emergency Medical Services Triage Using the Emergency Severity Index: Is it Reliable and Valid? J Emerg Nurs 2012 Jan 12. 49. Pointer JE, Levitt MA, Young JC, Promes SB, Messana BJ, Adèr ME. Can paramedics using guidelines accurately triage patients? Ann Emerg Med 2001;38:268-77. 50. Asplin BR. Undertriage, overtriage, or no triage? In search of the unnecessary emergency department visit. Ann Emerg Med 2001;38:282-5. 51. Boyle MJ. Is mechanism of injury alone in the prehospital setting a predictor of major trauma - a review of the literature. J Trauma Manag Outcomes 2007;1:4.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):215-218

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.92256

2-octyl-cyanoacrylate glue for fixation of STSG in genitourinary tissue defects due to Fournier gangrene: a preliminary trial Fournier gangrenine bağlı genitoüriner doku defektlerinde STSG fiksasyonu için 2-oktil-siyanoakrilat doku yapıştırıcının kullanımı: Bir ön çalışma Nazan SİVRİOĞLU, Saime İRKÖREN, Ender CEYLAN, Ali Murat SONEL, Eray COPÇU

BACKGROUND

AMAÇ

In these reported cases, we observed the outcomes of skin take and wound healing using 2-octyl-cyanoacrylate glue, which was used as tissue glue in the reconstruction of complex genital skin loss due to fournier gangrene.

Fournier gangrenine bağlı kompleks genital doku kayıplarının rekonstrüksiyonda 2-oktil-siyanoakrilat doku yapıştırıcısı kullanarak doku iyileşmesi ve greft tutması ile ilgili klinik sonuçlarımız ve gözlemlerimizi sunmayı amaçladık.

METHODS

GEREÇ VE YÖNTEM

Fifteen patients with Fournier’s gangrene were treated in this study. After initial surgical debridement, all defects were repaired using STSG. In this method a thin layer of 2-octylcyanoacrylate was dripped on the recipient site immediately before graft application. All wounds were followed up postoperatively and observed for evidence of graft take, seroma or hematoma formation, drainage, and infection. Patient and physician satisfaction were also determined. RESULTS

Grafts were completely accepted in all fifteen patients. None of the patients had wound infection, seroma, hematoma, or other complications. CONCLUSION

Bu çalışmada Fornier gangreni olan 15 hasta tedavi edildi. Cerrahi debridmanın ardından oluşan tüm defektler STSG kullanılarak tamir edildi. Greft uygulanmadan önce ince bir tabaka halinde 2-oktil-siyanoakrilat alıcı sahaya damlatıldı. Ameliyat sonrası dönemde tüm yaralar, greft tutması, enfeksiyon gelişimi, hemetom, seroma oluşumu ve drenaj açısından gözlemlendi. Aynı zamanda hasta ve doktor memnuniyeti belirlendi. BULGULAR

Tüm hastalarda uygulanan greftler tamamen kabul edildi. Hiçbir hastada enfeksiyon, seroma veya diğer ameliyat sonrası komplikasyonlar izlenmedi. SONUÇ

Use of 2-octyl-cyanoacrylate glue (Glueseal) for STSG fixation in complex genital skin defects after Fournier gangrene may be an acceptable alternative to conventional surgical closure with a good cosmetic outcome. Further studies are needed to confirm our initial success with this approach.

Fournier gangreninden sonra oluşan kompleks genital cilt kayıplarında uygulanan STSG’nin fiksasyonu için 2-oktilsiyanoakrilat (Glueseal) doku yapışrıcısının kullanımı iyi kozmetik sonuçları ile birlikte konvansiyonel cerrahi kapama prosedürlerine alternatif olabilir. Bu yöntem, bizim başlangıç başarılarımızın doğrulanması için ileri çalışmalarla desteklenmelidir.

Key Words: Cyanoacrylate; Fournier gangrene; skin graft.

Anahtar Sözcükler: Siyanoakrilat; Fournier gangreni; deri grefti.

Department of Plastic Surgery, Adnan Menderes University Faculty of Medicine, Aydin, Turkey.

Adnan Menderes Üniversitesi Tıp Fakültesi, Plastik Cerrahi Anabilim Dalı, Aydın.

Correspondence (İletişim): Saime İrkören, M.D. Adnan Menderes Üniversitesi Tıp Fakültesi, Plastik Cerrahi Anabilim Dalı, Aydın, Turkey. Tel: +90 - 256 - 218 18 00 e-mail (e-posta): saimeirkoren@hotmail.com

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Fournier first described cases of rapidly progressing fulminating genital gangrene in 1883. Fournier’s gangrene is a synergistic infection of the genitals and perineum that is produced by a combination of aerobic and anaerobic organisms. Along with broad spectrum antibiotics, treatment comprises aggressive surgical debridement that frequently leads to extensive loss of scrotal skin. The resultant tissue defects often need complex reconstruction including flaps or grafts. [1-3] The aim of the reconstructive procedures after the initial debridement is to attain good coverage of the defects and suitable cosmetic results. Cyanoacrylate tissue glue is an organic polymer that can close simple lacerations in humans and animals efficiently, and acts in a bacteriostatic fashion against Gram-positive microorganisms.[4,5] It results in more reliable wound healing of contaminated lacerations than conventional suture material.[4,6,7] This adhesive has now been used for skin graft fixation in multiple areas.

tion of complex genital skin loss due to fournier gangrene.

MATERIALS AND METHODS Between January 2009 and November 2011, fifteen patients with a diagnosis of Fournier’s gangrene were admitted to our clinic. These patients were referred to our Division of Plastic and Reconstructive Surgery for reconstruction of defects to the scrotum and/or perineum. All patients underwent antibiotic treatment and emergency surgical debridement performed by urologists or plastic surgeons. Fifteen patients participated in this trial; the patients’ ages ranged from 42 to 74 years (mean 52.6 years). Of the patients, 7 had hypertension, 10 had Diabetes (type 2) and 12 were cigarette smokers.

We conducted this study in order to report the outcomes of graft take and wound healing in this first reported series in which 2-octyl-cyanoacrylate glue (Glueseal) was used as tissue glue in the reconstruc-

Broad-spectrum antibiotics were prescribed for each patient, and these were changed to specific antibiotics after a specific organism was isolated from the wound culture. Local wound care was performed after debridement, and repeated surgical debridement was performed in the case of residual necrotic skin or soft tissue (Fig. 1a-c). Local wound care was performed

(a)

(b)

(c) 216

Fig. 1. (a) Preoperative view of 55-year-old man with scrotal and penile defect resulting from Fournier’s gangrene after debridement (underlying cause was unknown). (b) Patient from Fig. 1a with an intraoperative view after applying cyanoacrylate and skin graft. (c) Preoperative view of a diabetic 63-year-old man with scrotal defect resulting from Fournier’s gangrene debridement (cause was a scrotal abscess). (Color figures can be viewed in the online issue, which is avail able at www.tjtes.org).

Mayıs - May 2013


2-octyl-cyanoacrylate glue for fixation of STSG in genitourinary tissue defects due to Fournier gangrene

(a)

(b)

(c)

Fig. 2. (a) Early postoperative view of the patient from Fig. 1c after removal of xeroform gauze. (b) Postoperative view of the patient from Fig. 1c on the 17th day. (c) Postoperative 3 month view of the patient from Fig. 1c. (Color figures can be viewed in the online issue, which is available at www.tjtes.org).

using a wet-gauze dressing with saline-diluted iodine in fifteen patients. The wet-gauze dressing was applied and changed two to four times per day. Prior to grafting the testicles and cords were evaluated for tissue viability. The testis and spermatic cord were prepared for grafting by tangentially excising redundant granulation tissue. A thin layer of the cyanoacrylate glue was injected or sprayed evenly on the wound bed before graft placement. Finally, a 2:1 meshed skin (12/1000 in. thickness) was applied on the denuded testicles and cords and was fixed in place. A few interrupted quilting sutures and staples were used as needed to further secure the graft to the underlying tissue. Direct manual pressure was applied over the graft for 1 to 2 minutes to ensure good apposition (Fig. 1b). Grafts were covered with Xeroform gauze and then with fluff gauze for additional immobilization. The dressings were left intact for 3 to 5 days, and then daily changes were performed with Xeroform gauze until a physician deemed them unnecessary. All grafts were followed up closely for evidence of graft take and the presence or absence of hematoma, seroma, infection, or wound breakdown.

RESULTS In all cases, the cyanoacrylate glue allowed time for meticulous graft positioning. The excellent tissue adherence decreased the need for time-consuming quilting sutures. The grafts healed extremely well, with 100% graft take in all patients (Fig. 2a-c). No patients developed infection, hematoma, or seroma formation. Both the patients and physicians satisfaction were remarkable. The hospital stay varied between 7-12 days (mean=9 days). Cilt - Vol. 19 SayÄą - No. 3

DISCUSSION Fournierâ&#x20AC;&#x2122;s gangrene mostly occurs in patients with advanced age, diabetes, alcoholism and other preexisting medical problems. These may intensify their operative risk, predominantly for longer or multiple procedures.[1-3] The ideal method of coverage should be technically easy to accomplish and of lower cost. There are few reports in the medical literature in which tissue adhesives are used for skin graft fixation. Craven and Telfer reported good results for full-thickness skin graft fixation with N-butyl-2-cyanoacrylate (NBCA) compared to sutures in patients after Mohs surgery. [8,9] In the literature, and to the best of our knowledge, there are no studies using cyanoacrylate adhesive for split-thickness skin grafts in fournier gangrene. The proper fixation of skin grafts is important to prevent graft mobilization and, therefore, impaired revascularization and graft survival.[1,3,8] Cyanoacrylates have been studied in various animal models to evaluate their successfulness in the treatment of contaminated surgical incisions, excisional wounds and unclean burn wounds. Also, cyanoacrylates have a very important advantage because of lower infection rates compared to traditional suture techniques in contaminated wound models. The existing studies have shown that cyanoacrylates act like a barrier against microbial penetration and serve as an optimal wound dressing, while providing a moist environment to enhance wound healing.[4] Recent in vitro studies have shown that 2-octylcyanoacrylate is effective as an antimicrobial barrier for the first 72 h after application. The skin shaped by 2-octylcyanoacrylate is effective against Gram-positive and Gram-negative 217


Ulus Travma Acil Cerrahi Derg

bacteria, together with mobile and non-mobile species, such as S. epidermidis, S. aureus, Escherichia coli, Pseudomonas aeruginosa and Enterococcus faecium.[4-6,8,10] Suture material can act as a foreign body and trigger an infection during conventional wound closure, while cyanoacrylate tissue adhesives do not donate to foreign bodies that act as a reservoir for microorganisms. Therefore, it offers closure and protection with the advantage of better postoperative wound management and reduces costs. The skin adhesiveness forms a protective layer for the wound assisting a faster epithelization. We reported for the first time the use of absorbable cyanoacrylate graft sealant in fournier gangrene. Our impression; in terms of both graft survival and length of hospitalization; is that tissue adhesive is as good as the method using skin staples and sutures for skin graft fixation in patients with fournier gangrene. There are several potential advantages of cyanoacrylate surgical sealant over other conventional suturing techniques. First, cyanoacrylates were demonstrated to be good sealants even on wet surfaces with bacteriostatic and bactericidal effects in the previous studies.[4-13] Second, since cyanoacrylate closes the wound mechanically, bleeding is reduced and its effect is independent of the patient’s hemostatic function. This may be of particular importance for diabetic patients with atherosclerotic or fragile vessels. Third, owing to the capabilities of room temperatures storage and short preparation time, its application is easy and convenient. Fourth, skin staples and sutures, especially in large areas, are painful and time-consuming to remove. Fifth, the use of cyanoacrylate decreases the incidence of hematoma formation so as to achieve a higher graft survival rate. Sixth, the challenges posed by the complex contours of the male genitalia were overcome by the excellent adherence promoted by the cyanoacrylate adhesive. The graft may not be effective when applying it on an uneven or concave wound surface. The use of tissue adhesive overcomes these problems.[4-13] Last, for the directed usage, the cost of cyanoacrylate sealant is lower than most other sealants and conventional suture methods. In this preliminary study, it was stored at room temperature and was rapidly prepared in the applicator device for quick availability and use by the surgeon. The safety of this material in this study seemed tolerable with no adverse events linked to the use of the agent. Based on this initial data, a larger trial is now in progress to further evaluate safety and effectiveness.

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In conclusion, this case demonstrated the potential benefits of cyanoacrylate sealant applied for skin graft fixation to patients with fournier gangrene. Although further studies are required to identify patients who benefit most from its use, it seems to be reasonable to use cyanoacrylate sealant in fournier gangrene where there is a high risk of bleeding, infection and graft lysis complications. A long-term evaluation of this agent will still need to be done to be sure that it harbors no long-term risk to patients. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Maguiña P, Palmieri TL, Greenhalgh DG. Split thickness skin grafting for recreation of the scrotum following Fournier’s gangrene. Burns 2003;29:857-62. 2. Ozturk E, Ozguc H, Yilmazlar T. The use of vacuum assisted closure therapy in the management of Fournier’s gangrene. Am J Surg 2009;197:660-5. 3. Chen SY, Fu JP, Chen TM, Chen SG. Reconstruction of scrotal and perineal defects in Fournier’s gangrene. J Plast Reconstr Aesthet Surg 2011;64:528-34. 4. Losi P, Burchielli S, Spiller D, Finotti V, Kull S, Briganti E, Soldani G. Cyanoacrylate surgical glue as an alternative to suture threads for mesh fixation in hernia repair. J Surg Res 2010;163:e53-8. 5. Ellman PI, Brett Reece T, Maxey TS, Tache-Leon C, Taylor JL, Spinosa DJ, et al. Evaluation of an absorbable cyanoacrylate adhesive as a suture line sealant. J Surg Res 2005;125:161-7. 6. Costa HJ, Pereira CS, Costa MP, Fabri FS, Lancellotti CL, Dolci JE. Experimental comparative study in rabbits of three different ways of cartilage graft fixation: suture, gelatin-resorcin-formaldehyde and butyl-2-cyanoacrylate. Acta Otolaryngol 2007;127:947-51. 7. Saba D, Yilmaz M, Yavuz H, Noyan S, Avci B, Ercan A, et al. Sutureless vascular anastomoses by N-butyl-2 cyanoacrylate adhesive: an experimental animal study. Eur Surg Res 2007;39:239-44. 8. Adler N, Nachumovsky S, Meshulam-Derazon S, Ad-El D. Skin graft fixation with cyanoacrylate tissue adhesive in burn patients. Burns 2007;33:803. 9. Sageshima J, Ciancio G, Uchida K, Romano A, Acun Z, Chen L, et al. Absorbable cyanoacrylate surgical sealant in kidney transplantation. Transplant Proc 2011;43:2584-6. 10. Karatepe O, Ozturk A, Koculu S, Cagatay A, Kamali G, Aksoy M. To what extent is cyanoacrylate useful to prevent early wound infections in hernia surgery? Hernia 2008;12:603-7. 11. Taravella MJ, Chang CD. 2-Octyl cyanoacrylate medical adhesive in treatment of a corneal perforation. Cornea 2001;20:220-1. 12. Aksoy M, Turnadere E, Ayalp K, Kayabali M, Ertugrul B, Bilgic L. Cyanoacrylate for wound closure in prosthetic vascular graft surgery to prevent infections through contamination. Surg Today 2006;36:52-6. 13. Hallock GG. Expanded applications for octyl-2-cyanoacrylate as a tissue adhesive. Ann Plast Surg 2001;46:185-9.

Mayıs - May 2013


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):219-222

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.74050

Soccer ball related posterior segment closed-globe injuries in outdoor amateur players Amatör oyuncularda futbol topu ile oluşan arka segment kapalı göz yaralanmaları Gökçen GÖKÇE,1 Osman Melih CEYLAN,2 Fazil Cüneyt ERDURMAN,2 Ali Hakan DURUKAN,2 Güngör SOBACI2 BACKGROUND

AMAÇ

The aim of this study is to report the characteristics, treatment, and anatomical and functional outcomes of outdoor amateur soccer players with soccer ball-related posterior segment ocular trauma.

Çalışmamızın amacı amatör oyuncularda futbol topu ile oluşan arka segment kapalı göz yaralanmalarının anatomik ve fonksiyonel sonuçlarını ve uygulanan tedavileri incelemektir.

METHODS

2004-2008 yılları arasında futbol oynarken kapalı göz yaralanması geçiren 22 hastanın kayıtları geriye dönük olarak incelendi. Yaralanmalar okuler travma sınıflamasına göre değerlendirildi.

We conducted a retrospective chart review of 22 patients with diagnoses of closed-globe ocular trauma caused by soccer play activity from 2004 through 2008. Injuries were classified according to Ocular Trauma Classification. RESULTS

GEREÇ VE YÖNTEM

BULGULAR

All patients (n=22) were male, and all injuries were caused by contact with the soccer ball itself. Sixteen (72%) patients did not require any treatment. Surgery was performed on 5 (22%) patients. Twenty (91%) patients had 5/200 or better visual acuity (VA) at presentation and 2 (9%) had hand movements or worse VA. At the final visit, all patients had 5/200 or better VA (p<0.01).

Yirmi iki hastanın tümü erkekti ve yaralanmaların tümü futbol topu çarpmasına bağlıydı. On altı (%72) hastaya herhangi bir tedavi uygulanmadı. Beş (%22) hastaya cerrahi tedavi uygulandı. Yirmi (%91) hastanın başvuru anındaki görme keskinliği 5/200 ve üzerindeyken iki (%9) hastanın ise el hareketi ve altındaydı. Son kontrol muayenesinde 22 hastanın tümünde 5/200 ve üzeri görme keskinlik düzeyi elde edildi (p<0,01).

CONCLUSION

SONUÇ

A soccer ball can cause significant posterior segment trauma, and using eye protection equipment might be an appropriate solution.

Futbol topu ciddi arka segment travmasına neden olabilmektedir ve koruyucu ekipman kullanımı uygun bir çözüm olabilir.

Key Words: Closed-globe trauma; contusion; protection; soccer.

Anahtar Sözcükler: Kapalı göz travması; kontüzyon; koruma; futbol.

Soccer is the most popular sport in the world and it is the leading cause of sport related ocular trauma.[1] Soccer-related ocular injury is an important worldwide eye health problem because of the use of the unpro-

tected head for controlling the ball. Injury can result from contact of the head with another head, ground, or the kicked ball.

Presented at the 8th Congress of SEEOS meeting (May 19-22, 2011, Istanbul, Turkey).

8. SEEOS Kongresi'nde sunulmuştur (19-22 Mayıs 2011, İstanbul).

Department of Ophthalmology, Sarikamis Military Hospital, Kars; Department of Ophthalmology Gulhane Military Medical Faculty, Ankara, Turkey.

1

2

The aim of this study is to report the characteris-

1 Sarıkamış Asker Hastanesi, Göz Hastalıkları Kliniği, Kars; Gülhane Askeri Tıp Akademisi, Göz Hastalıkları Anabilim Dalı, Ankara.

2

Correspondence (İletişim): Gökçen Gökçe, M.D. Sarıkamış Asker Hastanesi, Göz Hastalıkları Servisi, 36200 Ankara, Turkey. Tel: +90 - 312 - 304 58 55 e-mail (e-posta): drgokcengokce@gmail.com

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Ulus Travma Acil Cerrahi Derg

tics, treatments, and anatomical and functional outcomes of outdoor amateur soccer players with soccer ball-related posterior segment (zone 3) ocular trauma.

MATERIALS AND METHODS This study was performed under an institutional ethics review board-approved protocol. We conducted a retrospective chart review of 22 patients admitted to the Department of Ophthalmology at the Gulhane Military Medical Academy (Ankara, Turkey) with diagnoses of closed-globe ocular trauma caused by a soccer ball from 2004 through 2008. All patients injured in soccer play underwent an initial evaluation. All interventions were performed at our department. Injuries resulting from head to head, head to upper or lower extremity, or head to ground or other surfaces were not included in the study. Patients with only ocular adnexal damage or minor ocular injuries such as corneal abrasions or corneal/conjunctival/scleral foreign bodies and patients with concomitant non-ocular injuries were not included in the study. Ocular injuries were classified according to the criteria of the Ocular Trauma Classification Group (OTG) including: type of injury (only zone 3 injuries were included in this study, but additional zone 1 and 2injuries were also recorded), visual acuity (VA) at initial examination, the presence of relative afferent pupillary defect (RAPD), and zone of injury.[2] The initial and final VA were categorized using the OTG grading system. Grade 1 was better than 20/40. Grade 2 was 20/50 to 20/100. Grade 3 was 19/100 to 5/200. Grade 4 was 4/200 to light perception. Grade 5 was no light perception. Final visual outcome was defined as poor if visual acuity was <5/200. The pars plana vitrectomy (PPV) procedure was performed using standard 20-gauge three-port pars plana technique. A non-contact fundus observation system (EIBOS; Möller-Wedel GmbH, Wedel, Germany) was used for wide-angle viewing. In the presence of lens damage, PPV was combined with Lens aspiration. One thousand centistokes (cs) silicone oil was used for internal tamponade. Silicone oil was chosen based on the surgeon’s preferences and the patient’s retinal conditions. Statistical analysis was performed using SPSS 15.0 for Windows (SPSS, Chicago, IL, USA). McNemar’s tests were used to analyze before vs. after comparisons. Statistical significance was set at p<0.05.

RESULTS Patients (n=22) ranged in age from 13 to 32 years (mean age 21.8±4.0 years) and were all male. All injuries were contusions caused by contact with a soccer ball. Mean follow up time was 12.6±7.7 (2-30) months. On initial ophthalmic examination, hyphema 220

existed in 8 (36%) patients, and commotio retinae was present in 8 (36%). Macular edema was found in 5 (22%) patients. One (4%) subject presented with choroid rupture. Retinal detachment (with retinal tears) was found in 5 (22%) patients. Retinal tears without detachment were found in 1 patient (4%). Traumatic lens injury was observed in 4 (18%) patients, one of which had lens subluxation. Vitreous hemorrhage was present in 11 (50%) subjects. RAPD was documented in only 1 (4%) patient. Sixteen (72%) patients did not require any treatment. Surgery (including lens aspiration, buckle, vitrectomy, or their combination) was performed in 5 (22%) patients. Twenty (91%) patients had 5/200 or better VA at presentation, and 2 (9%) had hand movements or worse VA. At the final visit, all 22 patients had 5/200 or better VA (p<0.01). Postoperative PVR was observed in 2 patients that underwent vitreoretinal surgery. No postoperative vitreoretinal complication requiring additional vitreoretinal surgery was noted in any of the eyes that underwent PPV. Silicone oil was left as a permanent tamponade in an eye with severe PVR in case of subsequent hypotony and phthisis. Demographic features of the patients and interventions are listed in Table 1.

DISCUSSION Closed-globe ocular trauma is a common result of sports-related injury. Although the integrity of the eye wall remains intact, contusion type trauma may cause serious posterior segment damage.[3] Because of the popularity of soccer all over the world, serious eye injuries might be encountered any time. According to Larrison, hyphema was the most frequent symptom after soccer-related eye injury.[4] Our study excluded isolated zone 1 and 2 contusion injuries. Vitreous hemorrhage was the posterior segment injury found in the highest percentage in our study (50%). Firm attachments of the vitreoretinal base in young population probably are responsible for these haemorrhages. The soccer ball is different from the other sports balls: orbital penetration is lower, but the time in the orbit is longer.[5] So the characteristics of eye trauma caused by a soccer ball is different from other traumas and may be associated with severe ocular morbidity and visual impairment. Studies revealed that soccer ball penetration is not significantly related to the size of the ball.[5] The impact-related energy causing ball molding to facial contours is more associated with penetration. The energy correlates with velocity. In a study, professional players kicked the ball at a mean velocity of 26.2 m/s (58.6 mph) while amateurs kicked the ball at a mean velocity of 18.5 m/s (41.4 mph). They both produced significant energy.[6] According to Reed, the energy from the kicked ball is not enough to cause retinal haemorrhage.[7] In contrast to this study, eight players (36%) had retinal haemorrhages in our Mayıs - May 2013


Soccer ball related posterior segment closed-globe injuries in outdoor amateur players

Table 1. Demographic features, ocular examinations of the patients and interventions No Age

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

21 27 30 23 19 21 26 45 20 21 13 21 21 17 21 21 20 21 21 20 23 21

Eye Right Left Left Right Left Right Right Right Left Left Left Right Left Right Right Right Right Left Left Right Right Left

Ocular presentation

Treatment

Follow up (m)

Initial Final VA VA

Final examination complication

I+VH VH+RT LI+Co RD H+VH Co H+VH+RH+Co H+VH H+Co H+VH+RT+RD LI+RD LI+LS+Co RH+ME+Co RH+ME+RD H+VH+Co H+RH+Co H+VH+RD VH+CR+RH+ME VH+RH I+ME LI+RH+ME VH+RH

No LPC No PPV+Buckle No No No No No Buckle L.Asp+PPV+Silicone oil No (patient refused) No PPV+Gas No No PPV+Gas+Buckle No No No No No

6 9 12 24 8 2 18 6 3 20 26 12 14 22 6 8 30 13 9 8 17 6

1 1 1 2 2 1 3 1 1 1 4 2 2 2 1 1 4 2 1 2 2 1

I (small) No Ca No No No MS No No No PVR Ca+LS No No No No PVR CR No I+MS Ca No

1 1 1 2 1 1 3 1 1 1 3 2 1 2 1 1 2 2 1 2 2 1

VA: Visual acuity; Ca: Cataract; Co: Commosio retina; H: Hyphema; I: Iridodialysis; VH: Vitreous hemorrhage; RH: Retinal hemorrhage; RD: Retinal detachment; RT: Retinal tear; ME: Macular edema; MS: Macular scar; No: No abnormality; CR: Choroid rupture; LS: Lens subluxation; PPV: Pars plana vitrectomy; LI: Lens injury, L.Asp: Lens aspiration; LPC: Laser photocoagulation; PVR: Proliferative vitreoretinopathy; m: Months.

study. Furthermore, we found that when the kicked ball hits the head and deforms significantly to fit facial contours, the energy is directly transmitted to the retina, resulting in tears. Retinal breaks are the most frequent diagnosis in follow up period.[8] In most cases (80%) retinal tears caused by soccer balls were associated with retinal detachment in our study, which may reveal that much more energy transmits to the retina than estimated. Although the injury is caused by inferotemporal contact with the ball in most cases (the frontal bone and nose usually make a protection from the impact coming from other directions[9]), it is essential to examine all the quadrants of peripheral retina. Retinal detachment was the main indication for vitreoretinal surgery in three patients in our study. The development of PVR was the most frequent reason for poor visual outcome in patients with retinal detachment and was responsible for surgical failure. A sudden anteroposterior compression and the expansion of the eyeball perpendicular to the direction of impact has been proposed as the major cause of the contusion injuries.[5] In all patients with ocular contusion, careful peripheral retinal examination with scleral depression should be performed irrespective of the presence Cilt - Vol. 19 Say覺 - No. 3

of damage to the anterior segment. Otherwise, retinal breaks may remain unnoticed for years until the development of retinal detachment.[3] However, in cases with vitreous hemorrhage from ocular trauma, this examination may not be possible and retinal damage may not be accurately and completely diagnosed. In such cases, B-mode ultrasonography is helpful for the assessment of the posterior segment.[10] Choroidal rupture is a common finding in smaller ball traumas (paint ball, tennis, golf) rather than soccer-related ones and it was an unusual finding in our study. It was temporally located near macula, and resulted in poor visual outcome. This finding may reveal that orbital penetration secondary to soccer ball is deeper than estimated. Some limitations in this study should be noted including its retrospective design. Additionally only males participated in our study. Gender differences that may be present within these injuries could not be analyzed. In our country, soccer is not popular among women, so this is the main source of this limitation. Another limitation of the study was the relatively short follow-up period; patients who underwent observation 221


Ulus Travma Acil Cerrahi Derg

without treatment could not be evaluated in terms of long-term complications. In our study we have identified that soccer can cause significant posterior segment trauma and using eye protection equipment according to ASTM standard F803 might be an appropriate solution for this important and frequent ophthalmologic problem. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Filipe JA, Barros H, Castro-Correia J. Sports-related ocular injuries. A three-year follow-up study. Ophthalmology 1997;104:313-8. 2. 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. 3. Erdurman CF, Ceylan MO, Acikel CH, Durukan HA, Mum-

222

cuoglu T. Outcomes of vitreoretinal surgery in patients with closed-globe injury. Eur J Ophthalmol 2011;21:296-302. 4. Larrison WI, Hersh PS, Kunzweiler T, Shingleton BJ. Sportsrelated ocular trauma. Ophthalmology 1990;97:1265-9. 5. Capão Filipe JA. Soccer (football) ocular injuries: an important eye health problem. Br J Ophthalmol 2004;88:159-60. 6. Vinger PF, Capão Filipe JA. The mechanism and prevention of soccer eye injuries. Br J Ophthalmol 2004;88:167-8. 7. Reed WF, Feldman KW, Weiss AH, Tencer AF. Does soccer ball heading cause retinal bleeding? Arch Pediatr Adolesc Med 2002;156:337-40. 8. Capão Filipe JA, Rocha-Sousa A, Falcão-Reis F, CastroCorreia J. Modern sports eye injuries. Br J Ophthalmol 2003;87:1336-9. 9. Kent JS, Eidsness RB, Colleaux KM, Romanchuk KG. Indoor soccer-related eye injuries: should eye protection be mandatory? Can J Ophthalmol 2007;42:605-8. 10. Erdurman FC, Sobaci G, Acikel CH, Ceylan MO, Durukan AH, Hurmeric V. Anatomical and functional outcomes in contusion injuries of posterior segment. Eye (Lond) 2011;25:1050-6.

Mayıs - May 2013


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):223-228

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.47542

The management of mesenteric vein thrombosis: a single institution’s experience Mezenter ven trombozuna yaklaşım: Tek merkez deneyimi Fatih YANAR, Orhan AĞCAOĞLU, Ali Fuat Kaan GÖK, İnanç Şamil SARICI, Beyza ÖZÇINAR, Nihat AKSAKAL, Murat AKSOY, Enver ÖZKURT, Mehmet KURTOĞLU BACKGROUND

AMAÇ

Mesenteric vein thrombosis occurs rarely and is responsible for approximately 5-15% of all cases of acute mesenteric ischemia. The aim of this report was to discuss the management of mesenteric vein thrombosis based on our experience with 34 patients.

Mezenter ven trombozu, akut mezenter iskemi olgularının yaklaşık %5-15’inden sorumlu olan ve nadir görülen bir durumdur. Bu çalışmanın amacı, 34 hastalık tecrübemizi paylaşmak ve mezenter ven trombozuna yaklaşımı tartışmaktır.

METHODS

Ocak 2007 ve Ocak 2010 tarihleri arasında acil cerrahi servisimize mezenter iskemi tanısı ile başvuran 34 hasta geriye dönük olarak incelendi. Peritonit bulgusu mevcut olan hastalara, başvurularında tanısal laparokopi uygulandı. Ameliyatın bitirilmesine yakın, karın sol alt kadrana 10 mm laparoskopi trokarı yerleştirildi. Anastomoz yapılan olgularda ameliyat sonrası ilk 72 saatlik dönemde laparoskopik ikincil bakı yapıldı. Tüm hastalar günde iki kez subkutan 100 mg/ kg enoksaparin uygulandı. Ven rekanalizasyonu değerlendirilmesi amacıyla tüm hastalara, 6. ve 12. aylarda bilgisayarlı tomografi (BT) anjiyografi görüntüleme yapıldı.

In the present study, 34 patients who were admitted to our emergency surgery department between January 2007 and January 2010 with a diagnosis of acute mesenteric vein thrombosis were assessed retrospectively. Patients with peritoneal signs first underwent diagnostic laparoscopy to rule out perforation or bowel gangrene. We performed a second-look laparoscopy within 72 hours of the first operation. All patients were administered 100 mg/kg of the anticoagulant enoxaparin twice daily. In the 6th and 12th months of follow up, CT angiography was performed to evaluate recanalization of the veins. RESULTS

CT angiography revealed superior mesenteric vein thrombosis in 25 (73%) patients, portal vein thrombosis in 24 (70%) patients, and splenic vein thrombosis in 12 (35%) patients. Eleven patients with peritoneal signs underwent diagnostic laparoscopy; eight of the patients underwent small bowel resection, anastomosis, and trocar insertion. During second-look laparoscopy, small bowel ischemia was found in two patients and re-resection was performed. CONCLUSION

GEREÇ VE YÖNTEM

BULGULAR

Bilgisayarlı tomografi anjiyografi ile 25 (%73) hastada superiyor mezenterik ven trombozu, 24 (%70) hastada portal ven trombozu ve 12 (%35) hastada splenik ven trombozu saptandı. Peritonit bulgusu olan 11 hastaya tanısal laparoskopi yapıldı. Bu hastaların 8 tanesine ince bağırsak rezeksiyonu ve anastomozu yapılarak ikincil bakı için trokar yerleştirildi. İkincil bakı yapılan hastalardan 2 tanesinde ince bağırsak iskemisi saptanarak re-rezeksiyon gerçekleştirildi. SONUÇ

Early diagnosis with CT angiography, surgical and nonsurgical blood flow restoration, proper anticoagulation, and supportive intensive care are the cornerstones of successful treatment of mesenteric vein thrombosis.

Mezenterik ven trombozunun tedavisinde BT anjiyografi ile erken tanı, cerrahi ya da cerrahi dışı yöntemlerle kan akımının sağlanması, uygun antikoagülan kullanımı ve yoğun bakım destek tedavileri, hastalığın başarılı bir şekilde yönetilmesinde hayati rol oynamaktadırlar.

Key Words: Algorithm; antithrombotic therapy; mesenter vein; thrombosis.

Anahtar Sözcükler: Algoritma; antitrombotik tedavi; mezenter ven; tromboz.

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

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

Correspondence (İletişim): Fatih Yanar, M.D. İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, 34280 Çapa, İstanbul, Turkey. Tel: +90 - 212 - 414 20 00 e-mail (e-posta): yanar_fatih@yahoo.com

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Acute mesenteric vein thrombosis (MVT) causes 5-15% of acute mesenteric ischemia cases.[1,2] Clinical signs of MVT are usually non-specific.[3] The most common presenting symptom is abdominal pain.[1] Of MVT cases, 25-55% are primary MVT cases, and recent reports have suggested that the incidence of primary MVT is declining. The incidence decline has been largely attributed to the progression and incorporation of hypercoagulability screening into daily practice, as well as, an increase in malignancy incidence. Both are crucial co-morbidities which are highly associated with MVT, and both should be sought for by managing MVT.[4,5] The most common causes of MVT are prothrombotic states, due to heritable or acquired disorders of coagulation or to cancer, intraabdominal inflammatory conditions, the postoperative state, cirrhosis, and portal hypertension.[1] Oral contraceptive use accounts for 9 to 18 percent of mesenteric venous thrombosis episodes in young women.[6,7] Due to recent advances in computed tomography (CT) technology and the introduction of CT angiography, early diagnosis of MVT has become possible. Furthermore, the administration of subsequent anticoagulation has resulted in lower surgical intervention rates.[8,9] No consensus exists regarding optimal treatment for MVT; some authors favor aggressive surgical interventions, while others prefer a more conservative approach.[10,11] Currently, no absolute consensus on or guide algorithm for treatment of MVT exists. In this report, we present our recent experience with acute MVT and discuss our treatment algorithm.

MATERIALS AND METHODS Thirty-four patients who presented to our emergency surgery department with acute abdomen and were diagnosed with acute MVT were assessed retrospectively. Presentation, diagnosis, diagnostic modality, and treatment protocols were assessed for each patient. Patient records were analyzed for age, gender, presenting symptoms, diagnostic modalities, thrombus location, treatment, surgical intervention, hospital stay, etiology, and follow-up. Patients presenting with acute abdomen suggesting mesenteric ischemia were evaluated with CT angiography after hemodynamic stabilization. Thrombosis of the superior or inferior mesenteric veins (SMV or IMV), the portal vein (PV), or the splenic vein (SV) was diagnosed as MVT (Figure 1). Patients with peritoneal signs and unstable hemodynamic parameters underwent initial exploration via diagnostic laparoscopy. If necrosis was found, a laparotomy with bowel resection was performed. Surgical options were limited to bowel resection and/ or second-look laparoscopy and, in one patient, thirdlook laparoscopy. 224

Fig. 1. Mesenteric vein thrombosis.

All patients were treated with enoxaparin, a low molecular weight heparin (LMWH) (100 mg/kg, twice daily), after diagnosis with MVT, until an oral anticoagulant (warfarin) could be administered, if indicated. Once a second surgical intervention seemed unlikely to be necessary, oral anticoagulation therapy was started with the aim of maintaining an international normalized ratio (INR) between 2.0 and 3.0. Anticoagulation treatment was continued throughout each patientâ&#x20AC;&#x2122;s life, and patients were followed up every three months. Patients were assessed for etiology; those without risk factors were classified as having primary MVT, while those with at least one risk factor were classified as having secondary MVT. Thrombophilia screening was performed for all patients with indications. All patients were diagnosed with CT angiography. To assess if the thrombosis cranes to the branches of the portal vein, additional mesenteric venous duplex US, including of the portal vein, was performed in eight patients.

RESULTS The study included 24 males (70%) and 10 females (30%) with a median age of 45 years (range 18-76 years). There were 19 patients (55%) with primary MVT and 15 patients (45%) with secondary MVT (Table 1). In seven patients, thrombophilia screening was positive, and six out of the seven had combined protein C/S deficiency. Twelve patients presented with abdominal pain only; 18 patients presented abdominal pain, as well as, nausea, vomiting, and distension. Three patients presented with gastrointestinal bleedTable 1. Secondary mesenteric vein thrombosis Etiology

n

%

A. Primary MVT B. Secondary MVT Prothrombotic factors Combined Protein C/S deficiency (2 patients with additional AT-III deficiency) Factor V Leiden mutation Cirrhosis / Portal Hypertension Necrotizing Pancreatitis Malignancy (gallbladder cancer, prostate cancer) Deep vein thrombosis

19 15 7 6

55 45

1 4 1 2 1

MayÄąs - May 2013


The management of mesenteric vein thrombosis

ing alone, and one patient presented with deep venous thrombosis (DVT). The median time elapsed until reference was three days (range 1-20). Computed tomography angiography was performed on all patients. Additional mesenteric venous duplex US, including the portal vein, was performed on eight patients, and there were no cases of thrombosis in the intrahepatic branches of the portal vein. The most common thrombus localizations were the superior mesenteric vein (25 patients) and the portal vein (24 patients). In three patients, an inferior vena cava thrombus was ascertained together with thromboses in the other three veins (Table 2). All patients received subcutaneous enoxaparin (100 mg/kg, twice daily) immediately following diagnosis with MVT. Serial abdominal exams were performed, Table 2. Computed tomography angiography findings Thrombus location

Superior mesenteric vein SMV SMV + PV SMV + PV + SV SMV + PV + SV + IVC Portal vein PV PV + SMV PV + SV PV + SMV + SV PV + SMV + SV + IVC Splenic vein SV SV + PV SV + SMV + PV SV + SMV + PV + IVC Inferior vena cava IVC + SMV + PV + SV

Patients n

%

25 11 8 3 3 24 6 8 4 3 3 12 2 4 3 3 3 3

73

70

35

8

SMV: Superior or inferior mesenteric; PV: Portal vein; SV: Splenic vein; IVC: Inferior vena cava.

Table 3. Treatment results Treatments

Medical treatment Surgical treatment Diagnostic laparoscopy Second look Third look Diagnostic laparoscopy+small bowel resection Second look Cilt - Vol. 19 Say覺 - No. 3

Patients n

%

23 11 3 2 1 8 2

68 32 9 6 3 24 6

Fig. 2. Laparotomy images of mesenteric vein thrombosis. (Color figur can be viewed in the online issue, which is avail able at www.tjtes.org).

and leukocyte counts and CRP levels were assessed. The absence of peritoneal signs excluded surgical intervention, and 23 patients (68%) were placed on oral anticoagulation (warfarin, 5 mg daily) therapy aimed at maintaining an INR between 2.0 and 3.0 (Table 3). After adequate INR levels were reached, administration of subcutaneous enoxaparin was stopped. Patients were then discharged and received follow up every three months, as well as, life-long oral anticoagulation. Eleven patients (32%) with peritoneal signs underwent surgical intervention. Diagnostic laparoscopy was performed initially to assess bowel viability, and bowel necrosis or perforation necessitated laparotomy. Eight of the patients underwent small bowel resection (Figure 2); in two patients, a port was left in-situ for second-look laparoscopy to assess the progression of low-flow state, bowel edema, and ecchymosis. Second-look laparoscopy was performed 24 hours after the resection, and resolutions to suspicious findings were noted for these patients. In three patients diagnostic laparoscopy was performed without a need for subsequent resection; two patients required secondlook laparoscopy, and one of the two required thirdlook laparoscopy (after 48 hours) which revealed resolution of ischemia on suspicious bowel segments (Table 3). Mortality occurred in three patients (8%), all of whom had been treated surgically. In two patients, subtotal bowel resection with anastomosis was performed, and in one patient, laparotomy revealed total small bowel, stomach, and colon ischemia, which was considered inoperable. One patient succumbed due to sepsis, one patient due to associated mesenteric arterial and celiac arterial thrombosis, and the remaining patient due to pulmonary failure. There were no late mortalities related to MVT, although two patients died because of malignancy. The mean hospital stay length was 13 days (range: 7-39 days). The mean follow-up period after discharge from the hospital was 24 months. In the 6th and 12th months of follow up, CT angiography was performed to determine recanalization of the veins. Of the patients, 26 (76%) had total recanalization and 8 225


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Table 4. Patients with partial or no recanalization in the 6th month and the 12th month Diagnosis Cirrhosis/Portal HT Malignancy Prothrombotic (protein C/S deficiency) Primary

Patients (n)

6th month

12th month

3 2 1 2

Partial No Partial Partial

Partial (n=2) Total (n=1) (Exitus) (n=2) Total (n=1) Partial (n=1) Total (n=1)

patients (24%) had partial or no recanalization in the 6th month. Within the latter group, three patients were diagnosed with cirrhosis/portal hypertension, two with malignancy, two with primary MVT, and one with combined protein C/S deficiency. In the 12th month of follow up, two patients died because of malignancy. Of the remaining six patients (18%), three patients (9%; one with cirrhosis/portal hypertension, one with primary MVT, and one with protein C/S deficiency) showed total recanalization and three (9%; two with cirrhosis/portal hypertension and one with primary MVT) showed partial recanalization (Table 4). Small bowel syndrome occurred in one patient (3%) who underwent bowel resection of 200 cm.

cer is present in 22% of cases and hepatic cirrhosis is present in 17%.[12,16]

DISCUSSION Mesenteric venous thrombosis was first described by Warren and Eberhardt in 1935.[2] Up until then, it had been a challenge to determine the underlying causes of MVT. To successfully diagnose MVT, physicians must first be aware of MVT and consider it in differential diagnosis. Because the onset of clinic is slower than arterial occlusions of mesenteric vessels, early diagnosis differs mortality and morbidity much more salutary. MVT presentation can be acute, subacute, or chronic.[1] Acute thrombosis is associated with a bowel infarction in one-third of patients. [12] The primary aim of treatment must be to avoid the pathological process that leads to necrosis, and early diagnosis is required to avoid transmural gangrene, perforation, and peritonitis.[13]

ACUTE ABDOMEN SUGGESTING MESENTERIC ISCHEMIA (Hemodynamic stabilization, hydration, correction of acidosis, treatment of sepsis)

Following advances in radiologic imaging, as well as, increasing awareness of mesenteric venous thrombosis, early detection and medical treatment obviating surgical intervention became feasible. MVT diagnosis via ultrasound is often limited by overlying bowel gas. CT and MRI scans should be considered the primary diagnostic techniques for patients who may have MVT.[14] Venous phase CT angiography is the most accurate imaging modality (sensitivity 90%) for diagnosing mesenteric venous thrombosis.[15] The causes of MVT in young patients are generally thrombophilia and the use of oral contraceptives, whereas, in elderly patients, malignancies must be ruled out. Moreover, autopsy studies have determined that abdominal can226

Anticoagulant therapy for venous thromboembolism was first demonstrated by Barritt and Jordan in 1960.[17] Their randomized study reported that if patients do not receive anticoagulant therapy, approximately 25% experience fatal recurrences and another 25% experience non-fatal recurrences.[17] Some studies have suggested that anticoagulant therapy increases venous recanalization up to 80%.[6,18] In the early phases of MVT, immediate administration of heparin, even intraoperatively, clearly increases survival and

CT-ANGIOGRAPHY Acute Mesenteric Vein Thrombosis (Early anticoagulation with LMVVH) Peritoneal signs (+) Diagnostik laparoscopy orlaparotomy

Peritoneal signs (–) Follow-up & Life-long oral anticoagulation with vitamin K antagonists

Ischemia (+) Ischemia (?) Ischemia (–) Laparotomy Resection

Laparotomy

Watchful waiting with close abdominal examination

Regresion of peritoneal signs No regresion or progresion

Second-look laparoscopy (24. hour)

Ischemia (+) Ischemia (?) Ischemia (–) (Continuing suspicion)

Third-look laparoscopy (48. hour)

Fig. 3. Diagnosis and treatment algorithm for mesenteric vein thrombosis. Mayıs - May 2013


The management of mesenteric vein thrombosis

significantly decreases the risk of recurrence.[19] In our series, total recanalization rates were 76% within six months of follow-up and 85% (91% if we exclude deaths caused by malignancies) within 12 months of follow-up. In a systematic review of management of acute non-cirrhotic and non-malignant portal vein thrombosis by Hall et al.,[20] 29 articles with 315 patients were included, and treatments and outcomes were analyzed. They described the treatment modalities as conservative management, anticoagulation, and thrombolysis and thrombectomy. They concluded that early anticoagulation with subcutaneous LMWH or intravenous heparin is important. They also determined that at least six months of oral anticoagulation is effective in reducing long-term morbidity and mortality in cases of portal vein thrombosis occurring concurrently with SMV or SV.[20] Correspondingly, in cases with prothrombotic risk factors, long-term or life-long anticoagulant treatment could be considered, as stated in recent published consensus statements.[7,20,21] After diagnosis with MVT, anticoagulation should be started promptly with the administration of enoxaparin 100 mg/kg twice daily. The reported overall mortality rate of 50% in the literature is mainly attributed to difficulties in diagnosis and subsequent delay of necessary therapeutic intervention.[15,22] The first step in treatment is hemodynamic stabilization accompanied by hydration, correction of acidosis, and treatment of sepsis using broad spectrum antibiotics (Figure 3). During the acute phase, serial abdominal exams are necessary to detect peritoneal signs. If there are no peritoneal signs and conservative treatment resolved, oral anticoagulation therapy (warfarin 5 mg daily), aimed at maintaining an INR of 2.0-3.0, must be started immediately. Peritoneal signs should be evaluated via laparoscopy, and appropriate intervention should be undertaken.[13] The optimal duration of anticoagulation therapy is still obscure. Some authors suggest six months of anticoagulation[13] and some recommend life-long anticoagulation.[7,21] If a bowel resection is mandatory, the aim must be conserving as much bowel segments as possible. However, if vascularization is suspected, ostomy or a port for secondlook laparoscopy 24 hours later are indicated.[23,24] The aim of second-look and third-look laparoscopy is to conserve as much bowel segment as possible. Mesenteric vein thrombosis has a high rate of recurrence, and recurrences are most common within 30 days after presentation.[25] We recommend lifelong anticoagulation through serious problems related with MVT. A non-operative approach to anticoagulation can be successful in more than 90% of patients. [26] In some studies, thrombolysis and endovascular treatments were attempted in patients diagnosed with Cilt - Vol. 19 Say覺 - No. 3

MVT and clinical success was reported.[27-32] However, there have been no randomized control trials to provide more certain evidence of the effectiveness of these procedures. Overall mortality due to MVT is approximately 50%.[15,22] whereas, in our series the mortality rate was 8% (three patients). One patient had total small bowel, stomach, and colon ischemia, which was considered inoperable, and died at postoperative day 3. One patient succumbed from sepsis due to intestinal perforation causing severe intraabdominal contamination. The third patient, who had previous history of pulmonary problems, died due to pulmonary failure after spending 10 days in the intensive care unit. In conclusion, early diagnosis of MVT, urgent treatment, selective surgical intervention, and proper anticoagulation are the cornerstones of successful treatment, resulting in lower morbidity and mortality. Although we present our clinical experience and treatment algorithm which resulted in successful outcomes, more studies with large series and systematic reviews are needed to clarify the management of MVT. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Kumar S, Sarr MG, Kamath PS. Mesenteric venous thrombosis. N Engl J Med 2001;345:1683-8. 2. Warren S, Eberhardt TP. Mesenteric venous thrombosis. Surg Gynecol Obstet 1935; 61:102-20. 3. Rhee RY, Gloviczki P. Mesenteric venous thrombosis. Surg Clin North Am 1997;77:327-38. 4. Bergenfeldt M, Svensson PJ, Borgstr繹m A. Mesenteric vein thrombosis due to factor V Leiden gene mutation. Br J Surg 1999;86:1059-62. 5. Morasch MD, Ebaugh JL, Chiou AC, Matsumura JS, Pearce WH, Yao JS. Mesenteric venous thrombosis: a changing clinical entity. J Vasc Surg 2001;34:680-4. 6. Amitrano L, Guardascione MA, Scaglione M, Pezzullo L, Sangiuliano N, Armellino MF, et al. Prognostic factors in noncirrhotic patients with splanchnic vein thromboses. Am J Gastroenterol 2007;102:2464-70. 7. Sarin SK, Sollano JD, Chawla YK, Amarapurkar D, Hamid S, Hashizume M, et al. Consensus on extra-hepatic portal vein obstruction. Liver Int 2006;26:512-9. 8. Hassan HA, Raufman JP. Mesenteric venous thrombosis. South Med J 1999;92:558-62. 9. Chen MC, Brown MC, Willson RA, Nicholls S, Surawicz CM. Mesenteric vein thrombosis. Four cases and review of the literature. Dig Dis 1996;14:382-9. 10. Klempnauer J, Grothues F, Bektas H, Pichlmayr R. Results of portal thrombectomy and splanchnic thrombolysis for the surgical management of acute mesentericoportal thrombosis. Br J Surg 1997;84:129-32. 11. Boley SJ, Kaleya RN, Brandt LJ. Mesenteric venous thrombosis. Surg Clin North Am 1992;72:183-201. 12. Acosta S, Alhadad A, Svensson P, Ekberg O. Epidemiology, risk and prognostic factors in mesenteric venous thrombosis. Br J Surg 2008;95:1245-51. 227


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13. Bergqvist D, Svensson PJ. Treatment of mesenteric vein thrombosis. Semin Vasc Surg 2010;23:65-8. 14. Bradbury MS, Kavanagh PV, Chen MY, Weber TM, Bechtold RE. Noninvasive assessment of portomesenteric venous thrombosis: current concepts and imaging strategies. J Comput Assist Tomogr 2002;26:392-404. 15. Bradbury MS, Kavanagh PV, Bechtold RE, Chen MY, Ott DJ, Regan JD, et al. Mesenteric venous thrombosis: diagnosis and noninvasive imaging. Radiographics 2002;22:52741. 16. Acosta S, Ogren M, Sternby NH, Bergqvist D, Bj繹rck M. Mesenteric venous thrombosis with transmural intestinal infarction: a population-based study. J Vasc Surg 2005;41:5963. 17. Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. Lancet 1960;1:1309-12. 18. Condat B, Pessione F, Helene Denninger M, Hillaire S, Valla D. Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy. Hepatology 2000;32:466-70. 19. Abdu RA, Zakhour BJ, Dallis DJ. Mesenteric venous thrombosis--1911 to 1984. Surgery 1987;101:383-8. 20. Hall TC, Garcea G, Metcalfe M, Bilku D, Dennison AR. Management of acute non-cirrhotic and non-malignant portal vein thrombosis: a systematic review. World J Surg 2011;35:2510-20. 21. Webster GJ, Burroughs AK, Riordan SM. Review article: portal vein thrombosis - new insights into aetiology and management. Aliment Pharmacol Ther 2005;21:1-9. 22. Janssen HL, Wijnhoud A, Haagsma EB, van Uum SH, van Nieuwkerk CM, Adang RP, et al. Extrahepatic portal vein thrombosis: aetiology and determinants of survival. Gut 2001;49:720-4. 23. Kispert J, Kazmers A. Acute intestinal ischaemia caused by

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mesenteric venous thrombosis. Semin Vasc Surg 1990;3:15771. 24. Yanar H, Taviloglu K, Ertekin C, Ozcinar B, Yanar F, Guloglu R, et al. Planned second-look laparoscopy in the management of acute mesenteric ischemia. World J Gastroenterol 2007;13:3350-3. 25. Jona J, Cummins GM Jr, Head HB, Govostis MC. Recurrent primary mesenteric venous thrombosis. JAMA 1974;227:1033-5. 26. Brunaud L, Antunes L, Collinet-Adler S, Marchal F, Ayav A, Bresler L, et al. Acute mesenteric venous thrombosis: case for nonoperative management. J Vasc Surg 2001;34:673-9. 27. al Karawi MA, Quaiz M, Clark D, Hilali A, Mohamed AE, Jawdat M. Mesenteric vein thrombosis, non-invasive diagnosis and follow-up (US + MRI), and non-invasive therapy by streptokinase and anticoagulants. Hepatogastroenterology 1990;37:507-9. 28. Goldberg MF, Kim HS. Treatment of acute superior mesenteric vein thrombosis with percutaneous techniques. AJR Am J Roentgenol 2003;181:1305-7. 29. Rosen MP, Sheiman R. Transhepatic mechanical thrombectomy followed by infusion of TPA into the superior mesenteric artery to treat acute mesenteric vein thrombosis. J Vasc Interv Radiol 2000;11:195-8. 30. Zhou W, Choi L, Lin PH, Dardik A, Eraso A, Lumsden AB. Percutaneous transhepatic thrombectomy and pharmacologic thrombolysis of mesenteric venous thrombosis. Vascular 2007;15:41-5. 31. Grisham A, Lohr J, Guenther JM, Engel AM. Deciphering mesenteric venous thrombosis: imaging and treatment. Vasc Endovascular Surg 2005;39:473-9. 32. Nakayama S, Murashima N, Isobe Y. Superior mesenteric venous thrombosis treated by direct aspiration thrombectomy. Hepatogastroenterology 2008;55:367-70.

May覺s - May 2013


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):229-234

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.22687

Çocuklarda ve erişkinlerde özofagus yabancı cisimleri: 20 yıllık deneyim Esophageal foreign bodies in children and adults: 20 years experience Sezai ÇELİK, Bülent AYDEMİR, Handan TANRIKULU, Tamer OKAY, Ilgaz DOĞUSOY

AMAÇ

BACKGROUND

Özofagus yabancı cisimleri her yaş grubunda sık görülür. Tedavinin yeterli olmaması özofagusta perforasyon gibi ciddi komplikasyonlara neder olabilir. Bu çalışmada amacımız özofagus yabancı cisimlerinin klinik özelliklerini belirlemek, girişimsel ve cerrahi yaklaşımımızı ve sonuçlarını analiz etmektir.

Esophageal foreign object ingestion is frequently seen in all ages. Failure to treat can cause serious complications such as esophageal perforation. The aims of this study were to characterize the clinical features related to foreign objects in the esophagus and to analyze the results of commonly used methods for their removal.

GEREÇ VE YÖNTEM

METHODS

Yirmi yılı aşkın sürede Siyami Ersek Hastanesi’ne başvurmuş ve özofagus yabancı cisim tanısı ile takip ve bir girişimsel işlem yapılarak tedavi edilen 512 hastanın kayıtları incelendi.

We analyzed 20 years of records from Siyami Ersek Hospital, Istanbul and identified 512 cases of foreign objects enlodged in the esophagus.

BULGULAR

In pediatric patients, the majority were aged between 2-5 years (34.4%), while in adult patients, the majority were above 55 years (38.7%). Coins were the most common foreign object detected in children (68.8%), whereas meat impaction was most common in adults (87.4%). The most common location of the foreign object was the cervical esophagus in children (78.2%), and the thoracic esophagus in adults (66.4%). In 30.8% of adults, there was esophageal or systemic disease. Objects were removed with a Magill clamp in 48.3% of children. Rigid endoscopy was the main treatment in adult patients. Perforation due to endoscopy developed in three patients. Surgical repair was performed on these patients but all died due to mediastinitis.

Çocuklarda yabancı cisim tıkacı en sık 2-5 yaş (%34,4) grubunda, erişkinlerde ise 55 yaş (%38,7) ve üzerinde saptandı. Çocuklarda özofagusta en sık saptanan yabancı cisim madeni paralar 232 (%68,8) iken erişkinlerde ise en sık et parçası 153 (%87,4) idi. Yabancı cisimler çocuklarda en sık servikal özofagusa (%78,2), erişkinlerde ise torasik özofagusa (%66,4) yerleşmişti. Erişkinlerin 54’ünde (%30,8) eşlik eden özofagus veya başka bir sistem hastalığı tespit edildi. Yabancı cisimler çocukların %48,3’ünde entübasyon laringoskopisinde Magill pensiyle başarıyla çıkarılmışken, erişkinlerin tamamına rijit özofagoskopi yapıldı. Çocuklarda mortalite görülmedi, erişkinlerde rijit özofagoskopi sırasında meydana gelen perforasyona bağlı mediastinit ve sepsisten 3 olguda ölüm meydana geldi. SONUÇ

RESULTS

CONCLUSION

Altta yatan özofagus hastalıkları veya eşlik eden sistemik hastalıklar erişkinlerde özofagus yabancı cisimlerine eğilimi artırmaktadır. Göğüs cerrahlarının klinik ve endoskopik tecrübelerinin artmasıyla son yıllarda özofagus yabancı cisimlerine bağlı morbidite ve mortalite azalmıştır.

Underlying esophageal or systemic diseases may predispose adults to foreign object ingestion in the esophagus. Improved endoscopic experience and clinical management of thoracic surgeons led to reduced morbidity and mortality in recent years.

Anahtar Sözcükler: Çocuklar; erişkinler; komplikasyonlar; özofagus; yabancı cisimler.

Key Words: Adults; children; complications; esophagus, foreign objects.

Siyami Ersek Göğüs Kalp ve Damar Cerrahisi Eğitim ve Araştırma Hastanesi, Göğüs Cerrahisi Kliniği, İstanbul.

Department of Thoracic Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey.

İletişim (Correspondence): Dr. Sezai Çelik. Fatih Sultan Mehmet Mah., Balkan Cad., Yeşilvadi Evleri, A3 Blok D: 36, Ümraniye, İstanbul, Turkey. Tel: +90 - 216 - 330 29 29 e-posta (e-mail): siyamie@gmail.com

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Ulus Travma Acil Cerrahi Derg

Özofagus üç yapısal darlık içermesi ve stratejik anatomik lokalizasyonda bulunması nedeniyle bünyesinde oluşan hastalıklardan dolayı ayrı bir öneme sahiptir. Özofagus yabancı cisimleri halen tüm dünyada bir halk sağlığı problemi olmaya devam etmektedir. Ellerine aldıkları her şeyi özellikle bir yaşından itibaren ağızlarına götürmelerinden dolayı çocuklarda daha sık özofagus yabancı cismi tanısı konulmaktadır.Diğer taraftan diş protezi kullanan veya ağız-diş sağlığı yetersiz olan bu nedenle de gıdaları çiğnemeden yutan yaşlılarda, özofagus yabancı cisimleri sıklıkla tespit edilmektedir. Meydana gelebilecek ciddi komplikasyonları nedeniyle bu yabancı cisimler derhal çıkarılmalıdır.[1,2]

Tablo 1. Özofagustan çıkarılan yabancı cisimlerin tipleri

Bu çalışmada, yabancı cisim yutma şüphesi ve hikayesi ile acil servise başvuran olgulardan klinik ve/ veya radyolojik karara göre özofagoskopi veya başkaca bir girişimsel işlem yapılan olguları hem klinik ve radyolojik yönden hem de yapılan işlemin sonuçları ve komplikasyonları bakımından inceledik.

7,42

GEREÇ VE YÖNTEM Özofagus yabancı cisim ön tanısı nedeniyle Siyami Ersek Göğüs Kalp ve Damar Cerrahisi Eğitim ve Araştırma Hastanesi Göğüs Cerrahisi Kliniği’ne Haziran 1987-Aralık 2007 tarihleri arasında yatırılan ve tedavisi yapılan 512 hastanın 337’si (%65,8) çocuk (229 erkek, %67,9, 108 kadın, %32,04, ortalama yaş 4,2±6,8); 175 (%34,1) erişkin (134 erkek, %76,5, 41 kadın, %23,4, ortalam yaş 55,6±14) dosyaları geriye dönük incelendi. Olgular yaş, cinsiyet, semptom, yabancı cisim lokalizasyonu ve tipi, radyolojik bulgular, eşlik eden veya altta yatan hastalıklar, endoskopik sonuçlar, tedavi yöntemleri ve sonuçları, morbidite ve mortalite yönünden değerlendirildi. Girişimsel veya bir cerrahi işlem yapılmayan 14 olgu çalışma dışı bırakıldı. Yine hastanemiz acil servisine başvuran 1 yaş altı çocuklara uygun özofagoskop olmadığından girişimsel bir işlem yapılmadı ve sevkli olduğundan çalışma dışı bırakıldı. Çalışmamızda “Number Cruncher Statistical System (NCSS) 2007&PASS 2008 statistical software (Utah, USA)” sistemi ile ortalama ve standart sapma gibi tanımlayıcı istatistik metodları kullanıldı.

Yabancı cisim Madeni para Et parçası Kemikli et Çengelli iğne Küpe Düğme Protez diş Plastik oyuncak Meyve koçanı Alkali mini pil Çeşitli (tahta parçası, kalem kapağı...)

n

%

232 7 5 16 9 14 – 11 10 4 29

68,8 2,07 1,48 4,74 2,67 4,15 3,26 2,96 1,18 8,6

Erişkin (n=175) n – 113 40 – – – 7 – 13 – 2

% – 64,5 22,8 – – – 4

1,14

özofagus’ta (%78,6), erişkinlerde ise torasik özofagusta (%62,2) saptanmıştır. Çocukların %65,6’sı ilk 12 saatte hastaneye getirilirken erişkinlerin ancak %12,6’sı ilk 12 saatte herhangi bir kliniğe müracaat etmiştir. Fakat, hastaların %33’ünde dosyalarından yabancı cismi yutma zamanı ile ilgili yeterli bilgi edinilememiştir. Çocuklarda en sık görülen semptom ve bulgu “verilen yiyecekleri reddetme ve ağızdan salya akması)”, erişkinlerde ise “yemek yerken öğürme veya ağrılı yutma” olmuştur (Tablo 2). Diğer taraftan erişkinlerin %30,8’inde primer bir özofagus hastalığı veya eşlik eden bir sistemik hastalık tespit edilmişken; çocuklarda bu oran %0,59 olarak gerçekleşmiştir (Tablo 3). Rijit özofagoskopi, gerek çocuklarda gerekse erişkinlerde yabancı cisimlerin tedavisinde kullanılan esas yöntem olmuştur. Çocukların %51,6’sında ise yabancı cisimler direkt laringoskopi altında Magill pensi kullanılarak çıkarılmıştır. Çocuklarda 67 (%19,8) olguda, erişkinlerde 125 (%71,4) olguda herhangi bir radyolojik bulgu sapTablo 2. Görülme sıklığına göre semptomlar

BULGULAR Özofagusta yabancı cisim tanısı ile yatırılan 512 olgunun 337’si (%65,8) çocuk, 175’i (%34,2) erişkindi. Çocuklarda yabancı cisim tıkacı en sık 2-5 yaş (%34,4) aralığında, erişkinlerde ise en sık 55 yaş (%38,7) ve üzerinde saptanmıştır.

Çocuklar

Çocuklarda erkek/kadın oranı 2:1, erişkinlerde ise 3:1 şeklinde gerçekleşmiştir. Çocuklarda özofagus’ta en sık madeni paralar; erişkinlerde ise et parçası ve kemikli et tespit edilmiştir (Tablo 1). Çocuklarda özofagusu tıkayan yabancı cisimler en sık servikal

Erişkinler

230

Çocuk (n=337)

1. Verilen yiyecekleri reddetme 2. Ağız suyunda artma 3. Yutma güçlüğü ve ağrılı yutma 4. Kusma 5. Öksürük, wheezing, interkostal çekilmeler 1. Yemek yerken öğürme ve ağrılı yutma 2. Yemek yerken takılma hissi 3. Tükürükle kan gelmesi Mayıs - May 2013


Çocuklarda ve erişkinlerde özofagus yabancı cisimleri

Tablo 3. Özofagusta yabancı cisim tespit edilen erişkinlerde eşlik eden hastalıklar Tanı

n

%

Hiatal herni Reflü özofajitis Skleroderma Diffüz özofagial spazm Demans Psikoz Geçirilmiş serebrovasküler olay Alkol ve uyuşturucu madde kullanımı Epilepsi Toplam

8 6 4 2 15 4 9 3 3 54

4,57 3,42 2,28 1,14 8,57 2,28 5,14 1,71 1,71 30,8

Tablo 4. Direkt grafi bulguları

Çocuk

Pozitif Negatif

n

%

270 67

80,1 19,8

Erişkin n

%

79 45,1 125 71,4

tanmamıştır (Tablo 4). Hikayesi pozitif, semptomu veya radyografik bulgusu olan 15 (%4,45) çocuk ve 8 (%4,57) erişkin hastada yapılan özofagoskopi de yabancı cisim bulunamamıştır. Bu gruptaki yabancı cisimlerin 14’ünün madeni para, 6’sının düğme, 5’inin

künt metal obje olduğu belirlenmiştir (Şekil 1). Şikayetlerinin devam etmesi nedeniyle çocukların 7’sinde (%2,07), erişkinlerin ise 8’inde (%4,5) yineleyen endoskopi ihtiyacı olmuştur (Tablo 5). Üç olguda rijit özofagoskopi sonrası ösofagus perforasyonu gelişmiştir. İlk olgu 1987, diğer iki olgu 1998 yılında meydana gelmiştir. 1998 yılından sonraki dönemde bir daha perforasyon tanısı konmamıştır. Üst damak total diş protezini yutan 68 yaşında erkek hastaya rijit özofagoskopi yapılmış ve birinci darlığa yerleşmiş olan yabancı cisim çıkarılmıştır. Beraberinde özofagusta perforasyon tespit edilen hasta mediastinit ve sepsis nedeniyle ölmüştür. Skleroderması da olan 19 yaşındaki erkek hasta ise bir haftadır devam eden yutma güçlüğü nedeniyle başvurmuş ve rijit özofagoskopi esnasında özofagus 2/3 alt kısımda sert, arka duvara fikse lezyon görülmüş ama çıkarılmaya çalışılırken perforasyon gelişmiştir. Ameliyata alınan hastada taşlaşmış köfte bulunmuştur. Kitle çıkarılmış ancak hasta gelişen mediastinit ve sepsis nedeniyle ölmüştür. 1998 yılının sonunda epilepsisi de olan 73 yaşında kadın hasta yediği eti yutamama şikayeti ile acil servisimize getirilmiş ve yapılan rijit özofagoskopi esnasında ikinci darlıktaki et tıkacı çıkarıldıktan 6 saat sonra yüksek ateş ve sağ hidrotoraks meydana gelmiştir. Sağ torakotomi ile interkostal kas flebi kullanılarak özofagus yırtığı tamir edilmiş ancak bu hastada ameliyat sonrası 7. günde mediastinit ve am-

Tablo 5. Olgulara yaklaşım ve sonuçları Direkt laringoskopik çıkarma (Magill pens ile) Rijit özofagoskopi ile çıkarma Foley kateter ile çıkarma Negatif özofagoskopi Yineleyen özofagoskopi

Çocuk

Erişkin

n

%

n

163 174 2 15 7

48,3 51,6 0,59 4,45 2,07

10 165 – 8 8

% 5,7 94,2 – 4,57 4,5

Tablo 6. Komplikasyonların cinsi ve dağılımı Cisme bağlı (çoğunlukla)

Sayı

Yüzde

Erozyon Hemoraji Ülserasyon Nekroz Toplam Rijit özofagoskopiye bağlı (toplam 354 işlem) Erozyon Hemoraji Perforasyon Mediastinit ve ampiyem Ölüm

238 59 7 1 305

46,4 19,4 2,3 1,19 59,5

43 21 3 3 3

12,1 5,9 0,84 0,84 0,84

Cilt - Vol. 19 Sayı - No. 3

231


Ulus Travma Acil Cerrahi Derg

Şekil 1. Özofagusun değişik lokalizasyonlarından çıkarılan bazı yabancı cisimler.

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

piyem nedeniyle ölmüştür. Çalışmamızda 2005 yılında 1 (%0,19) hastaya direkt cerrahi tedavi uygulanmış ve yutulan damak protezi başarıyla çıkarılmış ve hasta sorunsuz taburcu edilmiştir (Şekil 2a-d). Diğer komplikasyonlar özellikli tedaviler gerektirmeksizin iyileşmiştir. Yabancı cisme ve cihaz kullanımına bağlı olduğu düşünülen tüm komplikasyonlar Tablo 6’da sunulmuştur.

TARTIŞMA Özofagus yabancı cisimleri, çocuklarda yıllar içinde şekil ve karakter değiştirmekle beraber potansiyel komplikasyonları nedeniyle halen güncelliği devam etmekte ve erken müdahaleyi zorunlu kılmaktadır. Yutulan nesnenin şekline, yapısına, yerleşim yerine ve varsa altta yatan özofagusu da etkileyen hastalığın durumuna göre ciddi semptom ve bulgulara yol açar. Çocuklarda künt, erişkinlerde daha ziyade keskin özellikli yabancı cisimler görülür. Bazı çalışmalarda özofagus yabancı cisimlerinin çoğunluğunun erişkinlerde görüldüğü bildirilmiştir.[3-5] Nandi ve Ong,[3] 2394 olgunun %85’inin erişkinler tarafından oluşturulduğunu rapor etmiştir. Diğer taraftan Brooks ve arkadaşları[6] ile İnci ve arkadaşları[7] çocuk yaş grubunda daha sık görüldüğünü bildirmişlerdir. Bizim çalışmamızda olguların %65,8’ini çocuklar -sıklıkla da 2-5 yaş arası- oluşturmuştur. Bu durum, genelde farklı yaşam biçimi, coğrafya ve yeme alışkanlıklarına bağlı değişmektedir. Özofagus yabancı cisimlerinin neden olduğu semptom ve bulgular tıkanmanın yerine, tıkacın çapına ve şekline göre değişiklik gösterir. Bu tespite en iyi madeni paralar uymaktadır. Madeni paralar, ülkemizde değişik büyüklükte ve çok sayıda bulunduğundan ve çocukların eline en sık geçen maddelerden birisi olması nedeniyle ayrı bir öneme sahiptir. Çalışmamızda özofagusta saptanan madeni paraların 232

çapları 21-28 mm arasında ve sıklıkla da servikal özofagusa yerleşmişti. Literatürde hemen bütün yabancı cisimlerin ağrıya yol açabildiği, ancak düzgün ve künt olanların semptomsuz kalabileceği vurgulanmıştır. [8] Bununla birlikte çok sayıda hastada herhangi bir belirti bulunmaz. Çalışmamızdaki çocukların büyük çoğunluğu verilen yiyecekleri reddetme ve sialore şikayetleriyle kliniğimize getirilmiştir. Yaşları 14-22 ay arasında değişen 6 çocukta ise ön planda krup benzeri öksürük, nefes darlığı, “wheezing” ve interkostal çekilmeler saptanmıştır. Bu olguların direkt grafilerinde servikal özofagusa yerleşimli, çapları 27-29 mm olan madeni cisimler çıkarılmıştır. Bu paradoksun, yabancı cismin trakeanın arka duvarına yaptığı basıdan kaynaklanabileceği düşünülmüştür. Literatürde az sayıda bu şekilde rapor sunulmuştur.[2,9,10] Son yıllarda ülkemize Uzak Doğu’dan çok sayıda oyuncak ithal edilmektedir. Bunların birçoğu alkali mini pil içermektedir. Çalışmamızda 4 hastada bu cins mini pil özofagusun ikinci darlığında tespit edilmiştir.Bu olgulardan 2 yaşındaki erkek çocukta mini pil alındıktan sonra alkali erozyonu tespit edilmiş, konservatif tedavilerle taburcu edilen hastanın 2 ay sonra yapılan özofagoskopisinde lezyonun bütünüyle iyileştiği görülmüştür. Bu tür cisimler direkt radyografilerde bilamine yapıları nedeniyle çift dansite görünümleri ile ayırt edilirler ve derhal çıkarılmalıdırlar. Mini pillerin yapısı oldukça düzdür ve forsepsle yakalanması bu yüzden zordur. En iyi yaklaşım floroskopide Foley kateterle çıkarılmasıdır.[11,12] Hava yolu dikkatle açık tutulmalıdır. Çalışmamızdaki iki olgu da bu şekilde tedavi edilmiştir. Erişkinlerde özofagus yabancı cisimlerinin çoğunluğunun torasik özofagusa yerleştiği rapor edilmiştir.[4,13] Slaone ve arkadaşları ise 150 hastadan elde ettikleri sonuçlarda yabancı cisimlerin erişkinlerde %53 oranında diyafragmatik özofagusa yerleştiğini bildirmiştir.[4,14] Aynı çalışmada erişkinlerde buldukları bu sonucun özofagus hastalıklarının en sık lokalize olduğu yer olması açısından da uyumlu olabileceği dile getirilmiştir. Bizim çalışmamızda, erişkinlerde yabancı cisimlerin %62,2’si torasik özofagus’ta, %28’i diyafragmatik özofagus’ta, %9,8’i servikal özofagusta saptanmıştır. Bu durum tıkanmanın daha ziyade anatomik darlıklarla ilgili olabileceğini akla getirmektedir. Çalışmamızda radyolojik bulgunun varlığına rağmen çocukların %4,45’inde, erişkinlerde %4,57’sinde özofagoskopide bir yabancı cisim bulunamamıştır. Literatürde bu oran %7-62 arasında değişmektedir.[3,14] Bu olgularda genel anestezi indüksiyonunu takiben özofagus sfinkterlerinin gevşemesine bağlı olarak özellikle madeni yabancı cisimlerin mideye ilerlediği direkt grafilerle teyit edilmiştir. Ülkemizde erişkin nüfus arasında özofagusun et tıkaçları ayrı bir öneme sahiptir. Özellikle Kurban bayramı ve takip eden günlerde fazla miktarda et tükeMayıs - May 2013


Çocuklarda ve erişkinlerde özofagus yabancı cisimleri

(a)

(b)

(c)

(d)

Şekil 2. Hastanın, (a) ön-arka akciğer grafisinde sol hemitoraks içinde yabancı cisim görüntüsü, (b) göğüs yan grafisinde yabancı cismin özofagus içine yerleştiği görülmekte, (c) özofagomyotomi yapıldığında cismin metal kısmının görüntüsü, (d) cerrahi işlem sırasında çıkarılan materyali: Diş protezi görülmekte.

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

tilmektedir. Bayram periyodunda aşırı et yeme isteği, etlerin yeterince pişirilmeden yenilmesi ve iyi çiğnenmeden yutulması özofagusta et tıkacı ile hastane acillerine başvuranların sayısında artışa yol açmaktadır. Bu hasta grubunun hemen tamamının 50 yaş üstünde olması, hastaneye geç başvurmaları, yemek yiyememe ve su içememe şaşkınlığı ve telaşı içinde acil servislere intikal etmeleri nedeniyle öncelikle ve derhal sedatize edilmelerinin doğru olacağı kanaatindeyiz. Bu şekilde bir gecelik konservatif yaklaşımdan sonra, hastalara ertesi gün rijit özofagoskopi yapılması daha tedbirli bir yaklaşım olacaktır. Özofagus yabancı cisimlerinin tedavisinde gözlem, Magill pensi kullanılması, Foley kateter kullanımı, rijit veya fleksibl özofagoskopi, yabancı cismin mideye itilmesi, intravenöz glukagon kullanımı ve cerrahi tedavi seçenekleri mevcuttur. Çalışmamızda temel tedavi yöntemi rijit özofagoskopi olmuştur. Fleksibl özofagoskop ise kliniğimizde mevcut olmadığından kullanılmamıştır. Rijit özofagoskop, tecrübeli göğüs cerrahlarının Cilt - Vol. 19 Sayı - No. 3

elinde daima güvenilir ve oldukça da etkilidir. Çalışmamızda rijit özofagoskopi çocukların %51,6’sında, erişkinlerin %94,2’sinde başarıyla kullanılmıştır. Literatürde başarı ve komplikasyon oranları farklı farklı verilmiştir. Berggreen ve arkadaşları[15] %100, Li ve arkadaşları[16] ise %94,1 olarak bildirmiştir. Diğer taraftan Brooks, özofagus’tan 26 et parçasını rijit özofagoskopla çıkardığı çalışmasında 3 (%11,5) olguda perforasyon geliştiğini ve bunlardan 1’inin (%3,8) öldüğünü rapor etmiştir.[6] Çalışmamızda rijit özofagoskopiye bağlı majör komplikasyon oranı %0,84 olarak saptanmıştır. Ancak, bu olguların üçü de hastaneye 24 saat geçtikten sonra başvurmuştur. Perforasyon oluşumunda yabancı cisim yutulduktan sonra geçen sürenin, cisme bağlı meydana gelen enflamatuvar reaksiyonun ve enfeksiyonunda etkili olduğu düşünülmektedir.[6] Yirmi yıllık mortalite çocuklarda %0 iken; erişkinlerde %1,71 olarak gerçekleşmiştir. Son 10 yıllık mortalite ise erişkinlerde de %0’dır. 233


Ulus Travma Acil Cerrahi Derg

Magill pensi kullanımı, özellikle çocuklarda az sedasyon verilerek ve direkt görüş altında yapılabilirliği nedeniyle halen en geçerli yöntemlerden biridir. Floroskopi eşliğinde Foley kateter ise yine çocuklarda başarıyla kullanılmış, ancak rutin kullanımı tavsiye edilmemiştir.[15,17] Direkt cerrahi tedavi çalışmamız sürecinde 1 (%0,19) hastada uygulanmıştır. İnci ve arkadaşları[7] 682 olgudan oluşan çalışmalarında bu oranı %0,5 olarak rapor etmiştir. Direkt cerrahi tedavi 2005 yılında bir damak protezi için uygulanmıştır. Zira geçmiş yıllardaki tecrübelerimiz özellikle dental protezlerin özelliklerinden dolayı rijit özofagoskopide çıkarılırken perforasyona kolaylıkla yol açabileceği yönündedir. Bu nedenle cismin büyüklüğüne de bağlı olarak dental protezlerin direkt cerrahi çıkarılmasının uygun olduğu görüşündeyiz. Çalışmamızda erişkinlerde özofagus yabancı cisimlerinin 33’üne (%18,8) mental problemlerin eşlik ettiği bir klinik durum veya hastalık 21’inde (%12) primer özofagus hastalığı saptanmıştır. Türkyılmaz ve arkadaşlarının[18] 188 hastadan oluşan çalışmalarında özofagus’ta yabancı cisim çıkarılan 4 hastadan birinde Barett özofagusu, üçünde özofagus kanseri tespit ederlerken ayrıca 3 hastanın depresyon tanısı olduğunu bildirmişlerdir. Rijit özofagoskopi, çalışmamızda erişkinlerde 165 olguda 173 kez kullanılmış ve başarı oranı %98,2 olarak gerçekleşmiştir. İşleme bağlı perforasyon ve mortalite %1,73 olarak gerçekleşmiştir. Çocuklarda ise 174 olguda 181 kez rijit özofagoskopi yapılmış olup başarı oranı %100 olmuştur. Burada dikkat çekici olan perforasyon ve mortalitenin olduğu 3 olgunun ilk 10 yıla ait olmasıdır. Son 10 yılda ise hiç perforasyon ve ölüm olmamış ve kliniğimiz göğüs cerrahlarının zamanla edindiği klinik yaklaşım ve rijit özofagoskop kullanım tecrübesinin artmasına bağlı giderek yükselen oranda başarılı sonuçlar elde edilmiştir. Sonuç olarak, özofagus yabancı cisimleri ülkemizde bir halk sağlığı problemi olmaya ve acil toraks cerrahisi hastalıkları arasında önemini korumaya devam etmektedir. Çalışmamız göstermiştir ki, erişkinlerde altta yatan özofagus hastalığı veya eşlik eden sistemik hastalıklar, özofagus yabancı cisimlerine meyli artırmaktadır. Öte yandan son yıllarda göğüs cerrahlarının klinik ve endoskopik deneyimlerinin artmasıyla beraber özofagus yabancı cisimlerine bağlı morbidite ve mortalite azalmıştır.

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Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması yoktur.

KAYNAKLAR 1. Weissberg D, Refaely Y. Foreign bodies in the esophagus. Ann Thorac Surg 2007;84:1854-7. 2. Degghani N, Ludemann JP. Ingested foreign bodies in children: BC Children Hospital Emergency Room Protocol. BC Med J 2008;50:257-62. 3. Nandi P, Ong GB. Foreign bodies ingestion review and suggested guidlines for management. Endoscopy 1987;19:68-71. 4. Blair SR, Graeber GM, Cruzzavala JL, Gustafson RA, Hill RC, Warden HE, et al. Current management of esophageal impactions. Chest 1993;104:1205-9. 5. Nayak SR, Kirtane MV, Shah AK, Karnik PP. Foreign bodies in the cricopharyngeal region and oesophagus (a review of 226 cases). J Postgrad Med 1984;30:214-8. 6. Brooks JW. Foreign bodies in the air and food passages. Ann Surg 1972;175:720-32. 7. İnci İ, Özçelik C, Ülkü R, Eren N. Özofagus yabancı cisimleri: 682 olgunun incelenmesi. GKDC Dergisi 1999;7:14852. 8. Ashraf O. Foreign body in the esophagus: a review. Sao Paulo Med J 2006;124:346-9. 9. Martin-Hirsch DP, Newbegin CJ. Oesophageal foreign body presenting with paradoxical respiratory symptoms. Br J Clin Pract 1994;48:212-3. 10. D’Cruz OF, Whelan HT. Breathholding spells and esophageal foreign body. Clin Pediatr (Phila) 1991;30:295-6. 11. Votteler TP, Nash JC, Rutledge JC. The hazard of ingested alkaline disk batteries in children. JAMA 1983;249:2504-6. 12. Silverberg M, Tillotson R. Case report: esophageal foreign body mistaken for impacted button battery. Pediatr Emerg Care 2006;22:262-5. 13. Koirala K, Rai S, Chhetri S, Shah R. Foreign body in the esophagus: comparison between adult and pediatric population. NJMS 2012;1:42-4. 14. Derowe A, Ophir D. Negative findings of esophagoscopy for suspected foreign bodies. Am J Otolaryngol 1994;15:41-5. 15. Berggreen PJ, Harrison E, Sanowski RA, Ingebo K, Noland B, Zierer S. Techniques and complications of esophageal foreign body extraction in children and adults. Gastrointest Endosc 1993;39:626-30. 16. Li ZS, Sun ZX, Zou DW, Xu GM, Wu RP, Liao Z. Endoscopic management of foreign bodies in the upper-GI tract: experience with 1088 cases in China. Gastrointest Endosc 2006;64:485-92. 17. Uyemura MC. Foreign body ingestion in children. Am Fam Physician 2005;72:287-91. 18. Türkyilmaz A, Aydin Y, Yilmaz O, Aslan S, Eroğlu A, Karaoğlanoğlu N. Esophageal foreign bodies: analysis of 188 cases. Ulus Travma Acil Cerrahi Derg 2009;15:222-7.

Mayıs - May 2013


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):235-240

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.02073

Ateşli silah yaralanmasına bağlı periferik sinir lezyonlarında cerrahi tedavi sonuçlarımız: 28 olgunun değerlendirilmesi Surgical treatment outcomes ın peripheral nerve lesions due to gunshot injuries: assessment of 28 cases Ali Kıvanç TOPUZ,1 Ahmet EROĞLU,1 Cem ATABEY,1 Ahmet ÇETİNKAL2

AMAÇ

BACKGROUND

Bu geriye dönük çalışmada, kliniğimizde 8 yılı kapsayan sürede ateşli silah yaralanması nedeniyle ameliyat edilen periferik sinir lezyonlu 28 hastaya uygulanan cerrahi tedavi ve sonuçları sunuldu.

In this retrospective study, we present the results and outcomes in our clinic of 28 patients over 8 years who received surgical treatment for peripheral nerve lesions due to gunshot injury.

GEREÇ VE YÖNTEM

METHODS

Çalışmaya Ocak 2002-Şubat 2010 tarihleri arasında kliniğimize başvuran, etyolojide ateşli silah yaralanması olan, yaralanmadan 1-6 ay süre sonra başvurmuş ve periferik sinir lezyonu tanısı ile ameliyat edilen olgular alındı. Tüm hastalara ameliyat öncesi ve sonrası elektromiyografik inceleme (EMG) ve motor güç derecelendirmesi yapıldı. Olguların tümüne cerrahi tedavi uygulanarak, ameliyat sonrası 1, 6, 12. ayda kontrole çağırıldılar.

The patients came to our clinic between January 2002 and February 2010. All came within 1-6 months after the initial gunshot injury and underwent surgery due to the diagnosis of peripheral nerve lesion. Preoperative and postoperative electromyographic analysis (EMG) and motor strength rating were performed on all patients. All patients were called for postoperative follow-up at 1, 6 and 12 months after surgery.

BULGULAR

The mean time after initial injury before being seen at our clinic was 3.6 months (1 day - 6 months). The most commonly injured nerve was the sciatic nerve, in 14 cases (50%). Of the patients, 23 came due to a bullet injury (9 were civilian injury with a gun, 14 were military injury with a rifle) and 5 came due to shrapnel injury. Since in all cases integrity of the nervous tissue was fully intact, nerve grafting was not required during surgery. Relatively improved EMG findings, and recovery in motor functions were detected in cases who had undergone postoperative external epineurolysis plus decompression.

Hastaların ortalama başvuru süreleri 3,6 aydı (1 gün - 6 ay). En sık yaralanan sinir; 14 olgu (%50) ile siyatik sinirdi. Olguların 23’ü kurşun yaralanması (9’u tabanca ile sivil yaralanma, 14’ü tüfek ile askeri yaralanma), 5’i ise şarapnel yaralanmasına bağlı olarak meydana gelmişti. Olguların tümünde sinir dokusu bütünlüğü tam olduğundan cerrahide sinir grefti ihtiyacı olmadı. Cerrahi sonrası eksternal epinöroliz + dekompresyon yapılan olgularda, EMG sonuçlarının ve motor fonksiyonlardaki düzelmenin daha iyi olduğu saptandı. SONUÇ

RESULTS

CONCLUSION

Biz cerrahi teknik kurallara uyulması şartıyla (enfeksiyon, cilt defekti, vasküler yaralanma ve kemik kırığı varlığı dışında) ateşli silah yaralanmasına bağlı sinir lezyonlarında ilk altı ay içinde cerrahi tedaviyi önermekteyiz.

We recommend surgical treatment within the first six months in neural lesions, depending on gunshot injury, on the condition that surgical technique rules are obeyed (except infection, skin defect, vascular injury, and the presence of bone fracture).

Anahtar Sözcükler: Ateşli silah yaralanması; elektromiyografik inceleme; periferik sinir.

Key Words: Gunshot wounds; electromyographic investigation; peripheral nerve.

GATA Haydarpaşa Eğitim Hastanesi, Beyin Cerrahi Kliniği, İstanbul; 2 Kasımpaşa Asker Hastanesi Beyin Cerrahi Kliniği, İstanbul.

1

Department of Neurosurgery, GATA Haydarpasa Training Hospital, Istanbul; Department of Neurosurgery, Kasimpasa Military Hospital, Istanbul, Turkey.

1

2

İletişim (Correspondence): Dr. Ahmet Eroğlu. GATA Haydarpaşa Eğitim Hastanesi, Beyin Cerrahi Kliniği, İstanbul, Turkey. Tel: +90 - 216 - 542 28 15 e-posta (e-mail): drahmeteroglu@gmail.com

235


Ulus Travma Acil Cerrahi Derg

Ateşli silah yaralanmaları (ASY), ağır nörolojik ve/ veya diğer organ hasarları oluşturan yaralanmalardır. Etyolojide ASY olan periferik sinir yaralanmalarında ağır nörolojik hasarlar oluşabilmektedir. Periferik sinirlere ait ASY’nin insidansı hakkında verilen rakamlar ülkeden ülkeye değişiklikler göstermektedir.[1] Her yıl Amerika Birleşik Devletleri’nde ASY’ye bağlı olarak 24,000 kişi ölmekte, 300,000 kişi yaralanmaktadır.[2] Son yıllarda ülkemizde de yaşanan askeri ASY yaralanmaları sonucunda bu oran artmıştır.[3] Askeri yaralanmalarla sivil yaralanmaları ayıran en önemli nokta, yaralanmaya neden olan silahın cinsi ve dolayısı ile bu silahın sahip olduğu ateş gücü ve kitle etkisidir.[3] Silahtan çıkan parçanın, hızı, boyutu ve şekline bağlı olarak yaratacağı hasar da ancak balistik inceleme sonucunda anlaşılabilir. ASY’de sinir dokuları doğrudan, dolaylı veya geçici kavitasyona bağlı mekanizmalarla hasara uğrayabilmektedir.[2,3] Doğrudan yaralanmalarda parçanın kendisi hasara neden olurken, dolaylı yaralanmalarda ise hasarın esas nedeni parçanın hedefe çarptığı anda yarattığı şok dalgası ile meydana gelen basınç ya da oluşan kavitasyona bağlı meydana gelen kompartman sendromudur. ASY’nin büyük bir kısmında sinir bütünlüğü bozulmaz. Ancak bazen sinirde tam ya da kısmi sinir iletimi kaybı oluşabilir. Periferik sinir yaralanmalarında etyolojik neden ve mekanizmalara bağlı olarak prognoz değişmektedir.[4] Prognozu etkileyen faktörler arasında hasarlanmanın tipi, yaralanmanın şiddeti, hasar seviyesi ve hastanın yaşı sayılabilir.[5] Periferik sinirlerin ateşli silahla olan yaralanmalarının cerrahi tedavisi halen tartışmalıdır.[3] Kaynakların çoğunluğu askeri yaralanmaların sonuçlarına dayanmakla birlikte sivil ateşli silah yaralanmalarına ait yayınlar da vardır.[3] Bugüne kadar bildirilmiş olan sonuçlara bakıldığında tedavi protokollerinde halen bir standart yoktur. Bu çalışmada, ASY nedeniyle ameliyat edilen periferik sinir lezyonlarında, uygulanan cerrahi teknik, yaralanma mekanizması ve cerrahi öncesi sürenin cerrahi sonrası elde edilen fonksiyonel düzelmeye ve prognoza olan etkileri araştırıldı. Ameliyat edilen olgulardan elde edilen sonuçlar elektromiyografik inceleme (EMG) ve klinik inceleme ile birlikte değerlendirildi.

GEREÇ VE YÖNTEM Ocak 2002-Şubat 2010 tarihleri arasında GATA Haydarpaşa Eğitim Hastanesi Nöroşirürji Kliniği’ne başvuran ve etyolojide ateşli silah yaralanması olan, periferik sinir yaralanmasına maruz kalmış ameliyatlı 28 olgu geriye dönük olarak incelendi. Çalışmaya travma sonrası 1-6 ay arasında süre geçmiş ve daha önce ameliyat edilmemiş hastalar alındı. Çalışmada ameliyat öncesi ve sonrası dönemdeki klinik değerlen236

dirmeyi ortaya koyabilmek açısından EMG çalışması ve motor güç dereceleri temel ölçüt olarak alındı. Olguların ameliyat öncesi ve sonrası dönemdeki motor güç değerleri British Medical Research Council ölçeğine göre değerlendirildi (Tablo 1). EMG çalışması aynı nörolog tarafından Nihon Kohden Neuropack- 2 marka EMG cihazı ile yapıldı. Olguların tümüne cerrahi tedavi uygulandı. Genel anestezi altında olgulara mikrocerrahi yöntemle fasyatomi, eksternal veya internal nöroliz ve dekompresyon teknikleri kullanıldı. Kompartman sendromu gelişmiş olgularda fasyatomi yapıldı. Olgular ameliyat sonrası 1. ay, 6. ay ve 12. aydaki kontrollerinde nörolojik muayene ve EMG çalışmalarıyla değerlendirildi. Nörolojik değerlendirmenin EMG çalışması ile eş zamanlı yapılmasına dikkat edildi.

BULGULAR Çalışmaya katılan olguların tümü erkekti. Olguların yaşlara göre dağılımı 21-48 yaş (ort. yaş; 32,4 yıl) arasındaydı. Hastaların ortalama başvuru süreleri 3,6 aydı (1 ay - 6 ay). En sık yaralanan sinir; 14 olgu (%50) ile siyatik sinirdi. Yedi olguda (%25) peroneal sinir, 4 olguda (%14,2) brakiyal pleksus (Şekil 1a, b), 2 olguda (%7,1) radiyal sinir ve 1 olguda da (%3,5) ulnar + median sinirin birlikte olduğu lezyon mevcuttu (Tablo 2). Olgularda üst ekstremitede en fazla sinir yaralanması brakiyal pleksus ve alt ekstremitede ise siyatik sinirde tespit edildi. Yirmi üç olguda sinir lezyonu kurşun yaralanması (9’u tabanca ile sivil yaralanma, 14’ü tüfek ile askeri yaralanma) ile, 5 olguda ise şarapnel yaralanmasına bağlı olarak meydana gelmişti. Çalışmamızda doğrudan sinir dokusu yaralanması olmayıp, lezyonlar dolaylı yaralanmalara bağlı, parçanın hedefe çarptığı anda yarattığı şok dalgasıyla ortaya çıkan basınç veya oluşan kavitasyon sonucu meydana gelen kompartman sendromuna bağlı olarak oluşmuştu. Cerrahi tedavi olarak 8 olguya (%28,5) fasyatomi + dekompresyon, 4 olguya (%14,2) dekompresyon + internal nöroliz ve 16 olguya (%57,14) eksternal epinöroliz + dekompresyon yapıldı (Şekil 2a-c). Biz olgularda eğer epinöriyum bütünlüğü korunmuş ise eksternal nöroliz yaptık. Eğer epinöriyum bütünlüğü bozulmuş ve fibrotik bir tabaka ile sinir çevrilmiş ise internal nöroliz uyguladık. Olgularımızın tümünde siTablo 1. British Medical Research Council motor güç değerlendirme ölçeği[17] Derece

Değerlendirme

M0 M1 M2 M3 M4 M5

Hiç kasılma yok Eser miktarda kasılma var Yerçekimsiz ortamda aktif hareket var Yerçekimine karşı aktif hareket var Dirence ve yerçekimine karşı aktif hareket var Normal kuvvet şeklinde değerlendirilir Mayıs - May 2013


Ateşli silah yaralanmasına bağlı periferik sinir lezyonlarında cerrahi tedavi sonuçlarımız

(a)

(b)

Şekil 1. (a) Sol göğüs dış kısmından ateşli silah yaralanmasına bağlı gelişmiş sol brakial pleksusun kord düzeyinde hasarı (beyaz ok başı: kurşun giriş deliği). Yıldız: Klavikula 2/3 medialinden aksillaya doğru deltopektoral oluk üzerinden yapılan infraklavikular yaklaşıma ait cerrahi insizyon). (b) Kordlar düzeyinde brakiyal pleksusu oluşturan sinirlerin dekompresyon cerrahisi sonrası görünümü (us: ulnar sinir; ms: median sinir; mks: muskulokutanöz sinir; mk: medial kord; pk: posterior kord; lk: lateral kord).

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

nir dokusu bütünlüğü tam olduğundan cerrahide sinir greft dokusu ihtiyacı olmadı. Cerrahi sonrası eksternal epinörolizis + dekompresyon yapılan olgularda, EMG sonuçlarının ve motor fonksiyonlardaki düzelmenin daha iyi olduğu saptandı. Cerrahi sonrasında hiçbir olguda komplikasyon gelişmedi. Uygulanan cerrahi yaklaşım ile hastaların cerrahi öncesi ve sonrası EMG sonuçları ile motor fonksiyonlarının değerlendirilmesi Tablo 3’de verilmiştir. Total ve ağır parsiyel lezyonlu 17 olgunun ortalama 12 aylık EMG takiplerinde 6 olguda parsiyel lezyon seviyesine gerileme tespit ettik. Parsiyel aksonal hasarı olan 11 olgunun ise 12 aylık EMG takiplerinde 6 olguda tama yakın düzelme tespit ettik. İki ile 5 ay arası ameliyat edilen geç dönem cerrahi uygulanan olguların sonuçlarında anlamlı fark olmadığını gördük. Tüm olgular en kısa 9 ay, en uzun 18 ay, ortalama 12 ay süreyle izlendi.

TARTIŞMA Ateşli silahların, “avcılık” ve “savunma” amaçlı kullanım alanları mevcuttur. Gerek askeri gerek sivil alandaki bu yaygın kullanımı, kaçınılmaz bir şekilde yaralanmaların sıklığını da artırmaktadır.[6] ASY, ağır nörolojik ve/veya diğer organ hasarları oluşturan yaralanmalardır. Etyolojide ASY olan periferik sinir yaralamaları ağır nörolojik hasarlar oluşturabilmektedir. Oluşacak hasar kinetik olarak hareket halindeki parçanın kitlesi ve hızının karesi ile bağlantılı olarak sınıflandırılacak olursa yüksek, orta ve düşük hızlı yaralanmalar olarak nitelendirilebilir.[7] Ayrıca parçanın havada yol alırken yaptığı düzgün dönmeler, takla atarak ya da savrularak ilerlemeler gibi değişik gidiş Cilt - Vol. 19 Sayı - No. 3

şekilleri de yaralanmanın tipi ve derecesini etkilemektedir.[8] Doğrudan yaralanmada, parçanın kendisi yaralanmaya neden olabileceği gibi, parçalanan kemik ve disk parçaları da hasar oluşturabilir.[3] Dolaylı yaralanmada kurşunun komşu dokulara olan basınç, şok dalgası ve ısı etkisi ile hasar meydana getirdiği bilinmektedir.[7] Olgularımızda sinire yönelik doğrudan yaralanma yoktu ve sinir bütünlüğü tamdı. Ancak sinirdeki hasar gerek yabancı cismin izlediği yol gerekse intraoperatif gözlemlerimiz ile yaralanmaların dolaylı etki ile oluştuğunu gördük. Sivil yaralanmalar genellikle tabanca mermileriyle meydana gelen düşük hızlı yaralanmalardır. Ana mekanizma doğrudan yaralanma olup, askeri silahlarla meydana gelen yüksek hızlı yaralanmalarla kıyaslandığında oluşan hasar daha sınırlıdır.[3,9] Askeri silahların ateş gücünün çok daha yüksek olması, yani hız ve kitle etkilerinin daha büyük olması ve aynı anda birden çok parçanın hedefe isabet edebilmesi özellikleriyle yukarıda sözü edilen mekanizmaların hepsinin aynı anda oluşması sonucu meydana gelen hasarında Tablo 2. Periferik sinir lezyon dağılımı Sinir lezyonu Siyatik sinir Peroneal sinir Brakiyal pleksus Radiyal Ulnar + Median

Sayı

Yüzde

14 7 4 2 1

50 25 14,2 7,1 3,5 237


Ulus Travma Acil Cerrahi Derg

(a)

(b)

(c)

Şekil 1. Sağ uyluk posteriyolateralinden ateşli silah yaralanmasına bağlı gelişen sağ siyatik sinir hasarı. (a) Sağ gluteus alt kısmından uyluk 2/3 orta kısmına doğru uzanan orta hattan yapılan cerrahi insizyon. (b) Siyatik sinirin kurşun trasesi boyunca skar dokuları tarafından bası altında görünümü. (c) Cerrahi sonrası sağ siyatik sinirin dekomprese edilmiş görünümü (kt: kurşun trasesi; sd: skar dokusu; ss: siyatik sinir; siyah ok: kurşun giriş deliği; beyaz ok: planlanan cerrahi insizyon).

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

derecesini artırmaktadır.[2] Sivil ASY düşük hızlı yaralanmaya bağlı oldugundan cerrahi sonuçları daha yüz güldürücüdür.[10] Bizim 9 olgumuzda tabanca ile olan sivil ASY mevcuttu ve askeri ASY oranla cerrahi sonuçları daha iyi idi. Periferik sinirdeki hasarın seviyesi, eşlik eden yaralanmalar, elektrofizyolojik bulgular, ameliyat süresi, ameliyat sırasındaki bulgular, cerrahi teknik ASY’ye bağlı periferik sinir lezyonları için prognostik faktörlerdir.[11] Yapılan cerrahinin başarı oranı proksimal bölgede düşük iken, bu oran distale doğru gidildikçe artmaktadır.[10] Roganovic[10] Yugoslavya’da iç savaşta meydana gelen ASY’ye bağlı 157 olguluk siyatik sinir lezyonu cerrahisi çalışmasında proksimalde uyluk düzeyinde %10, popliteal düzeyde ise %31 başarı oranı bildirmiştir.

askeri kaynaklardan elde edilebilmektedir.[3] ASY’de periferik sinirler genelde uzunlamasına etkilenmektedir. Cerrahi teknik olarak epinöral onarım uzun yıllardır uygulanan standart bir yöntemdir ve bugün hala önemli bir yere sahiptir.[2,3] Sinir hasarı tamirinde interfasiküler otojen greft kullanımı Milesi ve arkadaşları[12] tarafından tarif edilmiştir. Biz olgularda eğer epinöriyum bütünlüğü korunmuş ise eksternal nöroliz yaptık. Eğer epinöriyum bütünlüğü bozulmuş ve fibrotik bir tabaka ile sinir çevrilmiş ise internal nöroliz uyguladık. Burada önemli nokta sinir anatomisine zarar vermeden OPMİ (Operasyon Mikroskopu) ile fasikülleri eperinöriyumdan diseke ederek serbestleştirmektir. Aksi takdirde cerrahi olarak endikasyonsuz veya deneyimsiz ellerde uygulanacak internal nöroliz fasiküllerde fibrozise neden olabilir.[13]

Cerrahi tedavide sinirin bütünlüğü ve yerleşimine göre eksternal nöroliz, sinir grefti ile interfasiküler anastomoz, fasiküler tamir, internal nöroliz, epinörotomi yapılmaktadır.[2,3] ASY sonrası oluşan periferik sinir lezyonlarına ait tedavi sonuçları ancak eski

Ateşli silah yaralanmalarına bağlı sinir yaralanmalarında genellikle sinirin kendiliğinden iyileşme olasılığı göz önüne alınarak beklenilebilir.[1] ASY dışındaki lezyonlarda tamirin zamanlaması sinir kesi ciddiyetine, eşlik eden kontüzyona, sinirin uzunlama-

Tablo 3. Cerrahi yaklaşım şekilleri ve EMG ile motor kuvvet sonuçları Cerrahi

Ameliyat öncesi EMG

Ameliyat sonrası EMG

Ameliyat öncesi hasta sayısı / motor kuvvet

Ameliyat sonrası hasta sayısı / motor kuvvet

Fasyatomi + dekompresyon

Total lezyon 5 Ağır parsiyel 2 Parsiyel 1

Total lezyon 4 Ağır parsiyel 2 Parsiyel 2

5 / M1 2 / M2 1 / M3

4 / M1 2 / M2 2 / M3

Eksternal epinöroliz + dekompresyon

Total lezyon 3 Ağır parsiyel 5 Parsiyel 8

Total lezyon 1 Ağır parsiyel 3 Parsiyel 7 Tama yakın 5

3 / M1 5 / M2 8 / M3 –

1 / M1 2 / M2 8 / M3 5 / M4

İnternal epinöroliz + dekompresyon

Total lezyon 1 Ağır parsiyel 1 Parsiyel 2

Total lezyon – Ağır parsiyel 1 Parsiyel 2 Tama yakın 1

1 / M1 1 / M2 2 / M3 –

– / M1 1 / M2 2 / M3 1 / M4

EMG: Elektromiyografik inceleme.

238

Mayıs - May 2013


Ateşli silah yaralanmasına bağlı periferik sinir lezyonlarında cerrahi tedavi sonuçlarımız

sına hasarına, lokal doku hasarının decesine ve yara kontaminasyonuna bağlı olarak değişir.[14] Bunların varlığında geç cerrahi önerilir. Cerrahide zamanlama konusunda literatürde bazı yayınlarda normal doku ile defektif doku arasında demarkasyon hattının daha iyi görüldüğü ve sinirdeki ödemin azalması nedeni ile travmadan 3 hafta sonra cerrahi yapılması gerektiği bildirilmiştir.[7] Kline ve arkadaşları[15] ASY’ye bağlı sinir yaralanmalarında 2-5 ay arasında konservatif kalınabileceğini, cerrahi girişimin bu süreden daha uzun bir zamana bırakılmamasını, oluşacak skar dokuları ve yapışıklıkların yapılacak cerrahiyi zorlaştıracağını belirtmişlerdir. Narakas ve arkadaşları[16] ise ASY’ye bağlı brakiyal pleksus yaralanmalarında sinir bütünlüğü bozulmuş seçilmiş olgularda erken dönemde (5-37 gün) greft ile sinir onarımı yaptıklarını, sonuçlarının ise yüz güldürücü olduğunu bildirmişlerdir. Roganovic[10] ASY’ye bağlı sinir yaralanması çalışmasında travma sonrası 7. aydan fazla süre geçmiş olgularda cerrahi tedavi sonuçlarının iyi olmadığını bildirmişdir.Oberlin ve Rantissi[2] ASY’ye bağlı periferik sinir yaralanmalarında erken dönemde (1-2 hafta) cerrahiyi önermişlerdir. Cerrahi tedavide ameliyat bulguların önemli olduğunu, temiz yaralanmalarda sinirin primer dikilebileceğini, özellikle siyatik sinir tamirinde ekstremitelerin fleksiyon-ekstensiyonuna izin vermesine dikkat edilmesi gerektiğini bildirmişlerdir. Bu tür yaralanmalarda sinire doğrudan temas olmasa da basınç ve kavitasyon etkisi ile hasar oluşmaktadır. Biz ateşli silah ile olan yaralanmalarda kopartman sendromu dışında yaralanma sonrası çevre dokuların onarımı için bir süre beklemenin daha iyi olduğu ve mevcut lezyonlarda bu süre içersinde düzelme olabileceği nedeniyle cerrahi tedavi için 5. aya kadar beklenebileceği görüşündeyiz. Ancak bu süre 6 ayı geçmemelidir. Çünkü geç cerrahinin en önemli dezavantajı endonöral tüp ve fasiküllerde zamanla progresif küçülme meydana gelir.[17] Dolayısı ile retrakte sinir uçlarının fibrozis ile kısalması nedeniyle ikinci bir ameliyat daha gerekmektedir. Bu nedenle ilk cerrahi sırasında ikinci bir tamir düşünülen olgularda sinir uçları çevre dokuya tutturulmalıdır. Bu retraksiyonu önler ve daha sonraki cerrahiyi kolaylaştırır.[17] Diğer taraftan kompartman sendromu gelişmesi nöral ve vasküler yaralanmalar açısından acil cerrahi endikasyondur. Kompartman sendromuna bağlı sinir lezyonu gelişmiş 8 olgunun bize başvurusu yaralanmadan bir ay sonraki zaman diliminde idi. Fasyatomi ve dekompresyona rağmen bu olgularımızdaki sonuçlarımızın başarı oranındaki düşüklüğü cerrahinin geç dönemde yapılmış olmasından kaynaklandığı görüşündeyiz. Sonuç olarak, ateşli silah yaralanmasına bağlı periferik sinir lezyonlarında, cerrahi anatomi, cerrahi zamanlama ve yaralanma mekanizmasının detaylı olarak bilinmesi sinir onarımı ve rekonstrüksiyonunda optimal planlama yapılabilmesi için gereklidir. Fakat sinir Cilt - Vol. 19 Sayı - No. 3

onarımında en önemli nokta; uygun zaman diliminde ve uygun bir mikrocerrahi tekniği kullanmaktır. Anahtar noktalar • Askeri yaralanmalarla sivil yaralanmaları ayıran en önemli nokta, yaralanmaya neden olan silahın cinsi ve dolayısı ile bu silahın sahip olduğu ateş gücü ve kitle etkisidir. • Doğrudan yaralanmalarda parçanın kendisi hasara neden olurken, dolaylı yaralanmalarda ise hasarın esas nedeni parçanın hedefe çarptığı anda yarattığı şok dalgası ile meydana gelen basınç ya da oluşan kavitasyona bağlı meydana gelen kompartman sendromudur. • Ateşli silah yaralanmalarının büyük bir kısmında sinir bütünlüğü bozulmaz. Ancak bazen sinirde tam ya da kısmi sinir iletimi kaybı oluşabilir. Bu tür yaralanmalarda sinire direkt temas olmasa da basınç ve kavitasyon etkisi ile hasar oluşmaktadır. • Periferik sinirdeki hasarın seviyesi, eşlik eden yaralanmalar, elektrofizyolojik bulgular, ameliyat süresi, intraoperatif bulgular, cerrahi teknik ASY’ye bağlı periferik sinir lezyonları için prognostik faktörlerdir. • Ateşli silah yaralanmasına bağlı periferik sinir lezyonlarında, cerrahi anatomi, cerrahi zamanlama ve yaralanma mekanizmasının detaylı olarak bilinmesi sinir onarımı ve rekonstrüksiyonunda optimal planlama yapılabilmesi için gereklidir. • Cerrahi tedavide sinirin bütünlüğü ve lokalizasyonuna göre; eksternal nöroliz, sinir grefti ile interfasiküler anastomoz, fasiküler tamir, internal nöroliz ve epinörotomi yapılmaktadır. • Eğer epinöriyum bütünlüğü bozulmuş ve fibrotik bir tabaka ile sinir çevrilmiş ise internal nöroliz uygulanmalıdır. • Ateşli silah ile olan yaralanmalarda kopartman sendromu dışında yaralanma sonrası çevre dokuların onarımı için bir süre beklenebilir ve mevcut lezyonlarda bu süre içersinde düzelme olabileceği nedeniyle cerrahi tedavi için 5. aya kadar beklenebilir. • Geç cerrahinin en önemli dezavantajı endonöral tüp ve fasiküllerde zamanla progresif küçülme meydana gelmesidir. Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması yoktur.

KAYNAKLAR 1. Persad IJ, Reddy RS, Saunders MA, Patel J. Gunshot injuries to the extremities: experience of a U.K. trauma centre. Injury 2005;36:407-11. 2. Oberlin C, Rantissi M. Gunshot injuries to the nerves. Chir Main 2011;30:176-82. 3. Secer HI, Daneyemez M, Tehli O, Gonul E, Izci Y. The clinical, electrophysiologic, and surgical characteristics of pe239


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4.

5. 6. 7. 8.

9.

ripheral nerve injuries caused by gunshot wounds in adults: a 40-year experience. Surg Neurol 2008;69:143-52. Uzun N, Tanriverdi T, Savrun FK, Kiziltan ME, Sahin R, Hanimoglu H, et al. Traumatic peripheral nerve injuries: demographic and electrophysiologic findings of 802 patients from a developing country. J Clin Neuromuscul Dis 2006;7:97-103. Taylor CA, Braza D, Rice JB, Dillingham T. The incidence of peripheral nerve injury in extremity trauma. Am J Phys Med Rehabil 2008;87:381-5. Çoltu A, Durak D. Adli otopsileri yapılmış 141 ateşli silah yaralanmasına bağlı ölüm olgusunun retrospektif incelenmesi. Adli Tıp Derg 1992;8:49-51. Kahraman S, Gonul E, Kayali H, Sirin S, Duz B, Beduk A, Timurkaynak E. Retrospective analysis of spinal missile injuries. Neurosurg Rev 2004;27:42-5. Yücel F. Çeşitli av tüfeği ve fişekleri ile yapılan atışlarda hedefte görülen namlu ürün artıklarına göre atış mesafesinin belirlenmesi (Tez). Cumhuriyet Üniversitesi, Adli Tıp Anabilim Dalı Uzmanlık Tezi; 1997. Yegiyants S, Dayicioglu D, Kardashian G, Panthaki ZJ. Traumatic peripheral nerve injury: a wartime review. J Craniofac Surg 2010;21:998-1001.

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10. Roganovic Z. Missile-caused median nerve injuries: results of 81 repairs. Surg Neurol 2005;63:410-9. 11. Khan R, Birch R. Latropathic injuries of peripheral nerves. J Bone Joint Surg Br 2001;83:1145-8. 12. Millesi H, Meissl G, Berger A. Further experience with interfascicular grafting of the median, ulnar, and radial nerves. J Bone Joint Surg Am 1976;58:209-18. 13. Thomas MB. Nerve repair and grafting. In: Green DP, Hotchkiss RN, Pederson WC, editors. Green’s operative hand surgery. Philadelphia: Churchill livingstone; 1999. p. 1381-404. 14. Dagum AB. Peripheral nerve regeneration, repair, and grafting. J Hand Ther 1998;11:111-7. 15. Kim DH, Murovic JA, Tiel RL, Kline DG. Penetrating injuries due to gunshot wounds involving the brachial plexus. Neurosurg Focus 2004;16:E3. 16. Narakas A, Bonnard C, Slooff B. Brachial plexus lesions. Drawings of explorations and reconstructions by Algimantas Otonas Narakas. Berlin Heidelberg New York: SpringerVerlag; 1999. 17. Topuz K, Eroğlu A, Atabey C, Göçmen S, Kutlay M, Demircan MN. Periferik sinir yaralanmalarında geç dönem cerrahi tedavi sonuçlarımız. Türk Nöroşirürji Dergisi 2011;1:8-13.

Mayıs - May 2013


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):241-245

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.64927

The role of bedside ultrasonography for occult scaphoid fractures in the emergency department Acil serviste gizli skafoid kırıkları için yatakbaşı ultrasonografinin rolü Ahmet YILDIRIM, Erden Erol ÜNLÜER, Nergiz VANDENBERK, Arif KARAGÖZ

BACKGROUND

AMAÇ

Our aim is to study the accuracy of emergency medicine (EM) physician-performed, bedside ultrasonography (BUS) in patients with clinical suspicion of scaphoid fracture and normal radiographs.

Amacımız, skafoid kırığı yönünden klinik şüphe taşıyan fakat radyografileri normal olan hastalarda acil tıp hekimi tarafından yapılan yatakbaşı ultrasonografinin (USG) doğruluğunu araştırmaktır.

METHODS

GEREÇ VE YÖNTEM

From January to December 2011, an EM physician used BUS to prospectively evaluate patients presenting to the emergency department (ED) with clinical suspicion of scaphoid fracture and normal radiographs. BUS examination of the scaphoid was conducted prior to a wrist magnetic resonance imaging (MRI) scan, within 24 hours of wrist trauma. The outcome was determined by official radiology reports of the MRI. The results were compared using the chi-square test.

2011 yılı Ocak-Aralık ayları arasında bir acil tıp hekimi, acile başvuran ve skafoid kırığı yönünden klinik şüphe taşıyan fakat radyografileri normal olan hastaları ileriye dönük olarak değerlendirmek için yatakbaşı USG’yi kullandı. Yatakbaşı USG, el bileği travmasını izleyen ilk 24 saat içinde ve el bileğinin manyetik rezonans (MR) görüntüleme incelemesinden önce uygulandı. Sonuç, MR görüntülemenin resmi radyolojik raporuyla belirlendi. Sonuçlar istatistiksel olarak ki-kare testi ile karşılaştırıldı.

RESULTS

BULGULAR

Of the 63 enrolled patients, 12 Patients were BUS-positive. Of these, MRI results agreed with the BUS findings in 12 patients who had cortical damage of the scaphoid with hematoma. In 35 instances, hematoma with no cortical damage was detected with BUS and corroborated by MRI. A scaphoid fracture was demonstrated by MRI in two patients from this group. The sensitivity, specificity, positive predictive value, negative predictive value, and negative likelihood ratio for BUS were 85.7%, 100%, 100%, 100% and 0.14, respectively. Accuracy of BUS was not statistically different from MRI. CONCLUSION

The diagnosis of scaphoid fractures is another BUS application in the ED. EM physicians should consider diagnosis of scaphoid fractures using BUS in the emergency department. Key Words: Bedside ultrasonography; emergency; fracture; scaphoid.

Department of Emergency Medicine, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey.

Çalışmaya alınan 63 hastanın 12’sinde yatakbaşı USG ile kırık saptandı. Bu 12 hastanın tamamında MR görüntülemede skafoid kemikte kortikal hasar ve hematom izlendi ve sonuç yatakbaşı USG’yi doğruladı. Otuz beş hastada ise yatakbaşı USG ile kortikal hasar olmadan hematom saptandı ve MR görüntüleme ile bu bulgu doğrulandı. Bu gruptaki 2 hastada MR görüntüleme ile skafoid kırığı saptandı. Yatakbaşı USG için duyarlılık, özgüllük, pozitif prediktif değer, negatif prediktif değer ve negatif olabilirlik oranı sırasıyla %85,7, %100, %100, %100 ve 0,14’tür. Yatakbaşı USG’nin doğruluğu istatistiksel olarak MR görüntülemeden farklı değildir. SONUÇ

Skafoid kırıklarının tanısı, acil serviste yatakbaşı USG’nin başka bir uygulama alanıdır. Acil tıp hekimleri, acil serviste skafoid kırıklarının tanısını yatakbaşı USG’yi kullanarak koyabilirler. Anahtar Sözcükler: Yatakbaşı ultrasonografi; acil; kırık; skafoid.

İzmir Katip Çelebi Üniversitesi, Atatürk Eğitim ve Araştırma Hastenesi, Acil Tıp Kliniği, İzmir.

Correspondence (İletişim): Erden Erol Ünlüer, M.D. İzmir Katip Çelebi Üniv., Atatürk Eğitim ve Araştırma Hastanesi, Acil Tip Klinigi, 35000 İzmir, Turkey. Tel: +90 - 232 - 244 44 44 / 2696 e-mail (e-posta): erdenun@yahoo.com

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Traumatic injury of the wrist is a common reason for patients to visit an emergency department (ED). Wrist trauma is a frequent cause of consultation in the emergency room that effects all ages but predominantly young patients. The scaphoid is one of the most frequently fractured carpal bones.[1] The evaluation of the wirst and hand injury generally consists of patient history and physical examination that is frequently complemented with diagnostic imaging. The clinical criteria for diagnosis of a suspected scaphoid fracture are wrist pain associated with tenderness on axial loading of the first ray of the elbow bones and swelling with tenderness at palpation of the anatomic snuffbox. Moreover, some fractured scaphoids may be occult at presentation and cannot be seen on the initial direct Xrays ordered after trauma. The routine radiographic series ordered for a suspected scaphoid fracture includes a neutral posteroanterior view and a lateral projection of the wrist, together with additional views such as a semipronated oblique scaphoid view, and a posteroanterior view with ulnar deviation. Nevertheless, 2025% of patients with fractured scaphoid have positive findings in physical examination but normal radiology reports following direct X-ray.[2] Magnetic resonance imaging (MRI) is a more appropriate diagnostic modality for demonstration of a scaphoid fracture, but the high costs and limited availability, as well as the long duration of the examination, have been a major hindrance to a wide application of MR imaging for wrist and hand injury. The technological development of ultrasound equipment and the availability of high frequency electronic transducers allows for an accurate evaluation of scaphoid fracture. In this study, we aimed to determine the accuracy of EM physician-performed bedside ultrasonography (BUS) in patients with history of hand trauma and suspected scaphoid fractures.

Fig. 1. Orientation of ultrasonography probe while longutudinal scanning of the scaphoid bone. (Color figur can be viewed in the online issue, which is avail able at www.tjtes.org).

Between January and December 2011, during shifts when one of the trained EM physicians was working in the ED, patients over 18 years old with clinical suspicion of a scaphoid fracture and radiographs underwent BUS examination of the scaphoid prior to a wrist MRI within 24 hours of wrist trauma. The clinical criteria for a suspected scaphoid fracture were wrist pain associated with tenderness on axial loading of the first ray and swelling and tenderness at palpation of the anatomic snuffbox. The routine radiographic series for a suspected scaphoid fracture consisted of a neutral posteroanterior and a lateral projection of the wrist together with additional views of the scaphoid, a semi-pronated oblique scaphoid, and a posteroanterior

MATERIALS AND METHODS The Ethics Committee of a local tertiary care government teaching hospital approved our study protocol. Sixty-three consecutive adult patients older than 18 years, admitted to our emergency department with clinical suspicion of scaphoid fracture and normal radiographs, underwent BUS examination of the scaphoid prior to a wrist MRI scan within 24 hours of wrist trauma. BUS examinations were performed by EM physicians who had undergone six hours of didactic and three hours of hands-on training with a radiologist in hand and wrist ultrasound techniques and the diagnosis of scaphoid fractures. The EM physicians examined patients for the presence of a cortical interruption of the scaphoid along with a radiocarpal or scaphotrapezium trapezoid effusion. 242

Fig. 2. Longitudinal view of the scaphoid bone with ultrasound shows cortical discontinuity (white arrows), along with radio-carpal effusion and surrounding hematoma, suggestive of scaphoid fracture (white arrow head). May覺s - May 2013


The role of bedside ultrasonography for occult scaphoid fractures in the emergency department

Table 1. Comparision of MR image and BUS findings in the diagnosis of scaphoid fracture

MR image Fracture positive

Fracture negative

Total

BUS

n

%

n

%

n

%

Fracture positive Fracture negative Total

10 0 10

100.0 0.0 22.2

23 12 35

65.7 34.3 77.8

33 12 45

73.3 26.7 100.0

BUS: Bedside ultrasonography; MR: Magnetic resonance.

view with the wrist in ulnar deviation. Patients with positive radiographs for scaphoid or other wrist bone fractures were excluded from the study. Immediately following the clinical examination, US was performed by the emergency physician. Images were obtained using the standard equipment available in the emergency department (DC 3, Mindray Bio-medical Electronics Co., Shenzhen, China), with a small, compact linear (5-13 MHz) transducer for superficial structures. The examination was made through transmission sonographic gel. Using the anatomical landmarks of the wrist, and commencing the examination at the radius, the scaphoid was identified by its bi-lobed or peanut shape with a smooth and hyperechoic bone surface contour.[3] In order to correctly elongate the scaphoid, the hand was positioned in ulnar deviation, both in frontal and sagittal planes. A neutral frontal plane image, with the palm lying on the table, was also obtained to assess the dorsal aspect of the bone (Fig. 1). Using these different wrist positions, BUS examination covered the volar, dorsal, and lateral aspects of the scaphoid, with images obtained in the longitudinal and axial planes of the bone. The radiocarpal and midcarpal recesses were inspected in the sagittal plane, for both the dorsal and volar planes of examination.[3,4] The emergency medicine physician was asked to assess the continuity of the scaphoid cortex (seen as a smooth, thin, hyperechoic line) and the presence of fluid effusion in the radioscaphoid and scaphotrapezium trapezoid spaces (Fig. 2).[3,5] Signs associated with scaphoid fracture were either the cortical disruption of the scaphoid contour, producing a focal deformity, or hemarthrosis, seen as hypoechoic fluid in the radioscaphoid or scaphotrapezium trapezoid spaces. [6,7] These findings have been reported in the literature as the most suggestive signs associated with scaphoid fracture.[3,5,8] MRI of the wrist was performed within 24 hours of the sonographic examination. The patient was placed prone on the examination table, with the hand positioned in full pronation. Images were routinely reformatted with a 2 mm thickness in coronal and sagittal planes. Immediately after BUS Cilt - Vol. 19 Sayı - No. 3

scanning, an MRI was performed by a radiologist. The radiologist’s official report of the MR images was accepted as definitive in this study. Data analysis Sensitivities, specificities, positive predictive values (PPVs), and negative predictive values (NPVs) of BUS were calculated and analyzed using SPSS, version 15.0 (SPSS, Inc, Chicago, USA). The chi-square test and the kappa statistic were used to compare EM physicians.

RESULTS During the study period, 63 patients with suspected wrist injuries were evaluated by the study physicians in our ED. All 63 patients (52.4% female, mean age 39.6±18.3 years, range 18-79 years of age) agreed to participate in the study. A scaphoid fracture was eventually demonstrated by MRI scan in 14 patients. BUS examination revealed signs suggestive of scaphoid fracture in 12 of the 14 patients with an MRI proven fracture. Of these, 12 were corroborated by MR images (true positive), and 0 found to be negative (false negative) (Table 1). In 45 cases, BUS was negative for scaphoid fracture, of which two were revealed to have a scaphoid fracture following the MRI (false negatives; Table 2). The results of BUS diagnoses of scaphoid fractures are listed in Table 2. The diagnostic accuracy of BUS Table 2. Results for bedside ultrasonography for diagnosis of scaphoid fracture Sensitivity Specificity Positive predictive value Negative predictive value + Likelihood radio – Likelihood radio Area under curve

Bedside 95% CI ultrasonography 100.0 34.29 30.3 100.0 1.52 0.00 0.671

69.2-100.0 19.1-52.2 15.6-48.7 73.5-88.8 1.0-2.4 – 0.515-0.804 243


Ulus Travma Acil Cerrahi Derg

and MRI did not differ significantly (kappa=0.188, p=0.031). A receiver operating characteristic (ROC) curve analysis was conducted to illustrate the performance of BUS in the diagnosis of scaphoid fractures (Table 2).

DISCUSSION EM physicians have used BUS to evaluate trauma patients since the early 1980s.[9-12] There is a growing body of evidence that patient care improves when ultrasound is included in the diagnostic workup of multiple-trauma patients.[13,14] Deployment of ultrasound in emergency departments could potentially provide critical information concerning traumatized patients and thereby optimize patient care. Ultrasonography has been widely used by emergency physicians to accurately diagnose many disease processes at the bedside with high sensitivity and specificity.[15-18] Improvements in ultrasound technology, and increasing clinical experience with ultrasonography, has led to its common use in situations such as thoracoabdominal trauma, ectopic pregnancy, abdominal aortic aneurysm, pericardial effusion, cardiac arrest, biliary disease, renal tract disease, and small bowel obstruction, and in procedures such as lumbar puncture, arthrocentesis and central venous access.[18-20] As a result, the emergency physician is ideally suited for the use of ultrasound technology at the patient’s bedside since these physicians are frequently presented with acutely ill or injured patients requiring immediate treatment. Traumatic injury of an extremity is one of the most common reasons for patients to visit an ED. The technological development of ultrasound equipment, and the availability of high frequency electronic transducers, allows an accurate evaluation of scaphoid fractures. Our study is one of the first to demonstrate the ability of EM physicians to evaluate scaphoid fractures using BUS. The results of our study suggest that the accuracy of BUS assessment performed by EM physicians trained in wrist and hand ultrasonography is comparable to that of radiologists performing US, and the two methods correlated well in this study. To our knowledge, this is the first study to assess the accuracy of BUS when performed by EM physicians trained in the performance and interpretation of this technique in relation to wrist joints. One limitation of our study was that the EM physicians were aware of the patients’ clinical assessments. Since the EM physicians knew they were being evaluated, they may have been more motivated to enhance their performance according to the criteria being studied. Since no standards exist for training EM physicians in the use of BUS for wrist joint evaluation, we cannot assume that our training program was 244

adequate. Further research needs to be performed to validate our suggested BUS methodology for detecting scaphoid fractures. In conclusion, the use of BUS in the ED to evaluate damage to wrist joints has the potential to improve the time required to diagnose fractures and to provide prompt care for patients with wrist and hand trauma. Our study shows that EM physicians can perform BUS to detect scaphoid fractures in the ED with a high degree of accuracy. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Haisman JM, Rohde RS, Weiland AJ; American Academy of Orthopaedic Surgeons. Acute fractures of the scaphoid. J Bone Joint Surg [Am] 2006;88:2750-8. 2. Hauger O, Bonnefoy O, Moinard M, Bersani D, Diard F. Occult fractures of the waist of the scaphoid: early diagnosis by high-spatial-resolution sonography. AJR Am J Roentgenol 2002;178:1239-45. 3. Jacobson JA. Fundamentalis of musculosketeal ultrasonud. Philadelphia: Saunders Elsevier; 2007. 4. Herneth AM, Siegmeth A, Bader TR, Ba-Ssalamah A, Lechner G, Metz VM, et al. Scaphoid fractures: evaluation with high-spatial-resolution US initial results. Radiology 2001;220:231-5. 5. Schubert HE. Scaphoid fracture. Review of diagnostic tests and treatment. Can Fam Physician 2000;46:1825-32. 6. Jelbert A, Vaidya S, Fotiadis N. Imaging and staging of haemophilic arthropathy. Clin Radiol 2009;64:1119-28. 7. Zukotynski K, Jarrin J, Babyn PS, Carcao M, PazminoCanizares J, Stain AM, et al. Sonography for assessment of haemophilic arthropathy in children: a systematic protocol. Haemophilia 2007;13:293-304. 8. Fusetti C, Poletti PA, Pradel PH, Garavaglia G, Platon A, Della Santa DR, et al. Diagnosis of occult scaphoid fracture with high-spatial-resolution sonography: a prospective blind study. J Trauma 2005;59:677-81. 9. Viscomi GN, Gonzalez R, Taylor KJ, Crade M. Ultrasonic evaluation of hepatic and splenic trauma. Arch Surg 1980;115:320-1. 10. Weill F, Bihr E, Rohmer P, Zeltner F, Le Mouel A, Perriguey G. Ultrasonic study of hepatic and splenic traumatic lesions. Eur J Radiol 1981;1:245-9. 11. Tso P, Rodriguez A, Cooper C, Militello P, Mirvis S, Badellino MM, et al. Sonography in blunt abdominal trauma: a preliminary progress report. J Trauma 1992;33:39-43. 12. Rozycki GS, Ochsner MG, Jaffin JH, Champion HR. Prospective evaluation of surgeons’ use of ultrasound in the evaluation of trauma patients. J Trauma 1993;34:516-27. 13. Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med 2006;48:227-35. 14. Ollerton JE, Sugrue M, Balogh Z, D’Amours SK, Giles A, Wyllie P. Prospective study to evaluate the influence of FAST on trauma patient management. J Trauma 2006;60:785-91. 15. Rowland JL, Kuhn M, Bonnin RL, Davey MJ, Langlois SL. Accuracy of emergency department bedside ultrasonograMayıs - May 2013


The role of bedside ultrasonography for occult scaphoid fractures in the emergency department

phy. Emerg Med (Fremantle) 2001;13:305-13. 16. Brooks A, Davies B, Smethhurst M, Connolly J. Prospective evaluation of non-radiologist performed emergency abdominal ultrasound for haemoperitoneum. Emerg Med J 2004;21:e5. 17. Soyuncu S, Cete Y, Bozan H, Kartal M, Akyol AJ. Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal haemorrhage in blunt abdominal trauma. Injury 2007;38:564-9. 18. Davis DP, Campbell CJ, Poste JC, Ma G. The association be-

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tween operator confidence and accuracy of ultrasonography performed by novice emergency physicians. J Emerg Med 2005;29:259-64. 19. American College of Emergency Physicians. American College of Emergency Physicians. Use of ultrasound imaging by emergency physicians. Ann Emerg Med 2001;38:469-70. 20. Unlüer EE, Yavaşi O, Eroğlu O, Yilmaz C, Akarca FK. Ultrasonography by emergency medicine and radiology residents for the diagnosis of small bowel obstruction. Eur J Emerg Med 2010;17:260-4.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):246-250

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.75688

Predominant causes and types of orofacial injury in children seen in the emergency department Acil servise başvuran çocuk hastalarda gözlenen orafasiyel yaralanma tipleri ve sık karşılaşılan nedenleri Gamze AREN,1 Elif SEPET,1 Arzu PINAR ERDEM,1 Ceren Güney TOLGAY,1 Sinem KURU,1 Cemalettin ERTEKİN,2 Recep GÜLOĞLU,2 Acar AREN3

BACKGROUND

AMAÇ

The aim of this study is to determine the type and cause of traumatic orofacial injuries in children up to 18 years of age.

Bu çalışmanın amacı, 18 yaşına kadar olan çocuk hastalarda travma nedeniyle oluşan orafasiyel yaralanmaların tipini ve nedenlerini belirlemektir.

METHODS

GEREÇ VE YÖNTEM

This retrospective study involved data collected from 12055 patients that came to Istanbul University, Medical Faculty, Department of Emergency in 2011. The patients’ data were evaluated with regard to age, gender, etiologic factor of the trauma, type and localization of the injury, and time interval between injury and treatment.

Bu geriye dönük çalışma, 2011 yılında İstanbul Üniversitesi Tıp Fakültesi Acil Servis’ine başvuran 12055 hastadan toplanan bilgileri kapsamaktadır. Hastalardan elde edilen bilgiler yaş, cinsiyet, travmanın etyolojisi, tipi, yerleşimi ve yaralanma ile tedavi arasındaki zaman aralığı dikkate alınarak değerlendirildi.

RESULTS

BULGULAR

A total of 1296 children in 12055 patients with orofacial trauma were evaluated. Trauma incidence was higher in boys (65%). The major etiologic factor of injury was falls (56%) and primary localization was in the frontal region (41%). The most frequent types of injury were laceration (30.1%) and hematoma (18.6%). 4% of the injuries were found in the orodental region including lips, teeth, tongue and oral mucosa of the mouth. 38% of the patients came to the emergency department within 30-60 minutes after the injury and 68% were sent home with symptomatic treatment.

Orafasiyel yaralanma gözlenen 12055 hastadan 1296 çocuk hasta değerlendirmeye alındı. Erkek çocuklarda travma görülme sıklığının daha fazla olduğu saptandı (%65). Yaralanmalarda başlıca nedenin düşme (%56) ve birincil lokasyonun frontal bölge olduğu (%41) belirlendi. En sık karşılaşılan yaralanma tipinin laserasyon (%30,1) ve hematom (%18,6) olduğu saptandı. Yaralanmaların %4’ünün oradental bölgede olduğu dudakları, dişleri, dil ve oral mukazayı kapsadığı belirlendi. Hastaların %38’inin acil servise yaralanmadan 30-60 dakika sonra başvurduğu ve %68’inin semptomatik tedaviden sonra taburcu edildiği belirlendi.

CONCLUSION

SONUÇ

Considering the high percentage of orofacial traumas, effective education is necessary regarding the appropriate diagnostic approach, emergency management and prevention of traumatic dental injuries.

Sık karşılaşılan orafasiyel travmalar göz önünde bulundurularak doğru tanı, acil tedavi yaklaşımı ve travmatik dental yaralanmaları önlemek adına etkin eğitimin gerekli olduğu unutulmamalıdır.

Key Words: Child; orofacial trauma; tooth.

Anahtar Sözcükler: Çocuk; orafasiyel travma; diş.

1 Department of Pedodontics, Istanbul University Faculty of Dentistry, Istanbul; 2Department of General Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul; 3Department of General Surgery, Istanbul Education and Research Hospital, Istanbul.

İstanbul Üniversitesi Diş Hekimliği Fakültesi, Pedodonti Anabilim Dalı, İstanbul; 2İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul; 3İstanbul Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul.

1

Correspondence (İletişim): Gamze Aren, M.D. İstanbul Üniversitesi Diş Hekimliği Fakültesi, Pedodonti Anabilim Dalı, Kat: 3, Fatih, İstanbul, Turkey. Tel: +90 - 212 - 414 20 20 / 30283 - 3030 e-mail (e-posta): gamzearen@hotmail.com

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Predominant causes and types of orofacial injury in children seen in the emergency department

Orofacial trauma is a serious public health problem among children, with most injuries constituting dental emergencies that require immediate assessment and management.[1] Dental-related emergencies including orofacial traumas and their dental complications commonly present for management by medical practitioners through hospital Emergency Departments (ED) and consulting rooms.[2] Whereas trauma to the facial bone structures is usually referred to oral and maxillofacial or plastic surgeons,[3] mild to moderate dental trauma and associated dental pain are collectively often not seen to be as important or might be overlooked in the context of other injuries. If there is delayed or lack of treatment, these conditions often have a persistent and negative effect on patients in terms of both cost and suffering.[4-6] Over the past three years, a number of studies have reported the types and prevalence of orofacial injuries seen in hospital emergency departments.[1] The information gathered in these studies provides useful descriptions of the common types of traumatic oral injuries that pediatric emergency care providers may encounter. Studies of the incidence, etiology, and distribution of these traumatic injuries provide health care planners with pertinent information to determine what types of emergency services should be available in the emergency department setting. The aim of this retrospective study is to determine the type and etiology of traumatic orofacial injuries, including injuries to soft tissue and bones, seen in children up to 18 years of age who came to Istanbul University Faculty of Medicine , Istanbul from Jan 1, 2011, to Dec. 31, 2011 and to determine the referral patterns for further treatment.

MATERIALS AND METHODS A retrospective design was used to address the aim of this investigation. Patient records and corresponding standard trauma form for 2011 were analysed retrospectively. All information regarding dental trauma was carefully screened, classified and allocated according to gender, age of the child at the time of trauma, type of injury, etiologic factors, injured region, treatment and the time elapsed between trauma and emergency care and diagnosis including soft tissue and bone injuries. Cases where the treatment protocol was insufficiently documented were grouped separately. RESULTS This retrospective study included patients between the ages of 0-18 years, visiting the Emergency Service Department at Istanbul University Faculty of Medicine, Istanbul, with dentofacial complaints during the year 2011. Of the 12055 examined records, 1296 patients met the study criteria. Trauma incidence was Cilt - Vol. 19 Say覺 - No. 3

higher in boys (65.0%) and in children less than five years of age (57.4%). The gender distribution of patients is shown in Table 1. Table 1. Gender distribution of patients with orofacial trauma Gender

n

%

Male Female

837 459

65 35

Table 2. Prevalence of orofacial trauma by age Age distribution 0 - 1 years 1 - 2 years 2 - 5 years 6 - 10 years 11 - 18 years

n

%

37 177 531 306 245

2.8 13.6 41 23.7 18.9

Table 3. Distribution of episodes of orofacial trauma by etiologic factor Fall Hitting the head Traffic accident Being hit by a sharp object Assault Epileptic seizure Burn Suicide Self-destructive behaviour Syncope Drowning

n

%

730 365 100 49 39 2 2 1 1 1 1

56 28.1 7.7 3.7 3 0.15 0.15 0.05 0.05 0.05 0.05

Table 4. Prevalence of orofacial trauma by the localization of the injury Localization of the injury Frontal region Parietal region Nasal region Orbital region Occipital region Eyebrows Orodental region Mandibular region Maxillary region Unspecific localization Cheeks Ears Zygoma Glabella Neck

n

%

734 220 173 171 156 103 83 52 20 28 17 15 11 6 5

41 12.2 10 9.9 9 5 4 3 1.6 1.4 1 0.8 0.6 0.3 0.2 247


Ulus Travma Acil Cerrahi Derg

The prevalence of orofacial injuries in patients according to their age at the time of trauma was higher in younger children (Table 2). When considered separately, trauma caused by falls was the most predominant etiologic factor (56.0%) as shown in Table 3. In the 1296 patients, orofacial injuries were seen in 1794 different locations, with some patients having more than one injured region. The frontal region was the most affected area (41%); the distribution is shown in Table 4. A total of 83 injuries were seen in the orodental region, involving the lips, teeth, oral mucosa, tongue and gingiva. Lips (79.5%) were the most affected area followed by teeth (15.7%) (Table 5). Soft tissue injuries, including lacerations, hematomas, and abrasions, were present in 65.2% of our study group (Table 6). Patients sought help for primary care at the emergency department of Medical Faculty of Istanbul. For 1275 injuries, it was possible to evaluate time elapsed between the trauma and the initial treatment. 97% of the patients came to the emergency department within the first 24 hours after injury (Table 7). Symptomatic treatment was the most frequently observed treatment. After primary trauma care, 68% of the patients were sent home with medical advice; 160 patients (12.2%) were sent to other clinics but none of them were sent for dental consultation within the first 24 hours. 60 patients (4.8%) overruled any treatment options and 46 of them (3.5%) left without permission (Table 8).

DISCUSSION The determination of the incidence and prevalence of orofacial trauma has some difficulties. For example, there are many different specifications of dental and oral trauma reported in the literature.[7-12] Determining the incidence of a particular event requires information on the number of new cases in a specified time period divided by the number of persons exposed to the risk during this period.[7] The prevalence of orofacial trauma in various epidemiological studies has also been found to differ considerably. The great variation may be due to a number of different factors such as the trauma classification, and geographical and behavioral differences between study locations and countries. [7] This study evaluated orofacial trauma and injuryassociated factors in children who visited an emergency department. A total of 1296 children in 12055 patients with orofacial trauma from 0 to 18 years of age were evaluated. Most of the orofacial trauma data available in the literature has been collected retrospectively from cross-sectional studies or from longitudi248

Table 5. Distribution of orodental region injuries Injuries in orodental region

n

%

Lips Teeth Oral mucosa Tongue Gingiva

66 13 2 1 1

79.5 15.7 2.4 1.2 1.2

Table 6. Prevalence of injury type in all patients Type of injury Laceration Hematoma Abrasion Swelling Ecchymosis Fracture Hypersensitivity Hemorrhage Hyperemia Otorrhea Dental injuries Epistacsis Deformity Pain Paralysis Deviation Finger marks Burn

n

%

428 262 226 148 138 135 32 15 12 7 4 3 3 2 2 1 1 1

30.1 18.6 16.5 10.6 10 9.5 2.3 1 0.8 0.4 0.05 0.04 0.04 0.02 0.02 0.01 0.01 0.01

Table 7. Distribution of the time period between injury and treatment in orofacial trauma patients Time elapsed before treatment 0-30 minutes 30 min-1 hour 1-6 hours 6-24 hours >24 hours

n

%

325 484 322 91 43

26 38 26 7 3

Table 8. Distribution of treatments for orofacial trauma patients Symptomatic treatment Hospitalization Department of Plastic Surgery Denial of treatment Absence without permission Department of Orthopedics Department of Otorhinolaryngology Department of Pediatrics Department of Neurology Department of Ophthalmology

n

%

877 148 101 60 46 24 23 4 4 4

68 11.6 7.8 4.8 3.5 1.8 1.7 0.3 0.3 0.3

May覺s - May 2013


Predominant causes and types of orofacial injury in children seen in the emergency department

nal studies of patient records.[1-7] In the current study, the assessment of standardized trauma records with information collected at the time of assistance enables the authors to obtain more reliable data relative to previous retrospective studies in which injuries were only registered if signs and/or symptoms were evident at the time of examination. An obvious difference was observed between genders affected by orofacial trauma. There is a consensus among international studies that boys experience significantly more dental injuries to permanent dentition than girls.[1,13,14] In our study trauma incidence was higher in boys (65.0%) Younger children are more susceptible to orodental trauma when they are learning to walk, combined with other behavioral factors, including their curiosity and lack of danger perception; these factors are known to contribute to facial trauma.[1,15-21] In fact, these occurred commonly as children became ambulatory but had not yet developed mature motor skills.[22] The findings of this study show a higher percentage of younger children, especially at the preschool age, with a history of orofacial trauma. The major etiologic factor of injury was falls (56%) and primary localization was in the frontal region (41%). Wilson et al. described a common scenario of lacerations occuring when a toddler bit the tongue or lip as the mandible struck an object during a fall.[23] This resulted from a younger child’s inability to use his or her upper extremities for bracing during a fall. [22,23] In our study, 4% of the injuries were found in the orodental region, which included lips, teeth, tongue and oral mucosa of the mouth. The time elapsed between trauma and treatment was divided into five categories in this study: 0-30 min (26%), 30 min-1 hour (38%), 1-6 hours (26%), 6-24 hours (7%) and >24 hours (3%). The percentage of children who came to the ED during the first 24 hours (97%) was high compared to other studies. The time delay between injury and treatment fell into the category of “1 day” for most of the cases. This study underlines the importance of extensive teaching on dental trauma for those who staff the ED. Despite the large number of patients, the hospital had no ED coverage by dentists during the study period. As a result, dental diagnosis and treatment were left to the general and plastic surgeons who staffed the ED. Education and training in the management of dental emergencies by medical practitioners might be inadequate. [2] This means that it is possible that some dental diagnoses were not labeled as such, while some of those labeled as dental were not. The findings of this study revealed that none of the patients who suffered from orodental trauma were sent for dental consultation. Cilt - Vol. 19 Sayı - No. 3

Traumatic injuries in children and adolescents are a common problem and several studies have reported that the prevalence of these injuries has increased during the past few decades.[7] In order to give proper emergency treatment to orofacial trauma cases, it is necessary to set up dental consultation and continuing education for ED physicians on dental emergency procedures. Acknowledgements This study was supported by the Research Found of the University of Istanbul (Project No: UDP-26573) Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Assunção LR, Ferelle A, Iwakura ML, Nascimento LS, Cunha RF. Luxation injuries in primary teeth: a retrospective study in children assisted at an emergency service. Braz Oral Res 2011;25:150-6. 2. Skapetis T, Gerzina T, Hu W. Management of dental emergencies by medical practitioners: recommendations for Australian education and training. Emerg Med Australas 2011;23:142-52. 3. Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 5: Dentoalveolar injuries. Emerg Med J 2007;24:429-30. 4. Tham RC, Cassell E, Calache H. Traumatic orodental injuries and the development of an orodental injury surveillance system: a pilot study in Victoria, Australia. Dent Traumatol 2009;25:103-9. 5. Shortridge EF, Moore JR. Use of emergency departments for conditions related to poor oral healthcare: implications for rural and low-resource urban areas for three states. J Public Health Manag Pract 2009;15:238-45. 6. Oliva MG, Kenny DJ, Ratnapalan S. Nontraumatic dental complaints in a pediatric emergency department. Pediatr Emerg Care 2008;24:757-60. 7. Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: a review of the literature. Aust Dent J 2000;45:29. 8. Stockwell AJ. Incidence of dental trauma in the Western Australian School Dental Service. Community Dent Oral Epidemiol 1988;16:294-8. 9. Perez R, Berkowitz R, McIlveen L, Forrester D. Dental trauma in children: a survey. Endod Dent Traumatol 1991;7:2123. 10. Galea H. An investigation of dental injuries treated in an acute care general hospital. J Am Dent Assoc 1984;109:4348. 11. Oulis CJ, Berdouses ED. Dental injuries of permanent teeth treated in private practice in Athens. Endod Dent Traumatol 1996;12:60-5. 12. Calişkan MK, Türkün M. Clinical investigation of traumatic injuries of permanent incisors in Izmir, Turkey. Endod Dent Traumatol 1995;11:210-3. 13. Altun C, Ozen B, Esenlik E, Guven G, Gürbüz T, Acikel C, Basak F, Akbulut E. Traumatic injuries to permanent teeth in Turkish children, Ankara. Dent Traumatol 2009;25:309-13. 14. Onetto JE, Flores MT, Garbarino ML. Dental trauma in chil249


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dren and adolescents in Valparaiso, Chile. Endod Dent Traumatol 1994;10:223-7. 15. Kramer PF, Zembruski C, Ferreira SH, Feldens CA. Traumatic dental injuries in Brazilian preschool children. Dent Traumatol 2003;19:299-303. 16. Cardoso M, de Carvalho Rocha MJ. Traumatized primary teeth in children assisted at the Federal University of Santa Catarina, Brazil. Dent Traumatol 2002;18:129-33. 17. Fleming P, Gregg TA, Saunders ID. Analysis of an emergency dental service provided at a childrenâ&#x20AC;&#x2122;s hospital. Int J Paediatr Dent 1991;1:25-30. 18. Galea H. An investigation of dental injuries treated in an acute care general hospital. J Am Dent Assoc 1984;109:4348.

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19. Rasmusson CG, Koch G. Assessment of traumatic injuries to primary teeth in general practise and specialized paediatric dentistry. Dent Traumatol 2010;26:129-32. 20. Granville-Garcia AF, de Menezes VA, de Lira PI. Dental trauma and associated factors in Brazilian preschoolers. Dent Traumatol 2006;22:318-22. 21. Skaare AB, Jacobsen I. Primary tooth injuries in Norwegian children (1-8 years). Dent Traumatol 2005;21:315-9. 22. Gordy FM, Eklund NP, DeBall S. Oral trauma in an urban emergency department. J Dent Child (Chic) 2004;71:14-6. 23. Wilson S, Smith GA, Preisch J, Casamassimo PS. Epidemiology of dental trauma treated in an urban pediatric emergency department. Pediatr Emerg Care 1997;13:12-5.

MayÄąs - May 2013


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):251-255

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.12268

Analysis of burn cases observed after the 2011 Van earthquake Van’da yaşanan 2011 depremi sonrası gözlenen yanık olgularının analizi Recep DURSUN,1 Sevdegül KARADAŞ,2 Gökay GÖRMELİ,3 Yasemin IŞIK,4 Cumhur ÇAKIR,5 Cemile Ayşe GÖRMELİ6

BACKGROUND

AMAÇ

The purpose of this study was to determine the epidemiological features of cases that were registered for burns and treated at a hospital after the Van earthquake to compare burn cases from the previous year and to determine the factors that influenced mortality.

Bu çalışma, Van’da yaşanan deprem sonrasında yanık nedeniyle başvuran ve hastanede tedavi edilen olguların epidemiyolojik özelliklerini belirlemek ve bir önceki yılın aynı aylarında başvuran yanık olgularıyla karşılaştırarak mortaliteye etkili olan faktörleri saptamak için planlandı.

METHODS

GEREÇ VE YÖNTEM

Patients who were admitted to the Van Region Training and Research Hospital within the 3-month period after the earthquake were categorized as group 1; patients who were admitted within the same time interval in the previous year were categorized as group 2.

Van Bölge Eğitim ve Araştırma Hastanesi’ne depremden sonra üç aylık periyotta başvuran hastalar grup 1, bir yıl önce aynı tarih aralığında başvuran hastalar grup 2 olarak belirlendi.

RESULTS

BULGULAR

There were 121 patients in Group 1 and 89 patients in Group 2. It was determined that there were 36% more burn cases in Group 1. Flame burns were observed 4.8 times more often in Group 1 compared to Group 1 (p=0.002). Exitus was observed in 25.4% of cases in Group 1 and in 7% of cases in Group 2 (p=0.0069).

Grup 1’de 121 hasta, grup 2’de ise 89 hasta vardı. Grup 1’deki yanık olgularının %36 oranında arttığı saptandı. Alev yanıkları grup 1’de grup 2’ye göre 4,8 kat daha fazla gözlendi (p=0,002). Grup 1’de olguların %25,4’ünde, grup 2’de %7’sinde ölüm görüldü (p=0,0069).

CONCLUSION

SONUÇ

It was determined that the number of burn cases registered after the earthquake, the number of flame burns, the percentage of burns and the rate of mortality were higher than the data before the earthquake.

Deprem sonrasında başvuran yanık olguları sayısı, alev yanıklarının sayısı, yanık yüzdesi ve mortalite oranını, deprem öncesine göre yüksek olduğu saptandı.

Key Words: Burn; earthquake; emergency service; tent.

Anahtar Sözcükler: Yanık; deprem; acil servis; çadır.

Earthquakes are among the natural disasters that cause the greatest numbers of deaths and injuries, both around the world and in Turkey.[1-3] A large part of our country is within a first-degree seismic zone, and nearly 100.000 people have lost their lives due to

earthquakes in the last century.[2-4] In addition to these deaths, there has been failure to take precautions to avoid these preventable occasions; the existence of old settlements in areas that are prone to destructive earthquakes, conurbanization, the building of earthquake-

Departments of 1Emergency Medicine, 3Orthopedic Surgery, 5Burn Unit, 6 Radiology, Van Region Training and Research Hospital, Van; Departments of 2Emergency Medicine, 4Anesthesiology and Reanimation, Yuzuncu Yil University Faculty of Medicine, Van, Turkey.

Van Bölge Eğitim ve Araştırma Hastanesi, 1Acil Tıp Servisi, 3 Ortopedi Kliniği, 5Yanık Ünitesi, 6Radyoloji Bölümü, Van; Yüzüncü Yıl Üniversitesi Tıp Fakültesi, 2Acil Tıp Anabilim Dalı, 4 Anesteziyoloji ve Reanimasyon Anabilim Dalı, Van.

Correspondence (İletişim): Recep Dursun, M.D. Van Bölge Eğitim ve Araştırma Hastanesi, Acil Tıp Servisi, 65100 Van, Turkey. Tel: +90 - 432 - 216 32 04 e-mail (e-posta): drrecepdursun@hotmail.com

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Ulus Travma Acil Cerrahi Derg

Table 1. Distribution of patients according to age and sex Group 1 Group 2

0-15 age (n)

15-30 age (n)

30-45 age (n)

45-80 age (n)

Mean age Mean±SD

Female (%)

Male (%)

Total (n)

51 32

22 24

20 16

26 17

14.87±14.68 19.42±16.81

52.38 47.37

47.62 52.63

121 89

prone houses, the inability of first responders to arrive at accident scenes promptly, and fires have prevented any reductions in the deaths and injury rates due to earthquakes.[5-7] The Van earthquake was of a destructive magnitude (7.2 Mw) and struck eastern Turkey, near the city of Van, on Sunday, the 23rd of October, 2011 at 13:41 local time. It occurred at a shallow depth of 19 km. There were 604 casualties caused by this earthquake. Seventeen days after the earthquake (on the 9th of November, 2011), another earthquake on a different fault line occurred at 21:23 local time, triggered by the first earthquake. It was centered at Edremit, which is southwest of Van and 10 km from our hospital. The magnitude was 5.6 (Mw), and it occurred at a depth of 5 km. Because many people had immigrated to other cities and others had settled into tents, there were only 40 casualties. While 222 people were rescued alive from the wreckage of both earthquakes, nearly 6000 people were injured. A total of 72.242 houses were determined to be destroyed or were heavily damaged.[8] Among the most important reasons for the morbidity and mortality observed after earthquakes are fires. [7-13] Determination of the reasons for these fires and of risk groups could help to decrease the morbidity and mortality that occur due to earthquakes. Therefore, in the current study, burn cases observed after the Van earthquake were compared with burn cases during the same months and in the same city during the previous year. Also, the changes that occurred in the number, cause, and degree of burns and the percentage of body surface burned were analyzed.

MATERIALS AND METHODS Patients who were admitted to the Van Region Education and Research Hospital after the earthquake, from the 23rd of October 2011 to the 23rd of January 2012, and who received in-patient treatment were categorized as Group 1; patients who were admitted to the hospital from the 23rd of October 2010 to the 23rd of January 2011, and who received in-patient treatment were categorized as Group 2. Cases were compared regarding age, sex, causes of burns, burn degree, burn percentage, hospital stay length, surgical intervention and complications. When determining the total burn surface area (TBSA) of the patients, first- and seconddegree burns were noted as superficial burns, while 252

third-degree burns were noted as deep burns. After the earthquake, only the hospital in which this study was carried out was at full capacity among the 4 state hospitals, 3 private hospitals and one university hospital. The structural integrity of the other hospitals failed. All cases of burns were monitored and treated in the hospital in which this study was conducted, which has a distinct burn unit. Statistical analysis The statistical significance of the data was analyzed with SPSS statistical software (ver. 9.0). A chisquare analysis and Spearman’s correlation were used for comparisons. Values of p<0.05 were determined to be significant as a result of statistical evaluations.

RESULTS Demographic data of the patients in both groups are provided in Table 1. There were no significant differences between the groups regarding age or sex. There were 121 patients in Group 1. Among the patients in Group 1, 16 of the cases were sent to other centers after the earthquake due to renovations of the local burn unit. Also, 42 cases received outpatient treatment and 63 cases received inpatient treatment at the burn unit. After being stabilized in our hospital, the transfer of patients whose consignment was decided was typically performed by either an air ambulance or ambulance ship between 12 and 24 hours later. There were 89 cases in Group 2; 4 of these cases were sent to other centers due to patient occupancy at the burn unit, 28 30 25 20

Flame burns Scald burns Electric burns

28

21 18

15

14

10 5 0

9 6 2

3

Outpatient cases

1 Dispatched cases

Inpatient cases

Fig. 1. Group 1: Burn cases following the earthquake. Mayıs - May 2013


Analysis of burn cases observed after the 2011 Van earthquake

45 40 35

Flame burns Scald burns Electric burns

12

43

8

25

22

20

6

15

4

10 0

Flame burns Scald burns Electric burns

10

30

5

12

6

4

2

Outpatient cases

2

1

8

2

1

Dispatched cases

0

Inpatient cases

3 2

2 1 0 Group 2

Group 1

Fig. 2. Group 2: Burns cases from the previous year.

Fig. 3. Reasons for mortality among hospitalized patients.

received outpatient treatment, and 57 cases received inpatient treatment in the burn unit. It was determined that there were 36% more burn cases in Group 1 than in Group 2. Scald burns were much more common than flame or electric burns in both groups, and the rate of scald burn was statistically significant in both groups compared to other types of burns (p=0.001). Flame burns were observed 4.8 times more often in Group 1 compared to Group 2 (p=0.002) (Figures 1-3). A total of 48% (39.6%) of the burn cases observed in Group 1 occurred due to 28 tent fires. Among the patients in Group 1, there were no patients with burns after the earthquake or after being rescued from the debris. The burns on the patients who formed Group 1 were either scald burns caused by accidents that occurred as a result of aftershocks or flash burns that occurred as a result of tent fires. Electrical burns were caused by leaks resulting from electrical installations that were constructed in tents or other housing.

between mortality and age, sex, burn degree, or intervention between the groups (Table 3). While 75% (n=12) of the casualties in Group I occurred as a result of flame burns caused by tent fires, 75% (n=3) of the casualties in Group 2 occurred due to electric shock (Figure 4a-c).

Both superficial and deep burns were more common in Group 1 compared to Group 2 (respectively, p=0.004 and p=0.001) (Table 2). While 86 surgical interventions were performed on 63 patients in the burn unit from Group 1, 65 surgical interventions were performed on 57 patients in the burn unit from Group 2.

DISCUSSION It has been reported that the causes of burn cases admitted to emergency units following earthquakes are generally explosions of fuel tankers or explosions due to gas pipe leaks, which occur during the collapses of buildings and which often result in deaths.[9,10] One recent example is the earthquake in Kobe, Japan, in which 142 fires occurred on the first day. While injuries due to flame burns are very common, scalding burns are rare.[9,11] In Turkey, there were 40 burn cases admitted to the hospital after the earthquake in Düzce in 1999; 13 of them were children, and 27 of them were adults. All of the burns were scalding Table 2. Total burn surface area of patients

Exitus was observed in 25.4% of the cases (n=16) in Group 1 and in 7% (n=4) of the cases in Group 2. There were no statistically significant relationships

Group 1

Group 2

Mean±SD

Mean±SD

Superficial burns 17.44±12.14 Deep burns 4.52±3.08

6.86±7.92 1.76±0.89

p 0.004 0.001

Table 3. Interventions in hospitalized patients

Fasciotomy (n) (%)

Escharotomy (n) (%)

Graft Number of total (n) (%)

Group 1 Group 2 Total

24 22 46

37 20 57

25 23 48

Cilt - Vol. 19 Sayı - No. 3

52.2 47.8 38.3

64.9 35.1 47.5

52.1 47.9 40.0

86 65 151 253


Ulus Travma Acil Cerrahi Derg

(a)

(b)

(c)

Fig. 4. (a) Pictures following a tent fire believed to have been caused by stoves. (b) A 14-year-old patient with 75% flame burns who was brought to the hospital after a tent fire. (c) A 2-year-old patient with 45% flame burns who was brought to the hospital after a tent fire. (Color figures can be viewed in the online issue, which is available at www.tjtes.org).

burns; there were no flame burns because there were no explosions or house fires.[9,12] Nakamori et al.[13] reported that following the earthquake in Hanshin Awaji in 1995, 68% of the burns were scalding burns, 20% were flame burns, and 12% were other types of burns. It was noted that of the burn cases following the Chile earthquake, 78% were flame burns, 16% were scalding burns, and 6% were electric burns, and there were no differences regarding the types of burns that occurred before the earthquake.[14] It was stated that the mean age of the burn cases that occurred before and after the Chile earthquake were close to each other (respectively, 49.2±19.8 and 49.2±21.1 year old).[12] It was observed in this study that burn cases increased compared to the previous year, and many of the cases were flame burns (44.4%). The reason for flame burns being observed often following the Van earthquake was that tents were generally used for temporary shelter. Moreover, due to the earthquake having occurred in winter and the temperature falling to -20°C in the city, stoves and electrical devices were used in the tents. Heating these flammable tents with such heating techniques posed a significant risk for fires. However, the flame burns that were predominantly observed in Kobe and Chile were due to natural gas pipelines. [9,11,14] The reason for the burn cases after the Hanshin earthquake being scalding was related to the time of the earthquake coinciding with the traditional time of miso soup preparation, which is a commonly consumed food.[13] In this study, the burn cases observed 254

both before and after the earthquake more commonly affected young people. In addition to this finding, the mean age of the cases observed after the earthquake was 4.55 years younger than the mean age of the cases before the earthquake. A total of 42.1% (n=51) of the 121 patients who were admitted after the earthquake were younger than 15 years old. In a study by Albornoz et al.[14] that compared burn cases after the Chile earthquake over a period of 4 months to cases registered during same period in the previous year, there were no differences between burn cases and burn types; however, the mortality from burn cases in the group before the earthquake was 1.22%, while mortality after the earthquake was 0.52%. After the Northridge earthquake, which occurred in 1994, Peek-Asa et al.[11] reported 10 burn cases as a result of house fires and electric burns in the first 15 days following the earthquake, 2 of which died. Moreover, it was reported that burn cases that occur after earthquakes comprised 7.3% of all traumas and 6.1% of all deaths. In this study, 7.56% (16/121) of burn cases and 25.4% of patients following the earthquake died. Before the earthquakes, 4.4% of the patients admitted with burns and 7% of hospital patients died. The reasons for the burns being more deadly in the series of patients presented here were numerous tent fires. This cause could be related to tents having only one exit and to most of these cases being children. Following the Hanshin Awaji earthquake, the Mayıs - May 2013


Analysis of burn cases observed after the 2011 Van earthquake

TBSA rate of the 34 cases (77%) who were admitted for burns was 20%, and the TBSA rate of the 10 cases (23%) who were not admitted for burns was more than 20%.[13] Following the Chile earthquake, the mean TBSA of burn cases before the earthquake was 21.7±21.9%, and the mean TBSA of deep burns was 8.4±12.7%, while the mean TBSA of burn cases after the earthquake was 16.78±14.3%, and the mean TBSA of deep burns was 3.92±7.1%.[14] In the current study, contrary to after the Chile earthquake, both the mean TBSA and deep burn TBSA of the burn patients observed following the earthquake were greater. The burn surfaces were broader for the types of burns in Group 1, which resulted from tent fires (39.6%). Moreover, the burns observed after the earthquake affected broad surfaces and were deep burns, resulting in an increase in the number of surgical interventions. In conclusion, in the study presented here, it was found that the number of cases admitted for burns, the number of flame burns, the percentage of total body surface burned and the mortality rate were higher after the earthquake compared to the time before the earthquake. To decrease the effect of disasters, it should be compulsory to plan for disasters. Precautions could make the consignments regarding burns decrease and could result in complete and early interventions in burned patients, such as having electricity installed in the tents by experts, surrounding the warm-up tools with protected structures to prevent any cases of burns, using tents that are not easily and/or quickly flammable or that are resistant to fire; making a quick transition from tents to other housing, stockpiling containers at certain places in the country instead of producing containers, having mobile burn units and mobile intensive care units along with mobile operating rooms, and having other mobile health services. Conflict-of-interest issues regarding the authorship or article: None declared.

Cilt - Vol. 19 Sayı - No. 3

REFERENCES 1. Akbulut G, Yilmaz S, Polat C, Sözen M, Leblebicioğlu M, Dilek ON. Afyon sultandagi earthquake. Ulus Travma Acil Cerrahi Derg 2003;9:189-93. 2. Dursun R, Görmeli CA, Görmeli G, Öncü MR, Karadaş S, Berktaş M, et al. Disaster plan of hospital and emergency service in the Van earthquake. JAEM 2012;11:86-92. 3. Taviloğlu K. Felaketlerde yaralılara yaklaşım ve hekimlik hizmetleri. İstanbul Tabip Odası Depremlerde Uzmanlık Hizmetleri. İstanbul: Ekspres Ofset; 2000. 4. al-Madhari AF, Keller AZ. Review of disaster definitions. Prehosp Disaster Med 1997;12:17-21. 5. Çakmakçı M. Felakette sağlık düzeni. Bilim Teknik Dergisi 1999;31:11-7. 6. Atasoy S, Ziyalar N, Alsancak B. Earthquake epidemiology in Turkey: 1900-1995, American Academy of Forensic Sciences 51. Annual Meeting. Poster presentation, Orlando, Florida, USA, February 1999. p. 15-20. 7. Taviloğlu K. 17 Ağustos 1999 Marmara depreminin ardından: Felaket organizasyonunda neredeyiz? Ulusal Cerrahi Derg 1999;15:333-42. 8. Dursun R, Görmeli CA, Görmeli G. Evaluation of the patients in Van Training and Research Hospital following the 2011 Van earthquake in Turkey. Ulus Travma Acil Cerrahi Derg 2012;18:260-4. 9. Ad-El DD, Engelhard D, Beer Y, Dudkevitz I, Benedeck P. Earthquake related scald injuries-experience from the IDF field hospital in Duzce, Turkey. Burns 2001;27:401-3. 10. TheKobe‘Firesfollowin earthquake’ in http://www.eqecat. com/catwatch/m-8-earthquake-near-east-coast-honshu-japan-2011-03-14/. 11. Peek-Asa C, Kraus JF, Bourque LB, Vimalachandra D, Yu J, Abrams J. Fatal and hospitalized injuries resulting from the 1994 Northridge earthquake. Int J Epidemiol 1998;27:459-65. 12. Proceedings ITU-IAHS International Conference on the Kocaeli Earthquake 17 August 1999: A Scientific Assessment and Recommendations for Re-Building; M Karaca and D. N. Ural, editors, Istanbul Technical University 1999, p. 193-204. http://earthquake.usgs.gov/research/groundmotion/ field/turkey/. 13. Nakamori Y, Tanaka H, Oda J, Kuwagata Y, Matsuoka T, Yoshioka T. Burn injuries in the 1995 Hanshin-Awaji earthquake. Burns 1997;23:319-22. 14. Albornoz C, Villegas J, Sylvester M, Peña V, Bravo I. Analysis of the burns profile and the admission rate of severely burned adult patient to the National Burn Center of Chile after the 2010 earthquake. Burns 2011;37:678-81.

255


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):256-260

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.36675

Ocular injuries caused by metal caps of carbonated mineral water bottles Soda şişelerinin metal kapaklarının neden olduğu göz yaralanmaları Fazıl Cüneyt ERDURMAN,1 Osman Melih CEYLAN,2 Volkan HÜRMERİÇ,2 Alfrida PELLUMBİ,2 Ali Hakan DURUKAN,2 Güngör SOBACI2

BACKGROUND

AMAÇ

Bottles containing carbonated drinks are potentially hazardous to the eye. In this study, we aimed to document the clinical characteristics and visual outcomes in a series of patients with ocular injury from flying metal caps of carbonated mineral water bottles.

Karbonatlı içecek şişeleri göz için potansiyel tehlike oluştururlar. Bu çalışmada, fırlayan metal soda şişe kapakları nedeniyle göz yaralanması oluşan hastaların klinik özelliklerini ve oluşan görsel sonuçları değerlendirmeyi amaçladık.

METHODS

GEREÇ VE YÖNTEM

Retrospective review of ocular injuries due to metal caps of carbonated mineral water bottles.

Soda şişelerinin metal kapaklarının neden olduğu göz yaralanmaları geriye dönük olarak gözden geçirildi.

RESULTS

BULGULAR

Sixteen eyes of sixteen patients were included in the study. All of the patients were male, with a mean age of 24 years. Ten of the patients had a history of using improper tools for bottle cap removal. The left eye was involved in twelve cases and the right eye in four cases. All patients had contusion-type closed-globe injury. Varying degrees of hyphema were observed in all patients, and vitreous hemorrhage was present in four. The visual acuity at the last follow-up was 20/20 in 15 of the patients.

On altı hastanın 16 gözü çalışmaya alındı. Hastaların tümü erkek ve ortalama yaş 24 yıldı. On hastada şişe kapağını uygun olmayan bir aletle açma öyküsü vardı. On iki olguda sol göz, 4 olguda sağ göz etkilenmişti. Tüm olgularda kontüzyon tipinde kapalı göz yaralanması oluşmuştu. Değişik derecelerde hifema olguların tümünde mevcuttu ve dördünde vitreus hemorajisi ile birlikteydi. Son yapılan muayenede görme keskinliği hastaların 15’inde 20/20 düzeyindeydi.

CONCLUSION

Sıkıştırılmış metal soda kapaklarına bağlı oluşan göz yaralanmalarının önlenmesinde açacak kullanılması önemlidir. Vidalı çevir-aç kapakların kullanımının yaygınlaştırılmasına ilave olarak, sıkıştırılmış metal kapaklı karbonatlı içecek şişelerinin üzerine tüketicileri olası göz yaralanmaları konusunda uyaran etiketler yerleştirilmelidir.

The use of a bottle cap opener is essential for preventing ocular damage from pressed metal caps of carbonated drinks. In addition to popularising the use of screw cap bottles, warning labels that alert consumers about the possibility of eye injury should be placed on carbonated drinks with pressed metal caps. Key Words: Carbonated drinks; ocular trauma; pressed bottle cap.

Department of Ophthalmology, Çanakkale Military Hospital, Çanakkale; 2 Department of Ophthalmology, Gülhane Military Faculty of Medicine, Ankara, Turkey.

1

SONUÇ

Anahtar Sözcükler: Karbonatlı içecekler; oküler travma; sıkıştırılmış şişe kapağı.

1 Çanakkale Asker Hastanesi, Göz Kliniği, Çanakkale; Gülhane Askeri Tıp Akademisi, Göz Hastalıkları Anabilim Dalı, Ankara, Turkey.

2

Correspondence (İletişim): Fazıl Cüneyt Erdurman, M.D. Çanakkale Asker Hastanesi, Göz Kliniği, 17100 Çanakkale, Turkey. Tel: +90 - 286 - 212 96 86 e-mail (e-posta): erdurman@yahoo.com

256


Ocular injuries caused by metal caps of carbonated mineral water bottles

Glass bottles containing carbonated drinks can cause different types of ocular injuries. Scattering glass fragments from exploding bottles are a well known cause of penetrating ocular injuries which may lead to severe visual impairment or even blindness.[1-7] Bottle cap and cork related ocular traumas are commonly associated with ocular contusion and rarely result in globe rupture.[1,3,7-10] Although the use of screw cap bottles has become more common because of the reduced risk of injury, glass bottles with metal caps (pressed metal caps with corrugated edges) are still being used in most countries and present a potential danger to consumers. In Turkey, carbonated mineral waters are usually sold in glass bottles with pressed metal caps. In this study, we aimed to document the clinical characteristics and visual outcomes in a series of patients with ocular trauma from pressed metal caps of carbonated mineral water bottles.

MATERIALS AND METHODS This study was conducted according to an institutional ethics review board-approved protocol. We performed a retrospective chart review of all patients admitted to our department with the diagnosis of ocular injury related to carbonated mineral water bottles from January 2006 through January 2011. Data included patient age, gender, the involved eye, initial ocular findings, treatment details, follow-up time, and visual outcomes. It was also noted whether an improper tool for removal of bottle cap was used. Initial ophthalmic examination included visual acuity, slit-lamp biomicroscopy, applanation tonometry, and, if possible, dilated fundoscopy. B-mode ultrasonography was performed in eyes with hyphema and/or vitreous hemorrhage precluding the fundus view. Hyphema was graded as follows: microhyphema, only red blood cells visible in the anterior chamber; grade 1, less than one-third of the anterior chamber; grade 2, one-third to one-half of the anterior chamber; grade 3, greater than one-half but less than the total; grade 4, total hyphema.

RESULTS Sixteen eyes from sixteen patients diagnosed with ocular injury from metal caps of carbonated mineral water bottles were identified in the study. All of the cases were male with a mean age of 24 years (range, 19-50 years). All injuries occurred during an attempt to open the bottle cap. The medical records provided detailed information about tools (e.g., spoon handle, lighter) used for bottle cap opening in ten of the patients. In the remaining six cases, there was no information about tools or cap removal technique. None of the patients was wearing eyeglasses at the time of injury, and none was a bystander. Cilt - Vol. 19 SayÄą - No. 3

The left eye was involved in twelve cases and the right in four cases. All of the patients had contusiontype closed-globe injury; one of these patients also had a corneal lamellar laceration from the corrugated edge of the metallic cap. Hyphema was the major anterior segment finding observed in all patients. Hyphema grade at presentation was recorded as microhyphema in 2 patients, grade 1 in three patients, grade 2 in six patients, grade 3 in four patients, and grade 4 in one patient. Other anterior segment changes included iris sphincter tear in five eyes, angle recession in four eyes, cataract in two eyes, mydriasis in two eyes, and iridodialysis in one eye. Retinal edema in at least one quadrant was the most frequent posterior segment finding and was observed in nine eyes. A retinal break was also found in four of these eyes. Vitreous hemorrhage was present in four cases; two cases with mild and two with moderate hemorrhage. All patients received cyclopentolate and/or tropicamide eye drops. Topical corticosteroid therapy (prednisolone) was used in fifteen of the patients. Topical antibiotics were also given in the presence of corneal abrasion. The treatment was combined with topical and/or systemic anti-glaucomatous agents in five patients with elevated intraocular pressure (>26 mmHg). Three patients required surgical intervention in addition to medical treatment; one patient, in whom rebleeding was observed, had anterior chamber washout for intraocular pressure control, one patient underwent cataract extraction and intraocular lens (IOL) implantation combined with iridodialysis repair, and one patient underwent anterior vitrectomy for prolapsed vitreous into the anterior chamber and cataract extraction and IOL implantation with capsular tension ring. Retinal laser photocoagulation was performed in four patients in whom retinal break was detected. The patients were followed-up for an average of 5 months (range, 2-12 months). The visual acuity at the last visit was 20/20 in fifteen of the patients and 20/25 in one remaining patient, who developed an epiretinal membrane. The patientsâ&#x20AC;&#x2122; age, eye laterality, injury type and mechanism, detailed anterior and posterior segment findings, treatments, and visual outcomes are summarised in Table 1.

DISCUSSION Here we present a retrospective review of sixteen patients who had ocular injury from flying metal caps of carbonated mineral water bottles. In population-based studies and case series, male gender has been identified as a strong risk factor for the occurrence of ocular injury, particularly among younger males.[11] All patients in our study were male, with a mean age of 24 years and 10 (63%) of the cases 257


Ulus Travma Acil Cerrahi Derg

Table 1. Details of patients with closed-globe injury from flying metal caps of carbonated mineral waters No

Age (years)

Eye

Use of improper tools to remove the bottle cap (Yes/No)

Anterior segment findings

Posterior segment findings

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

22 23 21 25 21 21 26 21 19 20 20 24 21 25 27 50

Right Right Left Right Left Left Left Left Left Right Left Left Left Left Left Left

No information No information Yes, lighter bottom No information Yes, spoon handle Yes, spoon handle Yes, lighter bottom No information Yes, spoon handle No information Yes, lighter bottom No information Yes, lighter bottom Yes, lighter bottom Yes, Yes, spoon handle

Corneal edema, No finding grade 2 hyphema Corneal edema, Retinal edema grade 2 hyphema, involving mydriasis macula Grade 3 hyphema, Moderate two clock hours vitreous of angle recession hemorrhage Grade 2 hyphema No finding Corneal abrasion, Retinal edema grade 2 hyphema, involving iris sphincter tear macula, retinal hemorrhages Corneal abrasion No finding and edema, microhyphema, iris sphincter tear Grade 1 hyphema Retinal edema, retinal hemorrhages Grade 3 hyphema, Retinal edema, iridodialysis, retinal hole cataract Lamellar corneal Retinal edema laceration, grade 3 involving hyphema macula Grade 2 hyphema, Retinal edema, iris sphincter tear, mild vitreous 360 degrees of hemorrhage, angle recession retinal hemorrhages, retinal hole Grade 1 hyphema, No finding iris sphincter tear Grade 3 hyphema, Retinal edema two clock hours involving of angle recession macula, retinal hemorrhages Grade 2 hyphema No finding Corneal abrasion, Retinal edema, grade 1 hyphema, mild vitreous mydriasis hemorrhage, retinal hemorrhages, retinal tear Corneal abrasion, Retinal edema, microhyphema retinal tear Grade 4 hyphema, Moderate vitreous prolapse vitreous into anterior hemorrhage chamber, iris sphincter tear, 270 degrees of angle recession, zonular dialysis, cataract

IOP at Treatment admission (mmHg)

VA at admission

VA Follow-up at last (months) followup

17 28 18

Topical corticosteroid and cycloplegic Topical corticosteroid and cycloplegic+ anti-glaucomatous agents Topical corticosteroid and cycloplegic

10/200

20/20

3

HM

20/20

6

LP

20/20

3

24 17

Topical corticosteroid and cycloplegic Topical corticosteroid, cycloplegic, and antibiotic

20/50

20/20

4

10/200

20/20

3

38

Topical corticosteroid, cycloplegic, antibiotic + anti-glaucomatous agents

20/50

20/20

3

25

Topical corticosteroid and cycloplegic

20/20

20/20

2

22 15

Topical corticosteroid and cycloplegic + Lens extraction, IOL implantation, iridodialysis repair + LPC Topical corticosteroid, cycloplegic and antibiotic

5/200

20/20

5

LP

20/20

8

10

Topical corticosteroid and cycloplegic + LPC

20/30

20/25† 12

11 40 49 11

Topical corticosteroid and cycloplegic Topical corticosteroid and cycloplegic + anti-glaucomatous agents+ Anterior chamber washout for IOP control‡ Topical corticosteroid and cycloplegic + anti-glaucomatous agents Topical corticosteroid, cycloplegic, antibiotic + LPC

20/25

20/20

2

HM

20/20

6

20/50

20/20

3

20/40

20/20

7

15 16§

Cycloplegic + antibiotic 20/20 LPC Topical corticosteroid and LP cycloplegic + anti-glaucomatous agents + Anterior vitrectomy for vitreous prolapse into anterior chamber, cataract extraction and IOL implantation using CTR

20/20

2

20/20

6

CTR: Capsular tension ring; IOL: Intraocular lens; IOP: Intraocular pressure; LP: Light perception; LPC: Laser photocoagulation; VA: Visual acuity. † Epiretinal membrane was observed 6 months after injury; ‡ Rebleeding occurred within 2 days and anterior chamber washout was carried out 7 days after injury; § IOP increased to 45 mmHg 13 days after injury.

258

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Ocular injuries caused by metal caps of carbonated mineral water bottles

had a history of using improper tools (i.e., bottom end of the lighter or spoon handle) to open the metallic cap. Data about the reasons for not using a bottle cap opener were not available in the medical records, and therefore, we could not define why improper tools were used for bottle cap opening. However, an Internet search showed that there are many websites demonstrating how to open the pressed metallic cap without using a bottle opener. Given the risk-taking attitudes and tendency to engage in more risky activities, young males seem to be prone to these types of injuries. In our study group, the left eye was involved in 12 (75%) of the sixteen patients. In previous reports on injuries caused by bottle cap and corks, no difference was reported in the laterality of eye involvement. [1,3,9,10] However, in a report on champagne cork injury, it was found that the left eye was more likely to be involved, and the predominance of left-sided injury was explained by the bottle position resulting from the right-hand dominance.[8] When attempting to open the bottle using the dominant right hand, the bottle is held with the left hand and kept on the left side of the body, such that the right eye is partially protected from the flying bottle cap by the nose. A bottle cap or cork hitting the eye can damage the anterior and posterior segment structures of the eye via direct tissue compression at the impact site (coup injury) as well as indirect effects at the site opposite the impact (contrecoup injury). Hyphema is one of the frequent findings observed following bottle-cap or cork trauma.[8,9] In our study, varying degrees of hyphema were noted in all cases following the trauma. Hyphema was recorded as grade 2 in six of the patients. Rebleeding was documented in one patient with grade 3 hyphema and anterior chamber washout was required for intraocular pressure control. In our previous report, retinal detachment was found to be the most frequent posterior segment pathology related to contusion type ocular trauma.[12] In current study, a retinal break was found in four patients and surrounded with laser photocoagulation. In one patient, who also had mild vitreous hemorrhage, an epiretinal membrane was observed six months after the injury. In Turkey, the production of carbonated mineral waters has increased approximately two-fold in the last five years.[13] Carbonated mineral waters are most commonly sold in metal-capped non-returnable glass bottles of 20 cl; however, there is no warning label on the bottles about cap-related injuries resulting from use of improper tools or opening techniques. Given the rapidly increasing consumption of glass-bottled carbonated mineral water with pressed metal caps, a conspicuous warning label indicating possible eye damage and illustrating a safe bottle-opening technique is essential for preventing eye injuries. Based on Cilt - Vol. 19 Say覺 - No. 3

the results of this study, as well as previous published reports, we are planning to contact the National Association of Mineral Water Manufacturers to inform them about the possible hazards of pressed metallic bottle caps and the importance of warning label placement on bottles. In the current study, visual acuity at last followup was 20/20 in all patients except one, in whom an epiretinal membrane was identified 6 months after injury. In a review of 34 cases with bottle cork and cap-related closed-globe injury, Cavallini et al.[9] reported that metal caps were not found to be associated with poor visual outcome (20/40 or less). It was suggested that the lighter weight and smaller size of the metallic caps were less associated with severe damage when compared to natural or plastic corks.[9] Although there were no patients with an open-globe injury in our study group, given the patient with corneal lamellar laceration, the relatively sharp edges of the metal caps are also likely to cause a full-thickness globe injury that may be associated with severe visual impairment. The limitations of our study include the retrospective design and relatively short follow-up period with regard to long-term complications. The data collected from medical records did not include detailed information about predisposing factors related to bottle cap related injury, such as shaking or heating the bottle before opening the cap. In conclusion, almost all such ocular injuries can be avoided with the use of a bottle cap opener with an appropriate technique. As a technique for the opening of a bottle, tightly holding the bottle with one hand and firmly covering of both the metallic cap and the cap opener from the top of the bottle with the other hand seems a safe way to prevent eye damage. In addition to increasing the use of screw cap bottles by the manufacturers, the carbonated mineral water bottles with metal caps should carry a warning label to alert consumers about the possibility of eye injury. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Al Salem M, Sheriff SM. Ocular injuries from carbonated soft drink bottle explosions. Br J Ophthalmol 1984;68:281-3. 2. Gupta AK, Moraos O. Ocular injuries due to accidental explosion of carbonated beverage bottles. Indian J Ophthalmol 1982;30:47-50. 3. Kuhn F, Mester V, Morris R, Dalma J. Serious eye injuries caused by bottles containing carbonated drinks. Br J Ophthalmol 2004;88:69-71. 4. Mondino BJ, Brown SI, Grand MG. Ocular injuries from exploding beverage bottles. Arch Ophthalmol 1978;96:2040-1. 5. Schrader WF, Gramer E. Open globe injuries induced by glass bottles containing carbonated drinks. Graefes Arch Clin Exp Ophthalmol 2010;248:313-7. 259


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6. Sellar PW, Johnston PB. Ocular injuries due to exploding bottles of carbonated drinks. BMJ 1991;303:176-7. 7. Spang S, Höh H, Ruprecht KW. Eye injuries caused by opening or explosion of beverage bottles. Ophthalmologe 1995;92:35-7. [Abstract] 8. Archer D, Galloway N. Champagne-cork injury to the eye. Lancet 1967;2:487-9. 9. Cavallini GM, Martini A, Campi L, Forlini M. Bottle cork and cap injury to the eye: a review of 34 cases. Graefes Arch Clin Exp Ophthalmol 2009;247:445-50. 10. Viestenz A, Küchle M. Eye contusions caused by a bottle

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cap. A retrospective study based on the Erlangen Ocular Contusion Register (EOCR). Ophthalmologe 2002;99:1058. [Abstract] 11. Négrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol 1998;5:143-6 12. Erdurman FC, Sobaci G, Acikel CH, Ceylan MO, Durukan AH, Hurmeric V. Anatomical and functional outcomes in contusion injuries of posterior segment. Eye (Lond) 2011;25:1050-6. 13. Turkish Statistical Institute. Turkey’s Statistical Yearbook, 2010. Available from: http://www.turkstat.gov.tr.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):261-266

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.01460

Abusive head trauma: report of 3 cases İstismara bağlı kafa travması: 3 olgu sunumu Nilgün DEMİRLİ ÇAYLAN,1 Gonca YILMAZ,2 Resmiye ORAL,3 Can Demir KARACAN,1 Pelin ZORLU1

Abusive head trauma (AHT) is perpetrated when an infant or young child is shaken violently by an abuser, resulting in injuries to various intracranial structures, historically called “shaken baby syndrome” (SBS). Three cases of AHT with different constellations of clinical symptoms are presented here. Case 1- Three-month-old female infant was admitted with recurrent seizures, drowsiness, and low grade fever. Ophthalmologic examination revealed retinal hemorrhages (RH) in the left eye. Computed tomography of cranium showed left frontal intra-parenchymal subdural hematoma (SDH). Case 2- Twelve-monthold male infant was admitted with a history of favoring left leg. Ophthalmologic examination revealed RH in the right eye. Cranial magnetic resonance imaging (MRI) revealed subacute SDH in the right frontoparietal region. Case 3- Three-month-old male infant was admitted with irritability and seizures. Ophthalmologic examination revealed bilateral disseminated RH. Cranial MRI scan showed bilateral frontoparietal subacute SDH. All cases were reported to Child Protective Services, who decided not to remove children from homes, but evaluated psychosocial risks and developed a safety plan, including home visits and family education. Physicians must be aware of possibility of AHT in infants presenting both subtle and overt neurologic symptoms. It is important to provide training on AHT to staff involved in the management of these cases.

İstismara bağlı kafa travmasının bir formu, süt çocuğu veya küçük bir çocuğun istismarcı tarafından şiddetle sarsılması ile ortaya çıkan, çeşitli intrakraniyal yapıların zedelenmesi ile sonuçlanan, tarihi adıyla “sarsılmış bebek sendromu”dur (SBS). Burada farklı klinik özellikleri olan 3 istismara bağlı kafa travması olgusu sunuldu. Olgu 1- Üç aylık kız bebek tekrarlayan nöbetler, uyuklama ve düşük derecede ateş yakınmaları ile kabul edildi. Oftalmolojik incelemede sol gözde retinal hemoraji (RH) saptandı. Kraniyal bilgisayarlı tomografi ile sol frontal bölgede intraparankimal subakut subdural hematom (SDH) gösterildi. Olgu 2- On iki aylık erkek bebek sol bacağının üzerine basamama yakınması ile kabul edildi. Oftalmolojik incelemede sağ gözde RH saptandı. Kraniyal manyetik rezonans görüntüleme (MRG) ile sağ frontoparyetal bölgede subakut SDH gösterildi. Olgu 3- Üç aylık erkek bebek irritabilte ve nöbet geçirme yakınmaları ile kabul edildi. Oftalmolojik incelemede iki taraflı yaygın RH saptandı. Kraniyal MRG ile iki taraflı frontoparyetal bölgede subakut SDH gösterildi. Olguların tümü, Çocuk Koruma Servisi’ne bildirildi ki bu servis psikososyal riskleri değerlendirerek ev ziyaretleri ve aile eğitimini içeren güvenli bir plan yaparak çocukları ailelerinden ayırmamaya karar verdi. Hekimler sinsi veya aşikar nörolojik semptomlarla başvuran süt çocuklarında istismara bağlı kafa travması olasığının farkında olmalıdırlar. Bu olguların yönetiminde rol alan tüm personele istismara bağlı kafa travması konusunda eğitim verilmesi önemlidir.

Key Words: Abusive head trauma; childhood; retinal hemorrhage; shaken baby syndrome; subdural hematoma.

Anahtar Sözcükler: İstismara bağlı kafa travması; çocukluk çağı; retinal hemoraji; sarsılmış bebek sendromu; subdural hematom.

Departments of 1Pediatrics, 2Social Pediatrics, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey; 3 Department of Pediatrics, University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA.

Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, 1Genel Pediatri Kliniği, 2Sosyal Pediatri Kliniği, Ankara; 3 Iowa Üniversitesi, Carver Tıp Fakültesi, Genel Pediatri Kliniği, Iowa Kenti, Iowa, ABD.

Correspondence (İletişim): Nilgün Demirli Çaylan, M.D. Dr. Sami Ulus Kadın Doğum, Çocuk Sağlığı ve Hast. Eğit. ve Araşt. Hast., 06080 Ankara, Turkey. Tel: +90 - 312 - 305 60 32 e-mail (e-posta): ncaylan@hotmail.com

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Abusive head trauma (AHT) is perpetrated when an abuser violently shakes an infant, creating a whiplash motion and rotational acceleration/deceleration forces resulting in injuries to various intracranial structures, historically called “shaken baby syndrome” (SBS). Shaking may or may not be associated with impact; when it is, the trauma is called shaken impact syndrome, another form of AHT. The American Academy of Pediatrics published a position paper stating that although the terminology “shaken baby syndrome” should be used in prevention-focused projects and research efforts, diagnostic terminology should be replaced with “abusive head trauma,” since shaking is not the only mechanism for inflicted traumatic brain injury.[1,2] Incidence of AHT is based on limited studies and hospital records. It is believed to be much higher than reported because milder forms of AHT may not require a hospital visit.[3] Extrapolation of the data from the few epidemiological studies revealed that SBS incidence may be as high as 15-30 per 100.000 children under the age of one year.[4,5] The estimation of fatality from this type of injury is 15-17% in affected children and morbidity in the form of serious neurological consequences may affect more than half of the survivors.[6] Professional awareness of AHT is still poor in Turkey,[7] leading to rare diagnosis at hospital settings. Few cases have been reported previously.[8] In this study, three cases of AHT with different constellations of clinical symptoms are presented to emphasize vital points.

CASE REPORTS Case 1- A three-month-old female infant was admitted with recurrent seizures, drowsiness, and fever. After her parents noted irritability, she was diagnosed to have abdominal colic by her primary physician. Six hours later, she developed seizures localized to her right arm and was referred to the hospital. On arrival, she was lethargic, had a bulging anterior fontanel, and Glasgow coma score (GCS) was 12. Ophthalmologic examination revealed 5-6 small retinal hemorrhages (RH) in zone 1 of posterior pole in the left eye. The rest of the physical examination was within normal limits. Complete blood count (CBC) including platelets, coagulation profile, renal and liver function tests were all within normal limits. The initial computed tomography (CT) of cranium showed left frontal intraparenchymal acute subdural hematoma (SDH) (Figure 1) and brain edema around the intra-parenchymal bleeding. Cranial magnetic resonance imaging (MRI) scan verified the CT findings. Lumbar puncture (LP) revealed normal cerebrospinal findings. The parents were interviewed and the possibility of vigorous shaking was also explored. Although the mother reported that her three-year-old daughter hit the infant’s head with a toy from time to time, she admitted to shaking the infant, which was triggered by inconsolable crying. She denied any inflicted impact. The neurosurgeon opted for conservative treatment approach with anti-edema and anti-seizure medication. The seizures were controlled by day 2 of admission, followed by

Fig. 1. Left frontal intracerebral and acute subdural hemorrhage in cranial computed tomography (Case 1). 262

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Abusive head trauma

(a)

(b)

Fig. 2. (a, b) Bilateral disseminated intraretinal and preretinal hemorrhages (Right and left eye of Case 3). (Color figures can be viewed in the online issue, which is available at www.tjtes.org).

mental status improvement and the patient’s neurologic examination returning to normal. The infant was discharged on day 21 of admission. Case 2- A twelve-month-old male infant was admitted with complaint of favoring his left leg. He was born at term gestation with unremarkable neonatal and post-neonatal course. On physical examination, his height, weight, and head circumference percentiles were compatible with his age. His neurologic examination revealed normal findings except for developmental delay. He could not sit without support. An

ophthalmologic examination revealed 7-8 small RH in the right eye in zone 1 of posterior pole. Denver developmental test revealed a delay in crude motor activities. He was able to utter only two words (mom, dad). His CBC including platelets, coagulation profile, renal and liver function tests, and metabolic screening were all within normal limits. Cranial MRI revealed subacute SDH in the right frontoparietal region approximately 3-4 weeks old. His mother admitted to shaking the infant frequently on a recurrent basis. The last shaking was three weeks before the infant’s hos-

Fig. 3. Bilateral fronto-parietal subacute subdural hemorrhage in Ax T2 Flair weighted cranial MRI (Case 3). Cilt - Vol. 19 Sayı - No. 3

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Table 1. Demographic and clinical features of patients related to child abuse Features

Patient 1

Patient 2

Patient 3

Age (month) Gender History of overt head trauma Seizures Intracranial bleeding External evidence of injury Skeletal survey Ocular findings Perpetrator

3 Female Yes (admitted shaking by mother 6 hours prior to admission) Yes ICH, aSDH No Normal Unilateral RH Mother (confessed)

12 Male Yes (recurrent shaking, last shaking episode 3 weeks prior to admission) No saSDH No Normal Unilateral RH Mother (confessed)

3 Male Yes (trivial fall 6 hours prior to admission, speculated unwitnessed shaking by brother Yes saSDH No Normal Bilateral RH Brother (questionable, attributed by mother)

ICH: Intracerebral hemorrhage; aSDH: Acute subdural hemorrhage; saSDH: Subacute subdural hemorrhage; RH: Retinal hemorrhage.

pital admission, followed by vomiting and irritability that had lasted one day. Medical care was not sought at that time. Case 3- A three-month-old male infant was admitted with irritability and seizures. The irritability had started suddenly, six hours before admission. The mother reported that she had dropped the baby onto the couch from her arms while she was standing. After this fall, he became hypotonic for one hour. He was referred to the university hospital by the local physician due to concern for intra-cranial injury. On arrival, he was lethargic and GCS was 13. Ophthalmologic examination revealed bilateral disseminated RH in the posterior poles and zones 1 and 2 of mid-peripheral areas extending to ora serrata (Figure 2a, b). CBC including platelets, coagulation profile, and renal and liver function tests were within normal limits. The initial CT of cranium showed bilateral frontoparietal SDH. MRI scan was performed and showed bilateral frontoparietal subacute SDH (Figure 3). The mother was re-interviewed after the findings were discovered and spontaneously made the accusation that the infantâ&#x20AC;&#x2122;s 10 year-old brother might have shaken him. However, she did not report any specific dates because she had not witnessed any shaking. Conservative treatment approach was opted for with anti-seizure medication. The infant was discharged on day 22 of admission. Demographic and clinical features of the patients are summarized in Table 1.

DISCUSSION Shaken baby syndrome, a form of AHT, presents with a variety of symptoms which range from mild to severe and nonspecific to diagnostic. Since signs and symptoms at presentation may be non-specific and history of trauma is rarely reliable, health care providers must have a high index of suspicion when infants and 264

young children present with subtle neurological signs such as lethargy, decreased level of consciousness, vomiting without fever and diarrhea, or unexplained, persistent irritability. If AHT is misdiagnosed, the victims may later be admitted with more severe morbidity or even mortality related to abuse.[9] The cases mentioned in this paper were seen by primary physicians and referred with diagnoses other than AHT. All infants applied to the hospital with a history of neurological deterioration, intracranial bleeding, and retinal hemorrhages with no medical or plausible accidental explanation to account for the constellation of findings. History-taking in suspect AHT cases is important. It is common that there will be no history of trauma to explain the findings. When there is a history of trauma, it may be a trivial trauma that does not fully explain the constellation of findings.[10] It is also common to accuse older sibling for the acts of trauma as in the cases 1 and 3 in this series.[11] Risk factors of AHT include single parenthood, mental health issues, domestic violence, substance abuse, and increased stress level within the family as well as child-related factors such as premature delivery, disability, poor parent-child bonding, etc.[1] AHT can occur in all social strata.[11,12] The families in these three cases are from low socioeconomic status. The perpetrators in two cases were the mothers with suspicion that it could be the case in the third one as well. In the literature, the perpetrator of AHT is a male caretaker in 70% of the cases, fathers being responsible for half the cases.[9,10] This discrepancy can be explained by the fact that in Turkish families, males are rarely the solitary caretaker of young infants. Bilateral RH are an important component of especially severe AHT. However, they are neither necessary nor sufficient for diagnosis.[13] RH are observed MayÄąs - May 2013


Abusive head trauma

in 50 to 100% of AHT cases depending on the severity of cases included in case series.[5,14] RH in AHT are typically bilateral; however, unilateral hemorrhages occur in nearly 15% of cases.[15] The first two cases in this series involved mild/moderate injuries causing mild and unilateral RH, which is consistent with the literature. On the other hand, there were widespread bilateral intraretinal and preretinal hemorrhages, which were consistent with the more severe injury in case 3. The American Academy of Pediatrics recommends cranial CT scan without contrast as the preferred initial imaging study.[1] If possible, MRI scan is advised 2-3 days later. MRI scan is helpful in demonstrating the parenchymal injury and in estimating the approximate age of the subdural hematoma.[16] MRI scan should include diffusion restriction images as well to reveal subtle parenchymal brain damage.[17] Initial head CT followed with an MRI scan were essential in establishing the diagnosis in all three cases presented in this report. Differential diagnosis of AHT includes meningoencephalitis, aneurysm, arteriovenous malformation, coagulopathies, metabolic disorders like galactosemia and glutaric aciduria type 1, arachnoid cyst, osteogenesis imperfecta type 1 and 4, Terson’s syndrome, accidental cerebral trauma, and increased intrathoracic pressure as in resuscitation, among others.[18] The diagnosis of AHT in all three cases in this report was established by excluding other possible diagnoses via a comprehensive work-up. All three cases in this study have been reported to Child Protective Services (CPS) and prosecutor’s office. The children were not removed from their families. CPS assessed the psychosocial risks involving the index cases and siblings and developed a safety plan to include frequent home visits and family education. A forensic report was prepared and filed with District Prosecutor’s Office. Trials are still ongoing. In addition to challenges related to recognition of AHT, interdisciplinary management involving medical, child protective, and legal professionals is rarely available in Turkey. Although CPS protects children by providing social support, family visits, and investigation of siblings, limited resources for removed children such as institutions working at full capacity and limited foster care make it difficult for CPS to protect every child at risk. In order to prevent AHT, every hospital providing delivery services should adopt a primary prevention program targeting parents of newborn infants in addition to advocating for public education programs. [19,20] To protect abused infants, health care providers must be aware of the possibility of AHT in children Cilt - Vol. 19 Sayı - No. 3

especially under 2 years of age who are presented with neurologic symptoms, retinal hemorrhages, subdural hematoma, and brain damage that cannot be explained by a credible accidental history or other medical conditions.[1] It is very important to provide more professional training on AHT to all agencies and staff who may potentially get involved in the management of these cases, including child protective workers, law enforcement, prosecutors, and judges.[21] Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. American Academy of Pediatrics: Committee on Child Abuse and Neglect. Shaken baby syndrome: rotational cranial injuries-technical report. Pediatrics 2001;108:206-10. 2. Christian CW, Block R; Committee on Child Abuse and Neglect; American Academy of Pediatrics. Abusive head trauma in infants and children. Pediatrics 2009;123:1409-11. 3. King WJ, MacKay M, Sirnick A; Canadian Shaken Baby Study Group. Shaken baby syndrome in Canada: clinical characteristics and outcomes of hospital cases. CMAJ 2003;168:155-9. 4. Barlow KM, Minns RA. Annual incidence of shaken impact syndrome in young children. Lancet 2000;356:1571-2. 5. Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal SH. A population-based study of inflicted traumatic brain injury in young children. JAMA 2003;290:621-6. 6. Duhaime AC, Gennarelli TA, Thibault LE, Bruce DA, Margulies SS, Wiser R. The shaken baby syndrome. A clinical, pathological, and biomechanical study. J Neurosurg 1987;66:409-15. 7. Balcı E, Gün I, Mutlu Şarlı Ş, Akpınar F, Yağmur F, Öztürk A, et al. Still an unknown topic: child abuse and “shaken baby syndrome”. Ulus Travma Acil Cerrahi Derg 2011;17:430-4. 8. Yağmur H, Asil F, Canpolat M, Per H, Coşkun A. Short distance falls and Shaken Baby Syndrome: case report. Turkiye Klinikleri J Med Sci 2010;30:766-71. 9. Oral R, Yagmur F, Nashelsky M, Turkmen M, Kirby P. Fatal abusive head trauma cases: consequence of medical staff missing milder forms of physical abuse. Pediatr Emerg Care 2008;24:816-21. 10. Starling SP, Patel S, Burke BL, Sirotnak AP, Stronks S, Rosquist P. Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Arch Pediatr Adolesc Med 2004;158:454-8. 11. Listman DA, Bechtel K. Accidental and abusive head injury in young children. Curr Opin Pediatr 2003;15:299-303. 12. Dubowitz H, Bennett S. Physical abuse and neglect of children. Lancet 2007;369:1891-9. 13. Aryan HE, Ghosheh FR, Jandial R, Levy ML. Retinal hemorrhage and pediatric brain injury: etiology and review of the literature. J Clin Neurosci 2005;12:624-31. 14. Pierre-Kahn V, Roche O, Dureau P, Uteza Y, Renier D, Pierre-Kahn A, et al. Ophthalmologic findings in suspected child abuse victims with subdural hematomas. Ophthalmology 2003;110:1718-23. 15. Drack AV, Petronio J, Capone A. Unilateral retinal hemorrhages in documented cases of child abuse. Am J Ophthalmol 1999;128:340-4. 16. Chabrol B, Decarie JC, Fortin G. The role of cranial MRI 265


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in identifying patients suffering from child abuse and presenting with unexplained neurological findings. Child Abuse Negl 1999;23:217-28. 17. Biousse V, Suh DY, Newman NJ, Davis PC, Mapstone T, Lambert SR. Diffusion-weighted magnetic resonance imaging in Shaken Baby Syndrome. Am J Ophthalmol 2002;133:249-55. 18. Matschke J, Herrmann B, Sperhake J, Körber F, Bajanowski T, Glatzel M. Shaken baby syndrome: a common variant of non-accidental head injury in infants. Dtsch Arztebl Int 2009;106:211-7.

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19. Dias MS, Smith K, DeGuehery K, Mazur P, Li V, Shaffer ML. Preventing abusive head trauma among infants and young children: a hospital-based, parent education program. Pediatrics 2005;115:e470-7. 20. Purple Programme in National Center on Shaken Baby Syndrome. Available at: http://dontshake.org/sbs.php?topNavID =4&subNavID=37&navID=672 Accessed November 2011. 21. Sahin F, Cepik-Kuruoğlu A, Demirel B, Akar T, DuyanCamurdan A, Iseri E, et al. Six-year experience of a hospital-based child protection team in Turkey. Turk J Pediatr 2009;51:336-43.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):267-270

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.49799

Human immunodeficiency virus ile enfekte bir hastada gelişen iki taraflı epidural hematom: Olgu sunumu Bilateral epidural hematoma in a patient with human immunodeficiency virus infection: a case report Bilal KELTEN,1 Alper KARAOĞLAN,1 Mehmet Alpay ÇAL,1 Osman AKDEMİR,2 Türker KARANCI3

İntrakraniyal epidural hematomlar hemen her zaman kafa travmasına ikincil gelişir ve sıklıkla tek taraflı olarak izlenir. İki taraflı intrakraniyal epidural hematomlar nadir olmakla birlikte mortalitesi oldukça yüksektir. Bu yazıda, araç dışı trafik kazası sonucu kafa travması nedeniyle acil servise getirilen 32 yaşında, human immunodeficiency virus (HIV) enfeksiyonlu, erkek hastada saptanan iki taraflı epidural hematom sunuldu. Kafa travması tek yönlü ve lateral planda olmasına rağmen HIV enfeksiyonlu bir hastada iki taraflı epidural hematom ile sonuçlanması nadir bir durumdur. HIV enfeksiyonunun komplikasyonları olan vaskülopati ve koagülopati sonucunda serebral damarlar frajil bir yapı alır ve bu komplikasyonlar birlikte kontrlateral intrakraniyal epidural hematom gelişmesini kolaylaştırır.

Intracranial epidural haematomas are almost always secondary to head traumas and usually occur unilaterally. Bilateral intracranial epidural haematomas are rare, but the mortality is very high. In our case, we report a bilateral epidural haematoma in a 32 year old, HIV infected male patient who came to the emergency service with a head trauma because of a motor vehicle-pedestrian accident. The occurrence of bilateral epidural haematoma in an HIV infected patient is a rare condition as a result of head trauma in a lateral direction on one side. As a result of the vasculopathy and coagulopathy, which are complications of HIV infection, the cerebral vessels have a fragile structure that leads to complications that facilitate the development of contralateral intracranial epidural haematoma together.

Anahtar Sözcükler: HIV; iki taraflı epidural hematom.

Key Words: HIV; bilateral epidural haematoma.

Epidural hematomlar genellikle arteria meningea medianın yırtılması sonucu tek taraflı olarak izlenir ve hemen her zaman travma kaynaklıdır. Nadir olmakla birlikte iki taraflı epidural hematom olguları da bildirilmiştir. İki taraflı epidural hematomlar acil olarak boşaltılmadığı sürece mortalite riski çok daha yüksektir. İntrakraniyal hematomlar arasında, genellikle bir enfeksiyon zemininde gelişen vaskülopati sonucu spontan epidural hematom gelişmesi son derece nadirdir. Human immunodeficiency virus (HIV), doğrudan serebral vasküler endotelyal hücreleri enfekte ettiği bilinen bir virüs olarak, endotelyal işlev bozukluğuna neden olmakta ve serebral vasküler yapıları frajil bir hale getirmektedir. HIV enfeksiyonlu hastalarda

sıklıkla serebral iskemi ve enfarktüse sebep olabilen serebral arterit izlenmektedir. Ancak, serebral vaskülite bağlı anevrizma ve intrakraniyal hemoraji görülme sıklığı çok daha azdır.[1] Hastamızda, kafa travması sonucu sol parietal fraktür altında epidural hematom gelişmiş, sağ parietal bölgede ise kırık hattı olmaksızın epidural hematom izlenmiştir. HIV enfeksiyonuna bağlı vaskülopati ve trombositopeni komplikasyonlarının birlikteliği zemininde frajil serebral damarların kolaylıkla yırtılması, kontrlateralde oluşan epidural hematomu açıklar. Bu yazıda, kuvvetin tek taraflı ve lateral yönde olduğu bir kafa travması sonucu HIV enfeksiyonlu bir hastada gelişen iki taraflı epidural hematom sunuldu.

Maltepe Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, İstanbul; 2 Taksim Eğitim ve Araştırma Hastanesi, Nöroşirürji Kliniği, İstanbul; 3 Kilis Devlet Hastanesi, Nöroşirürji Kliniği, Gaziantep.

1

Department of Neurosurgery, Maltepe University Faculty of Medicine, Istanbul; Department of Neurosurgery, Taksim Training and Research Hospital, Istanbul; 3 Department of Neurosurgery, Kilis State Hospital, Gaziantep, Turkey.

1 2

İletişim (Correspondence): Dr. Alper Karaoğlan. Feyzullah Cad., No: 39, 34843 Maltepe, İstanbul, Turkey. Tel: +90 - 216 - 444 06 20 e-posta (e-mail): drkaraoglan@yahoo.com

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Ulus Travma Acil Cerrahi Derg

OLGU SUNUMU Otuz iki yaşında erkek hasta, araç dışı trafik kazası sonucu gelişen çoklu travma nedeniyle acil servise getirildi. İlk incelemede iki taraflı femur ve tibia kırığı ile birlikte sol parietal bölgede cilt altı hematom ve her iki tibial bölge anteriyorunda eritematöz döküntüler izlenmekteydi. Hastanın ilk nörolojik incelemesinde bilinci kapalı, sağ pupil dilate ve ışık refleksi sağda (–) ve Glasgow koma skoru 5 (E1, M3, V1) olarak değerlendirildi. Acil çekilen bilgisayarlı beyin tomografisinde sol parietal bölgede kırık ve iki taraflı parietal epidural hematom izlendi (Şekil 1). Vital bulguların stabilizasyonunu takiben hasta acil ameliyata alınarak, aynı seansta önce sağ ve ardından sol parietal epidural hematomlar kraniyotomi ile boşaltıldı. Sağ parietal kemikte kırık izlenmemesine rağmen arteria meningea medianın laserasyonu dikkat çekti. Ameliyat sonrası takip için yoğun bakım ünitesine alınan hastada HIV enfeksiyonu saptanması üzerine gerekli önlemler alınarak takibi sürdürüldü. Laboratuvar testleri; Hb: 5,1 g/ dL, Hct: %15, eritrosit sayısı 1,67 uL, lökosit sayısı 9,5 uL, trombosit sayısı 61 uL, PT 30,9 sec, aPTT 61,7 sn, INR 2,70, BUN 9 mg/dL, kreatinin 0,53 mg/dL, ALT 23 U/L ve AST 51 U/L olarak izlendi. Bu bulgularla, kontrlateralde herhangi bir kemik kırığı olmaksızın daha büyük ve herniasyona sebep olan intrakraniyal epidural hematom gelişimi, nadir bir durum olarak, HIV enfeksiyonu komplikasyonları olan vaskülopati ve koagülopati birlikteliğine bağlandı. Acilen ameliyat edilen iki taraflı intrakranyal epidural hematomlu hastanın ameliyat sonrası dönemde bilinci kısmen açılarak

az da olsa kooperasyon kurulmaya başlandı, ancak HIV enfeksiyonuna bağlı gelişen diğer komplikasyonlar nedeniyle hasta ameliyattan iki hafta sonra kaybedildi.

TARTIŞMA İntrakraniyal epidural hematom, kafatası ile dura arasında kan birikmesidir ve hemen her zaman travma kaynaklıdır.[2] Epidural hematomlar genellikle arteria meningea medianın yırtılması sonucu tek taraflı olarak izlenir. Bu olguların çoğu, acil girişimle hematomun boşaltılmasını gerektirir. Bazı olgularda epidural hematomlar iki taraflı olarak da oluşabilmektedir. Bütün epidural hematomlar içinde, çift epidural hematom görülme insidansı farklı çalışmalarda %2 ile %25 arasında değişiklik göstermektedir ve iki taraflı olması son derece nadirdir.[3] HIV enfeksiyonlu hastamızda iki taraflı epidural hematom, sol parietal bölgede kemik kırığının eşlik ettiği intrakraniyal epidural hematom ile sağ parietal bölgede kemik kırığı olmaksızın intrakraniyal epidural hematom şeklinde gelişmiştir. Nadir bir durum olarak kontrlateralde oluşan epidural hematom için, HIV enfeksiyonunun vaskülopati ve trombositopeni komplikasyonları ile travmanın kolaylaştırıcı faktör olarak birlikteliği sorumlu tutulmuştur. İlk iki taraflı epidural hematom olgusu 1884 yılında Roy GC tarafından bildirilmiştir.[4] İki taraflı hematomlarda kuvvetin yönünün lateral planda olmaktan çok anteroposteriyor planda olması beklenmektedir.[5] Anteroposteriyor travma sonucunda oluşan kırık, orta hattın karşısına geçerek iki taraflı epidural hematom

Şekil 1. Acil serviste çekilen bilgisayarlı beyin tomografisinin parankim pencerede alınan kesitinde sol parietal bölgede cilt altı hematom ve kırık ile iki taraflı parietal epidural hematom izlenmekte. 268

Mayıs - May 2013


Human immunodeficiency virus ile enfekte bir hastada gelişen iki taraflı epidural hematom

oluşmasına sebep olabilir. Olgumuzda travmanın yönü sol taraflı lateral plandadır ve oluşan kırık orta hattı geçmemektedir. Kontrlateralde oluşan epidural hematom ise HIV enfeksiyonuna bağlı olarak damarların frajil bir yapı alması ve kırık olmadığı halde travma ile kolaylıkla lasere olmasına bağlanmıştır. Huda ve arkadaşlarının[6] bildirdiği olgu çalışmasına göre 1984 ve 2003 yılları arasında ameliyat edilen 1025 epidural hematom olgusunun 46’sı çift epidural hematom olarak izlenmiş ve bunların 39’u iki taraflı, 3’ü çoklu ve 4’ü ipsilateral çift epidural hematom olarak raporlanmıştır. Aynı çalışmaya göre iki taraflı hematom insidansı %3.8 olarak izlenmiştir ve iki taraflı olarak ameliyat edilen 39 iki taraflı hematom olgusunun 13’ünün ölümle sonuçlanarak mortalitenin %33 olarak izlendiği belirtilmiştir.[6] İki taraflı epidural hematomlar acil olarak boşaltılmadığı sürece mortalite riski çok daha yüksektir.[7] Görgülü ve arkadaşları[8] %80’ine ilk 6 saat içinde tanı konmuş olan 19 iki taraflı epidural hematom olgusunda %15.7 mortalite bildirmişlerdir. İntrakraniyal hematomlar arasında spontan epidural hematomlar da nadir görülmekle birlikte genellikle bir enfeksiyon zemininde gelişen vaskülopati veya koagülopati sonucu oluşur. Spontan epidural hematomların en sık sebebi komşu kranyofasiyal enfeksiyonlara bağlı olarak gelişen vaskülit sonucu vaskülitik damarın rüptüre olmasıdır.[9] HIV enfeksiyonlu hastalarda sıklıkla serebral iskemi ve infarktüse sebep olabilen serebral arterit izlenmektedir. Ancak, serebral vaskülite bağlı anevrizma ve intrakraniyal hemoraji görülme sıklığı çok daha azdır.[1] Olgumuzda, kontrlateralde kırık izlenmemesine rağmen oluşan intrakraniyal epidural hematom için, HIV enfeksiyonunun komplikasyonu olan serebral vaskülit neticesinde vasküler yapıların frajil bir yapıya geçmesi sorumlu tutulmuştur. HIV ile ilişkili vaskülitin oluşumu için önerilen mekanizmalar; endotelyal hücre enfeksiyonu, immün kompleks birikimi, sitokin ve adezyon moleküllerinin regülasyonunda bozukluk olmasıdır.[10] HIV ile ilişkili vaskülopatide vasküler lezyonlar küçük damarlarda hiyalin kalınlaşma, perivasküler alanda gevşeme ve neticesinde perivasküler yoğunluk ve basıncın azalması, damar duvarında mineralizasyon ve pigment birikimi, vaskülit için tanımlayıcı kanıt olmamakla birlikte perivasküler enflamatuvar hücre infiltrasyonu ile karakterizedir.[11] Bu vasküler değişiklikler, yaşlı, diyabetli ve hipertansiyonlu hastalardaki serebral aterosklerotik değişikliklere çok benzer.[12] AIDS hastalarında sıklıkla damar değişikliklerine sebep olabilen oportünist enfeksiyon etkenleri ise tüberküloz, toksoplazmoz, aspergilloz, Varisella zoster virüsü, Herpes simpleks, Sitomegalovirüs, hepatit B, sifiliz, kriptokokoz ve kandidiyazistir. [13] Olgumuzda oportünist enfeksiyon etkenlerine dair bir delil bulunmamıştır. Bunun yanı sıra, total plazma Cilt - Vol. 19 Sayı - No. 3

homosistein yüksekliği ile vasküler hastalıklar arasında bir ilişki bulunduğu da belirtilmektedir. Hiperhomosisteinemi genetik faktörlere bağlı olmaksızın beslenme yetersizliğinde de ortaya çıkmaktadır ve biliyoruz ki HIV ile enfekte hastalarda mikronutrisyonel (vitamin ve mineraller) yetersizlik sıklıkla gözlenmektedir. In vitro çalışmalara göre yüksek plazma homosistein düzeyi arter duvarının elastin içeriğinde azalma ile sonuçlanır.[14] HIV enfeksiyonunun kendisi doğrudan hematopoetik hücre serilerinin tamamını etkileyerek hematolojik anormalliklerle sonuçlanmaktadır.[15] Henüz mekanizması tam olarak açıklanabilmiş olmamasına rağmen HIV enfeksiyonunun erken evrelerinde trombositlerin immün destrüksiyonuna bağlı idiyopatik trombositopenik purpura sıklıkla izlenmektedir.[16] Olgumuzda trombosit sayısında belirgin bir azalma ve fiziksel incelemede trombositopeniye bağlı olduğu düşünülen hir iki pretibial bölgede eritematöz döküntüler mevcuttur. Buna karşın ileri evre HIV enfeksiyonu (AIDS) olan hastalarda virüsün doğrudan kemik iliğini süprese etmesiyle anemi, lökopeni ve trombositopeni görülür. Seropozitif olguların %3-8’inde, edinsel immün yetmezlik sendromlu (AIDS) olguların %30-45’inde trombositopeni gözlenir.[16] Sonuç olarak, HIV enfeksiyonlu hastalarda, HIV’ye bağlı komplikasyonlar olan vaskülopati ve koagülopatiye bağlı olarak, travma sonrası kontrlateralde kırık hattı olmaksızın intrakraniyal epidural hematom görülmesi olasıdır. Bu hastalarda anteroposteriyor yönde gelişmiş kafa travması olmadan, lateral planda bir kafa travması da bilateral intrakraniyal epidural hematoma sebep olabilir. Bu hastalarda bilgisayarlı beyin tomografisi hayati bir öneme sahiptir ve acil iki taraflı hematom drenajı gerektirir. Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması yoktur.

KAYNAKLAR 1. O’Charoen P, Hesselink JR, Healy JF. Cerebral aneurysmal arteriopathy in an adult patient with acquired immunodeficiency syndrome. AJNR Am J Neuroradiol 2007;28:938-9. 2. Ng WH, Yeo TT, Seow WT. Non-traumatic spontaneous acute epidural haematoma - report of two cases and review of the literature. J Clin Neurosci 2004;11:791-3. 3. Sharma V, Newton G. Bilateral extradural hematoma, Neurol India. 1990;38:455-9. 4. Roy GC. Fracture of skull, extensive extravasation of blood on dura mater, producing compression of brain, trephining, partial relief of symptoms, death. Lancet 1884;2:319. 5. Frank E, Berger TS, Tew JM. Bilateral epidural hematomas, Surg Neurol. 1982;17:218-222. 6. Huda MF, Mohanty S, Sharma V, Tiwari Y, Choudhary A, Singh VP. Double extradural hematoma: an analysis of 46 cases. Neurol India 2004;52:450-2. 7. Ramzan A, Wani A, Malik AH, Kirmani A, Wani MA. Acute 269


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bilateral extradural hematomas. Neurol India 2002;50:217-9. 8. Görgülü A, Cobanoglu S, Armagan S, Karabagli H, Tevrüz M. Bilateral epidural hematoma. Neurosurg Rev 2000;23:303. 9. Griffiths SJ, Jatavallabhula NS, Mitchell RD. Spontaneous extradural haematoma associated with craniofacial infections: case report and review of the literature. Br J Neurosurg 2002;16:188-91. 10. Bagasra O, Lavi E, Bobroski L, Khalili K, Pestaner JP, Tawadros R, et al. Cellular reservoirs of HIV-1 in the central nervous system of infected individuals: identification by the combination of in situ polymerase chain reaction and immunohistochemistry. AIDS 1996;10:573-85. 11. Felício AC, Silva GS, dos Santos WA, Pieri A, Gabbai AA, Massaro AR. Spontaneous artery dissection in a patient with Human Immunodeficiency Virus (HIV) infection. Arq Neu-

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ropsiquiatr 2006;64:306-8. 12. Mizusawa H, Hirano A, Llena JF, Shintaku M. Cerebrovascular lesions in acquired immune deficiency syndrome (AIDS). Acta Neuropathol 1988;76:451-7. 13. Kieburtz KD, Eskin TA, Ketonen L, Tuite MJ. Opportunistic cerebral vasculopathy and stroke in patients with the acquired immunodeficiency syndrome. Arch Neurol 1993;50:430-2. 14. Hankey GJ, Eikelboom JW. Homocysteine and vascular disease. Lancet 1999;354:407-13. 15. Wang JF, Liu ZY, Groopman JE. The alpha-chemokine receptor CXCR4 is expressed on the megakaryocytic lineage from progenitor to platelets and modulates migration and adhesion. Blood 1998;92:756-64. 16. Morris L, Distenfeld A, Amorosi E, Karpatkin S. Autoimmune thrombocytopenic purpura in homosexual men. Ann Intern Med 1982;96:714-7.

Mayıs - May 2013


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):271-273

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.58259

Larynx, hypopharynx and mandible injury due to external penetrating neck injury Eksternal penetran boyun yaralanmasına bağlı gelişen larinks, hipofarinks ve mandibula yaralanması Gül ÖZBİLEN ACAR, Muhammet TEKİN, Osman H. ÇAM, Emre KAYTANCI

Esophageal and laryngeal injuries due to ballistic injuries are seldom encountered. Ballistic external neck traumas generally result in death. Incidence of external penetrant neck injuries may vary between 1/5000-137000 patients among emergency service referrals. Vascular injuries, esophagushypopharynx perforations, laryngotracheal injuries, bony fractures, and segmentations may be encountered in external neck traumas. Here we report a 27-year-old male patient who was referred to our emergency department and presented with hyoid bone fracture, multiple mandibular fractures, and hypopharynx perforation due to a ballistic external neck injury.

Blastik travmalara bağlı özöfageal ve laringeal yaralanmalar nadir görülürler. Blastik travmalara bağlı gelişen dış boyun travmaları genellikle ölümle sonuçlanır. Penetran dış boyun travmalarının acil servise başvuran hastalar arasındaki insidansı 1/5000-137000 arasında değişmektedir. Dış boyun travmalarında vasküler yaralanmalar, özofagus-hipofarenks perforasyonları, laringotrakeal yaralanmalar, kemik yapılarda kırık ve parçalanmalar görülebilir. Bu yazıda, eksternal blastik boyun travmasına bağlı olarak acil servise başvuran hiyoid kırığı, multipl mandibula kırığı ve hipofarenks perforasyonu saptanan 27 yaşındaki erkek hasta sunuldu.

Key Words: Ballistic injury; external neck trauma; hypopharynx perforation; hyoid fracture; mandible fracture.

Anahtar Sözcükler: Blastik travma; eksternal boyun travması; hipofarenks perforasyonu; hiyoid kırığı; mandibula kırığı.

Pharyngoesophageal perforations due to blunt head and neck traumas are well described in the literature while laryngotracheal and pharyngoesophageal injuries due to ballistic traumas remain unclear due to the rarity of these cases. Traumas to the head and neck regions have vital importance because of major vascular structures.[1] Deaths due to traumas of the head and neck regions are generally related with vascular injuries. Neck injuries are classified in three zones.[2]

ment with ballistic neck trauma resulting in hyoid, hypopharynx, and mandibular injuries without major vascular injury.

In management of traumatic head and neck injuries, it is still controversial to make immediate surgical exploration or to make serial physical examinations[3] (including angiography, with endoscopic examinations and selective surgical exploration).

CASE REPORT A 27-year-old male was referred to our emergency department because of ballistic neck trauma in July 2009. In the first examination of the patient, soft tissue injury in the right cheek and mouth floor was observed. Edema and hematoma in the uvula and soft palate were also present. In palpation, edema in the left and right side of the mandible, malocclusion of the jaw, and stepping sign of the bony structure were discovered.

In this paper we report the approach and management of a patient admitted to the emergency depart-

The patient had difficulty swallowing and had blood mixed with saliva inside the mouth due to the fracture of the mandible. There were a total of three

Department of ENT, Istanbul Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey.

İstanbul Medeniyet Üniversitesi, Göztepe Eğitim ve Araştırma Hastanesi, KBB Kliniği, İstanbul.

Correspondence (İletişim): Osman H. Çam, M.D. Fahrettin Kerim Gökay Cad., Göztepe Eğitim ve Araştırma Hastanesi KBB Kliniği, İstanbul, Turkey. Tel: +90 - 216 - 566 40 00 / 9075 e-mail (e-posta): osman.cam@gmail.com

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bullet entry points: one in the left side of the neck on mandibular corpus, near the midline about 1 cm with irregular edges; a second about 1 cm in the left inferior lobule of auricle with irregular edges; and a third in the left side about 2 cm inferior mandibular corpus with irregular edges. In the left neck, air bubbles drew attention from one of the defects which was approximately 2 cm inferior from mandibular corpus. In the neck on the right side of the mandibular corpus, there were two 1 cm length bullet exits: the first in the midline and the second more anteriorly. Due to the entrance of the bullet in the left shoulder, there were two wounds about 1 cm in diameter with irregular edges, surrounded by ecchymosis, and one irregular wound on the right deltoideopectoral side 1 cm in diameter with ecchymosis around. All wounds had minimal hemorrhages. The patient had mild respiratory distress, and had moderate subcutaneous emphysema. However, due to lack of cyanosis, major airway pathology was not thought. after airway application with intravenous access, standard cranial and neck computed tomography (CT) and a 3D cranium CT imaging were performed. In the neck CT, hyoid bone corpus fracture was observed using an aerial image between soft tissue at the level of tongue base and neck. Additionally, foreign body artifact was seen inside the mouth. Multiple fracture lines including the right and left side of the mandibular corpus were seen. Doppler ultrasonography of bilateral carotid arteries and flow rates were within normal limits. The patientâ&#x20AC;&#x2122;s carotid sheath remained intact, so angiography was not performed. The patient was operated on by a team consisting of ear, nose, and throat (ENT), general, plastic, and cardiovascular surgeons. The patient was intubated nasotracheally under general anesthesia. Flexible endoscopy was performed by general surgeons. Esophagus was evaluated as normal. Then, direct laryngoscopy was performed by the ENT team. Edema and hyperemia were seen in the vocal cords and the band ventricles. Suspicious mucosal tears were observed in the mucosa of the left hypopharynx. Then, the neck was explored. Apron flap was elevated. The carotid sheath was investigated by vascular surgery consultant on the left side of the neck for possibility of a major vessel dissection. The carotid artery and the internal jugular vein were both intact. On the left side of the neck approximately 2 cm inferior to mandibular corpus, the tract caused by a skin defect was followed and was seen entering the hypopharynx. The left half portion of the hyoid bone corpus was fractured and the left side of the esophagus was perforated by a bullet. The right side of the hyoid bone was intact. The damaged portion of the hyoid 272

was excised. The left side of the esophageal injury was repaired. There was also damage on the right side of the esophagus at the same level of the hypopharynx. Esophageal injury was repaired on the right side. The muscles and subcutaneous tissues on right and left sides were transposed and sutured to the hypopharynx defect and reconstruction was performed. There was a 1 cm laceration in the soft palate on the left side. There was a defect approximately 1.5 to 2 cm in size in the mouth floor on the right side. All lacerations in the mouth were sutured. Two hemovac drains were inserted into the surgical field and tracheotomy was performed between second and third tracheal rings. Neck was closed with subcutaneous and skin sutures. Oropharynx was examined with the help of mouth gag opener. On the right side at the level of second and third molar teeth, there was a mandibular defect with a 1.5 to 2 cm laceration of the buccal mucosa adjacent. One bullet stuck in the lacerations among the soft tissues was removed. Other entry and exit holes in the neck were sutured, primarily after desepithelization. Upper and lower jaws were stabilized and fixated with the help of arch bars by the plastic surgeon. A nasogastric tube was applied. The patient was transferred to the Intensive Care Unit with tracheotomy. On postoperative seventh day, the patient underwent a control Doppler ultrasonography. The vascular flow rates were within the normal limits. After 10 days postoperatively, all the sutures were removed and the patient was decannulated and fed orally. The patient was discharged to be followed by plastic surgery outpatient clinic.

DISCUSSION As always, the first step in penetrating neck trauma patients is to ensure the safety of the airway. After making sure that there is no interruption or obstruction in the airway, vascular injury and hemodynamics must be checked. Three quarters of patients with laryngotracheal injury need airway intervention.[4] Intubation or emergent cricothyroidotomy must be performed in cases of airway interruption. In our patient, the existence of mild respiratory distress and subcutaneous emphysema as well as possible laryngotracheal or hypopharyngeal injury was considered. Vascular injury is one of the most important markers in determining mortality and morbidity. Although there was no evidence of vascular injury in carotid Doppler ultrasonography of our patient, carotid sheath was explored and followed during the vascular trace for exclusion of the blast effect of the bullet resulting a possible aneurysm, pseudoaneurysm, or dissection. In ballistic, injuries occult bullet embolism, either arteMayÄąs - May 2013


Larynx, hypopharynx and mandible injury due to external penetrating neck injury

rial or venous, is also well described in the literature. [5] Dyspnea, hemoptysis, and chest pain are the major symptoms of venous bullet embolism while claudication, peripheral ischemia, and thrombophlebitis are the symptoms of arterial embolism. Our patient had only mild dyspnea, so bullet embolism was not mainly considered. Indications that immediate exploration for any penetrating neck injuries, regardless of zone, is necessary include active external hemorrhage, hemoptysis, stridor, and pulsatile or expanding hematoma.[6] Our patient had none of the symptoms above. For asymptomatic patients, there are some studies envisaging vascular exploration for selective cases in neck injuries.[7] The hypopharynx and esophagus injury may occur as a result of direct damage, or it may occur by blast damage as well. In our patient, the skin defect was observed and the tract was followed up to the hypopharynx perforation. Currently there is no consensus regarding the conservative treatment of penetrating neck trauma patients. After CT angiography, endoscopy, and laryngoscopy, follow up is an option, as there are some authors who suggest aggressive surgical exploration especially in case of suspicious cervical esophageal injury.[8,9] Our patient had mild dyspnea, subcutaneous emphysema and mild oropharyngeal hemorrhage symptoms accompanied by edema and hyperemia in the vocal cords and the band ventricles. Possible laryngotracheal injury with/without vascular damage was prediagnosed and selective neck exploration was performed.

Cilt - Vol. 19 Say覺 - No. 3

In conclusion, ballistic neck traumas are crisis management cases and multidisciplinary evaluation is needed during approach. Selective neck exploration is still controversial. We need more studies with huge patient follow up to clarify this discussion. Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Preston T, Fedok FG. Blunt and penetrating trauma to the larynx and upper airway. Operative Techniques in Otolaryngology 2007;18:140-3. 2. Monson DO, Saletta JD, Freeark RJ. Carotid vertebral trauma. J Trauma 1969;9:987-99. 3. Osborn TM, Bell RB, Qaisi W, Long WB. Computed tomographic angiography as an aid to clinical decision making in the selective management of penetrating injuries to the neck: a reduction in the need for operative exploration. J Trauma 2008;64:1466-71. 4. Young O, Watters K, Sheahan P, Hughes J. Penetrating air gun wound in the neck. Auris Nasus Larynx 2008;35:426-8. 5. Greaves N. Gunshot bullet embolus with pellet migration from the left brachiocephalic vein to the right ventricle: a case report. Scand J Trauma Resusc Emerg Med 2010;18:36. 6. Sekharan J, Dennis JW, Veldenz HC, Miranda F, Frykberg ER. Continued experience with physical examination alone for evaluation and management of penetrating zone 2 neck injuries: results of 145 cases. J Vasc Surg 2000;32:483-9. 7. Klyachkin ML, Rohmiller M, Charash WE, Sloan DA, Kearney PA. Penetrating injuries of the neck: selective management evolving. Am Surg 1997;63:189-94. 8. Woo K, Magner DP, Wilson MT, Margulies DR. CT angiography in penetrating neck trauma reduces the need for operative neck exploration. Am Surg 2005;71:754-8. 9. Henderson E, Echav矇 V, Lalancette M, Langlois G. Esophageal perforation in closed neck trauma. Can J Surg 2007;50:E5-6.

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Ulus Travma Acil Cerrahi Derg 2013;19 (3):274-276

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.12354

Velpeau bandajı sonrası nadir bir komplikasyon: Hemopnömotoraks A rare complication after Velpeau bandage: hemopneumothorax Ali YEGİNSU, Makbule ERGİN, Kürşat GÜRLEK

Velpeau bandajı omuz bölgesindeki kırık ve çıkıklarda kolu gövdeye tespit eden bir tedavi yöntemidir. Velpeau bandajı çok nadiren komplikasyonlara yol açar. Kırk beş yaşında erkek hasta travma sonrası acil servise başvurdu. Radyolojik incelemelerde glenoid ve multipl kaburga kırığı tespit edildi. Cerrahi düzeltme öncesinde geçici Velpeau bandajı uygulandı. Bandaj uygulamasından 1 gün sonra hastada nefes darlığı ve göğüs ağrısı şikayetleri başladı. Göğüs grafisinde kaburga kırık bölgelerinde belirgin bir ayrışma ve hemopnömotoraks olduğu görüldü. Hastaya göğüs tüpü yerleştirildi. Glenoid kırık cerrahi olarak düzeltildi. Hasta 6. gün taburcu edildi. Bir ay sonraki incelemesinde sorunsuzdu.

Velpeau bandage is a treatment method that fixes the arm to the body in cases of fractures and dislocations at the region of shoulder. Velpeau bandage very rarely leads to complications. This case report involves a 45-year-old male admitted to the emergency service after trauma. Glenoid and multiple rib fractures were detected in radiological examinations. A transient Velpeau bandage was performed before surgical correction. Patient had dyspnea and chest pain 24 hours after bandage application. An obvious displacement at the rib fracture sites and hemopneumothorax were seen in the chest X-ray. A chest tube was inserted into the patient. Glenoid fracture was corrected surgically. Patient was discharged on the sixth day. He has no problems at readmission after the first month.

Anahtar Sözcükler: Hemopnömotoraks; kaburga kırığı; travma; velpeau bandajı.

Key Words: Hemopneumothroax; rib fracture; trauma; Velpeau bandage.

Velpeau bandajı (VB) ilk kez Alfred Armand Louis Marie Velpeau tarafından 1853 yılında tarif edilmiştir.[1] VB omuz bölgesindeki kırık ve çıkıklarda, sternoklavikular dislokasyonlarda, akromioklaviküler dislokasyonlarda, klavikula, akromiyon, skapula ve humerus kırıklarında kolu gövdeye tespit ederek kolun ve omuzun hareketine izin vermeyecek şekilde sabitleyen bir tedavi yöntemidir.[1,2] VB’ye bağlı komplikasyonlar oldukça nadir görülür.

omuzda minimal ekimoz, palpasyonla omuzda ve sağ meme altında hassasiyet mevcuttu. Krakman veya ciltaltı amfizemi yoktu. Solunum sesleri iki taraflı mevcut olan hastada yapılan radyolojik incelemede sağ 3, 4 ve 5. kaburgalarda nondeplase kırık (Şekil 1a), sağ glenoidde deplase kırık ve akromiyoklaviküler eklem çıkığı tespit edildi.

OLGU SUNUMU Yüksekten düşme nedeniyle acil servise başvuran 45 yaşında erkek hastanın fiziksel incelemesinde

Yapılan laboratuvar incelemesinde anormallik saptanmadı. Hasta ortopedi ve travmatoloji bölümü tarafından ameliyat planıyla hastaneye yatışı yapıldı. Ameliyat tarihine kadar omuz stabilizasyonu için VB yapılan hasta bandajdan 24 saat sonra nefes darlığı gelişmesi üzerine kliniğimize konsülte edildi. Radyolojik değerlendirmede daha önce tespit edilen kaburga nondeplase kaburga kırıklarının deplase olduğu ve ek olarak daha önce tespit edilemeyen 6 ve 7. kaburgalar-

Gaziosmanpaşa Üniversitesi Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, Tokat.

Department of Thoracic Surgery, Gaziosmanpasa University Faculty of Medicine, Tokat, Turkey.

Bu yazıda omuz bölgesi ve kaburga kırığı olan bir hastada VB sonrasında ortaya çıkan bir hemopnömotoraks olgusu sunuldu.

İletişim (Correspondence): Dr. Ali Yeginsu. Gaziosmanpaşa Üniversitesi Tıp Fakültesi Göğüs Cerrahisi Anabilim Dalı, 60100 Tokat, Turkey. Tel: +90 - 356 - 214 32 94 e-posta (e-mail): yeginsu@hotmail.com

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Velpeau bandajı sonrası nadir bir komplikasyon

(a)

(b)

Şekil 1. (a) Hastanın acil servise başvuru anında çekilen akciğer grafisi. Kırık hatları ok ile işaretlenmiştir. (b) Velpeau bandajından 24 saat sonra hastada gelişen hemopnömotoraks ve kaburga kırıklarındaki ayrışma. Kırık hatları ■; pnömotoraks alanı ▲ ve hemotoraks alanı O ile işaretlenmiştir.

daki kırıkların da deplase olduğu ve hemopnomotoraks geliştiği tespit edildi (Şekil 1b). Hastanın VB açılarak tüp torakostomi uygulandı. Hastadan 400 ml hemorajik mayi boşaltıldı. Kaçak devam etmedi. Sonrasında hastaya tekrar ve daha gevşek olarak VB uygulandı (Şekil 2a). Hastanın humerus kırığı tüp torakostomi sonrası 2. günde ameliyat edildi. Hastada internal kaburga fiksasyonu endikasyonu düşünülmedi. Hastaya kanüle vida ile glenoide osteosentez, klavikula distal uç rezeksiyonu, rotator cuff tamiri, Hamstring otogrefti ile korakoklavikuler ligament tamiri ameliyatı yapıldı. Ameliyat sonrası 4. günde dreni alınan hasta 6. günde taburcu edildi. Bir ay sonraki kontrolünde sorunsuzdu (Şekil 2b).

(a)

TARTIŞMA Vücutta oluşan tüm kırıkların %10-12’si klavikula, %7’si humerus ve %1’i skapula kırıklarıdır. Skapula kaslar tarafından çok iyi bir şekilde örtüldüğü için, travmalara karşı relatif bir korunmaya sahiptir.[3,4] Tüm kırıkların %1’ini, omuz bölgesi kırıklarının %5’ini teşkil eden skapula kırıkları nadir lezyonlardır. Skapula kırıkları genelde yüksek enerjili travmalar sonucu oluşurlar ve eşlik eden yaralanma oranı yüksektir.[5] Skapula kırıklarına %57 oranında toraks ve kafa travmasının eşlik ettiği bildirilmiştir.[3-5] Humerus kırıkları ise genellikle aktif genç hastalarda görülür. Kadın erkek oranı genelde eşittir ve sol taraf daha fazla etkilenir.[6]

(b)

Şekil 2. (a) Tüp torakostomi sonrası çekilen akciğer grafisi. (b) Hastanın 1 ay sonraki kontrolünde çekilen akciğer grafisi. Cilt - Vol. 19 Sayı - No. 3

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Omuz bölgesi kırıklarında öncelikle konservatif tedavi yaklaşımları tercih edilir. Kapalı olarak redükte edilemeyen kırıklar, patolojik kırıklar, çoklu kırıklarda, birlikte büyük damar yaralanmasının bulunduğu kırıklar, açık kırıklar cerrahi olarak tedavi edilirler.[7,8] Olgumuzda omuz bölgesinin çıkıklı kırığına ilave olarak deplase olmayan çoklu kaburga kırığı mevcuttu. Cerrahi tedavisi planlanan hastaya geçici olarak VB uygulandı ancak 24 saat sonra kaburga kırık uçlarının deplase olduğu ve hemopnömotoraks geliştiği görüldü. Biz bu olguda kaburgalardaki ayrışmanın kolun sıkı bir şekilde kırık hattı üzerine sarılması nedeniyle ortaya çıktığını ve hemopnömotoraks gelişiminin bandaj nedeniyle ayrışan kırık kaburga uçlarının toraks içerisine girerek viseral plevrayı yaralaması sonucunda ortaya çıkan bir komplikasyon olduğunu düşünüyoruz. Hemopnömotoraksın ortaya çıkış zamanı ve radyolojik bulgular da düşüncemizi teyit etmektedir. Diğer yandan hastanın nakli sırasında kırık kaburgaların ayrışması ihtimali de mevcuttur. Hasta acilde değerlendirilerek VB hasta nakledilmeden önce yapılmıştır. Burada VB’den hemen sonra servise nakledilmeden önce çekilen akciğer grafileri olmadığı için kesin bir yargıya varmak mümkün değildir. Ancak kaburgalarda ayrışma olması için hasta naklinin oldukça hoyrat ve özensiz yapılması gereklidir. Yine de böyle bir ihtimal de söz konusu olabilir. Velpeau bandajı sonrasında komplikasyonlar oldukça nadir görülür. Bunlar arasında cilt abrazyonu, enfeksiyonlar, kontakt dermatit, bası yaraları ve nörovasküler komplikasyonlar bildirilmiştir.[6] Biz literatürde VB uygulanmasının bir komplikasyonu olarak

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bildirilen hemopnömotoraks olgusuna rastlamadık. Sonuç olarak, kaburga kırığının eşlik ettiği omuz bölgesi kırık ya da çıkıklarında VB uygulaması kaburga kırık uçlarının ayrışmasına ve buna bağlı plevral ya da pulmoner komplikasyonların ortaya çıkmasına neden olabilir. Bu nedenle VB uygulaması sırasında bu durum göz önünde bulundurulmalıdır. VB’nin daha gevşek sarılması ya da VB uygulamadan hastanın direkt ameliyata alınması oluşabilecek plöropulmoner komplikasyonların önlenmesinde yararlı olabilir. Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması yoktur.

KAYNAKLAR 1. Hall MC. The Velpeau bandage. Can Med Assoc J 1963;88:92-3. 2. Gopal-Krishnan S, Shelton ML. Posterior dislocation of the shoulder; its diagnosis and treatment. J Natl Med Assoc 1972;64:106-8. 3. Tarhan O, Arkan C, Tolun U, Buluç L. Skapula kırıkları artroplasti. Artroskopik Cerrahi 2000;11:42-4. 4. Salimi J, Khaji A, Karbakhsh M, Saadat S, Eftekhar B. Scapular fracture: lower severity and mortality. Sao Paulo Med J 2008;126:186-9. 5. Tezer M, Kabukçuoğlu YS, Koçkesen TÇ, Ordueri M, Kuzgun Ü. Çocuk skapula cisim kırığı. Acta Orthop Traumatol Turc 1998;32:256-9. 6. Şener İU. Humerus diafiz kırıklarında tedavi sonuçlarımız. 2005; İstanbul (Tez). 7. McLaurin TM. Proximal humerus fractures in the elderly are we operating on too many? Bull Hosp Jt Dis 2004;62:2432. 8. Pehlivan Ö, Rodop O, Kıral A, Kuşkucu SM, Güdemez E, Kaplan H. Humerus cisim kırıklarının fonksiyonel tedavisi Artroplasti Artroskopik Cerrahi 2000;11:45-51.

Mayıs - May 2013


Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):277-281

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.66492

Total skalp, alın, sol kulak, kaşlar ve üst gözkapakları amputasyonunun başarılı replantasyonu ve 6 yıllık takip sonuçları A successful replantation of total scalp, forehead, left ear, eyebrows and upper eyelids amputation and 6-year follow-up results Özlenen ÖZKAN,1 Gamze BEKTAŞ,2 Anı CİNPOLAT,3 Ömer ÖZKAN1

Skalp amputasyonlarında mikrovasküler replantasyon teknik zorluklarına rağmen üstün estetik sonuçları, sosyal ve psikolojik avantajları nedeniyle ilk tercih olarak değerlendirilmesi gereken seçkin tedavi yöntemidir. Bu yazıda, saçlı derinin tamamına yakınının ayrıca sol kulak, tüm alın bölgesi, her iki kaş ile üst göz kapaklarını içeren tam bir amputasyonun başarılı replantasyonu ve olgunun ameliyat sonrası 6. yıldaki fonksiyonel değerlendirmesi yapıldı.

Despite the technical difficulties, microvascular replantation is the outstanding method of treatment for avulsed scalps because of superior aesthetic results and social and psychological benefits. We presented a successful replantation of almost the whole of the scalp as well as the left ear, the entire forehead, eyebrows, and upper eyelids. Functional assessment of the case in the postoperative sixth year was reported.

Anahtar Sözcükler: Avulsiyon; ear; replantasyon; skalp.

Key Words: Avulsion; ear; replantation; scalp.

Skalp avülsiyonları klinikte nadir rastlanan ve tedavisi zor olgulardır. Tedavisinde önceleri deri greftleri, kas flep transferleri, omentum flebi ve ekspansiyon yöntemleri sıkça kullanılmıştır. Fakat sonuçlar saç gelişimini olmaması ve skarlar nedeniyle hastaların beklentilerini karşılamaktan uzak kalmıştır.[1,2] 1976 yılında Miller ve arkadaşları[3] mikrocerrahi teknikle ilk kez avülze skalp replantasyonunu uygulamış ve mükemmel sonuç almışlardır. Bu çalışmadan sonra Buncke ve arkadaşları[4] Van Beek ve Zook[5] ve diğer başka yazarlar[6-8] kendi başarılı deneyimlerini sunmuşlardır ve skalp avülsiyonlarında mikrocerrahi ile replantasyon günümüzde kullanılan seçkin tedavi yöntemi halini almıştır.[9-17] Ancak, ekstremite amputasyonlarındakinin tersine kulak, burun, skalp gibi dokuların replantasyonu vasküler yapılarının boyut-

larının küçüklüğü ve de bunların yaralanmalarının natürüne bağlı zedelenmeleri nedeniyle, birçok mikrocerrahi kliniğinde elde edilen tecrübelere rağmen, günümüzde halen zorluk arzeder.

Akdeniz Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Antalya; 2 Tatvan Devlet Hastanesi, Plastik Rekonstrüktif ve Estetik Cerrahi Bölümü, Bitlis; 3 Adana Numune Eğitim ve Araştırma Hastanesi, Plastik Rekonstrüktif ve Estetik Cerrahi Bölümü, Adana.

Department of Plastic Reconstructive and Aesthetic Surgery, Akdeniz University Faculty of Medicine, Antalya; 2 Department of Plastic Reconstructive and Aesthetic Surgery, Tatvan State Hospital, Bitlis; 3 Department of Plastic Reconstructive and Aesthetic Surgery, Adana Numune Training and Research Hospital, Adana, Turkey.

1

Bu yazıda, tüm saçlı derinin ense bölgesi hariç tamamına yakını, sol kulak, tüm alın bölgesi, her iki kaş ile üst göz kapaklarını içeren tam bir amputasyon olgusunun başarılı replantasyonu sunuldu.

OLGU SUNUMU Otuz beş yaşındaki kadın hasta patoz makinasına saçlarını kaptırma sonucu tüm saçlı derinin ense bölgesi hariç tamamına yakını, sol kulak, tüm alın bölgesi, her iki kaş ile üst göz kapaklarını içeren tam amputasyonu nedeniyle Haziran 2006’da acil servise

1

İletişim (Correspondence): Dr. Özlenen Özkan. Akdeniz Üniversitesi Tıp Fakültesi, B Blok, 2. Kat, Plastik Rekonstrüktif ve Estetik Cerrahi AD., Antalya, Turkey. Tel: +90 - 242 - 249 60 00 e-posta (e-mail): ozlenend@yahoo.com

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(a)

(b)

Şekil 1. (a) Ampute parça. (b) Skalp defekti. Renkli şekiller derginin online sayısında görülebilir (www.tjtes.org)

başvurdu (Şekil 1a, b). Hastanın yaralanma sonrasında 6. saati olduğu öğrenildi. Bilinci açık olan hasta hayatı tehdit eden ek bir yaralanma ve servikal travma açısından değerlendirilerek replantasyona engel bir durum saptanmaması üzerine ilk müdehalenin ardından ameliyata alındı. Avülse skalp traş edildi, salin ile yıkanarak mümkün olduğunca iç yüzdeki saç parçalarından temizlendi. Cerrahi mikroskop altında damar durumu açısından incelendi. Avülse skalp üzerinde sağ ve sol superfisiyel temporal arter ve venler bulundu zarar görmüş kısımları sağlam intimaya kadar eksize edildi ve bulunan damarlar işaretlendi. Alıcı alan incelendi, alın ve kafa kemiklerinin periostunun sıyrılmış olduğu görüldü (Şekil 1b), alıcı damar olarak iki taraflı superfisyel temporal arter ve ven diseke edildi, zarar görmüş kısımlar çıkarıldı. Arada oluşan damar defekti için ön koldan alıcı damarlarla uygun çapta interpozisyonel ven greftleri alındı. Anastomozlar önce ampute parçadaki superfisiyel temporal arter ve ven ile interpozisyonel ven greftleri arasında yapıldı, daha sonra alıcı alana getirilerek final anastomozlar gerçekleştirildi. Anastomozlardan sonra skalp derisinin pembe renk olduğu ve yara kenarlarından kırmızı kanama olduğu görüldü ancak kulakta dolaşım yetersizliği mevcuttu, bunun kulak ile ana parça arasındaki kesiler ve cilt altı dokusundaki zedelenme nedeniyle olduğu düşünüldü. Kulak ön kenarından yapılan diseksiyonla ayrıca bulunan 1 arter ve 1 ven interpozisyonel ven grefti kullanılarak sol fasiyal arter ve vene anastomoz edildi. Takiben kulak dolaşımının düzeldiği görüldü. Skalp gevşek bir şekilde dikilerek altına hemovak drenler yerleştirildi. Hasta takip amaçlı pansumanı açık bırakılarak yoğun bakıma alındı. Ameliyat sonrası dönemde mikroanastomoz güven278

liği, skalp renk, refil ve sıcaklığı gibi klinik parametrelere bakılarak ve iğne ile kanama kontrolü yapılarak takip edildi. Proflaktik olarak heparin 3x5000 Ü iv ve penisilin grubu antibiyotik iv yoldan verildi. Sorun olmayan hasta 3 gün yoğun bakımda, 15 gün serviste takip edildi. İmmobilizasyona bağlı oksipital bölgede oluşan 2x2 cm’lik dekübit ülseri eksize edilerek greftlendi. Üçüncü ayda sol kulak meatusta daralma nedeni ile lokal anestezi ile ameliyat edilerek kontraktür açıldı. Ameliyat sonrası geç dönemde tamamiyle normale yakın kozmetik görünüm sağlandı (Şekil 2a). Şu anda 6. yıldaki takibinde olan hastanın replante skalpinden normal saç gelişimi olmakta ve göz açma, kapama hareketlerinde herhangi bir sorun yaşanmamaktadır. Frontal kas hareketleri geri kazanılmış olup kaşlarını kaldırabilmektedir (Şekil 2b). Hasta dış görünümüden tamamen memnun durumda bulunmaktadır. Replante skalp duyusunun geri geldiği gözlenmiştir.

TARTIŞMA Skalbin travmatik amputasyonları mikrocerrahinin gelişiminden önce sıklıkla komposite greftler veya deri greftleri ile onarılırdı.[1,2] İlk skalp replantasyonu Miller ve arkadadaşları[3] tarafından 1976 da rapor edildi. Daha sonra literatürde başarılı sonuçlardan oluşan olgu sunumları yayınlandı.[4-8] En geniş seri 20 olgu içermekteydi ve 1996 yılında Cheng tarafından yayınlanmıştı.[11] Skalp replantasyonunun saçların tekrar gelişimi açısından, skalp innervasyonunun geri kazanılması açısından, özellikle bizim olgumuzda olduğu gibi alın derisi, göz kapakları ve kulak gibi benzersiz yapıları yeniden kazandırabilmesi açısından kozmetik ve psikolojik yararları düşünüldüğünde diğer yöntemlere üstünlüğü tartışılmazdır.[4-11] Mayıs - May 2013


Total skalp, alın, sol kulak, kaşlar ve üst gözkapakları amputasyonunun başarılı replantasyonu

(a)

(b)

Şekil 2. Ameliyat sonrası (a) 2. yıl ve (b) 6. yıl görünümler. Renkli şekiller derginin online sayısında görülebilir (www.tjtes.org)

Skalbin majör kan akımı superfisiyel temporal ve oksipital arterden gelmektedir. Skalpte damarlar arasındaki zengin kollateral bağlantılar sayesinde tek bir arter ve ven anastomozu ile total skalp perfüzyonunun sağlanabileceği gösteren yayınlar mevcuttur. [9-12] Diğer yazarlar birden fazla damara anastomoz yapmak gerekliliğini savunurlar.[13-18] Hasta sayısının yeterli olmaması nedeniyle, anastomoz sayısınının yeterliliği üzerinde bir çalışma yapmak ve kesin bir yargıya varmak zordur. Ancak Cheng ve arkadaşları 20 olgudan oluşan serilerinde çoklu damar anastomozunun daha iyi sonuçlar verdiğini vurgulamıştır. [11] Üstelik avülse bir skalpte ilk baslangıçta dikkat çekmeyen yaralanmalar anastomozlardan sonra parsiyel dolaşım bozukluklarına neden olabilmektedir, bu da sıklıkla parsiyel flep kayıplarına neden olarak sekonder girişimler gerektirmektedir. Bizim sunduğumuz olguda da, avülse skalbin mikroskop altında damar durumu açısından incelenmesi sonucunda, 2 temporal artere de anastomoz yapmaya karar verdik ve yeterli debridman, interpozisyonel ven greftlerinin yerleştirilmesi, anastomozların tamamlanması sonrasında kulakta dolaşım bozukluğu olduğunu gördük. Bunun, kulak ile ana parça arasındaki kesilerden ve cilt altı dokusundaki zedelenmeden kaynaklandığını düşünerek kulak ön sınırında bulunan 1 adet arter ve veni, ven grefti kullanarak fasiyal arterve vene anastomoz ettik ve kulak dolaşımın düzeldiğini gördük. Bizim kanaatimize göre özellikle üzerinde kesiler ve zedelenmeler bulunan skalplerde birden fazla anastomoza ihtiyaç olabilmektedir ve ampute parçanın tamamının yaşatılabilmesi içinelden gelen tüm çaba sarfedilmeli ve böylece sekonder defisitlerden kaçınılmalıdır. Cilt - Vol. 19 Sayı - No. 3

Başarılı skalp replantasyonunda anahtar nokta teknik olarak iyi bir mikrovasküler anastomoz gibi durmaktadır. Diğer etkileyen faktörler iyi bir ameliyat öncesi değerlendirme, hemorajik şok ve eşlik eden yaralanmaların değerlendirilmesi, ampute skalbin değerlendirilerek avülse damar segmentlerinin çekinmeden debride edilmesi, ven greftleri kullanılarak anastomozlarda gerginlikten kaçınılması, eğer mevcutsa temporal damarlara mutlaka anastomoz yapılması önemli noktalardır. Yine skalpin zengin bir kan akımına sahip olması nedeniyle, geniş skalp yaralanmaları transfüzyon gerektirecek geniş kanamaya sebep olabilirler. Bu nedenle iskemik zamanı azaltmak ve kan kaybını önlemek için kontrendikasyon yoksa hastanın durumu stabilize edildikten sonra mümkün olan en kısa zamanda replantasyon yapılmalıdır. Skalp avülsiyonlarında venlerin arterlerden daha fazla zedelendiği bilinen bir gerçektir[19] ve başarılı skalp replantasyonu için venöz drenajı sağlamak kritik bir nokta gibi gözükmektedir.[20] Avülse skalpte anastomoz için uygun nitelikte ven bununamadığı durumlarda, skalpten ekstra arterler alıcı venlere anastomoz edilerek venöz drenaj sağlanabilir.[11,21] Bizim olgumuzda her arter için 1 ven anastomozu yapılarak toplamda 3 ven anastomozu yapıldı ve venöz drenajle ilgili bir sorun yaşanmadığı için ek yöntemlere başvurulmadı. Çözülemeyen bir venöz drenaj problemi olduğunda medikal sülüklerden yararlanmak faydalı bir çözüm olarak akılda tutulmalıdır.[22,23] Bunlar aynı zamanda konjesyon ve ödemi de azaltabilirler,[24] fakat yaratabilecekleri kan kaybına önemsiz gibi gözükse de dikkat edilmelidir.[22] Nahai ve arkadaşları[25] duyu siniri onarımı yapılmayan replante skalplerde koruyucu duyunun geri 279


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geldiğini göstermiştir. Cheng ve arkadaşları 20 olguluk çalışmalarında 7 olguya sinir koaptasyonu yapmış ve yapılmayanlarda sadece koruyucu duyu da hafif bir geri kazanım olmasına rağmen koaptasyon yapılanlarda 2 yıl sonunda iki nokta diskriminasyon testinin 15 mm olduğunu söylemişlerdir.[11] Ueda ve arkadaşları ise daha sonraki olgu sunumlarında sinir koaptasyonu yapılmayan olgularda 8. aydan itibaren sinir iyileşmesini başladığını ve 3. yılda tamamen normal sınırlara ulaştığını göstermişlerdir.[26] Biz de hastamızda da sinir onarımı yapmamamıza rağmen şu anda 6. yıldaki takibinde iki nokta diskriminasyon testinin 0.8 mm olduğunu gördük. Yani bulgularımız sinir onarımı yapılmayan skalp replatasyonu olgularında uzun dönemde sadece koruyucu duyunun değil aynı zamanda dokunma duyusunun da geri kazanıldığını destekler nitelikteydi. Motor fonksiyon yönünden değerlendirecek olursak ise, frontal kas hareketlerine baktığımızda, uzun dönemde sinir koaptasyonu yapmamıza rağmen hastanın kaşlarını kaldırabildiğini ve frontal kas nörotizasyonunun sağlandığını gözlemdik. Bu konuda Aydan Köse ve arkadaşları[18] tarafından yapılan bir çalışmada avülse bir skalbe uygulanan mikrovasküler replantasyon sonrası 38. ayda frontal kas hareketlerinin geri geldiği rapor edilmiştir. Rekonstrüktif cerrahide bir defekti giderirken en ideal yöntem kaybedilenin benzer doku ile yerine konmasıdır. Ancak, skalp dokusu asla başka bir çeşit doku ile replase edilemez niteliktedir. Günümüzde bu hedef sınırlı sayıda gerçekleştirilebilen allotransplantasyonlar haricinde ancak ampute bir parçanın replantasyonu ile mümkün olmaktadır. Replantasyonun sonuçları her zaman diğer tedavi seçenekleri olan serbest flepler, lokal flepler, deri greftlerinden çok üstündür. Başarılı bir replantasyon en iyi estetik ve fonksiyonel sonuçları sağlayacaktır. Bu nedenle kopan bir parçanın replantasyonu ve parçanın tüm komponentlerinin yaşatılabilmesi için tüm çabanın sarfedilmesi, tüm komponenetlerin ayrı ayrı değerlendirilerek gerekirse çoklu amputasyon gibi tedavi edilmesi gerektiğini düşünmekteyiz. Tüm zorluklarına rağmen kopan parçanın replantasyonu, diğer tüm rekonstrüktif cerrahi yöntemlerden belirgin üstün sonuçları nedeniyle titizlikle uygulanması ve parçanın tamamının yaşatılabilmesi için tüm şartların zorlanması gereken klinik bir durumdur. Başarılı replantasyon sonrası elde edilen sonuçlar hem hasta hem cerrah için oldukça yüz güldürücü olmaktadır. Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması yoktur.

KAYNAKLAR 1. Koss N, Robson MC, Krizek TJ. Scalping injury. Plast Reconstr Surg 1975;55:439-44. 2. Bhattacharya V, Sinha JK, Tripathi FM. Management of 280

scalp injuries. J Trauma 1982;22(8):698-702. 3. Miller GD, Anstee EJ, Snell JA. Successful replantation of an avulsed scalp by microvascular anastomoses. Plast Reconstr Surg 1976;58:133-6. 4. Buncke HJ, Rose EH, Brownstein MJ, Chater NL. Successful replantation of two avulsed scalps by microvascular anastomoses. Plast Reconstr Surg 1978;61:666-72. 5. Van Beek AL, Zook EG. Scalp replantation by microsurgical revascularization: case report. Plast Reconstr Surg 1978;61:774-7. 6. Nahai F, Hurteau J, Vasconez LO. Replantation of an entire scalp and ear by microvascular anastomoses of only 1 artery and 1 vein. Br J Plast Surg 1978;31:339-42. 7. Yaffe B, Shvoron A. Successful replantation of a totally avulsed scalp. J Reconstr Microsurg 1986;2:171-3. 8. McCann J, O’Donoghue J, Kaf-al Ghazal S, Johnston S, Khan K. Microvascular replantation of a completely avulsed scalp. Microsurgery 1994;15:639-42. 9. Juri J, Irigaray A, Zeaiter C. Reimplantation of scalp. Ann Plast Surg 1990;24:354-61. 10. Eren S, Hess J, Larkin GC. Total scalp replantation based on one artery and one vein. Microsurgery 1993;14:266-71. 11. Barisoni D, Lorenzini M, Governa M. Two cases of scalp reimplantation based on one artery and one vein with interposed vein grafts. Eur J Plast Surg 1997;20:51-3. 12. Wilhelmi BJ, Kang RH, Movassaghi K, Ganchi PA, Lee WP. First successful replantation of face and scalp with singleartery repair: model for face and scalp transplantation. Ann Plast Surg 2003;50:535-40. 13. Arashiro K, Ohtsuka H, Ohtani K, Yamamoto M, Nakaoka H, Watanabe T, et al. Entire scalp replantation: case report and review of the literature. J Reconstr Microsurg 1995;11:24550. 14. Chen IC, Wan HL. Microsurgical replantation of avulsed scalps. J Reconstr Microsurg 1996;12:105-12. 15. Cheng K, Zhou S, Jiang K, Wang S, Dong J, Huang W, et al. Microsurgical replantation of the avulsed scalp: report of 20 cases. Plast Reconstr Surg 1996;97:1099-108. 16. Sakai S, Soeda S, Ishii Y. Avulsion of the scalp: which one is the best artery for anastomosis? Ann Plast Surg 1990;24:3503. 17. Thomas A, Obed V, Murarka A, Malhotra G. Total face and scalp replantation. Plast Reconstr Surg 1998;102:2085-7. 18. Aydan Köse A, Sezgin M, Karabag-Li Y, Ozyilmaz M, Koçman E, Cetin C. Neurotization of the frontal muscle after scalp replantation: case report. J Reconstr Microsurg 2002;18:677-80. 19. Gatti JE, LaRossa D. Scalp avulsions and review of successful replantation. Ann Plast Surg 1981;6:127-31. 20. Yin JW, Matsuo JM, Hsieh CH, Yeh MC, Liao WC, Jeng SF. Replantation of total avulsed scalp with microsurgery: experience of eight cases and literature review. J Trauma 2008;64:796-802. 21. Hallock GG. Secondary expansion of a replanted scalp salvaged by an intrinsic arteriovenous shunt. Plast Reconstr Surg 1999;103:1957-60. 22. Mutimer KL, Banis JC, Upton J. Microsurgical reattachment of totally amputated ears. Plast Reconstr Surg 1987;79:53541. 23. Anthony JP, Lineaweaver WC, Davis JW Jr, Buncke HJ. Quantitative fluorimetric effects of leeching on a replanted Mayıs - May 2013


Total skalp, alın, sol kulak, kaşlar ve üst gözkapakları amputasyonunun başarılı replantasyonu

ear. Microsurgery 1989;10:167-9. 24. Barnett GR, Taylor GI, Mutimer KL. The “chemical leech”: intra-replant subcutaneous heparin as an alternative to venous anastomosis. Report of three cases. Br J Plast Surg 1989;42:556-8.

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25. Nahai F, Hester TR, Jurkiewicz MJ. Microsurgical replantation of the scalp. J Trauma 1985;25:897-902. 26. Ueda K, Nomatsi T, Omiya Y, Tajima S. Replanted scalp recovers normal sensation without nerve anastomosis. Plast Reconstr Surg 2000;106:1651-2.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (3):282-284

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.64436

Künt travma sonucu gelişen izole hiyoid kırığı: Olgu sunumu Isolated hyoid bone fracture due to blunt trauma: case report Mehmet Özgür ERDOĞAN,1 Mehmet KOŞARGELİR,1 Rasim YORULMAZ,1 Kaan MERİÇ,2 Barış ERDOĞAN3

Hiyoid kemik kırıkları nadir görülür. Hiyoid kemik kırığının tanı konması zor olup, yüksek şüphe ile tanısı konulabilir. Bu yazıda, künt travmaya bağlı gelişen izole hiyoid kırığı olgusu sunuldu. Yirmi altı yaşında kadın hasta araç içi trafik kazası kazası sonucu acil servisimize başvurdu. Hasta yutma güçlüğü, boyunda ağrı ve rahatsızlık hissinden şikayetçiydi. Fiziksel incelemede boyunda hiperemi ve hassasiyet mevcuttu. Boyun bilgisayarlı tomografisi çekilen hastada hiyoid kırığı gözlendi. Hastaya ilaç tedavisi uygulanarak 24 saat gözlendi. Poliklinik kontrolü önerilerek taburcu edildi. Acil hekimi, künt travmalarda hiyoid kırığı oluşma riskini dikkate almalıdır. Hiyoid kırıklı hastalar 24 saat gözlenmelidir. Genellikle bu hastalar için ilaç tedavisi yeterli sonuçları vermektedir.

Fractures of the hyoid bone are very rare. Diagnosis of hyoid fracture is difficult and can be made only with a strong degree of suspicion. We report a case of isolated hyoid bone fracture due to blunt trauma to the neck. A 26-year-old woman was admitted to emergency department for motor vehicle accident. She complained of dysphagia and anterior neck discomfort. Physical examination showed hyperemia and tenderness of neck. A tomographic scan of neck was performed. The findings demonstrated hyoid fracture. Patient was observed with medical therapy for 24 hours and discharged with recommendation of outpatient control. Emergency physician has to be aware of the possibility of hyoid fractures in blunt traumas. Patients with hyoid fracture should be observed for 24 hours. Generally, medical treatment is satisfactory in isolated hyoid fractures.

Anahtar Sözcükler: Hiyoid, kırık; künt travma.

Key Words: Hyoid, fracture; blunt trauma.

Ası dışında hiyoid kırıkları nadir görülür. Literatürde, yalnızca 27 hastada rapor edilmiştir. Bu yaralanmanın tanınabilmesi yüksek klinik şüphe gerektirir. [1] Açık hiyoid kırıklarında eksplorasyon önerilmektedir. İzole kapalı hiyoid kırıklarının tedavisinde, hava yolu tıkanıklığı riski yoksa konservatif yaklaşım önerilmektedir. Konservatif yaklaşım konusunda ortak bir algoritma geliştirilememiştir.[2] Amacımız, olgu sunumumuz ile bir algoritma geliştirilmesine katkı sağlamaktır. Bu yazıda, araç içi trafik kazası geçiren genç kadın hastada boyuna gelen künt travma sonucu gözlenen hiyoid kemik kırığı ve bu nadir duruma yaklaşım tartışıldı.

OLGU SUNUMU Yirmi altı yaşında kadın hasta, acil kliniğimize ayaktan başvurdu. Hastanın 12 saat önce araç içi trafik kazası geçirdiği, kaza anında arka koltukta oturduğu ve boynunu ön koltuğun köşesine çarptığı öğrenildi. Olay sonrası ağrı dışında şikayeti olmaması nedeniyle hastaneye başvurmadığı, sonrasında yutma zorluğu, artan boğaz ağrısı ve ses kısıklığı olması nedeniyle kliniğimize başvurduğu öğrenildi.

Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, 1 Acil Tıp Kliniği, 2Radyoloji Kliniği, İstanbul; 3 Şişli Etfal Eğitim ve Araştırma Hastanesi, Kulak Burun Boğaz Kliniği, İstanbul.

Departments of 1Emergency Medicine, 2Radiology, Haydarpasa Numune Training and Research Hospital, İstanbul; 3 Department of Otolaryngology, Sisli Etfal Training and Research Hospital, İstanbul, Turkey.

Hastanın fiziksel incelemesinde vital bulguları stabildi. Boyun ön kısmında oblik şekilde 7x3 santimetre boyutunda basmakla hassasiyet olan hiperemik alan

İletişim (Correspondence): Dr. Mehmet Özgür Erdoğan. Haydarpaşa Numune Hastanesi, Tıbbiye Cad., Kadıköy 34710 İstanbul, Turkey. Tel: +90 - 216 - 542 32 32 e-posta (e-mail): ozgurtheerdogan@mynet.com

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mevcuttu (Şekil 1a). Hastanın çekilen servikal grafilerinde patoloji yoktu. Hastanın boyun bilgisayarlı tomografisinde (BBT) hiyoid kemik kırığına rastlandı (Şekil 1b). Radyoloji kliniği tarafından hiyoid kırığı tanısı doğrulandı. Hasta, kulak burun boğaz (KBB) kliniği ile konsülte edildi. 70 derece açılı teleskopla transoral indirekt laringoskopisi yapılan hastada havayolunda ödem, laserasyon gözlenmedi. Hasta acil servis kliniğinde gözleme alındı. Hastaya baş elevasyonu, soğuk uygulaması, konuşma ve oral alım yasağı uygulandı. Sistemik steroid (60 miligram prednisolon) verilen hasta 24 saat gözlem sonrası klinik değişiklik olmaması nedeniyle taburcu edildi. Hastaya izlem amacı ile KBB polikliniğine başvurması önerildi.

TARTIŞMA Ası ve boğma girişimi haricinde, künt travmaya bağlı hiyoid kemik kırıkları nadir görülürler.[1] Bu kırığın nadir olmasının birkaç nedeni vardır. Hiyoid mandibula tarafından iyi korunmuş olup fasiyal travmalar genellikle mandibula kırığı ile sonuçlanır. [3] Hiyoid kemik vücutta herhangi bir kemikle eklem yapmayan bir kemik olup bu özelliği tüm yönlerde mobilite özelliğini kazandırmaktadır. Hiyoid kemiğin her yönde hareketliliği kırılmaya karşı koruyucu katkı sağlar.[4,5] Bizim olgumuzda hiyoid kemik hasta boynunu doğrudan araba ön koltuğunun köşesine çarptığı için mandibula tarafından korunmamıştır. Ayrıca hiyoid kemik servikal vertebra ile koltuk arasında sıkıştığı için mobiliteside kırılmaya karşı koruyucu olmamıştır. Literatürde genelde boğma girişimi ya da ası ile ilişkili hiyoid kırıkları mevcuttur. Hatta adli tıp uz-

(a)

manları otopsi esnasında kırık hiyoid varlığını boğulma açısından ararlar.[5,6] Bunun dışında literatürde direkt travma, spor ilişkili yaralanma, hiperekstansiyon kırığı şeklinde bildirilmiş olgular vardır.[7] Olgumuzda hiyoid üzerine gelen direkt travma sonucu ortaya çıkmıştır. Hiyoid kırıkları semptomsuz olabilir veya çoklu yaralanmaların arasında dikkatten kaçabilir.[8] Bizim olgumuzda, hastaneye olaydan 12 saat sonra şikayetlerinin artması üzerine başvurmuştur. Hiyoid kırıklarını göstermede en iyi yöntem BBT´dir. Larinks travması açısından klinik şüphe olduğu zaman tomografik değerlendirme önemlidir.[7] Bu olguda çekilen BBT net olarak hiyoid kemik kırığını ortaya koymaktadır. Hastanın hiyoid kırığı tanısının konulması; laringoskopi ile hava yolu açıklığının ve laserasyonların gösterilmesini gerekli kılar.[8] Bir çalışma, solunum sıkıntısının hızla gelişebildiğini ve hayatı tehdit edici düzeyde olabileceğini ifade etmiştir. [9] Bizim hastamızda yapılan indirekt laringoskopide hava yolu doğal değerlendirilmiştir. Uzun dönemde ise hiyoid kırığı sonrasında gelişen disfaji, boyun fleksiyonu esnasında krepitasyon ve eksternal karotis arter psödoanevrizması rapor edilmiştir.[9] Hiyoidin açık kırıklarında, hava yolu tıkanıklığı, laringeal perforasyonlar ve konservatif tedaviye yanıt vermeyen semptomların varlığında eksplorasyon gerekir.[2,8] Açık kırıklarda boyun eksplorasyonu debridman, stabilizasyon ve kopan parçaların çıkarılması açısından önemlidir.[8] Hiyoid kırıklarının çoğu cerrahi tedavi gerektirmez. Çoğunlukla 24 saatlik gözlem, baş boyun elevasyonu, oral gıda alımının kesilmesi,

(b)

Şekil 1. (a) Boyun ön kısmında oblik şekilde 7x3 santimetre boyutunda basmakla hassasiyet olan hiperemik alan mevcut. (b) Bilgisayarlı tomografide hiyoid kemik kırığına rastlandı.

Cilt - Vol. 19 Sayı - No. 3

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

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Ulus Travma Acil Cerrahi Derg

konuşma yasağı, sistemik steroidler ve ağrı kesiciler yeterli olmaktadır.[7] Bizim hastamızda da bu tedavi uygulanmış ve olası komplikasyonlar gelişmemiştir. Laringeal travmaların çeşitliliği ve görüntüleme yöntemlerindeki gelişim nedeniyle bu travmaların daha sık karşımıza çıkacağı açıktır.[8] Özellikle çene altından bağlanan motosiklet kasklarına bağlı kırık bildirilmiştir.[9] Yalnızca hiyoid kırıklarında değil asıdan künt boyun travmalarına kadar tüm laringeal travmalarda gereken gözlem süresine uymak, baş yükseltilmesi ile izlemini yapmak ve havayolu tıkanıklığı riski ile mücadele etmek hasta mortalitesini ve geç dönem komplikasyonları azaltacaktır.[7] Sonuç olarak, boyuna gelen künt darbelerde hiyoid kırığından şüphelenilmeli ve boyun hassasiyeti varsa tomografi ile kırık araştırılmalıdır. Hastalarda kırık olması durumunda baş yükselmesi, hava yolu tıkanıklığı açısından uzun süreli gözlem ve yakın takip önemlidir. Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması yoktur.

284

KAYNAKLAR 1. Campbell AS, Butler AP, Grandas OH. A case of external carotid artery pseudoaneurysm from hyoid bone fracture. Am Surg 2003;69:534-5. 2. Spielmann PM, Hathorn IF, Clarke JK, Denholm S. Hyoid bone fracture identified only with nasal Valsalva manoeuvre. J Laryngol Otol 2010;124:431-2. 3. Dickenson AJ. Fracture of the hyoid bone following minimal trauma. Injury 1991;22:420-1. 4. Williams PL, Bannister LH, Berry M, Collins P, Dyson M, Dussek JE, et al., editors. Gray’s anatomy. 38th ed. New York: Churchill Livingstone Inc; 1995. p. 582. 5. Saladin K. Anatomy and physiology. 2nd ed. New York: McGraw-Hill Companies Inc; 2001. 6. Mukhopadhyay PP. Predictors of hyoid fracture in hanging: Discriminant function analysis of morphometric variables. Leg Med (Tokyo) 2010;12:113-6. 7. Szeremeta W, Morovati SS. Isolated hyoid bone fracture: a case report and review of the literature. J Trauma 1991;31:268-71. 8. Levine E, Taub PJ. Hyoid bone fractures. Mt Sinai J Med 2006;73:1015-8. 9. Kuo LC, Lin HL, Chen CW, Lee WC. Traumatic hyoid bone fracture in patient wearing a helmet: a case report. Am J Emerg Med 2008;26:251.e1-2.

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Travma 2013-3  

The Turkish Journal of Trauma and Emergency Surgery (TJTES) is an official publication of the Turkish Association of Trauma and Emergency Su...

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