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ISSN 1306 - 696X

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

Volume 20 | Number 2 | March 2014

www.tjtes.org


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

www.tjtes.org


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

Recep Güloğlu Kaya Sarıbeyoğlu M. Mahir Özmen Ali Fuat Kaan Gök Hakan Teoman Yanar Gürhan Çelik Osman Şimşek

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

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

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

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

Annual subscription rates: 75.- (USD) 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. p-ISSN 1306-696x • e-ISSN 1307-7945 • Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ, and Turkish Medical Index (Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır.) Publisher (Yayımcı): KARE Yayıncılık (KARE Publishing) • Design (Tasarım): Ali Cangül • Graphics (Grafikler): Edibe Çomaktekin • Linguistic Editor (İngilizce Editörü): Corinne Can • Redaction (Redaksiyon): Erman Aytaç • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): March (Mart) 2014 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)

www.tjtes.org


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

tion, called “Upload Your Files”.

As from 2001, the journal is indexed in Index Medicus and Medline, as from 2005 in Excerpta Medica and EMBASE, as from 2007 in Science Citation Index Expanded (SCI-E) and Journal Citation Reports / Science Edition, and as from 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.

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

Submission of a manuscript by electronic means implies: that the work has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis); that it is not under consideration for publication elsewhere; and that its publication in the Turkish Journal of Trauma and Emergency Surgery is approved by all co-authors. The author(s) transfer(s) the copyright to the Turkish Association of Trauma and Emergency Surgery to be effective if and when the manuscript is accepted for publication. The author(s) guarantee(s) that the manuscript will not be published elsewhere in any other language without the consent of the Association. If the manuscript has been presented at a meeting, this should be stated together with the name of the meeting, date, and the place. Manuscripts may be submitted in Turkish or in English. All submissions are initially reviewed by the editor, and then are sent to reviewers. All manuscripts are subject to editing and, if necessary, will be returned to the authors for answered responses to outstanding questions or for addition of any missing information to be added. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication. Final galley proofs are sent to the authors for approval. Unless specifically indicated otherwise at the time of submission, rejected manuscripts will not be returned to the authors, including accompanying materials. TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medical Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for reviews and case reports. Open Access Policy: Full text access is free. There is no charge for publication or downloading the full text of printed material. Manuscript submission: TJTES accepts only on-line submission via the official web site (please click, www.travma.org.tr/en) and refuses printed manuscript submissions by mail. All submissions are made by the on-line submission system called Journal Agent, by clicking the icon “Online manuscript submission” at the above mentioned web site homepage. The system includes directions at each step but for further information you may visit the web site (http://www.travma.org/en/ journal/). Manuscript preparation: Manuscripts should have double-line spacing, leaving sufficient margin on both sides. The font size (12 points) and style (Times New Roman) of the main text should be uniformly taken into account. All pages of the main text should be numbered consecutively. Cover letter, manuscript title, author names and institutions and correspondence address, abstract in Turkish (for Turkish authors only), and title and abstract in English are uploaded to the Journal Agent system in the relevant steps. The main text includes Introduction, Materials and Methods, Results, Discussion, Acknowledgments, References, Tables and Figure Legends. The cover letter must contain a brief statement that the manuscript has been read and approved by all authors, that it has not been submitted to, or is not under consideration for publication in, another journal. It should contain the names and signatures of all authors. The cover letter is uploaded at the 10th step of the “Submit New Manuscript” sec-

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

References: All references should be numbered in the order of mention in the text. All reference figures in the text should be given in brackets without changing the font size. References should only include articles that have been published or accepted for publication. Reference format should conform to the “Uniform requirements for manuscripts submitted to biomedical journals” (http://www.icmje.org) and its updated versions (February 2006). Journal titles should be abbreviated according to Index Medicus. Journal references should provide inclusive page numbers. All authors, if six or fewer, should be listed; otherwise the first six should be listed, followed by “et al.” should be written. The style and punctuation of the references should follow the formats below: Journal article: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5. Chapter in book: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62. Our journal has succeeded in being included in several indexes, in this context, we have included a search engine in our web site (www. travma.org.tr) so that you can access full-text articles of the previous issues and cite the published articles in your studies. Review articles: Only reviews written by distinguished authors based on the editor’s invitation will be considered and evaluated. Review articles must include the title, summary, text, and references sections. Any accompanying tables, graphics, and figures should be prepared as mentioned above. Case reports: A limited number of case reports are published in each issue of the journal. The presented case(s) should be educative and of interest to the readers, and should reflect an exclusive rarity. Case reports should contain the title, summary, and the case, discussion, and references sections. These reports may consist of maximum five authors. Letters to the Editor: “Letters to the Editor” are only published electronically and they do not appear in the printed version of TJTES and PUBMED. The editors do not issue an acceptance document as an original article for the ‘’letters to the editor. The letters should not exceed 500 words. The letter must clearly list the title, authors, publication date, issue number, and inclusive page numbers of the publication for which opinions are released. Informed consent - Ethics: Manuscripts reporting the results of experimental studies on human subjects must include a statement that informed consent was obtained after the nature of the procedure(s) had been fully explained. Manuscripts describing investigations in animals must clearly indicate the steps taken to eliminate pain and suffering. Authors are advised to comply with internationally accepted guidelines, stating such compliance in their manuscripts and to include the approval by the local institutional human research committee.


YAZARLARA BİLGİ Ulusal Travma ve Acil Cerrahi Dergisi, Ulusal Travma ve Acil Cerrahi Derneği’nin yayın organıdır. Travma ve acil cerrahi hastalıklar konularında bilimsel birikime katkısı olan klinik ve deneysel çalışmaları, editöryel yazıları, klinik olgu sunumlarını ve bu konulardaki teknik katkılar ile son gelişmeleri yayınlar. Dergi iki ayda bir yayınlanır. Ulusal Travma ve Acil Cerrahi Dergisi, 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. Açık Erişim İlkesi: Tam metinlere erişim ücretsizdir. Yayınlanan basılı materyali tam metni indirmek için herhangi bir ücret alınmaz. Yazıların hazırlanması: Tüm yazılı metinler 12 punto büyüklükte “Times New Roman” yazı karakterinde iki satır aralıklı olarak yazılmalıdır. Sayfada her iki tarafta uygun miktarda boşluk bırakılmalı ve ana metindeki sayfalar numaralandırılmalıdır. Journal Agent sisteminde, başvuru mektubu, başlık, yazarlar ve kurumları, iletişim adresi, Türkçe özet ve yazının İngilizce başlığı ve özeti ilgili aşamalarda yüklenecektir. İngilizce yazılan çalışmalara da Türkçe özet eklenmesi gerekmektedir. Yazının ana metnindeyse şu sıra kullanılacaktır: Giriş, Gereç ve Yöntem, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekiller. Başvuru mektubu: Bu mektupta yazının tüm yazarlar tarafından okunduğu, onaylandığı ve orijinal bir çalışma ürünü olduğu ifade edilmeli ve yazar isimlerinin yanında imzaları bulunmalıdır. Başvuru mektubu ayrı bir dosya olarak, Journal Agent sisteminin “Yeni Makale Gönder” bölümünde, 10. aşamada yer alan dosya yükleme aşamasında yollanmalıdır. Başlık sayfası: Yazının başlığı, yazarların adı, soyadı ve ünvanları, çalışmanın yapıldığı kurumun adı ve şehri, eğer varsa çalışmayı destekleyen fon ve kuruluşların açık adları bu sayfada yer almalıdır. Bu sayfaya ayrıca “yazışmadan sorumlu” yazarın isim, açık adres, telefon, faks, mobil telefon ve e-posta bilgileri eklenmelidir. Özet: Çalışmanın gereç ve yöntemini ve bulgularını tanıtıcı olmalıdır. Türkçe özet, Amaç, Gereç ve Yöntem, Bulgular, Sonuç ve Anahtar Sözcükler başlıklarını; İngilizce özet Background, Methods, Results, Conclusion ve Key words başlıklarını içermelidir. İngilizce olarak hazırlanan çalışmalarda da Türkçe özet yer almalıdır. Özetler başlıklar hariç 190210 sözcük olmalıdır. Tablo, şekil, grafik ve resimler: Şekillere ait numara ve açıklayıcı bilgiler ana metinde ilgili bölüme yazılmalıdır. Mikroskobik şekillerde resmi açıklayıcı bilgilere ek olarak, büyütme oranı ve kullanılan boyama tekniği de belirtilmelidir. Yazarlara ait olmayan, başka kaynaklarca daha önce yayınlanmış tüm resim, şekil ve tablolar için yayın hakkına sahip 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.


TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 20

Number - Sayı 2 March - Mart 2014

Contents - İçindekiler

Experimental Study - Deneysel Çalışma Deneysel Çalışma - Experimental Study 79-85 The efficacy of a hemostatic agent in anticoagulant drug-induced rat bleeding model Hemostatik bir ajanın antikoagülan ilaç alan sıçan kanama modelindeki etkinliği Sönmez E, Çavuş UY, Civelek C, Dur A, Karayel E, Gülen B, Uysal Ö, İpek G

Klinik Çalışma - Original Original Articles - KlinikArticles Çalışma 86-90 Evaluation of the Alvarado score in acute abdominal pain Akut karın ağrısında Alvarado skorunun değerlendirmesi Kariman H, Shojaee M, Sabzghabaei A, Khatamian R, Derakhshanfar H, Hatamabadi H 91-96 Case series of non-operative management vs. operative management of splenic injury after blunt trauma Künt travma sonrası oluşan dalak yaralanmasının cerrahi ve cerrahi dışı tedavisini karşılaştıran olgu çalışmalarının bir karşılaştırması Cirocchi R, Corsi A, Castellani E, Barberini F, Renzi C, Cagini L, Boselli C, Noya G 97-100 Non-operative management (NOM) of blunt hepatic trauma: 80 cases Künt karaciğer travmalarında cerrahi dışı yaklaşım: 80 olgu Özoğul B, Kısaoğlu A, Aydınlı B, Öztürk G, Bayramoğlu A, Sarıtemur M, Aköz A, Bulut ÖH, Atamanalp SS 101-106 Comparison of diagnostic peritoneal lavage and focused assessment by sonography in trauma as an adjunct to primary survey in torso trauma: a prospective randomized clinical trial Travma olayında vücut travmasında birincil araştırmaya ek olarak tanısal periton lavaj (DPL) sıvısı ile travmaya odaklanmış ultrasonografi değerlendirmesinin (FAST) karşılaştırması: Bir prospektif randomize klinik çalışma Kumar S, Kumar A, Joshi MK, Rathi V 107-112 Are the neutrophil-lymphocyte ratio and platelet-lymphocyte ratio as effective for predicting the number of debridements in Fournier’s gangrene as Fournier’s gangrene severity index? Fournier gangreninde debridman sayısını öngörmede nötrofil lenfosit oranı ve trombosit lenfosit oranı Fournier gangreni şiddet indeksi kadar etkili midir? Kahramanca Ş, Kaya O, Özgehan G, İrem B, Dural İ, Küçükpınar T, Kargıcı H 113-119 Abdominal solid organ injury in trauma patients with pelvic bone fractures Karında solid organ yaralanmasıyla ilişkili pelvis kemiği kırıkları Kwon HM, Kim SH, Hong JS, Choi WJ, Ahn R, Hong ES 120-126 El ve önkol yaralanmalarında yaralanma ciddiyeti ile işe geri dönüş, bozukluk, aktivite ve katılım arasındaki ilişkinin incelenmesi Investigation of the relationship between severity of injury, return to work, impairment, and activity participation in hand and forearm injuries Çakır N, Özcan RH, Kitiş A, Büker N Ulus Travma Acil Cerrahi Derg, January 2014, Vol. 20, No. 2

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TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 20

Number - Sayı 2 March - Mart 2014

Contents - İçindekiler 127-131 İnvajinasyonda kolay, güvenli ve etkili bir tedavi yöntemi: Ultrason eşliğinde hidrostatik redüksiyon An easy, safe and affective method for the treatment of intussusception: ultrasound-guided hydrostatic reduction Bahadır Ülger FE, Ülger A, Karakaya AE, Tüten F, Katı Ö, Çolak M 132-135 Çocuklarda künt böbrek travmaları: Kırk bir olgunun geriye dönük olarak değerlendirilmesi Blunt renal trauma in children: a retrospective analysis of 41 cases Balcıoğlu ME, Boleken ME, Çevik M, Savaş M, Boyacı FN

Olgu CaseSunumu Reports- -Case OlguReports Sunumu 136-138 Acute liver failure secondary to hepatic compartment syndrome: case report and literature review Hepatik kompartman sendromuna bağlı akut karaciğer yetersizliği: Olgu sunumu ve literatürün gözden geçirilmesi Ye B, De Miao Y 139-142 Endoscopic endonasal removal of a sphenoidal sinus foreign body extending into the intracranial space İntrakraniyal uzanımı olan sfenoid sinüs içi yabancı cismin endoskopik endonazal tedavisi Yıldırım AE, Divanlıoğlu D, Çetinalp NE, Ekici İ, Dalgıç A, Belen AD 143-146 Catastrophic necrotizing fasciitis after blunt abdominal trauma with delayed recognition of the coecal rupture - case report Künt abdominal travma sonrası katastrofik nekrotizan fasiitle birlikte çökal rüptürün tanınmasında gecikme - olgu sunumu Pecic V, Nestorovic M, Kovacevic P, Tasic D, Stanojevic G 147-150 Subcutaneous emphysema, pneumo-orbita and pneumomediastinum following a facial trauma caused by a high-pressure car washer Yüksek basınçlı oto yıkama sonucu oluşan yüz travması sonrası gelişen cilt altı amfizemi, pneumo-orbita ve pnömomediastinum Yılmaz F, Çiftçi O, Özlem M, Komut E, Altunbilek E

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EXPERIMENTAL STUDY

The efficacy of a hemostatic agent in anticoagulant drug-induced rat bleeding model Ertan Sönmez, M.D.,1 Umut Yücel Çavuş, M.D.,3 Cemil Civelek, M.D.,1 Ali Dur, M.D.,1 Eda Karayel, M.D.,1 Bedia Gülen, M.D.,1 Ömer Uysal, M.D.,2 Göktürk İpek, M.D.4 1

Department of Emergency Medicine, Bezmialem Vakıf University Faculty of Medicine, Istanbul;

2

Department of Biostatistics, Bezmialem Vakıf University Faculty of Medicine, Istanbul;

3

Department of Emergency Medicine, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara;

4

Department of Cardiology, Siyami Ersek Training and Research Hospital, Istanbul

ABSTRACT BACKGROUND: Bleeding is a major problem in warfarin pretreated patients who need emergency surgical procedures. APH is a hemostatic agent with ultra-hydrophilic and particulate properties. This study aimed to evaluate the in vivo hemostatic effect of APH in rats pretreated with warfarin. METHODS: Forty-eight Wistar rats were divided into two main groups: one group was pretreated with warfarin and the other group was not. These two groups were further divided into three subgroups according to the administration of APH, wheat meal, or saline, for a total of six subgroups. Standard full thickness tissue defects were performed on the backs of the rats. Saline, wheat meal, or APH were administered to the bleeding defect site in both main groups. Hemostasis time and amount of bleeding were calculated. RESULTS: The bleeding time in rats administered APH was significantly shorter than those administered wheat meal and saline. Consequently, the amount of bleeding was significantly less in the APH groups than in the control groups. CONCLUSION: APH has an effective hemostatic property in rats pretreated or non-pretreated with anticoagulants. Hemostatic agents can be useful for incidences of external bleedings, which are increasing because of anticoagulation. Key words: Hemostatic; rat; warfarin.

INTRODUCTION Warfarin is an anticoagulant that reduces the effects of vitamin K dependent factors, and its effects are increased by many drugs.[1] Interruption of therapy for surgical intervention increases the risk of thromboembolism, although continuation of therapy increases the risk of bleeding in patients taking warfarin. The most preferred method for stabilization in major surgical interventions is discontinuation of oral warfarin therapy and temporarily taking up to parenteral LMWH. After surgery, warfarin is reintroduced. If warfarin

Address for correspondence: Ertan Sönmez, M.D. Bezmialem Vakıf Üniversitesi, Adnan Menderes Bulvarı (Vatan Cad.), 34093 Fatih, İstanbul, Turkey Tel: +90 212 - 523 22 88 E-mail: ertansonmez3@msn.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2014;20(2):79-85 doi: 10.5505/tjtes.2014.54938 Copyright 2014 TJTES

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treatment is stopped before surgery, the risk of thrombosis and the consequences of thrombosis need to be carefully considered. The reduction of this risk with bridge therapy with treatment dose LMWH or unfractionated heparin in the pre-operative and post-operative periods should also be well-evaluated.[2] An alternative option is the administration of intravenous vitamin K the day prior to surgical intervention. However, this method is used principally in the management of warfarin overdose, and studies about its usage in such cases are retrospective and heterogenous.[3] Although these methods are not definitive solutions, they are principally used in elective major surgery. In some minor surgical procedures such as joint injections,[4] cataracts,[5] and certain endoscopic procedures (including mucosal biopsy),[6] continuation of warfarin therapy is considered. However, the generally-preferred method in plastic surgery, dermatology, and minor or invasive surgical interventions in emergency medicine is to take measures to stop bleeding without changing the anticoagulant therapy. 79


Sönmez et al. The efficacy of a hemostatic agent in anticoagulant drug-induced rat bleeding model

External bleeding episodes due to warfarin are not limited to tissue defects secondary to any surgical procedure or trauma. Warfarin can cause various bleeding episodes that are clinically insignificant, but cause discomfort for patients, such as gingival bleeding after tooth brushing, epistaxis, and skin bleeding after shaving. Patients should be informed on such possible bleedings before starting these drugs.[3] These kinds of bleeding episodes are not life-threating, but hemostasis can often be bothering. Likewise, excessive bleeding in some patients during minor surgery and long episode of leakage in the postoperative period can lead to increased anxiety in surgeons and patients, respectively.

anticoagulant therapy. This study aimed to determine the efficacy and reliability of this agent in hemostasis in rats pretreated with warfarin.

MATERIALS AND METHODS Experimental Model Forty-eight adult male Wistar albino rats weighing between 250-300 g were randomly selected from our animal research center. The rats were randomized into six experimental groups of eight rats each, with sample sizes for attaining 0.9 power at 95% significance level. They were kept at a constant temperature (22±1°C) under a 12h light/dark cycle. The animals were supplied with standard laboratory pellet diet and water ad libitum. All experimental procedures were elaborately evaluated and approved by the Bezmialem Local Research Ethics Committee.

Long-term use of surgical tampons for bleeding control can cause discomfort in patients. Some clinicians use hemostatic agents as an alternative supportive therapy in cases requiring emergency surgery and traumatic bleeding. Since hemostasis can generally be provided with simple methods, and hemostatic agents bring extra costs, clinicians hold themselves back from prescribing such agents. Several hemostatic agents with different compositions are currently available that achieve hemostasis in different ways. Some provide primary hemostasis, whereas some stimulate fibrin formation or inhibit fibrinolysis.[7] Absorbable hemospheres produced by microporous polysaccharide hemospheres (MPH) technology were first used as a topical bleeding stopper. They were used to control bleeding wounds including traumatic wounds, cuts, and military wounds.[8]

Experimental Design Rats were randomly divided into two main groups as seen Table 1. The back regions of all animals in both groups were shaved and cleaned with povidone-iodine. The first group (n=24) did not receive any treatment. The second group (n=24) were treated with warfarin (2 mg/kg) dissolved in isotonic solution through oral feeding catheter daily for four days. International Normalized Ratio (INR) was assessed with INR monitoring systems (INRatio®; Hemosense, Calif) prior to and on the fifth day of warfarin treatment. INR value above 2 was accepted as adequate anticoagulation. All groups was further divided into three subgroups-A, B and C (eight rats per group) and animals were numbered from 1 to 8 as shown in Table 1. In order to administer to the sites of tissue defects of subgroups, 4 mL saline were prepared by injector for subgroup A; 3 mg APH in powdery form (HaemoCer™, Germany) were prepared for subgroup B; and wheat meal, which was similar in appearance and measurement of particle size to APH by light microscopy, was prepared for subgroup C on numbered paper sheets (Figure 1). Tare weights of numbered papers were determined on a precision scale, and then agents were weighed. On the fifth day, the rats were anesthetized with intraperitoneal 30 mg/kg ketamine hydro-

APH is a hemostatic agent with ultra-hydrophilic structure. When APH comes in contact with blood, it dries the blood by accelerating the concentration of platelets, red blood cells, and coagulation proteins at the bleeding site and consequently forms a mechanic barrier by turning into gel form. It is hydrolyzed by histamine and degraded to amylase and glucoamylase and then completely resorbed. Clinically, MPHs have produced very successful results in endoscopic nasal sinus surgery,[9] dermatologic surgery,[10,11] and laparoscopic surgery, causing no serious complications intra- and postoperatively.[12] Formerly, the hemostatic agent APH has not been used against bleeding of tissue defect in patients under Table 1. Study groups

Groups Subgroups* n Daily Method of drug Duration of drug (mg/kg) administration administration Without warfarin pretreatment

A

B 8 –

8

C 8 –

With warfarin pretreatment

A

8

2

Orally

4 days

B

8

2

Orally

4 days

C

8

2

Orally

4 days

*: Agents applied to bleeding area. A: 0.9% saline; B: APH; C: Wheat meal.

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SĂśnmez et al. The efficacy of a hemostatic agent in anticoagulant drug-induced rat bleeding model

Bleeding time The agents were administered after creation of full thickness tissue defect and observation of bleeding within one minute. It was observed that APH showed an effective hemostatic efficiency by forming a thick layer of gel very quickly, as seen Figure 2a, b.

Figure 1. APH and wheat meal appear macroscopically similar on the blotting paper. Particle size on the light microscope are close to each other.

chloride (Ketalar; Eczacibasi, Istanbul, Turkey) and 5 mg/kg xylazine (Rompun, 2% solution; Bayer, Germany). The middle of a piece of cardboard was cut out in the shape of an equilateral triangle of size 2x2x2 cm to make a pattern. Equilateral triangles were drawn on the back of rats using this pattern. Then full thickness tissue defects were performed by cutting skin with scissors.

Evaluation We waited to see precise bleeding after incision for one minute in all rats. Afterwards, the prepared materials were administered to the defect sites on the numbered animals by a laboratory technician who did not know the material on numbered papers. Then the defect sites were gently covered with sterile sponge, which were wetted with 20 mL of 0.9% saline, for one minute. The wet sponges were removed and bleeding time was monitored. The bleeding time was defined as the time between the removal of the sponge and hemostasis, and was monitored with a chronometer. The amount of bleeding was calculated using the weights of the numbered blotting papers that absorbed the blood in the defect site. Tare weights of these numbered papers were determined on a precision scale. Bleeding time and amount of bleeding were blindly measured by a laboratory technician.

Data Analysis Statistical analyses were conducted using IBM SPSS for Windows, version 19.0. Hemostasis time and amount of bleeding of the three subgroups were compared using one way ANOVA with Tukey HSD posthoc comparisons. The mean and standard deviation were calculated for each group. All data were expressed as means and 95% confidence intervals and p value of 0.005 or less was considered statistically significant.

RESULTS The rats were pretreated with warfarin for four days. INR values were measured before and on the fifth day of warfarin treatment. The INR values found were above 2, as seen in Table 2.

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In groups that were not pretreated with warfarin, the bleeding time was 1.20 minutes (95% CI 1.04-1.36) in the saline administered subgroup, 0.58 minutes (95% CI 0.44-0.73) in the wheat meal administered subgroup, and 0.15 minute (95% CI 0.120.18) in the APH administered subgroup. APH reduced the duration of bleeding in the non-pretreated group by 87.50% compared to saline-administered group, and 74.13% compared to wheat meal administered group (p<0.001) (See Table 3). In groups pretreated with warfarin, the bleeding time was 3.61 minutes (95% CI 2.82-4.40) in the saline administered subgroup, 2.40 minutes (95% CI 1,86â&#x20AC;&#x201C;2,94) in the wheat meal administered subgroup, and 0.38 minute (95% CI 0.16-0.60) in the APH administered subgroup. APH reduced the duration of bleeding in pretreated group by 89.48% compared to the saline administered group, and 84.1% compared to the wheat meal administered group (p<0.001) (Table 3).

Amount of Bleeding APH reduced both the bleeding time and amount. In the groups not pretreated with warfarin, the amount of bleeding was 0.11 mL (95% CI 0.10-0.13) in the saline administered subgroup, 0.06 mL (95% CI 0.05-0.07) in the wheat meal administered subgroup, and 0.04 mL (95% CI 0.03-0.05) in the APH subgroup. APH reduced the amount of bleeding in nonpretreated group by 63.63% compared to saline administered group, and 33.33% compared to wheat meal administered group (p<0.001) (Table 3).

Table 2. INR values Without Under warfarin pretreatment pretreatment*

A B C

A B C

1

0.9 1.1 1.2

5.6 7.5 2.7

2

1.2 1.2 1.1

2.7 4.5 2.1

3

1.2 1.3 1.2

2.4 3.2 4.5

4

0.8 1.1 0.8

2.1 5.2 7.5

5

1.1 1.1 1.2

5.6 2.4 2.2

6

1.2 1.1 1.3

2.1 7.5 3.9

7

1.2 1.0 1.3

4.8 4.8 2.2

8

1.1 1.3 1.2

2.4 2.1 2.4

Groups; A: 0.9% saline; B: APH; C: Wheat meal. *: INR values on the fifth day following daily application of warfarin (2 mg/kg) in isotonic solution through oral feeding catheter for four days.

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Sönmez et al. The efficacy of a hemostatic agent in anticoagulant drug-induced rat bleeding model

(a)

(b)

Figure 2. (a) Triangular-shaped full-thickness cut was made by surgical scissors, and bleeding became clear in one minute. (b) APH applied to the tissue defect after bleeding clarified. We cushioned gently with a wet sponge for one minute. Hemostasis was provided in 20 seconds after the sponge moved away.

In groups pretreated with warfarin, the amount of bleeding was 0.34 mL (95% CI 0.23-0.45) in the saline administered subgroup, 0.25 mL (95% CI 0.19-0.31) in the wheat meal

administered subgroup, and 0.05 mL (95% CI 0.03-0.07) in the APH subgroup. APH reduced the amount of bleeding in pretreated group by 85.30% compared to saline administered

Table 3. Duration and amount of bleeding for each agent applied, relative statistical meanings and percentages

95% Confidence interval for mean Group

Mean

Std.

Lower

Upper

ANOVA

APH vs. %

(ni=8) deviation bound bound Duration of A 1.20 0.19 1.04 1.36 F=99.11; – bleeding without p=0.001 B vs. A warfarin B 0.15 0.03 0.12 0.18 (tukeyHSD: B vs. C pretreatment all groups) C vs. A (min) C 0.58 0.17 0.44 0.73 Amount of A 0.11 0.02 0.10 0.13 F=60.91; – bleeding p=0.001 B vs. A without B 0.04 0.01 0.03 0.05 (tukeyHSD: B vs. C warfarin all groups) pretreatment (ml) C 0.06 0.01 0.05 0.07 C vs. A Duration of A 3.61 0.94 2.82 4.40 F=46.61; – bleeding p=0.001 B vs. A with B 0.38 0.27 0.16 0.60 (tukeyHSD: B vs. C warfarin all groups) pretreatment (min) C 2.40 0.64 1.86 2.94 C vs. A Amount of A 0.34 0.13 0.23 0.45 F=22.64; – bleeding p=0.001 with B 0.05 0.02 0.03 0.07 (tukeyHSD: B vs. A warfarin B vs AC) B vs. C pretreatment (ml) C 0.25 0.07 0.19 0.31 C vs. A

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Controls decrease – 87.50 74.13 51.66 – 63.63 33.33

45.45 – 89.48 84.17

33.52 – 85.30 80.00 26.48

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group, and 80.00% compared to wheat meal administered group (p<0.001) (Table 3).

DISCUSSION In this study, we evaluated the in vivo effect of APH, a hemostatic agent of plant origin, on the bleeding of skin defects in rats pretreated and non-pretreated with warfarin. The results of the study showed that APH was an effective hemostatic, reducing the bleeding time and amount in rats on and not on anticoagulant therapy. Warfarin has been used successfully in cases requiring longtime anticoagulation, such as atrial fibrillation, history of stroke, history of deep venous thrombosis or pulmonary embolism, valvular heart disease, presence of a mechanical heart valve, and underlying hypercoagulopathy.[13] If warfarin therapy is stopped, it takes about four days to reduce INR to 1.5 in order to perform the operation safely,[14] and if warfarin therapy is restarted, it takes about three days to reach 2.0 of INR.[15] Our study was performed on rats with INR over 2.0 (Table 2). If warfarin therapy is stopped for four days before surgery and is started as soon as possible following surgery, it means that INR values will be below therapeutic dosages for two days before surgery and two days after surgery, which means that patients would have minimal protection against thromboembolism.[13] This risk exists even in the absence of anticoagulation therapy one day before and one day after surgery.[16] Regardless of the approach to perioperative anticoagulation used, patients need to have a normal or nearly-normal state of coagulation during surgery, so the risk of thromboembolism is unavoidable. Since stopping anticoagulation can lead to life-threatening complications, therapy should not stop abruptly. Approximately 1.5-3.7% of patients on warfarin therapy undergo a cutaneous surgery. According to the studies, although warfarin therapy is stopped for patients in 80% of cutaneous surgeries, heparin is not administered as bridging therapy for 90% of these patients.[16] It is widely accepted that the risk of bleeding is low in patients taking warfarin during and after minor cutaneous surgery, and bleeding is easy to control. Alcalay[17] reviewed the intraoperative and postoperative bleedings for 16 patients on warfarin therapy. There were 14 cases with lesions of the head and neck region, 11 cases with Mohsâ&#x20AC;&#x2122; excisions, and 5 cases with excisional surgery. The measured INR values of patients with bleedings were 3.0 in 4 patients and above 2.0 in 6 patients a week prior to surgery. A group of patients on warfarin who underwent surgery on the same days served as the control group. There was no significant difference between test and control group in terms of intraoperative and postoperative bleedings. Billingsley and Maloney[16] studied the relation of preoperative warfarin use to intraoperative bleedings, need for dressing changes, and other postoperative procedures. In this study, Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2

332 patients underwent cutaneous Mohsâ&#x20AC;&#x2122; surgery and were examined; 3.6% of these patients had taken warfarin within two days before surgery. Intraoperative bleedings which took longer than three minutes to control were related to warfarin use. Although intraoperative bleedings were severe in 5 of the 12 patients on warfarin, no serious problem requiring early dressing change, frequent visits or having surgery again, were reported in the postoperative period. There was no statistical difference between patients who were or were not on warfarin therapy. According to these results, warfarin use can cause intraoperative complications, but cause no complications in the postoperative period. Bordeaux et al.[18] supported that warfarin use significantly increased the risk of bleeding (p<0.001). In their prospective study, Syed et al.[19] reported that there was more bleeding in patients on warfarin therapy when compared with the controls in cutaneous surgery. In our study, warfarin use in the control group increased the bleeding time from 1.20 minutes to 3.61 minutes and increased the amount of bleeding from 0.11 mg to 0.34; although these values were found to be highly significant, they did not cause life-threatening problems. On the other hand, there exist studies on complications of serious bleeding. In their prospective study of 102 patients, Kargi et al.[20] investigated the effect of warfarin in minor surgeries and showed that warfarin use was a risk factor for persistent bleeding, hematoma, or graft/flap infection. All of these studies underline that although warfarin prolongs the bleeding time, stopping warfarin therapy causes life-threatening risks; physicians approach these patients carefully, but should not withhold the drug. However, prolonged bleedingtime can cause stress both for the surgeon and the patient. In such a situation, the surgeon has to make a choice: he would either accept a theoretically-higher likelihood of bleeding and the patient would be anticoagulated, or take the risk of thromboembolism by stopping the anticoagulant therapy. The decision is often postponed and deferred to the caretakers. Caretakers often make a decision without previously being informed in detail on bleeding complications or seriousness of the complications. Studies have shown that many surgical procedures can be safely performed without stopping anticoagulation therapy. Surgeons can choose to operate without discontinuing anticoagulant therapy and can avoid potentially life-threatening thromboembolic complications.[13] The paradox of the surgeon is to sustain blood flow in the whole body while avoiding problems caused by this flow at the surgery site. For this very reason, hemostatic properties of adjuvant therapy methods without hindering normal blood flow are of the utmost importance. The control of apparent bleeding is performed primarily using mechanical means such as manual pressure, ligature, or application of a tourniquet. However, these methods can sometimes be labor-intensive and time-consuming. Bleeding 83


SĂśnmez et al. The efficacy of a hemostatic agent in anticoagulant drug-induced rat bleeding model

vessels can be interfered with electro-cauterization or laser cauterization. However, these methods constitute a necrotic tissue, burning the vessels with the surrounding tissue, and can cause a delay in wound healing by incurring an infection. [10] Conventional methods are also less effective in controlling bleeding from complex lesions and where access to the bleeding site is difficult. In such situations, use of topical hemostatic agents is recommended.[8] Currently, hemostatic agents are used in a wide-range of surgical interventions and have been reported by many authors as effective in controlling bleeding. For example, the direct application of absorbable hemospheres on superficial cerebral hemorrhage helped to stop bleeding and reduced the use of electrocautery, and thus shortened the surgical time in neurosurgery.[22] In a controlled study comparing the bleeding time in incisions, it was shown that MPH significantly reduced the time to hemostasis. For many incisions of 5x1 mm examined in the study, no relevance of the incision method to the bleeding time was found.[8] In cases of prolonged puncturesite bleeding in patients receiving hemodialysis, MPH technology was thought to reduce the normal average bleeding time of 35 minutes to 5 minutes.[23] In our study, bleeding time in rats non-pretreated with warfarin was 1.20 minutes in the saline administered subgroup, 0.58 minutes in the wheat meal administered subgroup, and 0.15 minutes in the APH administered subgroup. There was a significant statistical difference between APH and the other subgroups as to bleeding time (p<0.001). MPH technology provides fast and effective hemostasis in endoscopic nasal sinus surgeries,[9] dermatologic surgeries,[11] and laparoscopic surgeries[12] with no serious sideeffects or postoperative complications. With the increase of minimally-invasive surgical procedures with risks of bleeding, the importance of topical hemostats has also increased.[8] Hemostatics provide quite successful results in patients not receiving anticoagulants, but there are only a few studies on their effects on patients on warfarin therapy. The Syvek Patch, a polysaccharide, can be used in patients on anticoagulant therapy for the control of bleedings at vascular access site punctures, percutaneous catheter or tube sites, and surgical debridement sites.[24] King et al.[25] observed 10 hypothermic and coagulopathic trauma patients with severe visceral injuries who failed in conventional treatments. The authors showed that the application of MRDH (Modified Rapid Deployment Hemostat) stopped bleeding in these patients. In our study, bleeding time in the control group on warfarin therapy was 3.61 minutes in the saline administered subgroup, 2.40 minutes in the wheat meal administered subgroup and 0.38 minutes in the APH administered subgroup. The hemostatic effect of APH was apparent when compared with those of the control groups. Although no life-threatening problem exists in cases of prolonged bleeding-time due to anticoagulants, it is evident that APH effectively reduces the bleeding time and also the stress of the surgeons and patients in elective and emergency surgery. 84

Conclusion APH is an effective hemostatic agent in rats pretreated with anticoagulants. This agent could be an effective hemostatic in patients in plastic surgery and dermatology clinics and in patients with tissue defect applying to emergency centers, and could also raise the self-confidence of the surgeon. The hemostatic effect of APH should be investigated further in larger and more severe tissue injuries.

Acknowledgements All the authors of this article have no financial or personal relationship with any of the companies mentioned in the text.

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Sönmez et al. The efficacy of a hemostatic agent in anticoagulant drug-induced rat bleeding model therapy. Ann Intern Med 1997;126:133-6. 16. Billingsley EM, Maloney ME. Intraoperative and postoperative bleeding problems in patients taking warfarin, aspirin, and nonsteroidal antiinflammatory agents. A prospective study. Dermatol Surg 1997;23:381-5. 17. Alcalay J. Cutaneous surgery in patients receiving warfarin therapy. Dermatol Surg 2001;27:756-8. 18. Bordeaux JS, Martires KJ, Goldberg D, Pattee SF, Fu P, Maloney ME. Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications. J Am Acad Dermatol 2011;65:576-83. 19. Syed S, Adams BB, Liao W, Pipitone M, Gloster H. A prospective assessment of bleeding and international normalized ratio in warfarinanticoagulated patients having cutaneous surgery. J Am Acad Dermatol 2004;51:955-7. 20. Kargi E, Babuccu O, Hosnuter M, Babuccu B, Altinyazar C. Complications of minor cutaneous surgery in patients under anticoagulant treat-

ment. Aesthetic Plast Surg 2002;26:483-5. 21. Zwischenberger JB, Brunston RL Jr, Swann JR, Conti VR. Comparison of two topical collagen-based hemostatic sponges during cardiothoracic procedures. J Invest Surg 1999;12:101-6. 22. Galarza M, Porcar OP, Gazzeri R, Martínez-Lage JF. Microporous Polysaccharide Hemospheres (MPH) for cerebral hemostasis: a preliminary report. World Neurosurg 2011;75:491-4. 23. Ahmed Z, Lee J, Elivera H, Shah A, Ranganna KM. Use of microporous polysaccharide particles in prolonged vascular access bleeding after hemodialysis. Presented to the American Society of Nephrology, 1 November 2002; http://www.medaforinc.com/research/index.html [Accessed 12 September 2007]. 24. Hirsch JA, Reddy SA, Capasso WE, Linfante I. Non-invasive hemostatic closure devices: “patches and pads”. Tech Vasc Interv Radiol 2003;6:92-5. 25. King DR, Cohn SM, Proctor KG; Miami Clinical Trials Group. Modified rapid deployment hemostat bandage terminates bleeding in coagulopathic patients with severe visceral injuries. J Trauma 2004;57:756-9.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Hemostatik bir ajanın antikoagülan ilaç alan sıçan kanama modelindeki etkinliği Dr. Ertan Sönmez,1 Dr. Umut Yücel Çavuş,3 Dr. Cemil Civelek,1 Dr. Ali Dur,1 Dr. Eda Karayel,1 Dr. Bedia Gülen,1 Dr. Ömer Uysal,2 Dr. Göktürk İpek4 Bezmialem Vakıf Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İstanbul; Bezmialem Vakıf Üniversitesi Tıp Fakültesi, Biyoistatistik Anabilim Dalı, İstanbul; Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Ankara; 4 Siyami Ersek Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, İstanbul 1 2 3

AMAÇ: Varfarin ile tedavi edilen hastalarda özellikle acil cerrahi işlem gerektiğinde kanama önemli bir problemdir. APH ultra-hidrofilik ve toz halinde bir kanama durdurucu ajandır. Bu çalışmada, APH’nin varfarin alan sıçanlardaki kanama durdurucu etkisi araştırıldı. GEREÇ VE YÖNTEM: Kırk sekiz Wistar sıçan iki ana guruba ayrıldı. Bir gurup varfarin ile tedavi edilirken diğerine verilmedi. Bu iki gurup daha sonra üç altguruba bölündü. Birine APH, birine buğday unu ve birine de serum fizyolojik uygulanmak üzere toplam altı gurup yapıldı. Sıçanların sırtında standart tam kat doku defekti oluşturuldu. Her iki ana guruba da serum fizyolojik, buğday unu veya APH uygulandı. Kanama zamanı ve kanama miktarları hesaplandı. BULGULAR: APH uygulananlarda, serum fizyolojik veya buğday unu uygulananlara göre kanama zamanı önemli derecede kısa ve kanama miktarları oldukça az bulundu. TARTIŞMA: APH antikoagülan tedavi alan veya almayan sıçanlarda etkili bir kanama durdurucudur. Kanama durdurucu ajanlar antikoagülasyona bağlı artmış dış kanamalarda kullanılabilir. Anahtar sözcükler: Hemostatik; sıçan; varfarin. Ulus Travma Acil Cerr Derg 2014;20(2):79-85

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ORIGIN A L A R T IC L E

Evaluation of the Alvarado score in acute abdominal pain Hamid Kariman, M.D.,1 Majid Shojaee, M.D.,1 Anita Sabzghabaei, M.D.,1 Rosita Khatamian, M.D.,2 Hojjat Derakhshanfar, M.D.,1 Hamidreza Hatamabadi, M.D.1 1

Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran;

2

Department of Emergency Medicine, Birjand University of Medical Sciences, Khorasan, Iran

ABSTRACT BACKGROUND: The Alvarado score is utilized to determine the likelihood of appendicitis based on clinical signs, symptoms, and laboratory results. The goal of this study was to determine whether Alvarado scores can be used to aid in the accurate diagnosis of appendicitis. METHODS: Alvarado score evaluations were performed on 300 patients that were referred to or presented to the emergency room with acute abdominal pain. RESULTS: Out of the 300 patients, 85.66% had Alvarado scores of 7 or less and 14.33% had Alvarado scores greater than 7. For patients that had confirmed appendicitis, 25.7% had Alvarado scores of 7 or less, whereas 93% had Alvarado scores greater than 7. The Alvarado scoring system had poor sensitivity at 37%, and the specificity of this scoring system was high at 95%. CONCLUSION: Our findings suggest that patients presenting with abdominal pain and Alvarado scores greater than 7 are more likely to have appendicitis. As such, the Alvarado scoring system may be utilized to better predict whether a patient has appendicitis. An Alvarado score that is positive for appendicitis would consist of a score greater than 7, which suggests that the patient has a 93% chance of having appendicitis. A negative Alvarado score is 7 or lower, suggesting a 26% probability of having appendicitis. In all, the Alvarado scoring system is a good rule-in test, but it does not adequately rule-out appendicitis. Key words: Abdominal pain; Alvarado score; eppendicitis.

INTRODUCTION Abdominal pain is one of the most common clinical complaints and accounts for more than 10% of emergency department presentations. The hospitalization rate for patients over 60 years old ranges from 18% to 42%.[1] Following abdominal pain due to non-specific causes, appendicitis is the most common cause of abdominal pain that requires an emergent operation.[2] The prevalence of appendicitis is greater in men than in women.[2] Even though computed to-

Address for correspondence: Majid Shojaee, M.D. Emergency Department, Emam Hossein Medical Center, Shahid Madani Street, Tehran, Iran. Tel: +982173432380 E-mail: m.shojaee@sbmu.ac.ir Qucik Response Code

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mography (CT) and ultrasound imaging are utilized for diagnosing appendicitis, the false positive diagnosis rate has not improved. However, in pregnant women between 40-49 years old, the number of unnecessary appendectomies is greater than males. Unnecessary appendectomies are most prevalent in females older than 80 years of age.[3] Therefore, in order to further refine the accuracy of appendicitis diagnosis, it may be helpful to supplement clinical and imaging results with the Alvarado score (Table 1).[4] Many conditions have similar clinical manifestations to appendicitis. The most common sources of non-specific abdominal pain are acute cystitis, acute pancreatitis, diverticulitis, ulcerative colitis, peritonitis, bowel obstruction, trauma, hepatitis, dissecting aortic aneurysm, ovarian cyst, and ectopic pregnancy.[3] The decision to operate depends on a combination of obtaining a complete medical history, physical examination, imaging, and laboratory results; however, misdiagnosis or a delay in diagnosis and treatment still occurs and contributes to adverse patient outcomes. Thus, the main objective of this study was to determine whether obtaining Alvarado scores would increase the accuracy of diagnosing appendicitis. To achieve Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2


Kariman et al. Evaluation of the Alvarado score in acute abdominal pain

this, we evaluated the Alvarado scores in 300 patients that presented to the Imam Hossein Emergency Department with non-specific abdominal pain. Moreover, the patient population that we provide care to has great cultural and socioeconomic diversity, and the findings of this study may help clarify whether the validity of Alvarado scoring system is still adequate by calculating its positive and negative predictive value.

MATERIALS AND METHODS This study was conducted in 2011 and is a prospective, observational, descriptive-analytical and cross-sectional analysis. Alvarado scores were obtained from blinded evaluators that rated patients that presented with acute abdominal pain to the Imam Hossein Hospital Emergency Department. Initially, the patient sample numbered 380 such that the accepted margin of error was 5% with a confidence interval of 95%, and the distribution response was 50% for a population of 20,000. The Imam Hossein Hospital is an educational tertiary center, and patients are referred there if they are in need of further work-up or certain complex operations. Patients were frequently evaluated throughout their admission so to document whether their Alvarado scores changed over time. If appendicitis was diagnosed, an appendectomy was performed and the appendix tissues were examined by a pathologist so to verify diagnosis. Patients received follow-up for one week following discharge so to identify possible complications or the need to perform surgery. Patients older than 16 years of age that presented with abdominal pain due to extra-abdominal pathology such as pneumonia, acute myocardial infarction, drug intoxication, drug and alcohol misuse, mental retardation or other mental disorders, trauma to the abdomen, pregnancy, or had difficulties in verbal communication were excluded from the study (n=80). As such, the final study sample included 300 patients. Statistical data were evaluated with SPSS software version 13.0 to calculate and compare means, standard deviations and frequencies. Alvarado scoring system sensitivity and specificity was calculated so to determine its validity. Likelihood ratios (LRs) were also determined for the Alvarado scoring system. In all correlation analyses a p-value less than 5% was considered statistically significant. Patients were given a detailed description of the study and provided their informed consent before participating in this investigation.

Table 1. Alvarado scoring system example Characteristics Score Right lower quadrant tenderness

2

Rebound tenderness

1

Elevated temperature (>37.3°C or >99.1°F)

1

Migration of pain to the right lower quadrant

1

Anorexia 1 Nausea or vomiting

1

Leukocytosis >10.000 white blood cells

2

Leukocytosis with left shift

1

Table 2. Alvarado score distribution frequencies Frequency (%)

Alvarado characteristic

26

Migration of pain to right lower quadrant

45.3 Anorexia 61

Nausea and vomiting

57.7

Tenderness in right lower quadrant

32

Rebound pain

14

Elevated body temperature

49 Leukocytosis 31.7

Leukocytosis with left shift

had confirmed cases of appendicitis according to pathology reports. A total of 194 patients had abdominal pain due to other causes. Of the 106 patients that had confirmed appendicitis, 62.26% had an Alvarado score ≤7, whereas 37.73% of patients had Alvarado scores above 7. Of the 194 patients that were diagnosed with abdominal pain due to other causes, 98.4% had an Alvarado score ≤7 and only 1.54% of patients had Alvarado scores greater than 7 (Table 3).

As shown in Table 1, Alvarado scores were determined for each patient. On average, the study subjects were 39.97 years-old, 46.3% were female, and 65.3% were married. Only 14.7% of the patients were educated in the university. The overall mean Alvarado score was 4.23, and Alvarado score frequencies are shown in Table 2.

There were 3 cases that received an initial diagnosis of abdominal pain due to a cause other than appendicitis, but their Alvarado scores were greater than 7. During follow-up, 2 of these patients developed appendicitis and underwent an appendectomy. Of the 257 patients that had an Alvarado score ≤7, 25.7% of them had confirmed appendicitis and 74.3% of the patients had abdominal pain due to other causes (Tables 4 and 5). For the 161 male patients, 15 of them had Alvarado scores greater than 7, and for the 139 female patients, 28 had Alvarado scores greater than 7 (p<0.0076). There were significant differences in Alvarado scoring between males and females (Table 6). Mean Alvarado scores in the patients with appendicitis were significantly higher than those for patients without appendicitis (p<0.0001). Also this relation was found between men and women (Table 7).

From the 300 patients that participated in this study, 36%

Overall, 25.7% of patients that had Alvarado scores of 7 or

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Kariman et al. Evaluation of the Alvarado score in acute abdominal pain Table 3. Abdominal pain causes according to Alvarado score Abdominal pain due to other causes

Appendicitis

n %

n %

191

98.43

66

62.26

Alvarado score ≤7

3

1.54

40

37.73

Alvarado score >7

194

100

106

100

Total number of patients

Table 4.

Total

Other causes

n %

Appendicitis

n %

n %

257

100

191

74.3

66

25.7

Alvarado ≤7

43

100

3

7

40

93

Alvarado >7

patients with Alvarado scores greater than 7 were not initially diagnosed with appendicitis, but a week after discharge two of those patients were found to have appendicitis. In a study conducted in the Islam Abad Medical University in 2007, patients diagnosed with abdominal pain that received appendectomies were categorized based on Alvarado score: the first group had scores ≥7 and the second group had scores <7. They found that regardless of the Alvarado score, 53.54% had confirmed cases of appendicitis in the first group and 38.96% had appendicitis in the second group according to pathology reports. They determined that Alvarado score sensitivity was 58.2% and the sensitivity was 88.9%. [4] In comparison with our data, this study had attributed the Alvarado scoring system with a higher sensitivity and specificity.

less had confirmed cases of appendicitis; however, 93% of patients with Alvarado scores greater than 7 had appendicitis (p<0.0001) (Table 3). Alvarado scoring system sensitivity and specificity were found to be 37% with a 95% confidence interval (CI) of 0.23-0.46 and 95.65% with a 95% CI of 0.960.99, respectively. The positive likelihood ratio (LR) was 24.4 with a 95% CI of 0.077-0.979, and the negative LR was 0.63 with a 95% CI of 0.61-0.70.

DISCUSSION In this study, there was a statistically significant difference in the amount of patients that had confirmed cases of appendicitis if their Alvarado score was greater than 7 (p<0.0001). Additionally, the calculated sensitivity was 37% and specificity was 95.65% for the Alvarado scoring system. Only 3 Table 5. Alvarado scores according to diagnosis

Pancreatitis

Dyspepsia

Volvulus

Ovarian cyst

Malignancy

Diverticulitis

Peritonitis

EP

Renal colic

Cholecystitis

Unknown

Urinary Tract Infection

Appendicitis

Diagnosis Total

n % n % n % n % n % n % n % n % n % n % n % n % n % n %

Alvarado score ≤7

66 25.7 6 2.3 108 42.0 36 14.0 6 2.3 9 3.5 4 1.6 4 1.6 6 2.3 4 1.6 2 0.8 2 0.8 4 1.6 257 100.0

Alvarado score >7

40 93.0 0 0 3 7.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 43 100.0

Total

106 35.3 6 2.0 111 37.0 36 12.0 6 2.0 9 3.0 4 1.3 4 1.3 6 2.0 4 1.3 2 0.7 2 0.7 4 1.3 300 100.0

EP: Ectopic pregnancy; UTI: Urinary tract infection.

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Table 6. Comparison of Alvarado scores between males and females Alvarado Score

Male

Female

n %

n %

Score >7, 43 (100%)

27

62.7

16

37.2

111

43.2

146

56.8

Alvarado ≤7, 257 (100%) Chi-squared value

7.12

Degrees of freedom

1

Two-tailed p-value

0.0076

Table 7. Mean Alvarado scores for males and females Alvarado score

Diagnosis

Male

Female

Alvarado >7

Appendicitis

9.6

9.73

Other causes

8

8

Alvarado ≤7

Appendicitis

6.1

6.4

Other causes

3.2

2.8

In another study conducted in Pakistan during 2003, 100 patients with suspected appendicitis were categorized into 3 groups: group one had Alvarado scores ≥7 and underwent an appendectomy, group two had Alvarado scores ranging from 5-6 and were hospitalized for observation, and group three had Alvarado scores ≥4 and were discharged. Several patients that developed elevated Alvarado scores ≥7 in group two (that were initially given Alvarado scores ≤7) received an appendectomy and histological examination confirmed the diagnosis of appendicitis. In the 60 patients that underwent an appendectomy, 54 of them developed confirmed cases of appendicitis according to tissue pathology findings. Of the 15.6% patients that underwent unnecessary appendectomies, 7.8% of them experienced an appendix perforation. Overall, the Alvarado scoring system was found to have a positive predictive value of 84.35%.[5] The positive predictive value found in that study approaches our value of 93%, which is greater than previously reported. In 1996, an investigation was performed in England that was a prospective analysis of elderly female patients that received elective laparoscopic appendectomies. Modified Alvarado scores were also determined for patients with suspected appendicitis. Overall, 84 patients comprised the experimental group and 97 patients made up the control group. Depending on the group that the patients were assigned, they were treated by a separate medical team and Modified Alvarado scores and the presence leukocytosis were determined for all subjects. Patients that demonstrated leukocytosis with left shift were removed from the study. The experimental group was divided into 3 groups depending on Modified Alvarado Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2

score: 0-3, 4-6, and 7-9. In the experimental group, only 5% of the patients received an unnecessary appendectomy as compared to 18% of controls. Moreover, 10% of adult women were not found to have appendicitis according to laparoscopic examination, averting unnecessary appendectomies. [6] Overall, these results indicate that the Modified Alvarado scoring system has a good positive predictive value, which agrees with our findings. In another prospective study in southern India performed from 2004 to 2005, 231 patients with pain located in the right iliac fossa were evaluated. Patients were categorized between two groups based on their Alvarado scores: group one had scores ≤7 (n=118) and group two had scores ≥6 (n=113). Out of the 103 patients in group one that underwent surgery, 101 were found to have acute appendicitis. However, in group two, of the 29 patients that underwent an appendectomy, 6 patients had confirmed cases of appendicitis according to histological findings.[7] From ultrasound imaging, 110 cases of appendicitis were diagnosed and of those cases, 107 were confirmed. These findings indicate that 3 patients received false positive diagnoses. According to this study, it was found that the Alvarado scoring system had a sensitivity of 88.8%, which was higher than what we found, and a specificity of 75%, which was lower than what we determined in our study. In a study conducted by Sanabria and colleagues during 2007 in Columbia, it was found that unnecessary appendectomies were performed in 16.9% of males and 31.4% of females.[8] In men, clinical signs were more indicative of a diagnosis of appendicitis than laboratory results, but there were no such differences found in women. In our study, we did not ob89


Kariman et al. Evaluation of the Alvarado score in acute abdominal pain

serve these differences between men and women. In a study by Horzić et al.,[9] it was found that clinical findings were most critical in diagnosing appendicitis, but Alvarado scoring still demonstrated utility in diagnosing appendicitis due to the high specificity of this scoring system.[9] In a prospective study conducted in the surgical emergency unit of a teaching hospital in Baghdad, Iraq,[10] the Alvarado scoring system was utilized to help diagnose patients with suspected acute appendicitis (n=100). Of the patients with Modified Alvarado scores ≥7, 57.5% were female and 42.5% were male, and for those patients with Modified Alvarado score <7, 53.9% were female and 46.1% were male. Compared to our results, for patients that received Alvarado Scores >7, the percentage of females was lower, whereas for Alvarado scores <7, the percentage females was higher (Table 6). For Alvarado scores >7, the mean Alvarado score for females and males differed significantly for those diagnosed with acute appendicitis in our study. For patients with Alvarado Score <7, mean Alvarado scores between males and females were not significantly different (Table 7). These findings are similar to those in the P. D. Gurav et al. study performed in Government hospital in Sangli, India.[11] In conclusion, the results of our study revealed that the Alvarado scoring system can be used in patients with acute abdominal pain, and may be effective in predicting appendicitis. A positive score (Alvarado score >7) suggests a 93% chance of having appendicitis, whereas a negative test (Alvarado score ≤7) suggests a 26% probability of having appendicitis. In all, the Alvarado scoring system is a good rule-in test, but not an adequate rule-out test.

Conflict of interest: None declared.

REFERENCES 1. Marx JA. Rosen’s emergency medicine: concepts and clinical practice. In: Hockberger RS, et al. 7th ed., Philadelphia: Mosby-Elsevier; 2010. 2. Tintinalli JE. Tintinalli’s emergency medicine: a comprehensive study guide. 7th ed. Stapczynski JS, et al. McGraw-Hill; 2009. 3. Brunicardi F. Schwartz’s principles of surgery. 9th ed., Andersen D, et al. McGraw-Hill; 2009. 4. Ahmad A, Vohra L, Lehri A. Diagnostic accuracy of Alvarado score in the diagnosis of acute appendicitis. Pak J Med Sci 2009;25:118-21. 5. Khan I, ur Rehman A. Application of alvarado scoring system in diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad 2005;17:41-4. 6. Lamparelli MJ, Hoque HM, Pogson CJ, Ball AB. A prospective evaluation of the combined use of the modified Alvarado score with selective laparoscopy in adult females in the management of suspected appendicitis. Ann R Coll Surg Engl 2000;82:192-5. 7. Baidya N, Rodrigues G, Rao A, Khan S. Evaluation of Alvarado score in acute appendicitis: a prospective study. The Internet Journal of Surgery 2007;9:1. Available at: http://ispub.com/IJS/9/1/10672. 8. Sanabria A, Domínguez LC, Bermúdez C, Serna A. Evaluation of diagnostic scales for appendicitis in patients with lower abdominal pain. Biomedica 2007;27:419-28. 9. Horzić M, Salamon A, Kopljar M, Skupnjak M, Cupurdija K, Vanjak D. Analysis of scores in diagnosis of acute appendicitis in women. Coll Antropol 2005;29:133-8. 10. Thabit MF, Al An sari HM, Kamoona BR. Evaluation of modified Alvarado score in the diagnosis of acute appendicitis at Baghdad Teaching Hospital. The Iraqi Postgraduate Medical Journal 2012:11:675-83. 11. P. D. Gurav, N. N. Hombalkar, Priya Dhandore, Mohd. Hamid. Evaluation of Right Iliac Fossa Pain with Reference to Alvarado Score - Can We Prevent Unnecessary Appendicectomies. JKIMSU 2013:2:24-9.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Akut karın ağrısında Alvarado skorunun değerlendirmesi Dr. Hamid Kariman,1 Dr. Majid Shojaee,1 Dr. Anita Sabzghabaei,1 Dr. Rosita Khatamian,2 Dr. Hojjat Derakhshanfar,1 Dr. Hamidreza Hatamabadi1 1 2

Shahid Beheshti Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Tahran, İran; Birjand Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Khorasan, İran

AMAÇ: Apandisitten rahatsız hastalarda genellikle Alvarado skoru değerlendirilir. Bu çalışmada, nedenleri ne olursa olsun karın ağrısından rahatsız hastalarda Alvarado skorları karşılaştırıldı. GEREÇ VE YÖNTEM: Bu prospektif çalışmada akut karın ağrısı olan ve acil servise sevk edilen 300 hasta ağrının nedeni ne olursa olsun Alvarado skoruyla değerlendirildi. BULGULAR: Üç yüz hastadan 257’sinde (%85.66) Alvarado skorları 7 veya daha düşük iken 43 (%14.33) hastada 7’den daha yüksekti. Bu çalışmada Alvarado skorları 7 veya daha düşük olanlardan 66’sında (%25.7), Alvarado skorları 7’den daha yüksek olan 40 (%93) hastada, arada istatistiksel açıdan anlamlı farklılıklar olmak üzere apandisit saptanmııştı. Bu bulgu, karın ağrısı ve Alvarado skoru 7’den yüksek hastaların çok büyük bir olasılıkla apandisitten rahatsız olduğunu akla getirmektedir. Bu skorlama sisteminin apandisit için %95’lik bir özgüllük, ancak düşük bir duyarlılık (%37) derecesine sahip olduğu görünmektedir (%37). SONUÇ: Apandisiti öngörme açısından akut karın ağrısı olan hastalarda Alvarado skorlama sistemi kullanılabilir. Pozitif bir test (Alvarado skoru >7) %93, negatif bir test (Alvarado skoru ≤7) ise %26 oranında apandisit olasılığını gösterecektir. Bu nedenle bu test apandisit lehine iyi, apandisiti dışlamak için ise yeterli olmayan bir testtir. Anahtar sözcükler: Alvarado skoru; apandisit; karın ağrısı. Ulus Travma Acil Cerr Derg 2014;20(2):86-90

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Case series of non-operative management vs. operative management of splenic injury after blunt trauma Roberto Cirocchi, M.D.,1 Alessia Corsi, M.D.,1 Elisa Castellani, M.D.,2 Francesco Barberini, M.D.,2 Claudio Renzi, M.D.,1 Lucio Cagini, M.D.,3 Carlo Boselli, M.D.,2 Giuseppe Noya, M.D.2 1

Department of General Surgery, University of Perugia, St. Maria Hospital, Terni, Italy;

2

Department of General and Oncologic Surgery, University of Perugia, Perugia, Italy;

3

Department of Thoracic Surgery, University of Perugia, Perugia, Italy

ABSTRACT BACKGROUND: The spleen is the most easily injured organ in abdominal trauma. The conservative, operative approach has been challenged by several reports of successful non-operative management aided by the power of modern diagnostic imaging. The aim of our retrospective study was to compare non-operative management with surgery for cases of splenic injury. METHODS: We compared seven patients who were treated with non-operative management (NOM) between 2007 and 2011 to six patients with similar pre-operative characteristics who underwent operative management (OM). RESULTS: The average hospital stay was lower in the NOM group than in the OM group, although the difference was not statistically significant. The NOM group required significantly fewer transfusions, and no patients in the NOM group required admission to the intensive care unit. In contrast 83% of patients in the OM group were admitted to the intensive care unity. The failure rate of NOM was 14.3% in our experience. CONCLUSION: In our experience, NOM is the treatment of choice for grade I, II and III blunt splenic injuries. NOM is slightly less than surgery, but this is an unadjusted comparison and the 95% confidence interval is extremely wide - from 0.04 to 16.99. Splenectomy was the chosen technique in patients who met exclusion criteria for NOM, as well as for patients with grade IV and V injury. Key words: Non-operative management; operative management; spleen; splenic injury.

INTRODUCTION The spleen is the most easily injured organ in abdominal trauma. Isolated splenic injuries can be found in about one-third of blunt trauma and in 25-30% of patients who suffered a traffic accident.[1] Substantial changes in the treatment of blunt splenic injuries (BSIs) have occurred in the last forty years. The history of the splenectomy can be traced back to Aristotle,[2] who was the first person to consider the spleen to be a non-essential organ. The idea that a splenectomy is the Address for correspondence: Alessia Corsi, M.D. St. Maria Hospital, Via Tristano Di Joannuccio N. 4, 05100 Terni, Italy Tel: 07442051 E-mail: alessia.cor@libero.it Qucik Response Code

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only appropriate treatment for blunt splenic injuries (BSIs) was based on the concept that the spleen is a fragile, vascular structure unsuitable for suturing lacerations, that there is a risk of uncontrollable bleeding in the absence of surgical removal, and the high mortality rate associated with nonoperative management (NOM) (90-100%).[3] The first change in the attitude towards OM occurred with the article by King and Schumacker in 1952, which showed that patients who underwent a splenectomy had a greater susceptibility to infection by Streptococcus pneumoniae.[4] In 1968, Upadhyaya and Simpson published a retrospective clinical analysis of 52 children with splenic injury who underwent conservative medical treatment at the Hospital for Sick Children in Toronto.[5] The results of this study demonstrated that conservative treatment is efficacious in select patients. Currently, modern diagnostic imaging has enabled more accurate monitoring of BSIs and an improvement in interventional radiology techniques has encouraged the NOM approach.[6] Thus, a splenectomy is now one of several possible treatment 91


Cirocchi et al. Case series of non-operative management vs. operative management of splenic injury after blunt trauma

choices, rather than the only accepted approach. The aim of our retrospective study was to compare NOM with surgery.

MATERIALS AND METHODS Between January 2007 and December 2011, we treated seven patients with BSIs with NOM at the B Section of General and Emergency Surgery of Santa Maria Hospital in Terni. In more than half of the cases, the patients arrived to the emergency room after a car accident (65%). Accidental falls and occupational incidents each represented 15% of the causes.

an abdominal CT scan with contrast in order to assess the location and degree of parenchymal lesions, concomitant extraabdominal injuries and the extent of the hemoperitoneum. If the CT scan did not show “blushing,” we proceeded to NOM. However, if contrast medium was spreading during CT, patients were triaged to angioembolization (AE). Patients included in category B are those with active bleeding requiring continuous hemodynamic support. The therapeutic approach has therefore been OM if early hemodynamic stabilization is not obtained, which would move patients to category A.

All patients underwent an initial assessment upon arrival to the emergency room using the Advanced Life Trauma Support (ATLS) protocol that describes the absolute priorities using the acronym ABCDE: A (Airway), B (Breathing), C (Circulation), D (Disability) and E (Exposure).[1]

Group C consists of hemodynamically unstable patients unresponsive to intravenous fluids and intensive support. In these subjects, because of the severity of their condition, we used the principles of Damage Control to proceed with treatment, which is an approach based on controlling damage with the goal of helping the patient survive.[8]

Then, the patients underwent a FAST scan, which detects abdominal free fluid with a high degree of accuracy and has good sensitivity for liver and spleen injuries.[7]

To define the extent of the injury, we used the Organ Injury Scale of the American Association for the Surgery of Trauma (AAST), which describes 5 grades of splenic injury[9] (Table 1).

Subsequent diagnostic procedures were utilized based on the hemodynamic stability of patients, evaluated according to the criteria established by ATLS, which recognizes three categories: • A hemodynamically stable • B hemodynamically stabilized • C hemodynamically unstable.[7]

In our study, two patients undergoing NOM had a grade I injury, four patients had a grade II injury and one patient had a grade III injury.

Group A consists of patients with normal vital signs and includes subjects with a hemoperitoneum >500-1000cc who are hemodynamically stable after one bolus of crystalloids. Based on the ATLS protocol, a stable patient should receive

NOM was attempted in patients who satisfied the following inclusion criteria: • hemodynamic stability (systolic blood pressure > 90 mmHg, heart rate <100 bpm); • good response to prompt infusion of 2000 ml of crystalloid (i.e. Ringer’s lactate - RLS), with return to normal vital signs;

Table 1. Organ Injury Scale of the American Association for the Surgery of Trauma (AAST) (Federle,1998)[16]

92

Grade

Injury type

Description of injury

I

Hematoma

Subcapsular, nonexpanding, <10% della surface area

Laceration

Capsular tear, nonbleeding, <1 cm parenchymal depth

II

Hematoma

Subcapsular, nonexpanding, 10-50% surface area

Intraparenchymal, <2 cm in diameter, nonexpanding

Laceration

Capsular tear, active bleeding, 1-3 cm parenchymal depth

III

Hematoma

Subcapsular, >50% surface area or expanding

Laceration

Ruptured subcapsular hematoma with active bleeding

Intraparenchymal, >2 cm in diameter, or expanding >3 cm parenchymal depth

IV

Hematoma

Ruptured intraparenchymal hematoma with active bleeding

Laceration

Involvement of segmental or hilar vessels producing devascularization >25%

V

Laceration

Shattered spleen

Vascular

Hilar vascular injury devascularizes spleen

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• splenic injury grade I, II, III; • hemoperitoneum only if it extended to less than three abdominal quadrants; • concomitant abdominal injuries that did not require a surgical procedure. During hospitalization, patients undergoing NOM were closely monitored using clinical and laboratory data to ensure that rapid intervention could be performed if needed. In order to have a good OM group to compare to the NOM group, it was necessary to ensure that the characteristics of the patients in both groups were similar. We picked patients for the OM group using the departmental medical records. The institutional review board approved the study design and waived the need for informed consent. The present study was strictly observational and did not interfere with the decision-making process and clinical management. We identified 19 patients managed operatively from January 2001 to December 2005. The retrospective OM control group was created by choosing six patients who had similar characteristics to the NOM group, had been hemodynamically stable and had splenic lesions ranging from grade I to III. In total, there were seven patients in the NOM group (mean age 54.6 years) and six in the OM surgery (historical group). The preoperative characteristics of the two groups did not differ significantly. The following data were collected and analyzed: age, gender, vital signs at presentation, grade of splenic injury, Injury Severity Score (ISS),[10] concomitant injuries, injuries requiring surgical procedures and simultaneous extraabdominal pathologies. Failure of NOM was defined by the occurrence of any of the following: • evidence of hemodynamic instability during monitoring, notably the development of hypotension;[11] • increasing hemoperitoneum, evidenced by ultrasonography and consequent reduction in hematocrit; • presence of active bleeding requiring transfusion of more than 4 units of blood in the first 24 hours to achieve hemodynamic stability; • development of complications; • patient rejection of NOM.

(a)

(b)

Figure 1. (a, b) Abdominal CT with contrast. There are hypodense areas diffusely throughout the majority of the spleen and a subcapsular hematoma with active bleeding. There is no free peri-splenic fluid.

A 77-year-old man with a grade II splenic injury, who had been treated with arterial embolization of the splenic artery according to the inclusion criteria, died 13 days after the intervention from a myocardial infarction. This was the only patient in our study who underwent splenic artery embolization with spirals (Fig. 2) for a grade II splenic lesion with ongoing arterial bleeding seen on CT scan.

RESULTS This study included a total of 26 patients, 24 males and 2 females, whose mean age was 54 years. We compared seven patients who received NOM to six patients with similar preoperative characteristics who underwent OM. Six patients in the NOM group had concomitant traumatic injuries compared to five in the OM group. In the OM patients, the concomitant injuries were mostly intra-abdominal, whereas in the NOM patients, they were mostly extra-abdominal. Forty-two percent of the concomitant injuries were intra-abdominal and 58% were extra-abdominal. We noted an association between NOM and orthopedic injuries (57%)

We have chosen to include the latter criterion in our study to ensure statistical accuracy (modified intention to treat[12,13]), although in the past literature, this criterion has not been used. In our series, there was one case of NOM failure. The NOM failure occurred in a 41-year-old man who had a grade III splenic injury and met the inclusion criteria for NOM, but who did not agree to NOM and thus received a splenectomy (Fig. 1). Figure 2. Splenic angioembolization. Distal selective embolization.

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Study or Subgroup

NOM Events Total 1

n° pt

OM Events Total Weight

7

5

5

Total (95% CI) 1

Total events

Odds Ratio M-H, Fixed, 95% CI

6

100.0%

0.03 [0.00, 0.68]

6

100.0%

0.03 [0.00, 0.68]

Odds Ratio M-H, Fixed, 95% CI

5

Heterogeneity: Not applicable

0.01

Test for overall effect: Z=2.21 (p=0.03)

0.1

Favours experimental

1

10

100

Favours control

Figure 3. Transfusion rates in the NOM and OM groups. The NOM group required significantly fewer transfusions (14% NOM vs. 83% OM) (p=0.03).

and OM with traumatic lesions of the pancreas (50%). Furthermore, 54% of our patients had comorbid conditions that must be considered in estimating mortality, although this was not statistically significant (p=0.43). Thirty-one percent of the NOM had comorbidities compared to 23% of the OM group. The mean ISS of the OM group was 13.8 and was higher than the non-operative group that had a mean ISS of 8.8.

thesis. In the non-operative group, there were no readmissions. In the splenectomy group, there were five cases of acute respiratory failure, all treated with continuous mechanical ventilation for less than 96 consecutive hours in the ICU. There was no mortality difference between the two groups of patients (14% NOM vs. 17% OM) (p=0.91).The failure rate of NOM was 14.3% in our experience (Table 2).

The average length of hospital stay was lower in the NOM group (10.6±3.5 days) than in patients with OM (20.8±13.1 days), although the difference was not statistically significant (p=0.09). The hospital stays were lengthy in both groups because some patients had concomitant traumatic injuries. For example, in the NOM group, the patients with grade III lesions were monitored by ultrasound long to allow the reduction of hematoma liver. The NOM group required significantly fewer transfusions (14% NOM vs. 83% OM) (p=0.03) (Fig. 3).

DISCUSSION

No patient in the NOM group needed care in the ICU, whereas 83% of patients recovering from surgery required admission to the ICU. Our analysis revealed a slightly lower total morbidity in the splenectomy group (29% NOM vs. 17% OM) (p=0.62). In our study, the morbidity included acute respiratory failure, incisional hernia, non-healing surgical wound, acute myocardial infarction and concomitant traumatic injuries. Interventions for complications and readmissions were lower in the NOM group (0% NOM vs. 17% OM respectively) (p=0.41). The only readmission occurred one year after discharge and was secondary to an incisional hernia, which required a pros-

Our NOM success rate was 85.7%, which is similar to the past literature, which quotes rates around 80%.[14] There were no cases that required suspension of NOM and emergency laparotomy. This demonstrates the importance of an accurate assessment of patients on arrival and of using strict inclusion criteria for NOM. In 2005, the study by Peitzman[15] demonstrated that 30-40% of NOM failures were due to inappropriate selection of patients, particularly with regards to hemodynamic instability and initial misdiagnosis. It is also crucial to carefully monitor patients receiving NOM, according to the established protocol. It is important to note that when resuscitating hypotensive patients, large volumes of crystalloid given early during admission before hemostasis has occurred may increase bleeding. Hypotension is commonly seen in trauma cases without cranial injury.[16] In our analysis, the NOM failure rate was 14.3%, which is similar to the 17% failure rate reported in previous studies. Our failure rate may be skewed by the criteria used to define

Table 2. Description of case failure of NOM Failure of NOM A.T.

Age (years)

Sex

Grade of splenic injury

41

Male

III

Associated injuries

Cause of failure

Fracture of left ribs 8, 9 ,10 at the

Refusal of NOM

posterior arch; minimal posterior,

bilateral area of pulmonary contusion

NON: Non-operative management.

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failure, as we used patient refusal of NOM as an indication of failure. In our study, one patient refused NOM and dramatically impacted the rate due to the small number of cases included in this study.

cases in public academic hospitals and in 54% of cases in both non-academic and rural hospitals.[21] This difference points out the necessity of specialized equipment and staff for the management of polytrauma patients.

No complications occurred in patients who underwent NOM. We must however emphasize patients who underwent NOM had less severe spleen injuries due to the exclusion criteria for NOM.

NOM, as described in literature, should be adopted in most patients with splenic injuries, especially when the injury is isolated, but surgery is necessary for select cases and should not be interpreted as a defeat.[22]

The study by Di Saverio and Moore[17] highlighted how patients with grade IV through V splenic injury were at increased risk for developing complications and had a higher NOM failure rate, even though NOM is being utilized increasingly more for high-grade lesions. Similarly, the study by Peitzman and Richardson[18] showed that the NOM failure rate was proportional to the splenic injury grade: 5% in grade I, 10% in grade II, 20% in grade III, 33% in grade IV and 75% in grade V. Comparable failure rates were seen in the study conducted by Velmahos[19] in 14 trauma centers, in which the failure rate was 34.5% for patients with grade IV lesions and 60% for grade V lesions.

In the literature, there are no definitive and widely accepted guidelines on the appropriate length of hospitalization or follow-up. Non-operative management can be advantageous as it preserves splenic function and prevents laparotomy-associated complications.[14] Nonetheless, there are some risks: delayed splenic rupture and delayed treatment of unrecognized intra-abdominal injuries. In 2006, the study by Franklin and Cas贸s[23] described a mortality rate from Overwhelming Post-Splenectomy Infection (OPSI) of 1/10.000 for adult splenectomised patients. The odds of a patient dying from NOM are 20 times higher than this rate. Patients are now receiving more preventative treatment and are less likely to have OPSI. Our patients were vaccinated against Pneumococcus, Meningococcus and Haemophilus (ACWY quadrivalent meningococcal conjugate vaccine135 and ACT-HIB conjugated H. influenzae type b-vaccine).

A higher failure rate was found in the study by Malhotra,[20] which included patients with splenic and liver injuries that had either associated or single organ injuries. The failure rate for patients with associated injuries was 11.6% and 5.8% in patients with single organ injuries. It was not possible to compare these results to our study because patients in the Malhotra splenectomy group had a higher number of associated injuries. Mortality in the NOM group was 14% in our study, and similarly, the rate was 12.6% in the past literature (12.6%).[15] The patient who died in the NOM group was a 77-year-old man in poor condition suffering from lung cancer with lymphatic and pleuric metastases who died of heart failure. Mortality after NOM failure should be correlated with delayed treatment of any associated intra-abdominal injuries. It is estimated that reducing the delay in treatment of associated injuries would prevent mortality in 70% of cases.[15] Taking this into consideration, the presence of intra-abdominal injuries requiring surgical management is one of the NOM exclusion criteria used in this study. Peitzman and Richardson[18] have described NOM as the treatment of choice in 61.5% of splenic injuries. However, in our study, NOM was only used for 27% of cases. This value is lower than the literature value because of the limited number of patients in this study and exclusion of patients with high grade lesions (IV and V) from the NOM group. Treatment options seem to be influenced by the type of hospital a patients presents to. An analysis of 14901 patients with splenic injury showed that NOM was attempted in 60% of Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2

Limitations In addition to potential bias due to temporal confounders (changes in aspects of management over time), there was an insufficient sample size to adjust for other potentially important confounders (age, concomitant abdominal injuries, injury severity as measured by any of the validated trauma scores, etc). These limitations introduce significant potential for bias in the results.

Conclusions In this study, patients with splenic injury treated operatively between 2001-2005 were compared to patients treated nonoperatively between 2007-2011. In our experience, NOM was the treatment of choice for multiple reasons in blunt splenic injuries grade I, II and III. NOM is slightly less than surgery, but this is an unadjusted comparison and the 95% confidence interval is extremely wide - from 0.04 to 16.99. Splenectomy was the chosen technique in patients with exclusion criteria for NOM, as well as in those with grade IV and V injury. In the literature, the use of NOM in patients with grade IV and V splenic injuries is still under debate, and no unanimous opinion has been reached to date. The authors make a lot of conclusions based on a very small sample size (n=13). The conclusions are not warranted based on the data. Therefore new and larger studies are needed in order to assess usefulness of conservative approach in IV and V grade and costs of NOM in all grades of splenic injury. 95


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Conflict of interest: None declared.

REFERENCES 1. Buccoliero F, Ruscelli P. Splenic trauma. In the management of trauma. From the territory to the Trauma Center. Edited by: Cenammo A. Napoli: Italian Society of Surgery; 2010. p. 138-50. 2. Upadhyaya P. Conservative management of splenic trauma: history and current trends. Pediatr Surg Int 2003;19:617-27. 3. King H, Shumacker HB Jr. Splenic studies. I. Susceptibility to infection after splenectomy performed in infancy. Ann Surg 1952;136:239-42. 4. Surgeons. ACo. Manual ATLS (Advanced Trauma Life Support) by American College of Surgeons. 6th ed. 5. Upadhyaya P, Simpson JS. Splenic trauma in children. Surg Gynecol Obstet 1968;126:781-90. 6. Cirocchi R, Boselli C, Corsi A, Farinella E, Listorti C, Trastulli S, et al. Is non-operative management safe and effective for all splenic blunt trauma? A systematic review. Crit Care 2013;17:R185. [Epub ahead of print] 7. Surgeons. ACo. Manuale ATLS (Advanced Trauma Life Support). 8. Cirocchi R, Abraha I, Montedori A, Farinella E, Bonacini I, Tagliabue L, et al. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev 2010;1:CD007438. 9. Prokop M GM. Spleen. In Verlag. GT (ed) Computed tomography; spiral and multilayer. Edition Gernany: 2003;514. 10. Trauma.org [http://www.trauma.org/archive/scores/iss.html]. In Edition. 11. Forsythe RM, Harbrecht BG, Peitzman AB. Blunt splenic trauma. Scand J Surg 2006;95:146-51. 12. Abraha I, Montedori A. Modified intention to treat reporting in randomised controlled trials: systematic review. BMJ 2010;340:c2697. 13. Montedori A, Bonacini MI, Casazza G, Luchetta ML, Duca P, Cozzolino F, et al. Modified versus standard intention-to-treat reporting: are there differences in methodological quality, sponsorship, and findings in ran-

domized trials? A cross-sectional study. Trials 2011;12:58. 14. Tan KK, Chiu MT, Vijayan A. Management of isolated splenic injuries after blunt trauma: an institution’s experience over 6 years. Med J Malaysia 2010;65:304-6. 15. Peitzman AB, Harbrecht BG, Rivera L, Heil B; Eastern Association for the Surgery of Trauma Multiinstitutional Trials Workgroup. Failure of observation of blunt splenic injury in adults: variability in practice and adverse consequences. J Am Coll Surg 2005;201:179-87. 16. Morrison CA, Carrick MM, Norman MA, Scott BG, Welsh FJ, Tsai P, et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma 2011;70:652-63. 17. Di Saverio S, Moore EE, Tugnoli G, Naidoo N, Ansaloni L, Bonilauri S, et al. Non operative management of liver and spleen traumatic injuries: a giant with clay feet. World J Emerg Surg 2012;7(1):3. 18. Peitzman AB, Richardson JD. Surgical treatment of injuries to the solid abdominal organs: a 50-year perspective from the Journal of Trauma. J Trauma 2010;69:1011-21. 19. Velmahos GC, Zacharias N, Emhoff TA, Feeney JM, Hurst JM, Crookes BA, et al. Management of the most severely injured spleen: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Arch Surg 2010;145:456-60. 20. Malhotra AK, Latifi R, Fabian TC, Ivatury RR, Dhage S, Bee TK, et al. Multiplicity of solid organ injury: influence on management and outcomes after blunt abdominal trauma. J Trauma 2003;54:925-9. 21. Todd SR, Arthur M, Newgard C, Hedges JR, Mullins RJ. Hospital factors associated with splenectomy for splenic injury: a national perspective. J Trauma 2004;57:1065-71. 22. Castellani E, Covarelli P, Boselli C, Cirocchi R, Rulli A, Barberini F, et al. Spontaneous splenic rupture in patient with metastatic melanoma treated with vemurafenib. World J Surg Oncol 2012;10:155. 23. Franklin GA, Casós SR. Current advances in the surgical approach to abdominal trauma. Injury 2006;37:1143-56.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Künt travma sonrası oluşan dalak yaralanmasının cerrahi ve cerrahi dışı tedavisini karşılaştıran olgu çalışmalarının bir karşılaştırması Dr. Roberto Cirocchi,1 Dr. Alessia Corsi,1 Dr. Elisa Castellani,2 Dr. Francesco Barberini,2 Dr. Claudio Renzi,1 Dr. Lucio Cagini,3 Dr. Carlo Boselli,2 Dr. Giuseppe Noya2 1 2 3

Perugia Üniversitesi, St. Maria Hastanesi, Genel Cerrahi Anabilim Dalı, Terni, İtalya; Perugia Üniversitesi, Genel ve Onkolojik Cerrahi Anabilim Dalı, Perugia, İtalya; Perugia Üniversitesi, Göğüs Cerrahisi Anabilim Dalı, Perugia, İtalya

AMAÇ: Karın travmalarında dalak en kolay yaralanan organdır. Başarılı cerrahi dışı tedavi ve modern tanısal görüntülemeye ilişkin birkaç rapor konservatif yaklaşımın yayılmasına giderek daha fazla olanak tanımıştır. Bu retrospektif çalışmada cerrahi dışı tedavi ile cerrahi tedavi karşılaştırıldı. GEREÇ VE YÖNTEM: 2007 ila 2011 arasında benzer ameliyat öncesi özellikleri olan cerrahi dışı tedavi alan 7 hasta ile cerrahi tedavi alan 6 hasta karşılaştırıldı. BULGULAR: Cerrahi dışı tedavi grubunda ortalama hastanede kalış süresi cerrahi tedavi alanlara göre istatistiksel açıdan anlamlı olmamakla birlikte daha kısaydı. Cerrahi dışı tedavi grubu anlamlı derecede daha az transfüzyona gerek göstermiş, bu grupta hiçbir hasta yoğun bakım ünitesinde (YBÜ) kalmayı gerektirmemişken cerrahi tedaviden sonra kendine gelen hastaların %83’ünün YBÜ’de kalması gerekmiştir. Deneyimlerimizde cerrahi dışı tedavinin başarısızlık oranı %14.3 düzeyindeydi. TARTIŞMA: Deneyimimizde, cerrahi dışı tedavi, I, II, ve III. derece künt dalak yaralanmalarında birkaç avantajı sayesinde seçilen tedavi idi. Cerrahi dışı tedavi, cerrahiye göre biraz daha az avantajlı olmasına rağmen bu düzeltilme yapılmamış bir karşılaştırma olup %95 güven aralığı son derece genişti (0.04 ila 16.99 arasında). Cerrahi dışı tedavi için dışlanma kriterlerini taşıyan hastalarla birlikte IV ve V. derece yaralanmaları olanlarda splenektomi seçilen teknikti. Anahtar sözcükler: Cerrahi dışı tedavi; cerrahi tedavi; dalak; dalak yaralanması. Ulus Travma Acil Cerr Derg 2014;20(2):91-96

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ORIGIN A L A R T IC L E

Non-operative management (NOM) of blunt hepatic trauma: 80 cases Bünyami Özoğul, M.D.,1 Abdullah Kısaoğlu, M.D.,1 Bülent Aydınlı, M.D.,1 Gürkan Öztürk, M.D.,1 Atıf Bayramoğlu, M.D.,2 Murat Sarıtemur, M.D.,2 Ayhan Aköz, M.D.,2 Özgür Hakan Bulut, M.D.,1 Sabri Selçuk Atamanalp, M.D.1 1

Departmant of General Surgery, Ataturk University Faculty of Medicine, Erzurum;

2

Departmant of Emergency, Ataturk University Faculty of Medicine, Erzurum

ABSTRACT BACKGROUND: Liver is the most frequently injured organ upon abdominal trauma. We present a group of patients with blunt hepatic trauma who were managed without any invasive diagnostic tools and/or surgical intervention. METHODS: A total of 80 patients with blunt liver injury who were hospitalized to the general surgery clinic or other clinics due to the concomitant injuries were followed non-operatively. The normally distributed numeric variables were evaluated by Student’s t-test or one way analysis of variance, while non-normally distributed variables were analyzed by Mann-Whitney U-test or Kruskal-Wallis variance analysis. Chi-square test was also employed for the comparison of categorical variables. Statistical significance was assumed for p<0.05. RESULTS: There was no significant relationship between -patients’ Hgb level and liver injury grade, outcome, and mechanism of injury. Also, there was no statistical relationship between liver injury grade, outcome, and mechanism of injury and ALT levels as well as AST level. There was no mortality in any of the patients. CONCLUSION: During the last quarter of century, changes in the diagnosis and treatment of liver injury were associated with increased survival. NOM of liver injury in patients with stable hemodynamics and hepatic trauma seems to be the gold standard. Key words: Liver; nonoperatif management; trauma.

INTRODUCTION Blunt trauma is one of the most serious and most common cause of death in youth.[1] Specifically, liver is the most frequently injured organ during abdominal trauma.[2] Advances in imaging modalities such as ultrasound and computed tomography, interventional radiology, critical care, and the introduction of damage control surgery during the past two decades have greatly influenced the diagnosis and treatment algorithm in trauma surgery.[3] During the last century, the

Address for correspondence: Bünyami Özoğul, M.D. Atatürk Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Yenişehir, 25070 Erzurum, Turkey Tel: +90 442 - 316 63 33 / 2216 E-mail: bozogul57@hotmail.com Qucik Response Code

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management of blunt force trauma to the liver has changed from mainly operative intervention, to the current practice of selective operative and non-operative management (NOM). [4] NOM of blunt liver injuries has become the standard for care patients with stable hemodynamics, which account for approximately 85% of all those with blunt hepatic trauma.[5] Avoidance, if at all costs, of a laparotomy with its short and long term risks is of great benefit to the patient.[6] We present a group of patients with blunt hepatic trauma that were managed without any invasive diagnostic tools and/or surgical intervention.

MATERIALS AND METHODS Study Sample Patients who were admitted to our ED with blunt trauma between January 2002 and December 2012 were screened for radiological diagnosis of liver injury and were collected retrospectively. The patients with hemodynamic instability, altered level of consciousness, penetrant liver injury, less than 16 years old, and needed invasive and/or surgical intervention were all excluded from this study. A total of 80 patients with 97


Özoğul et al. Non-operative management (NOM) of blunt hepatic trauma

Table 1. American Association for the Surgery of Trauma grading scale for hepatic injuries Liver injury grade

Sub-capsular hematoma

Laceration

Grade I

<10% surface area

<1 cm in depth

Grade II

10-50% surface area

1-3 cm

Grade III

>50% or >10 cm

>3 cm

Grade IV

25-75% of a hepatic lobe

Grade V

>75% of a hepatic lobe

Grade VI

Hepatic avulsion

blunt liver injury that were hospitalized to the general surgery clinic or other clinics due to concomitant injuries were followed non-operatively.

Collection of Data and Definitions Baseline characteristics of patients with blunt liver injury such as age, gender, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mechanism of injury, preferred imaging modality, liver injury grading scale according to American Association for the Surgery of Trauma (AAST) (Table 1), and patient hospitalization were recorded. Blood samples drawn at admission such as serum Hgb, AST, and ALT levels were recorded. Blunt liver injury was defined as radiological findings on abdominal ultrasonography and/or computed tomography (CT) with no evidence of penetrant injury. Hemodynamic stability was defined as systolic blood pressure above 90 mmHg, heart rate below 110/minute, and normal level of consciousness on arrival or during follow-up. [7] NOM consisted of closely monitoring with repeated clinical assessment including the evaluation of vital signs such as SBP, HR, temperature, and fluid balance with estimating input and output of fluids in the body and measurement of Hgb and hematocrit four times daily for the first 48 hours and later twice a day until the end of the 5th day follow-up.

Statistical Analysis Statistical Package for Social Sciences software (SPSS 19.0, Chicago, IL, USA) was used for statistical analysis. Continuous

(a) Blunt trauma (3.75%)

Animal backlash (6.25%)

(b)

USG (7.50%)

variables were expressed as mean±standard deviation values, whereas categorical variables were presented as percentages. The differences between normally distributed numeric variables were evaluated by Student’s t-test or one way analysis of variance, while non-normally distributed variables were analyzed by Mann-Whitney U-test or Kruskal-Wallis variance analysis as appropriate. Chi-square (X²) test was employed for the comparison of categorical variables. Statistical significance was assumed for p<0.05.

RESULTS Of the cases studied, 55 (69%) were male and 25 (31%) were female. The mean age was 36.49±18.14 years (min=15, max=85). The most common mechanism of injury (n=58; 72.5%) was motor vehicle accident and the most commonly preferred imaging modality (n=71; 89%) was abdominal CT. Distribution of patients according to their mechanism of trauma and preferred imaging modality is shown in Figure 1a and Figure 1b, respectively. The most frequently graded liver injury for the patients tested were grades I and II (n=35; 44% and n=28; 35%, respectively) (Figure 1c). The mean systolic blood pressure was 113.98±7.202 mmHg (min=100, max=130), the mean diastolic blood pressure was 72.05±8.409 mmHg (min=40, max=80), and the average heart rate was 85.68±5.811 (min=72, max=100) per minute. Hgb values were statistically different between male and females. The average value for women was 12.3±2.42 (min=8.1

CT ve USG (3.75%)

Fall (17.50%)

(c)

Grade 4 (5.00%) Grade 3 (16.25%)

Motor vehicle accident (72.50%)

CT (88.75%)

Grade 2 (35.00%)

Grade 1 (43.75%)

Figure 1. (a) Mechanism of injury. (b) Radiology. (c) Lesions.

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Özoğul et al. Non-operative management (NOM) of blunt hepatic trauma

max=15.9) and for men was 13.61±1.5 (min=9.8 max=17.5). There was no difference in AST and ALT between genders, ALT: 287.54±353.91 (min=12 max=2248) and AST: 286.48±305.68 (min=11 max=1522). There was no significant relationship between patient Hgb level and liver injury grade, outcome, and mechanism of injury (p=0.283; p=0.87, p=0.586, respectively). Also, there was no relationship between liver injury grade, outcome and mechanism of injury, and ALT levels (p=0.592; p=0.262; p=0.811, respectively) as well as AST levels (p=0.112; p=0.127; p=0.822, respectively). Of the cases, 62 were admitted to general surgery clinic and discharged with recovery. Three patients were followed in different clinics because of additional problems. Two patients were discharged from thoracic surgery clinic and one from orthopedic clinic with healing. Twelve patients were transferred to other clinics from general surgery after treatment (six to orthopedic, three to thoracic surgery, two to intensive care unit and one to neurosurgery clinics). Three cases underwent an operation in the following days of which two had spleen laceration and one had small bowel perforation. There was no mortality in any of the patients.

DISCUSSION Diagnostic peritoneal lavage was the most important diagnostic procedure for liver trauma in the last quarter of the twentieth century. This test had a low complication rate and high accuracy. Even so, it was not possible to determine the degree of liver injury in the absence of intra-abdominal bleeding.[8,9] In the early 1990s with the introduction of focused assessment with sonography for trauma (FAST), the detection of free fluid in the abdomen was more easily observed. The main disadvantage of this method was the insufficiency of detecting bleeding sites and degree of liver injury. Computed tomography (CT) which was introduced from the second half of the 1990s, was very useful for surgeons to identify the degree of liver injury in addition to the determination of site and amount of bleeding.[10,11] Our experience of non-operative treatment in patients with liver injury has increased with this technological advancement in the last 25 years. Based on this information, non-operative treatment of patients with stable hemodynamics and blunt liver trauma seems to be the better treatment option. Recent studies have showed that success rate ranges from 87% to 98%.[12] In our study, the percentage was 96.25% with CT demonstrating great effectiveness in the detection of bleeding as well as bleeding site and degree of injury. CT was also very useful in the determination of the most accurate treatment method and in the follow-up of the patients in the clinic. In patients with non-operative liver trauma, is it possible that other intra-abdominal injuries may be overlooked with CT follow-up? Although Miller at al.[13] showed that the rate of failure was 1.1%, the incidence of bowel or diaphragm injuries in association with spleen or liver injury in patients underUlus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2

going laparotomy after blunt trauma was reported between 0.5% and 12% in the literature.[13,14] Yanar et al.[15] reported one patient for whom NOM failed because of the mesenteric laceration. In our study, one patient (1.25%) was overlooked and had to be operated on due todeterioration of the general condition during the clinical follow-up and small bowel injury was detected. The different failures have been described in various studies. Velmahos et al. showed that failure of NOM occurred in onethird of patients for reasons other than the solid organ injury. [16] In another study, Holmes et al.[17] reported that bicycle crashes were associated with increased risk of NOM failure. They also found that the rate of NOM failure was 10.9% to 38.2% in isolated organ injury but 54.4% to 70.0% in multiple organ injury. Malhotra et al.[18] managed non-operatively 4 of (36%) the 11 patients with high-grade injury to both the liver and spleen successfully. Although the number is small, this may support the contention that selected patients with higher-grade injuries to multiple solid organs can be managed non-operatively. Yanar et al.[15] reported that multiplicity of solid organ injury is not a predictive marker of NOM failure, and subset analysis of organ combination revealed no association with NOM failure. In our study, 17 patients (21.25%) with grade III and IV injury were treated with NOM successfully. Of the 3 patients with NOM failure, there was grade II injury in two patients and grade I injury in one patient. Two of these patients were operated on due to spleen laceration and the other patient was operated due to small bowel perforation. The low number of patients with NOM failure in our study makes it difficult to explain the factors that cause this condition. The deterioration of hemodynamic stability in these three patients led us to immediate surgery. Some authors have stated that hemodynamic instability is more important than grading of liver injury in children with blunt liver trauma. In addition, a decrease in hemoglobin value and deterioration of liver function tests was found to be the reason for emergency surgery in some studies.[19] In our study, decreases in hemoglobin values in two patients with splenic laceration lead us to move immediate surgery. Hemoglobin values in other follow-up patients remained stable. The frequency of delayed bleeding is higher in splenic injury than in hepatic injury, and this may decrease the success rate of NOM.[15] Yanar et al. reported that among the four patients for whom NOM failed because of delayed bleeding, two grade IV splenic injuries, one grade II splenic injury, and one grade IV renal injury were detected during the operation. [15] In our study, NOM failed in two patients because of grade II splenic injury. Shapiro et al.[20] stated that NOM of neurologically impaired, patients with stable hemodynamics, blunt injuries of the liver, spleen, or kidney is commonly practiced and is successful in greater than 90% of cases. In conclusion, changes during the last quarter of century in the diagnosis and treatment of 99


Özoğul et al. Non-operative management (NOM) of blunt hepatic trauma

liver injury are associated with increased survival. NOM in patients with stable hemodynamics, hepatic trauma seems to be the gold standard. Although CT is important for follow-up and treatment of patients with blunt liver trauma, it should be correlated with hemodynamic instability.

9. Nagy KK, Roberts RR, Joseph KT, Smith RF, An GC, Bokhari F, et al. Experience with over 2500 diagnostic peritoneal lavages. Injury 2000;31:479-82.

Conflict of interest: None declared.

11. Weninger P, Mauritz W, Fridrich P, Spitaler R, Figl M, Kern B, et al. Emergency room management of patients with blunt major trauma: evaluation of the multislice computed tomography protocol exemplified by an urban trauma center. J Trauma 2007;62:584-91.

REFERENCES 1. Vukovic G, Lausevic Z. Diagnostics and treatment of liver injuries in polytrauma. Healthmed 2012;6:2796-801. 2. Jiang H, Wang J. Emergency strategies and trends in the management of liver trauma. Front Med 2012;6:225-33. 3. Petrowsky H, Raeder S, Zuercher L, Platz A, Simmen HP, Puhan MA, et al. A quarter century experience in liver trauma: a plea for early computed tomography and conservative management for all hemodynamically stable patients. World J Surg 2012;36:247-54. 4. Stassen NA, Bhullar I, Cheng JD, Crandall M, Friese R, Guillamondegui O, et al. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73(5 Suppl 4):288-93. 5. van der Wilden GM, Velmahos GC, Emhoff T, Brancato S, Adams C, Georgakis G, et al. Successful nonoperative management of the most severe blunt liver injuries: a multicenter study of the research consortium of new England centers for trauma. Arch Surg 2012;147:423-8. 6. Peitzman AB, Ferrada P, Puyana JC. Nonoperative management of blunt abdominal trauma: have we gone too far? Surg Infect (Larchmt) 2009;10:427-33. 7. Raza M, Abbas Y, Devi V, Prasad KV, Rizk KN, Nair PP. Non operative management of abdominal trauma -- a 10 years review. World J Emerg Surg 2013;8:14. 8. Fischer RP, Beverlin BC, Engrav LH, Benjamin CI, Perry JF Jr. Diagnostic peritoneal lavage: fourteen years and 2,586 patients later. Am J Surg 1978;136:701-4.

10. Huber-Wagner S, Lefering R, Qvick LM, Körner M, Kay MV, Pfeifer KJ, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009;373:1455-61.

12. Trunkey DD. Hepatic trauma: contemporary management. Surg Clin North Am 2004;84:437-50. 13. Miller PR, Croce MA, Bee TK, Malhotra AK, Fabian TC. Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management. J Trauma 2002;53:238-44. 14. Durham RM, Buckley J, Keegan M, Fravell S, Shapiro MJ, Mazuski J. Management of blunt hepatic injuries. Am J Surg 1992;164:477-81. 15. Yanar H, Ertekin C, Taviloglu K, Kabay B, Bakkaloglu H, Guloglu R. Nonoperative treatment of multiple intra-abdominal solid organ injury after blunt abdominal trauma. J Trauma 2008;64:943-8. 16. Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg 2003;138:844-51. 17. Holmes JH 4th, Wiebe DJ, Tataria M, Mattix KD, Mooney DP, Scaife ER, et al. The failure of nonoperative management in pediatric solid organ injury: a multi-institutional experience. J Trauma 2005;59:1309-13. 18. Malhotra AK, Latifi R, Fabian TC, Ivatury RR, Dhage S, Bee TK, et al. Multiplicity of solid organ injury: influence on management and outcomes after blunt abdominal trauma. J Trauma 2003;54:925-9. 19. Cox JC, Fabian TC, Maish GO 3rd, Bee TK, Pritchard FE, Russ SE, et al. Routine follow-up imaging is unnecessary in the management of blunt hepatic injury. J Trauma 2005;59:1175-80. 20. Shapiro MB, Nance ML, Schiller HJ, Hoff WS, Kauder DR, Schwab CW. Nonoperative management of solid abdominal organ injuries from blunt trauma: impact of neurologic impairment. Am Surg 2001;67:793-6.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Künt karaciğer travmalarında cerrahi dışı yaklaşım: 80 olgu Dr. Bünyami Özoğul,1 Dr. Abdullah Kısaoğlu,1 Dr. Bülent Aydınlı,1 Dr. Gürkan Öztürk,1 Dr. Atıf Bayramoğlu,2 Dr. Murat Sarıtemur,2 Dr. Ayhan Aköz,2 Dr. Özgür Hakan Bulut,1 Dr. Sabri Selçuk Atamanalp1 1 2

Atatürk Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Erzurum; Atatürk Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Erzurum

AMAÇ: Karaciğer karın travmalı hastalarda en sık yaralanan solid bir organdır. Bu çalışmada, tedavisinde ve takibinde herhangi bir invaziv tanısal girişim ya da cerrahi girişim yapılmayan bir grup künt karaciğer travmalı hasta değerlendirildi. GEREÇ VE YÖNTEM: Genel cerrahi kliniğine yatırılan ve bunun yanısıra ek yaralanmaları sebebiyle diğer kliniklere yatırılıp genel cerrahi tarafında bu kliniklerde takibi yapılan toplam künt karaciğer yaralanması olan 80 hasta cerrahi yapılmadan izlendi. Normal dağılım gösteren veriler Student’s t-testi veya tek yönlü varyans analizi ile değerlendirildi. Anormal dağılım gösteren veriler ise Mann-Whitney U-testi veya Kruskal-Wallis varyans analizi ile incelendi. Kategorik veriler ki-kare testi ile analiz edildi ve p<0.05 istatistiksel olarak anlamlı kabul edildi. BULGULAR: Takip edilen hastaların hemoglobin düzeyleri, karaciğer yaralanma derecesi ve taburcu olması ile yaralanma mekanizması arasında istatistiki olarak anlamlı bir ilişki bulunamadı. Aynı zamanda karaciğer yaralanması derecesi, taburcu olması ve yaralanma mekanizması ile ALT ve AST değerleri arasında da istatistiki olarak anlamlı bir ilişki yoktu. Hastaların hiçbirinde ölüm olmadı. TARTIŞMA: Karaciğer yaralanmasının tanı ve tedavisinde son 25 beş yıl boyunca hayatta kalma süresini uzatan değişiklikler olmuştur. Cerrahi dışı yaklaşım hemodinamik olarak stabil olan karaciğer travmalı hastaların takip ve tedavisinde altın standart olarak görülmektedir. Anahtar sözcükler: Karaciğer; nonoperatif yaklaşım; travma. Ulus Travma Acil Cerr Derg 2014;20(2):97-100

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doi: 10.5505/tjtes.2014.20737

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ORIGIN A L A R T IC L E

Comparison of diagnostic peritoneal lavage and focused assessment by sonography in trauma as an adjunct to primary survey in torso trauma: a prospective randomized clinical trial Sunil Kumar, M.S., Abhay Kumar, M.S., Mohit Kumar Joshi, M.S., Vinita Rathi, M.D. Department of Surgery, University College of Medical Sciences, Delhi, India

ABSTRACT BACKGROUND: Lately, Focused Assessment with Sonography in Trauma (FAST) is preferred over diagnostic peritoneal lavage (DPL) as adjunct to primary survey. However, this is not evidence-based as there has been no randomized trial. METHODS: In this study, 200 consecutive torso trauma patients meeting inclusion criteria were randomized to undergo either DPL or FAST. The results were then compared with either contrast enhanced computerized tomography (CECT) (in patients managed non-operatively) or laparotomy findings (in patients undergoing operative treatment). Outcome parameters were: result of the test, therapeutic usefulness, role in diagnosing bowel injury and time taken to perform the procedure. RESULTS: Two hundred patients with a mean age of 28.3 years were studied, 98 in FAST and 102 in DPL group. 104 sustained blunt trauma and 76 sustained penetrating trauma due to stabbing. In addition, 38 (38.7%) were FAST positive and 48 (47%) were DPL positive (p=0.237, not significant). As a guide to therapeutically beneficial laparotomy, negative DPL was better than negative FAST. For non-operative decisions, positive FAST was significantly better than positive DPL. DPL was significantly better than FAST in detecting as well as not missing the bowel injuries. DPL took significantly more time than FAST to perform. CONCLUSION: This study shows that DPL is better than FAST. Key words: Diagnostic peritoneal lavage; focused assessment with sonography in trauma; torso trauma.

INTRODUCTION Physical examination of a patientâ&#x20AC;&#x2122;s abdomen with torso trauma is important but frequently unreliable for assessment of internal injuries due to the inaccessibility of pelvic region, upper abdominal and retroperitoneal organs to palpation, associated severe injuries,[1] and altered mental status consequent to head injury, drugs or alcohol.[2] To overcome this difficulty, several diagnostic modalities have been used as adjunct to

Address for correspondence: Dr. Mohit Kumar Joshi, C-1/1201, Olive County, Sec-5, Vasundhara 201012 Ghaziabad, UP, India Tel: +91120-6768837 E-mail: drmohitjoshi@gmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2014;20(2):101-106 doi: 10.5505/tjtes.2014.37336 Copyright 2014 TJTES

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the primary survey. These include focused assessment sonography in trauma (FAST), diagnostic peritoneal lavage (DPL), computed tomography (CT) scan and laparoscopy.[3] FAST has emerged as a useful diagnostic tool.[4-6] This limited ultrasound scan directed at detecting intra-peritoneal/pericardial fluid is economical, non-invasive, rapid, and repeatable.[7,8] The greatest advantages of FAST is that it can be done at bedside without disturbing resuscitation.[7] FAST has sensitivity between 80-85% and specificity of 97-100%. [9] However, it may not be accurate in obese patients, in patients with ileus, or subcutaneous emphysema. Further, it is an operator dependent technique and does not differentiate between blood and free bowel contents. On the other hand, DPL can differentiate between blood and free bowel contents. It is an invasive, rapid, accurate, bed-side procedure, and the most sensitive tool to determine presence of intra-abdominal injuries.[9] Even though it has low specificity, DPL has been shown to be more efficient than CT scan in identifying patients that require surgical exploration. [10] Like FAST a positive DPL does not necessarily mandate 101


Kumar et al. Comparison of DPL and FAST as an adjunct to primary survey in torso trauma

immediate laparotomy in a patient with stable hemodynamics.[11] However, unlike FAST this is non-repeatable, takes longer to perform, and alters subsequent physical examination of the abdomen. DPL may be contraindicated in patients with deranged coagulation profile, previous laparotomy, marked obesity, and advanced pregnancy. Thus, it appears that FAST and DPL may have their own relative merits and de-merits. The current trend to prefer FAST over DPL remains unjustified in the absence of any prospective randomized trial. We took this opportunity to compare these two diagnostic procedures, which is to our knowledge the first to investigate the specific attributes of FAST and DPL by conducting a randomized-clinical trial (RCT).

MATERIALS AND METHODS This prospective randomized clinical study was conducted from November 2009 to April 2012 in the Department of Surgery of a large volume tertiary care teaching hospital. The study was approved by the local ethical committee. Written informed consent for inclusion was obtained from patients or their family members (for minor and patients with altered sensorium). Criteria for exclusion in the study were: age younger than 12 years or more than 65 years, gun-shot wounds, patients with unstable hemodynamics, isolated penetrating abdominal trauma, clinical features of peritonitis at presentation, free gas under the diaphragm, impaled objects, prolapsed bowel, or omentum following penetrating injury, known coagulopathy/liver disease, previous abdominal surgery, morbid obesity, and patients denying consent for FAST or DPL. Remaining torso trauma patients were randomized using computer generated random number table to undergo either FAST (group A) or DPL (group B). All FAST exams were performed by the same surgeon (SK) throughout using 3.5 MHz convex transducer. Time taken to perform FAST examination was noted. All DPLs were done by the same surgeon (AK) throughout by an open technique using infraumbilical

midline 2-cm vertical incision. DPL was considered grossly positive if ≥10 ml of free blood, bile, or fecal matter was aspirated. Microscopically, presence of ≥100000/µl RBCs, ≥500 WBCs, vegetative matter or fecal content and bacteria (on gram staining) were considered as positive DPL. Time taken to perform DPL and complications, if any, were recorded in each patient. Thereafter, these patients were subjected to CECT scan of the abdomen, if required. Further treatment, operative or non-operative was decided based on a number of factors such as continuing blood loss, subsequent appearance of signs of peritonitis and free air on CECT abdomen. All the details were recorded in a predesigned proforma. Outcome parameters were result of the intervention-test, therapeutic usefulness, time taken to perform the intervention-test and role in diagnosing bowel injury. In addition, mortality and cause of death were also evaluated. Data was expressed as either mean (+SD) or percent, as per the need. Tests applied were 2 proportion Z-test and chi-square. Significance was taken at 5%.

RESULTS Two hundred fifty consecutive eligible patients with torso trauma were enrolled into this RCT, with equal number of patients in both groups. However, 27 FAST group patients were excused for various reasons such as post-randomization equipment failure and patient’s refusal for admission following initial treatment. Similarly, 23 DPL group patients were excused due to various reasons such as non-availability of DPL set, DPL being done by different surgeon and the use of local anesthesia without epinephrine. Therefore, 200 patients remained for analysis: 98 in FAST group and 102 in DPL. Mean age of the patients was 28.3 years. There were 186 males with a demographic profile of the patients depicted in Table 1. One hundred twenty four patients [road traffic injury (RTI)=62, fall from height=36, crush injury=12, blunt assault=06, industrial accident=06,

Table 1. Demographic parameters of study subjects Demographic parameter

DPL (n=102)

FAST (n=98)

Age range (yrs)

12-64

13-55

Mean age (±SD)

27.86 (±12.77)

28.78 (±11.07)

94:8

92:6

Male: Female ratio Mode of injury Blunt

62

62

Penetrating

40

36

DPL: Diagnostic peritoneal lavage; FAST: Focused assessment sonography in trauma; SD: Standard deviation.

102

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Kumar et al. Comparison of DPL and FAST as an adjunct to primary survey in torso trauma

train accident=02] sustained blunt trauma while remaining 76 sustained penetrating trauma due to stabs. Random group wise, FAST group (total n=98) had RTI (n=30), fall from height (n=14), stabs (n=36), crush injury (n=08), blunt assault (n=06), train accident (n=02) and industrial accident (n=02) as the causes of acute admission. Similarly, DPL group (total n=102) had RTI (n=32), fall from height (n=22), stabs (n=40), crush injury (n=04) and industrial accident (n=04) as the cause of acute admission. Eighty four patients underwent exploratory laparotomy; 36 had sustained stab injury and 48 had sustained blunt trauma. Thus, from blunt trauma category (n=124), 76 were managed non-operatively and 48 underwent laparotomy. Similarly, from penetrating trauma category (n=76), 40 patients were managed non-operatively and 36 underwent exploratory laparotomy. FAST was recorded as positive in 38 (38.7%) and DPL was re-

corded positive patients in 48 (47%) patients. This difference was not statistically significant (Table 2). The usefulness of FAST/DPL in guiding therapeutic decisions is shown in Table 3. A correct decision to operate was statistically similar when the results were positive. However, a negative DPL was significantly better than negative FAST in guiding for therapeutically beneficial laparotomy. Results were comparable for positive as well negative DPL or FAST when the patient underwent negative laparotomy or therapeutically non-beneficial but positive laparotomy. A positive FAST was significantly better than positive DPL in taking non-operative decisions. A negative FAST or DPL were comparable in guiding for non-operative treatment. Bowel injury was found in 42 patients: 22 of these were in FAST group and 20 were in DPL group. Twelve of 22 patients in FAST group were test positive as against 18 from 20 in DPL group. Similarly, 10 of 22 from FAST group were test

Table 2. Results of the intervention test Test result

Focused assessment sonography in trauma (n=98)

Positive

Diagnostic peritoneal lavage (n=102)

38

p

48 0.237

Negative 60

(Not significant)

54

Table 3. Therapeutic usefulness of FAST and DPL

FAST DPL p FAST DPL p (n=98) (n=102) (n=98) (n=102)

Positive Negative (n=38) (n=48)

Therapeutically beneficial

24^ (04)#

Positive Negative (n=60) (n=54)

38^ (08)# Z=1.61 10~

02~~ Z=2.25

(positive) laparotomy p>0.05 p<0.05 (NS) (SIG) Negative laparatomy

0

0

02*(02)# 04* Z=0.97

p>0.05 (NS) Therapeutically

0

04** Z=1.82 0

0

non-beneficial p>0.05 (positive) laparotomy Conservative

14

06

(NS) Z=2.65

48 (02)# 48 Z=1.3

management p<0.05 p>0.05 (SIG) (NS) #: Died (total deaths = 16; eight from FAST and eight from DPL); *: Laparotomy on progressive deterioration of patient proved to be entirely due to pelvic trauma; **: Though laparotomy revealed intraperitoneal solid viscus injuries, bleeding had stopped and thus laparotomy could have been avoided; ~: False negative FAST: could be because of early presentation, suboptimal test-skill or true handicap of the FAST. ~~: False negative DPL: could be because of early presentation or true handicap of the DPL. ^Represents true positive: comparable.

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Kumar et al. Comparison of DPL and FAST as an adjunct to primary survey in torso trauma

Table 4. Test results as against the bowel injury

Bowel injury (n=42)

p

FAST DPL

Positive

12

18

Negative

10 02

0.011 (sig)

FAST: Focused assessment sonography in trauma; DPL: Diagnostic peritoneal lavage.

Table 5. Mortality (n=16)

Blunt trauma

Penetrating trauma

Laparotomy 12^ Non-operative 02**

02* 0

^: 04 FAST positive and 08 DPL positive; *: FAST positive; **: FAST negative.

negative and only two of 20 were test negative in DPL group. Therefore, DPL was significantly better than FAST in detecting bowel injuries (Table 4). Fourteen patients died postoperatively, and two died on nonoperative management (total deaths 16). Fourteen belonged to blunt trauma group, and two belonged to penetrating injury group (Table 5). Operative or autopsy findings in these patients are shown in Table 6.

Eight were from FAST group. Six FAST positive patients underwent laparotomy that was justified due to the extensive intraperitoneal injuries; however, these patients died of postoperative morbidity (respiratory failure, sepsis and fat-embolism). Two were FAST negative and died of pelvic trauma and consequent hemorrhagic shock. Intra-peritoneal injuries were ruled out by autopsy in both patients. A total of eight patients died in the DPL group and all were DPL positive and underwent laparotomy. Two of these had extensive retroperitoneal hematoma from pelvic fracture resulting in the DPL being positive association. Four patients were DPL positive for bowel contents. Two laparotomy patients were found to have small bowel perforation with gangrene while other two had gastric perforation and also underwent laparotomy. The remaining two patients underwent perihepatic packing but both died of continuing retroperitoneal blood loss from pelvic fracture; laparotomy was justified in these two patients too.

Time Taken To Perform DPL and FAST Mean time taken to perform FAST and DPL was 2.53Âą0.52 and 12.19Âą2.49 minutes, respectively. The difference was statistically significant (p<0.001). There were no complication or technical difficulties attributable to DPL in any of 102 patients undergoing DPL.

DISCUSSION As per the Advanced Trauma Life Support (ATLS) protocol, initial assessment of multiply injured patients involves clinical

Table 6. Operative findings and possible cause of death (n=16) No

Group

Injury

Time of death

Findings

1

FAST+

Penetrating

12 days Post-op

Multiple gastric and colonic perforations

2

DPL+

Blunt

03 days post-op

Pelvic fracture, hemo-pneumothorax

3

DPL+

Blunt

04 days Post-op

Gastric perforation, liver laceration

4

FAST-

Blunt

6 hour post-injury

Pelvic fracture, pneumothorax

5

FAST+

Blunt

03 day post-op

Pelvic fracture, mesenteric tear, bowel contusion

6

FAST+

Penetrating

17 days post-op

Multiple bowel lacerations, diaphragm injury

7

DPL+

Blunt

05 days post-op

Pelvic fracture, bowel perforation

8

DPL+

Blunt

03 days post-op

Liver laceration, head injury

9

FAST+

Blunt

10 days pot-op

Liver and spleen laceration, retroperitoneal hematoma

10

DPL+

Blunt

02 days pot-op

Duodenal and pancreatic injury

11

FAST-

Blunt

13 hour post-injury

Pelvic fracture, bowel injury, suspected cardiac contusion

12

DPL+

Blunt

03 days post-op

Liver laceration, bowel injury, pneumpothorax

13

DPL+

Blunt

04 days post-op

Pelvic fracture, hemothorax, flail chest

14

FAST+

Blunt

02 days post-op

Bowel injury, mesenteric tear, splenic laceration

15

DPL+

Blunt

02 days post-op

Liver laceration, IVC tear, shattered kidney

16

FAST+

Blunt

03 days post-op

Bowel injury, pulmonary contusion

DPL: Diagnostic peritoneal lavage; FAST: Focused assessment sonography in trauma.

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Kumar et al. Comparison of DPL and FAST as an adjunct to primary survey in torso trauma

evaluation by ABCDE approach along with use of adjuncts such as chest and pelvis X-Ray, FAST or DPL. Later, especially if immediate surgery is not warranted patients may be subjected to CT scan, laparoscopy, or observation.[3] CT scan, useful in detecting otherwise occult injuries to both intra and retroperitoneal structures, has a high accuracy (about 95%) and a very high negative predictive value (almost 100%).[12] FAST and DPL are bedside, economical, and rapid means of evaluation of trauma patients. Their greatest advantage lies in the fact that these do not interfere with ongoing resuscitation of the patient.[7] There are relative merits and demerits to these two adjuncts. However, we believe that DPL offers several advantages over FAST such as no need for USG machine and trained man-power to perform and interpret the result, and its ability to differentiate blood and bowel contents which is not possible with FAST.[13] Therefore, the declining role of DPL should be re-evaluated especially since our novel evidence demonstrates a convincing role for DPL as a superior technique to the FAST procedure in determination of blunt trauma. In this large RCT, we used 200 patients to investigate and compare the role of FAST and DPL in the management of truncal trauma. Most of our patients were males and young. This is consistent with the fact that young males are at the greatest risk of injuries. In our study, stabs constituted the single most common type of injury followed by RTI and fall from a height. To the best of our knowledge, this is the only study wherein this large number of stabbed patients has been studied. Further, in this study more than 50% of stabbed patients were managed non-operatively successfully. This proves that selective non-operative management of stab-abdomen is as successful as that following blunt trauma. We feel that this was possible due to a diligent clinical approach and appropriate use of FAST and/or DPL. In this study, instead of studying the traditional parameters like sensitivity and specificity, and true positive and true negative values we studied and compared the role of FAST and DPL in taking decisions for laparotomy and conservative management. We feel that is is where the exact role of these investigations lies. On this parameter, positive FAST and DPL were comparable to each other in guiding the surgeon to therapeutically beneficial laparotomy. However, the fact that therapeutically beneficial laparotomy was performed in significantly larger number of patients with negative FAST than in situations with negative DPL indicates that overall, DPL is better than FAST in regulating therapeutically beneficial laparotomy. However, a positive FAST was a better determinant of successful non-operative management as compared to the positive DPL. A negative FAST or DPL was inferior to positive test results for dictating a successful non-operative management, but comparably so. For the remaining therapeutic outcomes (like negative laparotomy and therapeutically non-beneficial laparotomy) the results of FAST as well as DPL were comparable. Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2

Further, in comparison to FAST, DPL proved to be significantly better in detecting bowel injuries. Also, fewer bowel injuries were missed by DPL as compared to FAST. Collectively, this suggests that since bowel injuries are common in blunt as well as penetrating trauma scenarios, the surgeon must keep the DPL as one of the important adjunct to primary survey. DPL can be a useful tool in the impact mortality ratio by detecting bowel injuries early. Overall, 16 patients died. Six of these were FAST (true) positive, two FAST (true) negative and six were DPL (true) positive and two DPL (false) positive. Deaths in true positive DPL or FAST signifies ongoing bleeding and need to control the same to prevent an immediate death or late death on account of shock related complications. Two true negative FAST patients died of pelvic trauma, again highlighting the importance of arresting the ongoing bleeding. We had fewer deaths in penetrating trauma than the blunt trauma. This is definitely related to the promptness with which we handled our penetrating trauma patients, in contrast to the blunt trauma where it is not uncommon to miss intra-abdominal injuries. These results are a mandate to be extra-vigilant in blunt trauma patients. A trained surgeon performed the FAST in this study. This has become an acceptable practice as the accuracy of surgeon and radiologist performed emergency ultrasonography has been shown to be comparable and high.[14,15] Furthermore, both can perform comparable quality of FAST in comparable time.[16] Our study too confirms that trained surgeons can reliably perform FAST. There is little doubt that DPL continues to be a reliable diagnostic adjunct in torso trauma, with 95.9% sensitivity, 99% specificity and 98.2% accuracy.[17]

Conclusions Although DPL requires significantly more time to perform, it is better than FAST as an adjunct for the initial assessment of a patient suspected to be having intra-abdominal injury. Conflict of interest: None declared.

REFERENCES 1. Rozycki GS, Root HD. The diagnosis of intraabdominal visceral injury. J Trauma 2010;68:1019-23. 2. Hoff WS, Holevar M, Nagy KK, Patterson L, Young JS, Arrillaga A, et al. Practice management guidelines for the evaluation of blunt abdominal trauma: the East practice management guidelines work group. J Trauma 2002;53:602-15. 3. Feliciano DV. Diagnostic modalities in abdominal trauma. Peritoneal lavage, ultrasonography, computed tomography scanning, and arteriography. Surg Clin North Am 1991;71:241-56. 4. Byars D, Devine A, Maples C, Yeats A, Greene K. Physical examination combined with focused assessment with sonography for trauma examination to clear hemodynamically stable blunt abdominal trauma patients. Am J Emerg Med 2013;31:1527-8.

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Kumar et al. Comparison of DPL and FAST as an adjunct to primary survey in torso trauma 5. Sheng AY, Dalziel P, Liteplo AS, Fagenholz P, Noble VE. Focused Assessment with Sonography in Trauma and Abdominal Computed Tomography Utilization in Adult Trauma Patients: Trends over the Last Decade. Emerg Med Int 2013;2013:678380. 6. Kirkpatrick AW, Ball CG, D’Amours SK, Zygun D. Acute resuscitation of the unstable adult trauma patient: bedside diagnosis and therapy. Can J Surg 2008;51:57-69. 7. Radwan MM, Abu-Zidan FM. Focussed Assessment Sonograph Trauma (FAST) and CT scan in blunt abdominal trauma: surgeon’s perspective. Afr Health Sci 2006;6:187-90. 8. Smith J. Focused assessment with sonography in trauma (FAST): should its role be reconsidered? Postgrad Med J 2010;86:285-91. 9. Amer MS, Ashraf M. Role of FAST and DPL in assessment of blunt abdominal trauma. Prof Med J 2008;15:200-4. 10. Day AC, Rankin N, Charlesworth P. Diagnostic peritoneal lavage: integration with clinical information to improve diagnostic performance. J Trauma 1992;32:52-7. 11. Blow O, Bassam D, Butler K, Cephas GA, Brady W, Young JS. Speed and efficiency in the resuscitation of blunt trauma patients with multiple

12. 13.

14.

15.

16.

17.

injuries: the advantage of diagnostic peritoneal lavage over abdominal computerized tomography. J Trauma 1998;44:287-90. Stapp JP. Human tolerance to deceleration. Am J Surg 1957;93:73440. Henneman PL, Marx JA, Moore EE, Cantrill SV, Ammons LA. Diagnostic peritoneal lavage: accuracy in predicting necessary laparotomy following blunt and penetrating trauma. J Trauma 1990;30:1345-55. McKenney MG, McKenney KL, Compton RP, Namias N, Fernandez L, Levi D, et al. Can surgeons evaluate emergency ultrasound scans for blunt abdominal trauma? J Trauma 1998;44:649-53. Thourani VH, Pettitt BJ, Schmidt JA, Cooper WA, Rozycki GS. Validation of surgeon-performed emergency abdominal ultrasonography in pediatric trauma patients. J Pediatr Surg 1998;33:322-8. Velmahos GC, Demetriades D, Stewart M, Cornwell EE 3rd, Asensio J, Belzberg H, et al. Open versus closed diagnostic peritoneal lavage: a comparison on safety, rapidity, efficacy. J R Coll Surg Edinb 1998;43:235-8. Meyer DM, Thal ER, Weigelt JA, Redman HC. Evaluation of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma 1989;29:1168-72.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Travma olayında vücut travmasında birincil araştırmaya ek olarak tanısal periton lavaj (DPL) sıvısı ile travmaya odaklanmış ultrasonografi değerlendirmesinin (FAST) karşılaştırması: Bir prospektif randomize klinik çalışma Dr. Sunil Kumar, Dr. Abhay Kumar, Dr. Mohit Kumar Joshi, Dr. Vinita Rathi Tıp Bilimleri Üniversite Koleji, Cerrahi Bölümü, Delhi, Hindistan

AMAÇ: Son zamanlarda birincil araştırmaya ek olarak tanısal periton lavajına (DPL) göre travmaya odaklanmış ultrasonografi değerlendirmesi (FAST) tercih edilmektedir. Ancak herhangi bir randomize çalışma olmadığından kanıtlara dayalı bir bulgu değildir. GEREÇ VE YÖNTEM: Çalışmaya dahil edilme kriterlerini karşılayan 200 ardışık beden travması hastası ya DPL, ya da FAST’ye randomize edildi. Sonuçlar daha sonra ya kontrastla güçlendirilmiş bilgisayarlı tomografi (BT) (cerrahi dışı yöntemlerle tedavi edilen hastalar) veya laparotomi (cerrahi tedavi geçiren hastalar) bulgularıyla karşılaştırıldı. Sonuç parametreleri: Test sonucu, tedavinin yararlılığı, bağırsak yaralanmasının tanısındaki rolü ve prosedürü uygulamak için geçen zaman idi. BULGULAR: Yaş ortalaması 28.3 yıl olan, FAST grubunda 98 ve DPL grubunda 102 kişi olmak üzere 200 hasta incelendi. Yüz dört kişi künt travmaya, 76 kişi bıçaklanma sonucu delici travmaya maruz kalmış olup 38’i (%38.7) FAST ve 48’i (%47) DPL pozitif idi (p=0.237, anlamlı değil). Tedavi olarak yararlı laparotomiye kılavuz olma açısından negatif DPL, negatif FAST’tan daha iyi idi. Cerrahi dışı kararlar için pozitif FAST, pozitif DPL’den anlamlı derecede daha iyi idi. Bağırsak yaralanmalarının tespiti ve atlanmaması açısından DPL, FAST’den daha iyi idi. DPL’yi uygulama, FAST’yi uygulamaya göre anlamlı derecede daha fazla zaman almıştı. TARTIŞMA: Bu çalışma, DPL’nin FAST’den daha iyi olduğunu göstermektedir. Anahtar sözcükler: Tanısal periton lavajı; travmaya odaklanmış ultrasonografi değerlendirmesi; beden travması.ı. Ulus Travma Acil Cerr Derg 2014;20(2):101-106

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doi: 10.5505/tjtes.2014.37336

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ORIGIN A L A R T IC L E

Are the neutrophil-lymphocyte ratio and platelet-lymphocyte ratio as effective for predicting the number of debridements in Fournier’s gangrene as Fournier’s gangrene severity index? Şahin Kahramanca, M.D.,1 Oskay Kaya, M.D.,2 Gülay Özgehan, M.D.,2 Burak İrem, M.D.,2 İbrahim Dural, M.D.,2 Tevfik Küçükpınar, M.D.,2 Hülagü Kargıcı, M.D.2 1

Department of General Surgery, Kars State Hospital Ministry of Health, Kars;

2

Department of General Surgery, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara

ABSTRACT BACKGROUND: Fournier’s gangrene (FG) is a rapidly progressive and necrotizing infection of the subcutaneous and fascial tissues with a high mortality rate. In the present study, we aimed to investigate prognostic factors and analyze the outcomes of 68 patients in a tertiary reference hospital. METHODS: Patients admitted to the emergency department were investigated retrospectively between January 2006 and January 2013 and divided into two groups. The patients in Group I (G1) required one debridement, and Group II (G2) patients required more than one. Patient demographic and clinical characteristics were encoded. Fournier’s Gangrene Severity Index (FGSI) scores, neutrophillymphocyte ratios (NLR), and platelet-lymphocyte ratios (PLR) were calculated. Prognostic factors were compared between the groups. RESULTS: There were no statistically significant differences between the groups in terms of mean age, female-male ratio, or duration of symptoms on admission; however, there were more infection sources, predisposal factors, and positive culture results in G2. Additionally, hospital stay, total cost, and mortality rate values were high in G2. We found statistically higher NLR and PLR ratios in G2, but there was no significant difference in FGSI scores between the groups. CONCLUSION: The FGSI scoring system was not found to be valuable in determining prognosis. However, NLR and PLR were valuable, and previous use of NLR and PLR for determining Fournier’s gangrene prognosis could not be found in the English literature. Key words: Fournier’s gangrene; neutrophil-lymphocyte ratio; platelet-lymphocyte ratio; prognostic factor.

INTRODUCTION Fournier’s gangrene (FG) is an acute and rapidly progressive polymicrobial inflammatory process. Generally known as necrotizing fasciitis, it affects the subcutaneous and fascial structures on perianal, perineal, and/or genitourinary regions.[1] It is named for Jean Alfred Fournier, a Parisian

Address for correspondence: Şahin Kahramanca, M.D. Kars Devlet Hastanesi, Genel Cerrahi Kliniği, Kars, Turkey Tel: +90 474 - 225 10 18 E-mail: drkahramancasahin@gmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2014;20(2):107-112 doi: 10.5505/tjtes.2014.62829 Copyright 2014 TJTES

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dermatologist and venereologist. He presented a young man with perineal gangrene in a lecture in 1883. However, Bourienne in 1764 and Avicenna in 1877 originally described the same disease.[2] The main principals of therapy are aggressive debridement, effective antibiotic use, and supportive drugs. Unfortunately, FG still has a high mortality rate despite advances in antimicrobial drugs, surgical techniques, and intensive care facilities. In the largest series, the mortality rate was reported as 16-30%.[2-5] The disease predominantly affects adult males but also occurs in females and at every age, even in children with similar patterns.[6-8] There have been many efforts to find valuable prognostic criteria in the literature.[9-11] However, we did not find use of the neutrophil-lymphocyte ratio (NLR) and the platelet-lymphocyte ratio (PLR) in the English literature. We aimed to investigate the factors affecting the number of debridements, mortality rate, and cost, as well as the relationship between NLR, PLR, and prognosis. 107


Kahramanca et al. Predicting the number of debridements in Fournier’s gangrene

MATERIALS AND METHODS After the approval of the local institution’s ethics committee, patients admitted to the emergency department were investigated retrospectively between January 2006 and January 2013. The patients had perineal, genitourinary, or perianal symptoms, such as pain, swelling, and discharge, and were diagnosed with FG and operated on after general surgery consultations. The study hospital, a tertiary referral center, is considered the top site for trauma and emergency surgery in the city. After admission, patients’ oral intake was stopped and intravenous fluids, proper broad spectrum antibiotics, and other supportive additives were administered. Serious cases were transferred to the intensive care unit, where medicalsurgical interventions were performed. All of the patients’ operations were performed by one of five surgeons who had been working together since 1992 and had been educated with the same surgical notion. Information was missing from the files of nine patients, so they were excluded from the study. For the 68 patients included in the study, full background information was obtained from the hospital database. Age, gender, origin of the infection, duration between the beginning of the symptoms and admission, and predisposal factors, such as diabetes mellitus, number of debridements, need for protective ostomy, bacteriologic results of wound cultures, routine laboratory test results, NLRs, PLRs, Fournier Gangrene Severity Index (FGSI) scores on admission, mortality rates, and total costs, were encoded. The patients were divided into two groups: Group I (G1) included patients who needed one debridement, and Group II (G2) included patients who needed more than one. Wound and tissue cultures were obtained surgically from each patient.

Statistical Analysis

53.13±15.36 years, and the female-to-male ratio was 5:12. There were 15 (22.06%) patients older than 65 who were categorized in the geriatric patient group. From admission, the mean duration of symptoms was 5.93±4.54 days. Infection sources were identified in 18 (26.47%) cases. There were 10 perianal abscesses: two fistulas, one rectal malignancy, four anorectal injuries, two urogenital infections, and one gynecological operation in the patient series (Table 1). Predisposal factors included 22 (32.35%) patients with a diabetes mellitus (DM) history and one patient with an immunosuppressant condition due to chemotherapy. Wound and tissue cultures were positive for only 20 (29.41%) patients. Thirteen Escherichia coli sources, 4 Acinetobacter sources, 2 methicillin resistant Staphylococcus aureus (MRSA) sources, and 1 Candida source were found (Table 2). One patient required orchiectomy and penectomy, and two patients were treated with vacuum-assisted devices (VAC) in addition to debridement. Debridement of the skin, subcutaneous tissue, and superficial fascia was performed in 33 (48.53%) patients, but 35 (51.47%) cases underwent debridement of deeper tissue. Fifteen (22.06%) patients required colostomy for wound protection from fecal material. The procedure was performed at the time of first debridement for each patient. The mean cost was 8376±9627 Turkish Liras (TL) per patient. Five patients in G2 died; the mortality rate was 7.35%. The mean age of the five patients was 60.2 ± 19.07 years, and the mean age of the surviving patients was 52.57±15.07 years. The difference

Table 1. Origins of infection in Fournier’s gangrene cases None 50 Perianal abscesses – fistula

10

Rectal cancer

1

Anorectal injury

4

Data analysis was performed using SPSS for Windows, version 17.0 (SPSS Inc., Chicago, IL, United States). The Shapiro Wilk test was used to test the distributions of continuous variables for normality. Descriptive statistics for continuous data are shown as mean ± standard deviation or median (minimummaximum), as applicable. Categorical data are shown as numbers and percentiles. The differences between groups were compared using Student’s t test for means and the MannWhitney U-test for medians. Categorical data were analyzed using Pearson’s chi-square or Fisher’s exact test, as appropriate. Degrees of association among continuous variables were evaluated using Spearman’s Correlation analysis. A p value less than 0.05 was considered statistically significant. The cut-off values of parameters for discrimination between the groups were determined using ROC analysis. For each value, the sensitivity and specificity for each outcome under study.

Urogenital infection

2

Gynecological operation

1

RESULTS

Candida 1

The mean age and standard deviation of the 68 patients were 108

Total 68

Table 2. Culture results Isolated and produced types of Number of microorganisms cultures None 48 Escherichia coli 13 Acinetobacter 4 Methicillin resistant Staphylococcus aureus 2 (MRSA) Total 68

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Kahramanca et al. Predicting the number of debridements in Fournier’s gangrene

Table 3. Patient characteristics Patient characteristics

n

Patients (total number)

%

Mean±SD

68

Female/male ratio

20/48

42

Mean age (years)

53.13±15.36

Geriatric patients (older than 65 years)

15

22

Patients with known sources

18

27

Patients with diabetes mellitus histories

22

32

Patients with positive cultures

20

29

Mean hospital stay (days)

15.37±14.05

Mean cost (Turkish Lira)

8376±9627

Mortality rate

5/68

7

Table 4. Comparison of parameters between group I (only one debridement) and group II (more than one debridement) Parameter Number of patients

Group I

Group II

27

41

p

Female/male ratio

6/21

14/27

0.291

Mean age (years)

51.33±16.05

54.32±14.96

0.437

Patients with known sources

3

15

0.020

Patients with diabetes mellitus histories

4

18

0.012

6.33±3.60

5.66±5.10

0.128

3

17

0.007

Mean duration of symptoms (days) Positive cultures Mean hospital stay (days)

6.78±6.71

21.02±14.79

<0.001

Mean cost (Turkish lira)

3502.93±3337.32

11585.71±11019.69

<0.001

Mean Fournier Severity Index Score

2.22±1.58

3.07±2.18

0.121

Neutrophil-lymphocyte ratio

7.69±10.63

14.48±9.30

<0.001

182.45±162.68

304.44±200.82

<0.001

Platelet-lymphocyte ratio

was not statistically significant (p=0.288). Patient characteristics are shown in Table 3.

had longer hospital stays and higher health expenditures (p values <0.001; Table 4).

In G1 and G2, the female-to-male ratios were 2:7 and 14:27, respectively, and there was no statistical difference between the groups (p=0.291). The mean ages were 51.33±16.05 years and 54.32±14.96 years, respectively, a difference that was not significant (p=0.437). DM history was detected in 4 of 27 patients in G1 and in 18 of 41 patients in G2, a statistically significant difference (p=0.012). In G2, the source of infection was apparent in a significantly higher number of patients (p=0.020). Positive culture ratios were high in G2 (p=0.007). There was no significant difference between the groups in duration of symptoms on admission (p=0.128). FGSIs were higher in G2 than in G1, but there was no statistically significant difference between the groups (p=0.121). G2 patients

To predict debridement numbers, the NLRs and PLRs were calculated; the ratios were statistically higher in G2 compared to G1 (p<0.001). Cut-off values were calculated using ROC curve analysis for NLR and PLR, and were 8.595 and 198.1, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value for NLR were 70.73%, 70.37%, 78.38%, and 61.29%, respectively. The same values for PLR were 75.61%, 74.07%, 81.85%, and 66.67%, respectively. Higher NLR and PLR values were significantly associated with higher fecal ostomy rate (p=0.002 and p=0.038, respectively). Culture positive patients had significantly higher NLR and PLR levels than culture negative cases on admission (p=0.001 and p=0.022, respectively). FGSI scores

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Kahramanca et al. Predicting the number of debridements in Fournier’s gangrene

and the need for preventive ostomy were not statistically correlated (p=0.234).

DISCUSSION Fournier’s gangrene is an aggressive clinical condition that affects subcutaneous and fascial tissues on perianal, perineal, and/or genitourinary areas and causes severe necrosis. Fournier’s gangrene has been known since the 18th century. The disease may affect all ages and both genders but predominantly strikes adult males.[1-3] In our series, there were 68 patients with a median age of 53 years, 58% of whom were male and 22% of whom were older than 65 years. Old age itself is not a predisposing factor, but those with poor self-care and poor nutritional status are more susceptible to the disease and have a poor prognosis.[12] In the present study, no difference in prognosis was observed in the older patient group. Five patients died during the study. The mean age of these patients was higher than of the survived patients, but the difference was not statistically significant because the number who died was small (p=0.288). The characteristic feature of the disease is polymicrobial and synergistic infection. Pathophysiology is probably triggered with endarteritis obliterans and microthrombosis of small vessels in the subcutaneous tissues.[13,14] Collagenase and heparinase produced by anaerobes, combined with platelet aggregation and complement fixation induced by aerobes, causes microvascular thrombosis with subsequent dermal necrosis. Hyaluronidase, streptokinase, and streptodornase produced by Streptococcus and Staphylococcus contribute to tissue damage.[6] Our study was limited by the lower rate of culture positive patients. Surgery under emergency conditions and the necessity of beginning broad spectrum antibiotics early without first being able to obtain a culture were the probable reasons. Microorganisms were produced in 20 (29.41%) cases, the majority of which were E. coli. The clinical presentation of Fournier’s gangrene changes from obscure onset and slow progression to rapid onset and fulminant course. Tissue necrosis can progress as fast as 2 cm per hour.[13,15,16] Thus, early intervention is very important and life-saving. Our mortality rate (7%) was lower than the literature average of 16-30%.[2-5] Our hospital is an accepted trauma and urgent surgery tertiary care center. Patients who apply under urgent conditions and are found to have indications for urgent operation immediately undergo surgery. Depending upon the degree of progression, the skin may be normal, red, or shiny in appearance or may show evidence of ecchymosis, crepitus, or gangrene.[17] The spread of infection is along the fascial planes and is usually limited by the attachment of the Colles’ fascia in the perineum. Deeper infection that extends below the fascial layers causing myonecrosis is not generally thought of as classical Fournier’s gangrene, 110

although it has been described. When performing debridement, care must be taken not to accidentally open deeper fascial planes that were not initially involved.[2,4] In our series, debridement was performed at the skin, subcutaneous tissue, and superficial fascia level in 33 (48.53%) patients but deeper in 35 (51.47%) cases. Testicular involvement is rare in FG. Testicles are usually spared as their blood supplies originate intra-abdominally. Testicular involvement indicates retroperitoneal origin or spread of infection.[2,4] We had only one case that required orchiectomy and penectomy. Usually scrotal skin and subcutaneous tissues over the testes are excised during the debridement procedure, and testes are placed into the inguinal subcutaneous areas after healing.[14] Initially, FG was defined as an idiopathic entity, but the sources of infection are known in the vast majority of cases today. In most series, they are categorized into four groups to determine origin: anorectal, genitourinary, dermatologic, and idiopathic.[2,4,15] In our series, there were 15 anorectal and 3 genitourinary origins. Many predisposal factors have been documented in the literature. DM is the most mentioned factor, affecting up to 70% of patients in a series. Alcohol abuse, smoking, and immunocompromised status have also been reported.[6,18] Hyperglycemia has been found to affect adherence, chemotaxis, and bactericidal activities of phagocytes. It has also been shown to have detrimental effects on cellular immunity.[14,18] In the present series, there were 22 (32.35%) diabetic patients and one immunosuppressed patient, due to chemotherapy. Fecal and/or urinary diversion procedures should be undertaken for prevention against additional contamination of debridement areas. In a study of 37 patients with FG of the anorectal region, a preventive colostomy was found necessary for 19 patients.[18] Special silicone catheters, such as the Flexi-seal Fecal Management System (FMS, ConvaTec, USA), can be used for this purpose.[4] Fifteen (22.06%) of our patients required colostomy, and the procedure was performed during the first debridement. Currently, VAC devices are widely used in FG cases. VAC devices support the reduction of edema and can increase fibroblast migration and cell proliferation, improving clinical outcome.[2,4,17] In the current study, this technique was used in two cases. In addition, topical wound care agents, such as honey and hyperbaric oxygen therapy, are among more recent alternatives.[17] We have had no experience with honey or hyperbaric oxygen. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) is a robust laboratory measurement score capable of determining even clinically early cases of necrotizing fasciitis.[9] FGSI scores were determined according to the Acute Physiology and Chronic Health Evaluation score (APACHE II) Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2


Kahramanca et al. Predicting the number of debridements in Fournier’s gangrene

developed by Laor and colleagues in 1995.[10] They reported that a severity index above 9 indicates a 75% mortality probability, while a score under 9 indicates a 78% survival probability. This scoring system is widely used in the literature, and there are many studies supporting these results.[13-15,19] However, a study by Sallami et al. reported the opposite results.[20] Yilmazlar et al.[11] modified this scoring system and added two parameters: dissemination degree and age scores. In a study of 36 cases, the factors affecting the number of debridements in FG were investigated. The study found no significant differences between the clinical data of patients who required single and multiple debridement sessions; however, FGSI was found to be useful in deciding on repeated procedures.[16] In the present study, original FGSI scores were used. Patients were divided into two groups, and the multiple debridement group was determined to have higher FGSI scores than the single debridement group. Similar correlations between FGSI scores and hospital stay durations, and between FGSI scores and total expenditures were also found. The five patients who died had higher FGSI scores than those who survived. NLR and PLR were used to predict the prognoses of patients with different inflammatory and ischemic events in the literature.[21-23] However, we did not find use of these parameters for determining prognosis in cases of FG in the English literature. In our study, we identified strong correlations between these parameters and the prognosis of the disease. High NLR and PLR values were associated with statistically significant increases in the number of debridements, hospital stay duration, cost, and mortality rate.

Conclusion FG is still a disease with a high rate of mortality. Early and effective treatment is as essential as early diagnosis. Estimation of poor prognosis is possible with calculated FGSI scores and NLR and PLR values. If these values are found to be high, it is possible to inform the patient and relatives about clinical course and outcome. Conflict of interest: None declared.

REFERENCES 1. Morpurgo E, Galandiuk S. Fournier’s gangrene. Surg Clin North Am 2002;82:1213-24. 2. Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I, Mammen K. Fournier’s gangrene and its emergency management. Postgrad Med J 2006;82:516-9. 3. Eke N. Fournier’s gangrene: a review of 1726 cases. Br J Surg 2000;87:718-28. 4. Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS. Fournier’s Gangrene: Current Practices. ISRN Surg 2012;2012:942437. 5. Sorensen MD, Krieger JN, Rivara FP, Klein MB, Wessells H. Fournier’s gangrene: management and mortality predictors in a population based study. J Urol 2009;182:2742-7. 6. Liang SG, Chen HH, Lin SE, Chang CL, Lu CC, Hu WH. Fourni-

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er’s gangrene in female patients. J Soc Colon Rectal Surgeon (Taiwan) 2008;19:57-61. 7. Nakatani H, Hamada S, Okanoue T, Kawamura A, Chikai T, Yamamoto S, et al. Fournier’s gangrene in elderly patient: report of a case. J Med Invest 2011;58:255-8. 8. Ekingen G, Isken T, Agir H, Oncel S, Günlemez A. Fournier’s gangrene in childhood: a report of 3 infant patients. J Pediatr Surg 2008;43:e3942. 9. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 2004;32:1535-41. 10. Laor E, Palmer LS, Tolia BM, Reid RE, Winter HI. Outcome prediction in patients with Fournier’s gangrene. J Urol 1995;154:89-92. 11. Yilmazlar T, Ozturk E, Alsoy A, Ozguc H. Necrotizing soft tissue infections: APACHE II score, dissemination, and survival. World J Surg 2007;31:1858-62. 12. Yeniyol CO, Suelozgen T, Arslan M, Ayder AR. Fournier’s gangrene: experience with 25 patients and use of Fournier’s gangrene severity index score. Urology 2004;64:218-22. 13. J. Gutiérrez-Ochoa, HH. Castillo-de Lira, RF. Velázquez-Macías, M. Landa-Soler, MA. Robles-Scott. Utilidad del índice de gravedad en la Gangrena de Fournier. Estudio comparativo Usefulness of Fournier’s gangrene severity index: a comparative study. Rev Mex Urol 2010;70: 27-30 14. Canbaz H, Cağlikülekçi M, Altun U, Dirlik M, Türkmenoğlu O, Taşdelen B, et al. Fournier’s gangrene: analysis of risk factors affecting the prognosis and cost of therapy in 18 cases. Ulus Travma Acil Cerrahi Derg 2010;16:71-6. 15. Altarac S, Katušin D, Crnica S, Papeš D, Rajković Z, Arslani N. Fournier’s gangrene: etiology and outcome analysis of 41 patients. Urol Int 2012;88:289-93. 16. Göktaş C, Yıldırım M, Horuz R, Faydacı G, Akça O, Cetinel CA. Factors affecting the number of debridements in Fournier’s gangrene: our results in 36 cases. Ulus Travma Acil Cerrahi Derg 2012;18:43-8. 17. Zagli G, Cianchi G, Degl’innocenti S, Parodo J, Bonetti L, Prosperi P, et al. Treatment of Fournier’s Gangrene with Combination of VacuumAssisted Closure Therapy, Hyperbaric Oxygen Therapy, and Protective Colostomy. Case Rep Anesthesiol 2011;2011:430983. 18. Akcan A, Sözüer E, Akyildiz H, Yilmaz N, Küçük C, Ok E. Necessity of preventive colostomy for Fournier’s gangrene of the anorectal region. Ulus Travma Acil Cerrahi Derg 2009;15:342-6. 19. Unalp HR, Kamer E, Derici H, Atahan K, Balci U, Demirdoven C, et al. Fournier’s gangrene: evaluation of 68 patients and analysis of prognostic variables. J Postgrad Med 2008;54:102-5. 20. Sallami S, Maalla R, Gammoudi A, Ben Jdidia G, Tarhouni L, Horchani A. Fournier’s gangrene : what are the prognostic factors? Our experience with 40 patients. Tunis Med 2012 Oct;90(10):708-14. 21. Azab B, Shah N, Akerman M, McGinn JT Jr. Value of platelet/lymphocyte ratio as a predictor of all-cause mortality after non-ST-elevation myocardial infarction. J Thromb Thrombolysis 2012;34:326-34. 22. Turkmen K, Erdur FM, Ozcicek F, Ozcicek A, Akbas EM, Ozbicer A, et al. Platelet-to-lymphocyte ratio better predicts inflammation than neutrophil-to-lymphocyte ratio in end-stage renal disease patients. Hemodial Int 2013;17:391-6. 23. Ishizuka M, Shimizu T, Kubota K. Neutrophil-to-Lymphocyte Ratio Has a Close Association With Gangrenous Appendicitis in Patients Undergoing Appendectomy. Int Surg 2012;97:299-304.

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KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Fournier gangreninde debridman sayısını öngörmede nötrofil lenfosit oranı ve trombosit lenfosit oranı Fournier gangreni şiddet indeksi kadar etkili midir? Dr. Şahin Kahramanca,1 Dr. Oskay Kaya,2 Dr. Gülay Özgehan,2 Dr. Burak İrem,2 Dr. İbrahim Dural,2 Dr. Tevfik Küçükpınar,2 Dr. Hülagü Kargıcı2 1 2

Kars Devlet Hastanesi, Genel Cerrahi Kliniği, Kars; Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Ankara

AMAÇ: Fournier gangreni (FG) ciltaltı ve fasial dokuların hızlı seyirli, nekrotizan ve ölümcül enfeksiyöz bir hastalığıdır. Bu çalışmada, tersiyer bir referans hastanesinde 68 hastaya ait prognostik faktörleri ve tedavi sonuçlarını irdelemeyi amaçladık. GEREÇ VE YÖNTEM: Ocak 2006 ve Ocak 2013 tarihleri arasında acil servise başvuran hastalar iki gruba ayrıldı ve geriye dönük olarak incelendi. Grup I’deki (G1) hastalar bir debridman gereksimi duyanlar ve Grup II’deki (G2) hastalar birden fazla debridman gereksinimi olanlardı. Demografik ve klinik özellikler kaydedildi. Fournier gangreni şiddet indeksi (FGSI) puanları, nötrofil-lenfosit oranları (NLO) ve trombosit-lenfosit oranları (TLO) hesaplandı. Prognostik faktörler gruplar arasında karşılaştırıldı. BULGULAR: Gruplar arasında yaş ortalaması, kadın-erkek oranı, başvuru anındaki belirti süresi yönünden fark yoktu ama enfeksiyon kaynağı, predispozan faktör, pozitif kültür sonuçları G2’de yüksekti. Hastanede kalış süresi, toplam maliyet ve mortalite oranı da G2’de yüksekti. G2’de NLO ve TLO yönünden istatistiksel olarak anlamlı yükseklik vardı ama FGSI skorları yönünden gruplar arasında fark saptanmadı. TARTIŞMA: Bulgularımıza göre FGSI puanlama sisteminin prognoz belirlemede değeri yoktu. Buna karşılık daha önce İngilizce literatürde bu amaçla kullanımına rastlayamadığımız NLO ve TLO değerli bulundu. Anahtar sözcükler: Fournier gangreni; nötrofil lenfosit oranı; platelet lenfosit oranı; prognostik faktör. Ulus Travma Acil Cerr Derg 2014;20(2):107-112

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ORIGIN A L A R T IC L E

Abdominal solid organ injury in trauma patients with pelvic bone fractures Hyo-Min Kwon, M.D., Sun-Hyu Kim, M.D., Jung-Seok Hong, M.D., Wook-Jin Choi, M.D., Ryeok Ahn, M.D., Eun-Seog Hong, M.D. Department of Emergency Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea

ABSTRACT BACKGROUND: We analyzed the clinical progression of trauma patients with pelvic bone fractures so to determine the risk factors associated with sustaining concurrent abdominal solid organ injuries. METHODS: This study was a retrospective chart review. Subjects were categorized based on injury type: solid organ versus nonsolid organ injury groups. These study groups were compared based on demographics, treatments, and clinical outcomes. Potential risk factors that may contribute to the occurrence of abdominal solid organ injury in trauma patients with pelvic bone fractures were evaluated. RESULTS: The solid organ injury group included 17.4% of all the patients in the study (n=69). Fall from height occurred at greater distances in patients that sustained solid organ injuries as opposed to patients with non-solid organ injuries. Initial blood pressure and Revised Trauma Scores were lower in the solid organ injury group. Shock diagnosed immediately upon emergency department arrival was a risk factor for intra-abdominal solid organ injuries in trauma patients with pelvic bone fractures. Clinical prognosis for patients in the solid organ injury group was poorer and more invasive treatments were performed for patients in this group. CONCLUSION: Traumatic pelvic fracture patient prognosis needs to be improved through early diagnosis and prompt delivery of aggressive treatments based on rapid identification of abdominal solid organ injuries. Key words: Abdominal injuries; fractures; pelvic bones.

INTRODUCTION Pelvic bone fractures are commonly caused by high energy external forces such as those sustained in traffic accidents or falls, and these patients are at a high risk for associated injuries.[1-3] Pelvic bone fractures with abdominal solid organ injuries have a poorer prognosis.[4,5] In patients with pelvic bone fractures, it is possible to overlook concurrent solid organ injury, especially if the abdominal symptoms are not severe. Diagnosing abdominal solid organ injury in the context of pelvic bone fractures is critical, as the clinical management and patient prognosis changes. Computed tomography (CT)

Address for correspondence: Sun-hyu Kim, M.D. 290-3 Jeonha-dong Dong-gu 682-71 Ulsan, South Korea Tel: +82-52-250-8405 E-mail: stachy1@paran.com Qucik Response Code

rather than plain X-ray or ultrasonography is the preferred method in evaluating patients with complicated injuries, especially if the injury affected the abdominal viscera.[6-10] If CT scan can be utilized to predict the probability of having an intra-abdominal solid organ injury in patients with pelvic bone fractures, then prognosis may improve.[11] Previous studies have investigated the clinical progression of patients with pelvic fractures with various associated injuries. [4,12,13] However, no studies have investigated the risks of incurring intra-abdominal solid organ injuries when pelvic bone fractures are sustained. We evaluated the clinical progression of patients that had pelvic fractures and received abdominal CT scans to determine if concurrent abdominal solid organ injury occurred. By gathering these data, we investigated the early risk factors that indicate the presence of solid organ injuries within minutes of arrival to the emergency department (ED) before obtaining precise radiologic images like CT scan.

Ulus Travma Acil Cerr Derg 2014;20(2):113-119 doi: 10.5505/tjtes.2014.72698

MATERIALS AND METHODS

Copyright 2014 TJTES

This is a retrospective chart review of 386 patients that presented with pelvic bone fractures from January 2000 to December 2011 to the Emergency Department at the Ulsan

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University Hospital in Korea (Figure 1). Only patients that received CT imaging that clearly indicated the presence or absence of abdominal solid organ injuries were included in the study. Exclusion criteria were if the patient did not receive an abdominal CT scan, if the presence or absence of abdominal solid organ injury could not be determined from CT imaging, and if the CT imaging reports could not be procured.

Table 1. Abdominal solid organ injuries in patients with pelvic bone fractures

Study subjects were categorized depending on CT findings: solid organ injury group who had abdominal solid organ injury and non-solid organ injury group who had not abdominal solid organ injury. Pelvic bone fractures were classified into lateral compression (LC) type I, II or III; antero-posterior compression (APC) type I, II or III; vertical shear (VS) type, and combined type according to the Young-Burgess pelvic bone fractures classification scheme. To differentiate pelvic bone fractures based on stability, LC I and APC I were defined as stable pelvic fractures while the other classifications were unstable.[14,15] A licensed radiologist determined abdominal solid organ injury severity based on CT scan results for the liver, spleen, kidneys, pancreas, and adrenal glands in accordance with the American Association for the Surgery of Trauma (AAST) organ injury scales. Demographic and clinical data included age, sex, mechanism of injury, pelvic bone fracture stability (stable or unstable), initial blood pressure taken at the ED, and the Revised Trauma Score (RTS) to determine the physiologic severity grade. The Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) were determined for all injuries and were utilized to assess the injury severity shortly following ED treatment. Complete blood count and arterial blood gas samples that were taken immediately after ED presentation were evaluated. Transfusion within 24 hours of ED presentation, shock occurrence at the time of ED presentation and shock within 24 hours after ED arrival were also evaluated. Shock was

Solid organ injury type

n

%*

Single organ injury

48

69.6

Liver

21

30.4

Spleen

10

14.5

Kidney

12

17.4

Pancreas

2

2.9

Adrenal gland

3

4.3

Multiple organ injury

21

30.4

Liver + spleen

3

4.3

Liver + kidney

5

7.2

Liver + pancreas

3

4.3

Liver + adrenal gland

2

2.9

Spleen + kidney

5

7.2

Spleen + adrenal gland

1

1.4

Kidney + pancreas

1

1.4

Liver + spleen + kidney

1

1.4

*: Percentages were calculated from a total of 69 patients that had solid viscera injuries.

defined as a systolic blood pressure below or equal to 90 mmHg. Clinical management, subsequent admission to the intensive care unit (ICU) or to the general medicine ward, and mortality were evaluated for all patients. This study was reviewed and approved by the Institutional Review Board. Clinical progression and outcomes were compared between the solid organ injury and non-solid organ injury groups via the chi-squared test and Studentâ&#x20AC;&#x2122;s t-test. Upon arriving to the ED and before CT scanning, certain clinical findings were

482 Pelvic bone fractures with abdomen CT

Excluded

86 Unable to determine solid organ injury due to abdomen CT loss

396 Pelvic bone fractures 327 Non-solid organ injury

69 Solid organ injury

Figure 1. Study subject selection. Of all 482 patients that presented to the ED with pelvic bone fractures and had received an abdominal CT scan, 396 patients were included in the study. A total of 86 patients were excluded from the study because the nature of their abdominal organ injury could not be determined due to a loss of CT scan.

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Kwon et al. Pelvic bone fractures and abdominal solid organ injury

identified as statistically significant via univariate analysis. Then a bivariate logistic regression was performed to evaluate early risk factors associated with abdominal solid organ injury in patients with pelvic bone fractures. All statistical analyses were performed using SPSS version 19.0 software (SPSS, Chicago, IL, USA), and a p-value less than 0.05 was statistically significant.

RESULTS On average the study subjects were 43.2±18.9 (mean ± standard deviation) years-old, and the majority of the patients were male at 58.6%. The solid organ injury group comprised 17.4% of all patients. For patients that sustained a solid organ injury, 49.3% suffered a liver injury (n=34), 34.8% had an injury to the kidney (n=24), 29.0% experienced a spleen injury (n=20), 8.7% sustained an injury to the pancreas (n=6), and 8.7% had an adrenal gland injury (n=6). If only one internal organ was injured, the liver, kidney and spleen were the most commonly harmed in isolation at 30.4% (n=12), 17.4% (n=12), and 14.5% (n=10), respectively. If multiple abdominal viscera sustained injuries, then the liver, spleen and kidney were also the most commonly involved at 7.2% (n=5) (Table 1). Subjects in the solid organ injury group were younger in

comparison to the other groups. The distribution of males and females did not differ significantly between the groups. Patients in the non-solid organ injury group mainly experienced trauma due to traffic accidents at 57.5% (n=188) and were more often pedestrians (n=106) as opposed to drivers (n=25) or passengers (n=15). In the solid organ injury group, injuries due to traffic accidents occurred in 69.6% patients (n=48). Injuries sustained from falling from height comprised 20.3% of patients in the solid organ injury group (n=14) versus 20.5% of patients in the non-solid organ injury group (n=65). On average, patients fell greater distances in the solid organ injury group at 7.3 m as opposed to the non-solid organ injury group that fell an average of 4.4 m. Unstable pelvic bone fractures were evident in more than 60% of patients in both solid and non-solid organ injury groups. Initial blood pressure and RTS were decreased, and the presence of shock upon presenting to the ED was more prevalent in the solid organ injury group (Table 2). Shock upon ED presentation was identified as an early risk factor for abdominal solid organ injury in trauma patients with pelvic bone fractures (Table 3). On average, ISS was higher in the solid organ injury group, but initial hemoglobin levels did not differ

Table 2. Patient demographics and clinical characteristics

Non-solid organ injury (n=327)

n % Mean±SD

Solid organ injury (n=69)

p

n % Mean±SD

Age, years 44.2±18.9 38.4±18.0 0.022 Sex 0.134 Male

186

56.9

46

66.7

Female

141

43.1

18

33.3

Injury mechanism 0.075 Traffic accident

188

57.5

48

69.6

Pedestrian

106

32.4

26

37.7

Driver

25

7.6

7

10.1

Fellow passenger

15

4.6

8

11.6

Motorcycle

42

12.8

7

10.1

Fall from height

67

20.5

14

20.3

Other

72

22.0

7

10.1

Height from fall (m)

4.4±3.5

7.3±4.1

Pelvic bone fracture type Stable

129

39.4

25

36.2

Unstable

198

60.6

44

63.8

0.008 0.618

Systolic blood pressure (mmHg)

119.1±26.1

104.6±27.1

<0.001

Diastolic blood pressure (mmHg)

76.8±43.6

64.0±20.7

0.018

Revised trauma score

11.7±1.2

11.0±1.9

Shock at ED presentation

35

10.7

23

33.3

0.006 <0.001

ED: Emergency department; SD: Standard deviation.

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Kwon et al. Pelvic bone fractures and abdominal solid organ injury

Table 3. Early clinical findings associated with abdominal solid organ injuries

Odds Ratio

95% Confidence Interval

p

Systolic blood pressure

0.994

0.979 - 1.009

0.406

Revised trauma score

0.955

0.773 - 1.181

0.673

Shock at emergency department presentation

3.049

1.245 - 7.463

0.015

*p-values were computed by multiple logistic regression analysis controlling for age and gender.

Table 4. Outcomes for pelvic fracture patients with either solid or non-solid organ injuries

Non-solid organ injury (n=327)

Solid organ injury (n=69)

n % Mean±SD

p

n % Mean±SD

Injury Severity Score

15.8±8.8

27.9±9.9

<0.001

Initial arterial blood pH

7.39±0.09

7.30±0.10

<0.001

Initial hemoglobin (g/dL)

12.4±2.1

12.1±2.4

0.276

Initial prothrombin time INR

1.08±0.16

1.23±0.29

<0.001

24-hour packed red blood cells

1.24±3.29

6.41±11.90 0.001

Transfusion packed red blood cells

78

23.9

39

56.5

<0.001

within 24 hours Treatment <0.001 Conservative

312

95.4

51

73.9

Invasive

15

4.6

18

26.1

Operative

6

1.9

2

3.3

Embolization

6

1.9

11

15.9

Operative + embolization

3

0.9

5

7.2

Intensive care unit stay, days

1.8±4.6

7.4±10.0

Mortality

10 3.1

8 11.6

Hypovolemic shock

3

3

0.9

<0.001 0.006

4.3

Septic shock

3

0.9

2

2.9

Brain lesion

4

1.3

1

1.4

Respiratory failure

0

0.0

1

1.4

Multi-organ failure

0

0.0

1

1.4

INR: International normalized ratio.

between solid and non-solid organ injury groups. Initial arterial blood gas pH was decreased and prothrombin time was prolonged in the solid organ injury group. Packed red blood cell transfusions were performed more often in patients with solid organ injuries within 24 hours of arriving to the ED as compared to the non-solid organ injury group (6.4 vs. 1.2, respectively; p<0.001). Invasive treatments including surgery and arterial embolization were more commonly performed, ICU stays were longer and mortality was higher in the solid organ injury group (Table 4). Surgical operations such as bowel or mesentery 116

repairs were often performed in the non-solid organ injury group, but splenectomies or nephrectomies occurred more commonly in the solid organ injury group. The internal iliac and renal arteries were the most frequently injured vessels in the solid organ injury group. Surgery following arterial embolization was performed in 2 patients in the non-solid organ group and in 4 patients in the solid organ injury group (Table 5).

DISCUSSION The extent to which pelvic bone fractures contribute to poorer prognosis in trauma patients remains unclear.[1-5] Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2


Kwon et al. Pelvic bone fractures and abdominal solid organ injury

Table 5. Invasive treatments for pelvic bone fractures with either solid or non-solid organ injuries

Non-solid organ injury Solid organ injury (n=15/327) (n=18/69)

Operation (n)

6

2

Gastric perforation repair, 1

Splenectomy, 1

Colon perforation repair, 1

Splenectomy + nephrectomy, 1

Small bowel resection, 3

Mesentery repair, 1

Arterial embolization (n)

6

11

Internal iliac artery, 1

Internal iliac artery, 4

hepatic artery, 1

Renal artery, 3

Cystic artery, 1

Hepatic artery, 1

Gluteal artery, 1

Splenic artery, 1

Internal pudendal artery, 1

Internal iliac + lumbar artery, 1

Gluteal + femoral artery, 1

Renal + hepatic artery, 1

Arterial embolization + operation (n)

3

5

Internal pudendal artery

Internal iliac artery

+ bladder, diaphragm repair 1

+ bladder repair, 1

Internal iliac artery

Internal iliac artery

+ bladder repair, 1

+ bowel repair, colostomy, 1

Bladder repair

Gluteal artery

+ internal iliac artery, 1

+ exploratory laparotomy, 1

Hepatic artery

+ small bowel resection, 1

Small bowel repair

+ internal iliac artery, 1

However, patients with pelvic bone fractures with concurrent internal organ injuries, hypotension, head injuries, and lower hemoglobin levels have worse outcomes.[4,13,16] Elevated ISS in patients with pelvic bone fractures and internal organ injuries rather than stability type of pelvic bone fractures, is associated with a higher risk for mortality.[13] A previous study reported that pelvic bone fracture instability does not increase the likelihood of abdominal solid organ injury. Age, mechanism of injury, hypotension, and injury to the chest are all prognostic factors of mortality.[17] Therefore, patients with abdominal solid organ injuries may have less favorable prognoses as compared to patients without such injuries. We found that patients with internal organ injuries had worse prognoses and higher mortality rates, longer ICU stays, elevated ISS, relatively more transfusions, and a greater likelihood of receiving surgery and/or arterial embolization. It is imperative to rapidly diagnose injury to the abdominal solid organ in the setting of pelvic bone fractures so to deliver appropriate treatment, and our data suggest that patients presenting with shock are at even higher risk of having abdominal solid organ injuries. Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2

Patient prognosis after sustaining a fall from height depends on the distance of the fall.[18-20] The greater the distance that the patient falls, the more likely the patient sustains solid organ injuries based on univariate analysis in our study (odds ratio 1.188, 95% confidence interval (CI) 1.032-1.368, p=0.016). Yet, fall injuries only constituted 20% of all injury mechanisms in this study, and so estimating the risk of experiencing concurrent solid organ injuries via multivariate regression was limited. There is controversy regarding the clinical utility of obtaining abdominal CT scans selectively only for patients that complain of abdominal tenderness, cases of suspected hemoperitoneum, abdominal ultrasonography revealing suspected injury to the viscera, hematuria, or routinely for all trauma patients that were exposed to great external forces so to determine whether the patient experienced concurrent abdominal organ injuries with pelvic bone fractures.[11,21-24] Selective utilization of CT scanning has been advocated for due to radiation exposure and cost.[22-24] However, it has been reported that the treatment plan was changed in 6.4% of cases 117


Kwon et al. Pelvic bone fractures and abdominal solid organ injury

due to diagnoses determined from CT imaging.[11] It is difficult to conclusively state whether CT scans should be performed selectively or routinely so to better diagnose abdominal solid viscera injury in patients with pelvic bone fractures because of the limitations of our study. Although, routine abdominal CT scans are preferred when working up patients with pelvic bone fractures at Ulsan University Hospital. In this study 17% (n=69) of the patients with pelvic bone fractures were diagnosed with internal solid organ injury on abdominal CT imaging. It may be useful to perform abdominal CT scans routinely in patients with pelvic bone fractures, so to identify the presence of organ injuries. Since this study only included subjects that received abdominal CT scans to determine the presence of pelvic bone fractures, this study has limited power in estimating the prevalence of abdominal solid organ injury. Further studies are needed to determine whether abdominal CT scans should be utilized in diagnosing abdominal solid organ injuries in patients with pelvic bone fractures. Injury to abdomen in the pelvic area is associated with pelvic fractures, and the viscera that are most frequently injured are the liver, kidney and spleen, in order of decreasing prevalence of injury.[4] These organs were also commonly injured in our study. It is very important when treating trauma patients to determine early on whether further diagnostic methods and treatments are necessary in the ED based on clinical findings such as patient history, initial physical examination, and vital signs. Severe pelvic bone fractures may be easily detected on physical examination. Yet, it is difficult to discern abdominal solid organ injury because the viscera, unlike bone, are not as easily palpated in physical examination. Especially for trauma patients that present with shock to the ED, it is imperative to diagnose abdominal solid organ injury quickly so to expedite the delivery of appropriate treatment interventions. Pelvic packing as well as arterial embolization are effective interventions that control bleeding for hemodynamically unstable patients with pelvic fractures.[25,26] However, pelvic packing was not performed in this study, so we did not evaluate the efficacy of pelvic packing in patients with unstable pelvic fractures. Limitations of this study are that it is a retrospective chart review and that it was conducted with data from one university hospital. Also, the patient charts did not reveal the exact indications for taking the abdominal CT scans for patients with pelvic bone fractures during the study period. Since abdominal solid organ injury may not have been confirmed if CT scanning was not performed, in spite of the presence of traumatic pelvic bone fractures, there may have cases in which injury to the viscera was missed. Although, abdominal CT scans were conducted in the majority of the patients with suspected abdominal injuries upon presenting to the ED, making it less likely that such a diagnosis was overlooked. Also, the average age of patients with solid organ injuries was generally younger in our study. This may be due to the fact that the study population, which was comprised of physically active and young individuals, was more likely to engage in high 118

risk activities that predispose them to severe traumatic insults. Therefore, the overrepresentation of this age group in our study makes it more difficult to estimate the relationship of age with the occurrence of solid organ injuries in pelvic fracture patients. These limitations may be overcome with further prospective, multicenter studies.

Conclusion There is a need to improve prognosis by diagnosing abdominal solid viscera injury early such that the appropriate aggressive treatments may be rapidly administered to trauma patients with shock and pelvic bone fractures in the ED. Conflict of interest: None declared.

REFERENCES 1. Manson TT, Nascone JW, Sciadini MF, O’Toole RV. Does fracture pattern predict death with lateral compression type 1 pelvic fractures? J Trauma 2010;69:876-9. 2. Abrassart S, Stern R, Peter R. Morbidity associated with isolated iliac wing fractures. J Trauma 2009;66:200-3. 3. Schulman JE, O’Toole RV, Castillo RC, Manson T, Sciadini MF, Whitney A, et al. Pelvic ring fractures are an independent risk factor for death after blunt trauma. J Trauma 2010;68:930-4. 4. Gustavo Parreira J, Coimbra R, Rasslan S, Oliveira A, Fregoneze M, Mercadante M. The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures. Injury 2000;31:677-82. 5. Giannoudis PV, Grotz MR, Tzioupis C, Dinopoulos H, Wells GE, Bouamra O, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma 2007;63:875-83. 6. Miller MT, Pasquale MD, Bromberg WJ, Wasser TE, Cox J. Not so FAST. J Trauma 2003;54:52-60. 7. Poletti PA, Wintermark M, Schnyder P, Becker CD. Traumatic injuries: role of imaging in the management of the polytrauma victim (conservative expectation). Eur Radiol 2002;12:969-78. 8. Self ML, Blake AM, Whitley M, Nadalo L, Dunn E. The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injuries. Am J Surg 2003;186:609-14. 9. Shanmuganathan K, Mirvis SE, Sherbourne CD, Chiu WC, Rodriguez A. Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma. Radiology 1999;212:423-30. 10. Exadaktylos AK, Sclabas G, Schmid SW, Schaller B, Zimmermann H. Do we really need routine computed tomographic scanning in the primary evaluation of blunt chest trauma in patients with “normal” chest radiograph? J Trauma 2001;51:1173-6. 11. Deunk J, Brink M, Dekker HM, Kool DR, van Kuijk C, Blickman JG, et al. Routine versus selective computed tomography of the abdomen, pelvis, and lumbar spine in blunt trauma: a prospective evaluation. J Trauma 2009;66:1108-17. 12. Ali J, Ahmadi KA, Williams JI. Predictors of laparotomy and mortality in polytrauma patients with pelvic fractures. Can J Surg 2009;52:271-6. 13. Lunsjo K, Tadros A, Hauggaard A, Blomgren R, Kopke J, Abu-Zidan FM. Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients. J Trauma 2007;62:687-91. 14. Manson T, O’Toole RV, Whitney A, Duggan B, Sciadini M, Nascone J.

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Kwon et al. Pelvic bone fractures and abdominal solid organ injury Young-Burgess classification of pelvic ring fractures: does it predict mortality, transfusion requirements, and non-orthopaedic injuries? J Orthop Trauma 2010;24:603-9. 15. Lefaivre KA, Padalecki JR, Starr AJ. What constitutes a Young and Burgess lateral compression-I (OTA 61-B2) pelvic ring disruption? A description of computed tomography-based fracture anatomy and associated injuries. J Orthop Trauma 2009;23:16-21. 16. Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology 1986;160:445-51. 17. Gabbe BJ, de Steiger R, Esser M, Bucknill A, Russ MK, Cameron PA. Predictors of mortality following severe pelvic ring fracture: results of a population-based study. Injury 2011;42:985-91. 18. Velmahos GC, Demetriades D, Theodorou D, Cornwell EE 3rd, Belzberg H, Asensio J, et al. Patterns of injury in victims of urban free-falls. World J Surg 1997;21:816-21. 19. Ong A, Iau PT, Yeo AW, Koh MP, Lau G. Victims of falls from a height surviving to hospital admission in two Singapore hospitals. Med Sci Law 2004;44:201-6. 20. Hingson R, Howland J. Alcohol as a risk factor for injury or death resulting from accidental falls: a review of the literature. J Stud Alcohol

1987;48:212-9. 21. Salim A, Sangthong B, Martin M, Brown C, Plurad D, Demetriades D. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Arch Surg 2006;141:468-75. 22. Grieshop NA, Jacobson LE, Gomez GA, Thompson CT, Solotkin KC. Selective use of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma 1995;38:727-31. 23. Garber BG, Bigelow E, Yelle JD, Pagliarello G. Use of abdominal computed tomography in blunt trauma: do we scan too much? Can J Surg 2000;43:16-21. 24. Richards JR, Derlet RW. Computed tomography and blunt abdominal injury: patient selection based on examination, haematocrit and haematuria. Injury 1997;28:181-5. 25. Osborn PM, Smith WR, Moore EE, Cothren CC, Morgan SJ, Williams AE, et al. Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury 2009;40:54-60. 26. Tosounidis TI, Giannoudis PV. Pelvic fractures presenting with haemodynamic instability: treatment options and outcomes. Surgeon 2013;11:344-51.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Karında solid organ yaralanmasıyla ilişkili pelvis kemiği kırıkları Dr. Hyo-Min Kwon, Dr. Sun-Hyu Kim, Dr. Jung-Seok Hong, Dr. Wook-Jin Choi, Dr. Ryeok Ahn, Dr. Eun-Seog Hong Ulsan Üniversitesi Tıp Fakültesi, Ulsan Üniversite Hastanesi, Acil Tıp Kliniği, Ulsan, Güney Kore

AMAÇ: Bu çalışmada, pelvis kemiği kırıklarının klinik özellikleri ve prognozu ile eşlik eden karında solid organ yaralanmasının oluşu ve risk faktörleri incelendi. GEREÇ VE YÖNTEM: Geriye dönük olarak tıbbi kayıtlar toplandı. Denekler, demografik özellikler, sonuçlar ve prognozu karşılaştırma amacıyla karında solid organ travması açısından solid organ yaralanması olan ve olmayan gruplara ayrıldı. Pelvis kemiği kırıkları olan hastalarda karında solid organ yaralanmasının oluşu açısından risk faktörleri değerlendirildi. BULGULAR: Solid organ yaralanması olan grupta 69 (%17.4) hasta vardı. Solid organ yaralanması olmayan gruba göre solid organ yaralanması olan grupta yüksekten düşüşler daha fazlaydı. Solid organ travması grubunda başlangıçtaki kan basıncı ölçümleri ve gözden geçirildi, travma skorları daha düşük bulundu. Acil servise gelişin hemen sonrası şok, pelvis kemiği kırıkları olan travma hastalarında karında solid organ yaralanması için bir risk faktörüydü. Solid organ yaralanması grubu kötü bir prognoza sahip olup bu grupta daha invaziv tedavi uygulandı. TARTIŞMA: Şok ve pelvis kemiği kırıkları kuşkusu ile acil servise gelen travma hastalarında prognozun karında solid organ yaralanmasının erkenden öngörüsüne göre erken tanı ve agresif tedavi ile iyileştirilmesi gerekir. Anahtar sözcükler: Abdominal yaralanmalar; kırıklar; pelvis kemikleri. Ulus Travma Acil Cerr Derg 2014;20(2):113-119

doi: 10.5505/tjtes.2014.72698

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K Lİ NİK Ç A LI ŞM A

El ve önkol yaralanmalarında yaralanma ciddiyeti ile işe geri dönüş, bozukluk, aktivite ve katılım arasındaki ilişkinin incelenmesi Fzt. Negihan Çakır,1 Dr. Ramazan Hakan Özcan,2 Fzt. Ali Kitiş,3 Fzt. Nihal Büker3 1

Bornova Türkan Özilhan Devlet Hastanesi Fizik Tedavi Ünitesi, İzmir;

2

Pamukkale Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerahi Anabilim Dalı, Denizli;

3

Pamukkale Üniversitesi Tıp Fakültesi, Fizik Tedavi ve Rehabilitasyon Yüksekokulu, Denizli

ÖZET AMAÇ: Önkol ve el yaralanmaları işle ilişkili özrün temel nedenidir. Bu çalışmada, el ve önkol yaralanmaları sonrası hastaların yaralanma ciddiyetleri ile işe geri dönüş süresi, aktivite ve katılım düzeyleri arasındaki ilişki incelendi. GEREÇ VE YÖNTEM: Çalışmaya yaş ortalamaları 31±11.13 yıl (18-63 yıl) olan el ve önkol yaralanmalı toplam 130 hasta alındı. Modifiye El ve Önkol Yaralanması Ciddiyet Skorlaması (MEYCS) ile yaralanma ciddiyeti belirlendi. Yaralanmadan sonra sekizinci haftada Jebsen El Fonksiyon Testi ( JEFT), Buck-Gramko skorlaması uygulandı. Bozukluk/semptom skorunun değerlendirilmesi için 12. haftada Kol, Omuz ve El Sorunları Anketi’nin Türkçe versiyonu (DASH-T) kullanıldı ve kavrama kuvveti ölçümü yapıldı. Hastaların işe geri dönüş süreleri kaydedildi. BULGULAR: Çalışmanın sonunda MEYCS ile hastaların eski işlerine geri dönüş süresi, kavrama kuvveti değerleri, DASH-T skorları ve Buck Gramko skorları arasında istatistiksel olarak anlamlı ilişki olduğu gözlendi (p<0.05). MEYCS ile JEFT arasında istatistiksel olarak anlamlı ilişkiye rastlanmadı (p>0.05). Hastalar Uluslararası Fonksiyonellik, Özür ve Sağlık Sınıflaması Sistemi’ne (UFÖSS) göre değerlendirildiğinde; vücut işlevleri bölümünde vücut yapı ve fonksiyonları (1.86±1.47), aktivite bölümünde yazı yazmada (2.06±1.50) en yüksek bozukluk düzeyine sahip oldukları bulundu. SONUÇ: Sonuç olarak yaralanma ciddiyet düzeyinin yüksekliği aktiviteye geri dönüşü, katılımı, işe geri dönüşü geciktirmiştir. DASH-T skorlarının işe geri dönüşe en fazla etki eden faktör olduğu sonucuna varılmıştır. Ayrıca el, önkol yaralanmalı hastalarda, aktiviteye geri dönüş ve katılım ile işe geri dönüş zamanı arasında pozitif ilişki vardır. Anahtar sözcükler: Aktivite ve katılım; bozukluk; el ve önkol yaralanması; işe geri dönüş; yaralanma ciddiyeti.

GİRİŞ Üst ekstremite yaralanmaları çeşitli kişisel, psikolojik ve sosyal sonuçlara neden olmaktadır. Bu sonuçlar, hastaların günlük yaşam aktivitelerine daha geç dönmesi, işe geri dönüşün gecikmesi, ekstremitenin görünümü, sosyal ve mesleki aktivitelerdeki kısıtlanmalarla ortaya çıkan psikolojik problemlerle birlikte seyretmektedir.[1-3] Yaralanmanın ciddiyeti, tipi ve yaralanan yapıların özellikleri gibi faktörlerin rehabilitasyonun Sorumlu yazar: Dr. Ali Kitiş, Pamukkale Üniversitesi Fizik Tedavi ve Rehabilitasyon Yüksek Okulu, Kınıklı Kampüsü, 20100 Denizli Tel: +90 258 - 296 23 00 E-posta: alikitis@pau.edu.tr Ulus Travma Acil Cerr Derg 2014;20(2):120-126 doi: 10.5505/tjtes.2014.04741 Telif hakkı 2014 TJTES

120

uzun dönem sonuçlarını ve işe geri dönüşü etkileyen farklı unsurlar oldukları rapor edilmiştir.[3-7] El yaralanmaları hastaların günlük yaşamda yaptıkları işleri olumsuz yönde etkileyerek, büyük bir stres kaynağı ve yaşamdan kopma sebebi olabilir. İnsan eli yaşamdaki bağımsızlık hissinin ve aktiviteye katılımın sürdürülmesindek başlıca enstrüman olduğu için el yaralanmaları kişinin yaşamdaki hedeflerini, ekonomik düzeyini ve aile içindeki rollerini değiştirebilir.[6-9] Yaralanmanın fonksiyonel, sosyal ve mesleki sonuçlarını ortaya çıkarmada geçerli ve güvenilir metodların kullanılması, klinik açıdan da önemlidir. Uluslararası Fonksiyon Sınıflaması’nın (International Classification of Functioning, Disability and Health - ICF) tanımlanmasıyla hastalığın sağlık üzerindeki etkisini belirlemek için vücut yapı ve fonksiyonları, aktivite ve katılım kavramları kullanılmıştır. Son yıllarda üst ekstremite yaralanmalarının değerlendirilmesinde kullanılan sonuç ölçümleri de bu kavramlar çerçevesinde uygulanmaktadır.[10-12] Ulus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2


Çakır ve ark. El ve önkol yaralanmalarında yaralanma ciddiyeti ile işe geri dönüş, bozukluk, aktivite ve katılım arasındaki ilişkinin incelenmesi

Çalışmamızın amacı, herhangi bir el ve önkol yaralanmasına sahip hastalarda yaralanma ciddiyeti ile işe dönüş, aktivite ve katılım düzeyleri arasındaki ilişkiyi incelemek, ICF modelinde önerilen değerlendirme ve sonuç ölçümlerini kullanarak sosyo-demografik özellikler, yaralanmaya ve mesleğe ilişkin özelliklerin işe dönüş zamanı ile ilişkili olup olmadığını incelemek, vücut yapı ve fonksiyonu, aktivite ve katılımla ilişkili kayıpların işe dönüş üzerindeki etkilerini araştırmaktı.

GEREÇ VE YÖNTEM Bu çalışmaya, herhangi bir el ve önkol yaralanması nedeniyle Eylül 2010 ile Kasım 2012 tarihleri arasında ameliyat edilmiş 130 hasta alındı. Hastalara çalışma öncesi yapılacak değerlendirme yöntemleri hakkında bilgi verildi, bilgilendirilmiş onam formuna imzaları alındı. Hastaların çalışmaya alınma ölçütleri; el ve önkolu içine alan herhangi bir ortopedik travma geçirmiş olmak, geçirilen yaralanma sonrası uygun cerrahi tedaviyi almış olmak, cerrahi sonrası düzenli olarak el terapi ve rehabilitasyonunu sürdürmüş olmak ve herhangi bir işte çalışıyor olmak idi. Dışlanma ölçütleri ise; herhangi bir ortopedik, nörolojik ya da romatolojik bir hastalığa sahip olma, çalışmaya alınan ekstremite ya da ekstremitelerde daha önce geçirilmiş bir travma varlığı, kontrol değerlendirmelerine devam etmeme ve replante edilmemiş amputasyonların varlığı idi. Hastalar başlangıç değerlendirme sonrası yaralanmış olan yapılara yönelik geleneksel rehabilitasyon programları ile haftada üç gün olmak üzere 12 hafta boyunca takip edildi. Hastaların ameliyat sonrası 1-5. günlerde sosyo-demografik verileri kayıt formuna kaydedildi. Çalışmamızda hastaların yaralanma ciddiyet düzeyini belirlemek için Modifiye El Yaralanmaları Ciddiyet Skorlaması (MEYCS) kullanıldı. Bu skorlama sadece karpal kemiklerin distalindeki yaralanmalar için geliştirilmiş, el bileği ve önkol yaralanmalarını da içine alacak şekilde modifiye edilmiştir. Skorlamadaki her bir bölüm mutlak skorlar ve değerlendirilen vücut yapısının ve bölümünün günlük yaşamdaki fonksiyonelliğe etkisi göz önüne alınarak ağırlıklı skorlar içermektedir. Toplam MEYCS tüm komponentlerin skorlarının toplanması ile bulundu. Toplam MEYCS dört kategoriye ayrıldı ve minör, orta, ciddi ve majör yaralanma (minör MEYCS <20; orta, MEYCS 21-50; ciddi MEYCS 51-100; majör MEYCS >101) olarak kategorize edildi.[13,14] Çalışmamızda hastaların yaralanma sonrası eklem hareket açıklığını (EHA) değerlendirmede sekizinci haftada gonyometre ile yapılan ölçüm sonrası Buck-Gramko skorlaması kullanıldı. Parmak ucu-distal palmar palmar çizgi mesafesi, total ekstansiyon kaybı, modifiye total aktif hareket (TAH) ölçüldü. Modifiye TAH ölçülürken ilgili parmağın metafarpofalangeal (MF) eklem hareket açıklığına, proksimal interfalangeal (PİF) eklem hareket açıklığının iki katı ve distal interfalangeal (DİF) eklem hareket açıklığının üç katı eklendi. Elde edilen skorlar şu şekilde kategorize edildi: Mükemmel; 16-17 puan, Çok iyi; Ulus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2

14-15 puan, İyi; 11-13 puan, Kötü; 7-10 puan, Çok kötü; 0-6 puan.[15,16] Kavrama kuvveti Amerikan El Terapistleri Derneği’nin önerdiği pozisyonda Jamar el dinamometresi ile değerlendirildi. Ölçümde hastalar sırtı destekli kolçaksız bir sandalyede oturma pozisyonunda iken el bileği 90 derece fleksiyonda, önkol nötral pozisyonda ve hasta Jamar el dinamometresini ikinci tutuş pozisyonunda tutarak yapıldı. Ölçümler üç tekrarlı yapıldı ve kilogram cinsinden kaydedildi. Değerlendirme sonucunda üç ölçümün ortalaması alındı.[17] Üst ekstremite aktiviteleri ve fonksiyonelliğinin değerlendirilmesinde 12. haftada omuz, kol ve el sorunları anketinin Türkçe sürümü (DASH-T) kullanıldı. Hudak ve ark.nın 1996 yılında tanımladığı 30 sorudan oluşan DASH-T, üst ekstremitenin fonksiyonel durumunu Likert ölçeğine göre subjektif olarak değerlendirir. Hastaların anketi kendilerinin doldurmaları istendi, elde edilen puanların toplamı, anket için geliştirilmiş bir formülle 0 ile 100 puan arasında değişen toplam bir skora dönüştürüldü.[18] Üst ekstremitelerin günlük yaşam aktivitelerindeki fonksiyonel durumunu belirlemek için sekizinci haftada JEFT kullanıldı. Test, yazı yazma, kart çevirme, küçük cisimleri toplama, yemek yemeyi uyarma, yemek yeme taklidi, fişleri yerleştirme, boş kutuları hareket ettirme ve dolu kutuları hareket ettirme olmak üzere yedi alt testten oluşmaktadır. Her bir alt test önce nondominant, daha sonra dominant elle yapıldı, değerlendirmeler standart bir süre ölçer kullanılarak saniye cinsinden kaydedildi.[19] Tüm değerlendirmeler aynı fizyoterapist tarafından yapıldı. Bu çalışma için, Denizli Klinik Araştırmalar Etik Kurulu tarafından onay alındı (20.09.2010 tarihli 05 sayılı). Ayrıca Pamukkale Üniversitesi Bilimsel Araştırma Projeleri kapsamında 2010SBE011 proje numarası ile maddi olarak desteklenmiştir. Tüm istatistiksel analizler için Windows işletim sistemi altında “SPSS for Windows (versiyon 16.0)” paket programı kullanıldı. Tanımlayıcı istatistiksel bilgiler ortalama±standart sapma (Ort.±SS) veya yüzde (%) şeklinde verildi. Tüm istatistiklerde p değeri 0.05’in altında olduğunda istatistiksel olarak anlamlı ilişki varlığı kabul edildi. Normal dağılıma uyan verilerde olgular arasındaki anlamlılığın test edilmesi için “İlişkili örneklemler için tek yönlü ANOVA”, farklılığı yaratan verileri test etmek için “t-testi”, normal dağılma uymayan verilerde olgular arasındaki anlamlılığın test edilmesi için “Mann-Whitney U testi” ve “Kruskal-Wallis varyans analizi” uygulandı. Çalışmamızda korelasyon analizleri için “Pearson korelasyon analizi”ne başvuruldu.

BULGULAR Çalışmamıza yaşları 18-63 yıl arasında değişen, yaş ortalaması 31±11.13 yıl olan el ve önkol yaralanması geçirmiş toplam 130 121


Çakır ve ark. El ve önkol yaralanmalarında yaralanma ciddiyeti ile işe geri dönüş, bozukluk, aktivite ve katılım arasındaki ilişkinin incelenmesi

hasta alındı; 130 hastanın 107’sinde (%82) yaralanma nedeni kesilme iken, 13 (%10) hastada ezilme tarzı yaralanma vardı. Hastalara ve yaralanmaya ait diğer tanımlayıcı veriler Tablo 1’de verilmiştir. Türkiye İş Kurumu’nun (İŞKUR) meslek sınıflamasına göre hastaların mesleki özellikleri incelendiğinde; en büyük hasta grubunu (%72) tesis ve makine operatörleri ve montajcıların oluşturduğu görülmektedir. Yirmi altı hasta (%20) hizmet ve satış elemanı sınıfında yer alırken, 10 hasta (%8) tarım ve hayvancılıkla uğraşanlar grubunda idi (Tablo 1). Çalışmaya alınan hastaların 64’ünde tendon yaralanması, 21’inde sinir yaralanması, 11’sinde metakarp ve falanks kırığı, 35’inde ise arter ve ven yaralanmasını da içeren komplike yaralanma vardı. Dört hastanın dışındaki tüm yaralanmalarda deri ve deri altı dokularda da hasar meydana geldiği saptandı. Tendon yaralanmaları incelendiğinde de; 41 fleksör, 23 ekstansör tendon yaralanmasına rastlandı. Fleksör tendon yara-

Tablo 1. Hastalara ve yaralanmaya ait tanımlayıcı veriler Değişkenler Yaş (yıl)

Min.-Maks. Ort.±SS Sayı 18-63

Yüzde 31±11.13

Cinsiyet Kadın

38

29

Erkek

92

71

İlköğretim

52

40

Lise

69

53

9

7

Eğitim durumu

Yüksek öğrenim

Dominant taraf Sağ

112

86

Sol

18

14

Meslek

Tesis/makine operatörü

94

72

Hizmet/satış elemanı

26

20

Tarım ve hayvancılık işçisi

10

8

Kesme

107

82

13

10

10

8

Tendon

64

49

Sinir

21

16

Metacarp/falanks kırığı

10

8

Komplike yaralanma

35

27

Yaralanma nedeni Ezilme

Diğer Yaralanma tipi

Min.: Minimum; Maks.: Maksimum; Ort.: Ortalama; SS: Standart sapma.

122

lanmalarının %10’u (4) tendonla birlikte kırık ve/veya arter yaralanmasını da içermekte, 12 (%29) yaralanmaya tendonla birlikte periferik sinir yaralanması eşlik etmekte idi. En sık yaralanma V. bölgede idi (n=17, %41). Bunu %37 ile II. bölge yaralanmaları takip etmekte idi. Ekstansör tendon yaralanmalarının %65’i (15) izole, %22’si (5) kırıkla birlikte meydana gelmiş yaralanmalardı. Yaralanma bölgeleri incelendiğinde en sık yaralanmaya V. bölgede (%72) rastlanırken, V. bölgenin distalindeki yaralanmalara %14 oranında rastlanmıştı (Tablo 1). Yaralanma ciddiyetine göre EHA ölçümlerinden elde edilen sonuçlar karşılaştırıldığında; yaralanma ciddiyetleri “hafif” olan hastaların Buck-Gromcko skorları mükemmel (17±1.33), orta derecede yaralanma ciddiyetine sahip hastaların iyi (12±2.48) ve ciddi ve majör tip yaralanma ciddiyetine sahip olan hastaların ise kötü (8±5.76) olduğu bulundu. Gruplar arasındaki fark istatistiksel açıdan anlamlı idi (p<0.05). Yaralanma ciddiyetine göre kavrama kuvveti incelendiğinde; 12. haftanın sonunda hafif MEYCS’ye sahip olan hastalarda sağlam ekstremitenin kavrama kuvveti düzeyinin %92’sine, orta MEYCS’ye sahip hastaların %70’ine, ciddi ve majör tip yaralanma düzeyine sahip hastaların ise %66’sına ulaşabildikleri görüldü. Çalışmaya katılan hastaların işe geri dönüş süreleri incelendiğinde; çalışmaya katılan hastaların ortalama 101.16±19.3 (52-126 gün) günde işlerine dönebildikleri görüldü. Yaralanma şekline göre incelendiğinde, tüm yaralanmaların içinde fleksör tendon yaralanmasına sahip hastalarda ortalama işe dönüş süresi 90-140 gün (83.55±14.74 gün) arasında değişmekte idi ve diğer yaralanmalara göre daha uzundu. Bunun yanında fleksör tendon yaralanmalarının içinde III. bölge (77.07±17.35 gün), ekstansör tendon yaralanmalarının içinde de birinci bölge yaralanmaları (70.15±13.7 gün) işe dönüş süreleri en erken olan yaralanma tipleri idi. Ayrıca ezilme tarzı yaralanması olan 13 hastanın ikisi bir yıl içinde eski işine dönememişti. Hastaların MEYCS sonuçları ile işe geri dönüş süreleri karşılaştırıldığında; “hafif”, “orta”, “ciddi ve majör” yaralanmalar şeklinde tanımlanmış olan gruplar arasında istatistiksel olarak anlamlı farklılık olduğu bulundu (p<0.05). Hastaların yaş gruplarına göre işe dönüş süreleri incelendiğinde; en erken dönen grubun 18-25 yaş aralığı (71.21±15.78 gün), en geç dönen yaş grubunun 45 yaş ve üstü (91.6±21.09 gün) olduğu ve yaş grupları arasında anlamlı farklılık olduğu görüldü (p<0.05). Hastaların ekstremite dominansına göre işe geri dönüş süreleri incelendiğinde; dominant ekstremiteleri yaralanmış olan 92 hastanın işe dönüş süresinin (102.47±1.73 gün), nondominant ekstremiteleri yaralanmış olan hastaların işe dönüş süresinden (85.53±21.02 gün) daha uzun olduğu sonucuna ulaşıldı. Ekstremite dominansına göre işe dönüş süresi arasındaki farklılık anlamlı bulundu (p<0.05). Bunun yanında eğitim düzeyine göre hastalar incelendiğinde, ilköğretim mezunu olan hastaların işe geri dönüş sürelerinin lise ve yükseköğrenim mezunu olan hastalara göre daha uzun olduğu saptandı (p<0.05) (Tablo 2). Hastaların 12. haftadaki DASH-T skoru 15.07±12.78 idi. Değerlendirmeye alınan hastaların 12. haftadaki JEFT sonuçları Ulus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2


Çakır ve ark. El ve önkol yaralanmalarında yaralanma ciddiyeti ile işe geri dönüş, bozukluk, aktivite ve katılım arasındaki ilişkinin incelenmesi

Tablo 2. Hastaların işe dönüş süreleri ile MEYCS skoru ve tanımlayıcı veriler arasındaki ilişki Değişkenler (n)

İşe geri dönüş süresi Min.-Maks. Ort.±SS p

MEYCS Hafif (47)

52-84

67.13±11.19

Orta (39)

69-116

81.17±20.04

Ciddi (44)

97-126

112.24±23.16

52-93

71.21±15.78

<0.05

Yaş (yıl) 18-25 (23) 26-35 (51)

61-118

74.41±24.56

36-45 (40)

62-126

87.22±16.01

<45 (16)

77-119

91.6±21.09

Dominant (92)

79-126

102.47±19.73

Nondominant (38)

52-103

85.53±21.02

<0.05

Ekstremite dominansı <0.05

Eğitim durumu* İlköğretim (52)1

79-126 100.17±21.12

Lise (69)

52-115 82.13±16.66 <0.05

Yüksek öğrenim (9)3

66-102 81.21±18.65

2

Yaralanma nedeni Kesme (107)

65-121

92.17±22.12

Ezilme (13)

88-126

104.16±15.55

Diğer (10)

52-107

97.10±19.23

Endüstri (82)

78-126

117.63±11.81

Diğer yaralanmalar (48)

52-104

82.00±14.81

<0.05

Yaralanma ortamı <0.05

: p<0.05; 1-3: p<0.05. MEYCS: Modifiye El ve Önkol Yaralanması Ciddiyet Skorlaması; Min: Minimum; Maks: Maksimum; Ort: Ortalama; SS: Standart sapma.

*1-2

incelendiğinde, sağlam ve yaralanmış ektremiteye ait yedi alt test sonucunda da istatistiksel açıdan anlamlı farklılığa rastlanmadı (p>0.05). Hastaların MEYCS sonuçlarıyla işe dönüş süresi, BuckGramko, DASH-T ve JEFT sonuçları karşılaştırıldığında; MEYCS ile işe geri dönüş süresi arasında pozitif yönde, BuckGramko skoru, kavrama kuvveti, DASH-T skoru arasında ise negatif yönde bir ilişkiye rastlandı. Bunun yanında, MEYCS ile JEFT’nin sadece fişleri üst üste koyma alt testi arasında pozitif yönde istatistiksel olarak anlamlı bir ilişki bulundu (p<0.05). İşe dönüş süresi ile MEYCS ve DASH-T arasında pozitif yönde, Buck-Gramko skoru ile negatif yönde istatistiksel olarak anlamlı bir ilişki saptandı (p<0.05) (Tablo 3).

TARTIŞMA Üst ekstremitede meydana gelen herhangi bir yaralanma ya da travma işe dönüşün gecikmesi ve ekonomik kayıpla sonuçUlus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2

lanan yaralanmalardır. Endüstriyel ortamda meydana gelmiş yaralanmalar ise diğer üst ekstremite yaralanmalarından daha ciddi sonuçlara neden olmaktadır. Yaralanmanın ciddiyeti, tipi ve yaralanan yapıların özellikleri gibi faktörlerin rehabilitasyonun uzun dönem sonuçlarını ve işe geri dönüşü etkileyen farklı unsurlar olduğu rapor edilmiştir.[20,21] Bu çalışmada da farklı yaralanma tiplerinde işe geri dönüş süresinde farklılıklar görülmekle birlikte, hastaların yaralanmayı takiben en geç 126 günde işlerine geri döndükleri bulunmuştur. İşe geri dönüşte, hastaların tamamen iyileşerek ekstremitelerini tekrar işte de güvenli bir şekilde kullanabilir hale gelmelerinin yanında, rapor sürelerinin dolmuş olması, hastaların çalışabilir yaşta olması, işyerlerinden gelen baskı ya da ekonomik nedenlerden dolayı işe geri dönmek zorunda kalmalarının da ülkemiz için önemli gerçekler oldukları açıktır. Üst ekstremite yaralanmalarında yaralanmanın fonksiyonel, sosyal ve mesleki sonuçlarını ortaya çıkarmada geçerli ve güve123


Çakır ve ark. El ve önkol yaralanmalarında yaralanma ciddiyeti ile işe geri dönüş, bozukluk, aktivite ve katılım arasındaki ilişkinin incelenmesi

Tablo 3. MEYCS ile hastaların işe geri dönüş süresi, BuckGramko skoru, DASH-T skoru ve JEFT sonuçları arasındaki ilişkinin incelenmesi MEYCS

r

p*

İşe geri dönüş (gün)

0.424

0.025

Buck-Gramko skoru

-0.424

0.012

Kavrama kuvveti

-0.553

0.002

DASH-T

-0.494 0.006

JEFT (yaralanmış el)

Yazı yazma

- 0.125

0.512

Kart çevirme

0.254

0.176

Küçük cisimleri toplama

0.191

0.246

Yemek yeme

0.084

0.658

Fişleri yerleştirme

0.479

0.007

Boş kutuları çevirme

0.173

0.361

Dolu kutuları çevirme

0.188

0.320

*Pearson korelasyon analizi. MEYCS: Modifiye El ve Önkol Yaralanması Ciddiyet Skorlaması; DASH-T: Kol, Omuz ve El Sorunları Anketi’nin Türkçe versiyonu; JEFT: Jebsen El Fonksiyon Testi.

nilir metodların kullanılması, klinik açıdan önemlidir. Literatürde, üst ekstremite yaralanmalarının değerlendirilmesinde kullanılan sonuç ölçümlerinde vücut yapısındaki bozukluk, aktivite limitasyonu ve katılımın kısıtlanması gibi kavramlar çerçevesinde uygulandığı gözlenmiştir.[20,22] Literatür incelendiğinde el ve önkol yaralanmalarında yaralanma ciddiyeti ile işe geri dönüş süresini inceleyen çok az sayıda çalışmaya rastlanmış,[21,22] yaralanma ciddiyeti ile fonksiyonel durum, aktivite ve katılım arasındaki ilişkiyi inceleyen herhangi bir çalışmaya rastlanmamıştır. Bu nedenle, el ve önkol yaralanması geçiren hastaların yaralanma ciddiyet düzeyleri ile işe geri dönüş zamanları, fonksiyona, aktiviteye ve katılıma geri dönüş sürelerini öngörebilmek ve aralarındaki ilişki varlığını saptayabilmek amacıyla amaca yönelik sonuç ölçümleri seçilerek bu çalışma planlanmıştır. Literatürde ağırlıklı olarak endüstriyel el yaralanmaları sonrası işe geri dönüşü inceleyen çalışmalara sıkça rastlanırken, bu çalışmaya sadece endüstriyel el yaralanmaları geçirmiş hastalar değil, genel olarak işe bağlı yaralanma geçirmiş tüm hastalar alınmıştır. Çalışmaya alınan hastaların %71’ini erkek hastalar oluşturmuştur. Çalışmamıza katılan hastaların çoğunda literatüre uyumlu olarak kesilme tarzı yaralanma sonucu el ve önkol yaralanması meydana geldiği görülmüştür.[3,6,7,20] Çalışmamızda ayrıca tendon yaralanmalarının cilt kesilerinden sonra ikinci en sık yaralanan vücut yapısı olduğu bulunmuştur. Çalışmamıza katılan hastaların çoğu (%40) ilkokul mezunu, en sık el ve önkol yaralanması geçiren meslek grubunun tesis ve makine operatörü ile montajcılar (%53.3) olması ve ge124

lir düzeylerin asgari standartlarda olmasının işe geri dönüşü sosyo-ekonomik nedenlerden zorunlu kılan etkenler oldukları açıktır. Tendon yaralanmaları kendi içinde incelendiğinde literatüre uyumlu olarak bu çalışmada da fleksör tendon yaralanmalarının ekstansör tendon yaralanmalarına göre daha sık görüldüğü belirlenmiştir. Tendon yaralanmaları içinde II. bölgedeki fleksör tendon yaralanmlarında, tendona eşlik eden yaralanmalarda ve V. bölgedeki ekstansör tendon yaralanmalarında işe geri dönüş süresinin diğer yaralanma tiplerine göre işe geri dönüş süresinin uzun olması literatürdeki prevelans çalışmaları ile uyumludur.[5-7,20,23] Cerrahi ve el terapisi yönünden zaman alıcı ve çeşitli komplikasyonlara sahip II. bölge fleksör ve V. bölge ekstansör tendon yaralanmaları, son yıllarda erken kontrollü hareket yöntemleri ile el terapistleri tarafından daha başarılı sonuçlarla rehabilite edilmektedir. Bununla birlikte ezilme tipi ve tendona eşlik eden yaralanmalarda işe geri dönüş süresinin uzun olması, yaralanma ciddiyeti ile ilişkili bir sonuçtur. El Yaralanmaları Ciddiyet Skorlaması (EYCS) kullanılarak yapılan çalışmalarda, travma sonrası EYCS ile işe dönüş zamanı, işten uzak kalma süresi ve iyileşme süresi arasında bir korelasyon olduğu saptanmıştır.[13,24,25] Bununla birlikte, EYCS ile el yaralanması sonrası ortaya çıkan fonksiyonel durum arasında da anlamlı bir ilişki olduğu, yaralanma ciddiyet skoru arttıkça fonksiyonel durumun kötüleştiğini gösteren çalışmalara rastlanmıştır.[13,14,25,26] Bu skorlama daha sonra modifiye edilerek el bileği ve önkol yaralanmalarını da içine alacak şekilde geliştirilmiştir ve MEYCS olarak adlandırılmıştır. Urso-Baiarda ve ark. [27] MEYCS’nin el ve önkol yaralanmalarında işe geri dönüş süresini öngörebilmek için önemli bir belirleyici olduğunu bildirmişlerdir. El, el bileği ve önkolun birlikte fonksiyonel bir zincir oluşturduğunu düşünerek MEYCS’nin işe geri dönüş süresini öngörmede daha geçerli olabileceğini düşünüyoruz ve bizde çalışmamızda MEYCS’yi kullandık. Araştırma sonuçlarımıza göre hafif yaralanma ciddiyetine sahip olan hastaların ortalama 56 günde, orta yaralanma ciddiyetine sahip olan hastaların ortalama 75 günde ve ciddi ve majör yaralanması olan hastaların ise ortalama 94 günde işe dönebildikleri görülmüştür. Çalışmamızda ciddi yaralanma geçiren iki hasta ve majör yaralanması olan hasta toplam beş hasta bir yıllık takip süresi içinde işlerine geri dönememişlerdir. Bu çalışmadan elde edilen sonuçlar ile literatürdeki çalışmaların sonuçları paralellik göstermektedir. Bunun birlikte, çalışmaya alınan hasta sayısının az olması, işe geri dönmede mesleki, sosyolojik, kültürel ve ekonomik baskıların varlığının çalışma sonuçlarını da etkileyebileceği görüşündeyiz. Konuya ilişkin kapsamlı çalışmalarda da bildirildiği üzere; MEYCS skoru 25’in altında olan tüm hastaların eski işlerine dönebildikleri, ciddi yaralanma düzeyindeki hastaların ancak yarısının eski işlerine dönebildikleri, MEYCS skorları 150 ve üzerinde olan hastaların eski işlerine geri dönemedikleri sonucu çarpıcıdır. [24-27] Zira, bu sonuçlar el ve üst ekstremite yaralanmalarında cerrahi teknik, erken fizyoterapi, ekip çalışması ve hasta uyuUlus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2


Çakır ve ark. El ve önkol yaralanmalarında yaralanma ciddiyeti ile işe geri dönüş, bozukluk, aktivite ve katılım arasındaki ilişkinin incelenmesi

mu faktörlerinin önemini bir kez daha ön plana çıkarmıştır. El ve ön kol yaralanmalarında yaralanma sonrası işe geri dönüş süresi ile hastaların yaşı arasında istatistiksel olarak anlamlı bir ilişkiye rastlanmadı. Yapılan çalışmalarda yaş etkeninin işe geri dönüş süresi ve oranı üzerinde etkili olduğu; cinsiyet, stres ve fonksiyonel kısıtlılıkların işe geri dönüş süresini etkilediğini ve genç hastaların daha kısa sürede işe geri döndükleri rapor edilmiştir.[28,29] Çalışmamızda farklı sonuç elde edilmesi genç hasta grubunun genelde endüstriyel alanda çalışan hastalardan oluşması ve endüstriyel işlerde makine kullanımı sonucu oluşan kazalarda işe geri dönüş süresinin artmasına bağlı olabileceğini düşündük. Hastalarımızdan yaralanan eli dominant olanların işe geri dönüş süresinin daha uzun olduğu gözlenmiştir. Bunun sebebinin kendine bakım aktivitelerinde ve işe yönelik aktivitelerde çoğunlukla dominant ekstremitenin kullanılması ve dominant eli yaralanan hastaların ağrı veya kısıtlılık gibi nedenlerle ellerini iş ve diğer aktivitelerde kullanmaktan kaçınmalar olabilir. Nondominant eli yaralanan bazı hastalar dominant elleri ile iş ve diğer aktivitelerde yaralanan ekstremiteyi kolay kompanse edebildiklerinden, tam iyileşmeden işlerine dönmüş olmaları da beklenebilir. Hastaların eğitim düzeylerinin rehabilitasyonu takip edebilme potansiyelleri ile ilişkili olabileceğini düşünerek eğitim düzeyini değerlendirmeyi uygun bulduk. Hastaların eğitim düzeyinin yaralanmanın sonuçlarını daha iyi anlamalarında, iyileşme düzeyleri ile ilgili daha gerçekçi beklentiler edinebilmelerinde ve değişen şartlara daha kolay uyum göstermeleri konusunda da etkili olduğunu düşünüyoruz. Literatürdeki iki çalışmada hastaların eğitim düzeyinin işe geri dönüş üzerinde etkisi olduğu gösterilmiş ve hastaların eğitim düzeyi arttıkça işten uzak kalma süresinin kısaldığı bildirilmiştir.[28,30] Çalışmamızda hastaların işe geri dönüş süreleri eğitim durumları göz önüne alınarak karşılaştırıldığında, farklılık bulunamamıştır. İşe geri dönüşü etkileyen diğer parametrelerin standardize edildiği daha homojenize çalışmalarla daha farklı sonuçlara ulaşılabileceğini düşünüyoruz. Çalışmanın sonunda MEYCS ile DASH-T skoru arasında anlamlı bir ilişki varlığına rastlanması, Matsuzaki ve arkadaşlarının yaptıkları çalışma ile uyumludur.[24] Literatürde daha önce MEYCS ile Buck-Gramko sonuçları ve kavrama kuvveti arasındaki ilişkiyi inceleyen bir çalışmaya rastlanmamıştır. Bu çalışmada MEYCS ile Buck-Gramko skoru ve kavrama kuvveti arasındaki anlamlı bir ilişki varlığı, yaralanma ciddiyeti arttıkça hastaların beklenen kavrama kuvveti değerinin düştüğü, EHA’nın azaldığı ve bunların sonucu olarak da üst ekstremitenin fonksiyonel düzeyinin de azaldığı sonucunu desteklemektedir. Çalışma sonuçlarımıza göre dikkat çeken bir diğer nokta II. bölge fleksör tendon yaralanmalarının işe geri dönüş süresinin oldukça uzun olmasıydı. Bu hastaların ortalama MEYCS çok yüksek olmasa bile (24±11.32) işe geri dönüş süreleri 90±17.72 gün gibi uzun bir süreydi. Bu sonucun sorunlu bölge olarak bilinen ikinci bölgenin cerrahi tamir, dikiş tekniği, dikiş materyali, postoperatif rehabilitasyon gibi tüm etmenlerin Ulus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2

işe geri dönüş ve aktiviteye katılımda yaralanma ciddiyetinden daha önemli faktörler olduklarını göstermektedir. Sonuç olarak, travma çeşitliliğinin yanında literatürden farklı olarak yaralanma ciddiyetinin işe dönüşün yanında fiziksel değerlendirme, aktiviteye katılım ve fonksiyonel durum ile ilişkisini ortaya koyması bu çalışmanın yön gösterici taraflarıdır. El ve önkol yaralanmalarından sonra tedavi sonuçlarının izlenmesinde UFÖSS’nin önerdiği değerlendirme yöntemlerinin kullanılmasının yaralanmanın yol açtığı sosyolojik, psikolojik, mesleki ve ekonomik etkilerini ortaya koymada rasyonel sonuçlara ulaşmamızı sağlayacaktır.[12,18,31] Bunun yanında, el rehabilitasyonunda seçilmiş protokollere ekstremitenin günlük yaşam aktivitelerinde kullanımına yönelik aktivitelerin de ilave edilmesinin, meslek öncesi hazırlığa yönelik terapi programlarının sosyal katılım ve mesleki aktivitelere dönüşü kolaylaştıracağı ve hastaları bu yönde motive edeceği düşüncesindeyiz. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR 1. O’Sullivan ME, Colville J. The economic impact of hand injuries. J Hand Surg Br 1993;18:395-8. 2. Rosberg HE, Carlsson KS, Höjgård S, Lindgren B, Lundborg G, Dahlin LB. Injury to the human median and ulnar nerves in the forearm--analysis of costs for treatment and rehabilitation of 69 patients in southern Sweden. J Hand Surg Br 2005;30:35-9. 3. Angermann P, Lohmann M. Injuries to the hand and wrist. A study of 50,272 injuries. J Hand Surg Br 1993;18:642-4. 4. Bernstein ML, Chung KC. Hand fractures and their management: an international view. Injury 2006;37:1043-8. 5. Hill C, Riaz M, Mozzam A, Brennen MD. A regional audit of hand and wrist injuries. A study of 4873 injuries. J Hand Surg Br 1998;23:196200. 6. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 2001;26:908-15. 7. Rosberg HE, Carlsson KS, Dahlin LB. Prospective study of patients with injuries to the hand and forearm: costs, function, and general health. Scand J Plast Reconstr Surg Hand Surg 2005;39:360-9. 8. Bear-Lehman J. Factors affecting return to work after hand injury. Am J Occup Ther 1983;37:189-94. 9. Tuncalı D, Toksoy K, Terzioğlu A, Aslan G. Üst ekstremite akut tendon yaralanmaları: Epidemiyolojik değerlendirme. Türk Plast Surg 2005;13:24-7. 10. Clay FJ, Newstead SV, Watson WL, Ozanne-Smith J, McClure RJ. Bio-psychosocial determinants of time lost from work following non life threatening acute orthopaedic trauma. BMC Musculoskelet Disord 2010;11:6. 11. MacDermid JC. Measurement of health outcomes following tendon and nerve repair. J Hand Ther 2005;18:297-312. 12. Schoneveld K, Wittink H, Takken T. Clinimetric evaluation of measurement tools used in hand therapy to assess activity and participation. J Hand Ther 2009;22:221-36. 13. Campbell DA, Kay SP. The Hand Injury Severity Scoring System. J Hand Surg Br 1996;21:295-8. 14. Saxena P, Cutler L, Feldberg L. Assessment of the severity of hand injuries using “hand injury severity score”, and its correlation with the func-

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Çakır ve ark. El ve önkol yaralanmalarında yaralanma ciddiyeti ile işe geri dönüş, bozukluk, aktivite ve katılım arasındaki ilişkinin incelenmesi tional outcome. Injury 2004;35:511-6. 15. Buck-Gramcko D, Dietrich FE, Gogge S. Evaluation criteria in followup studies of flexor tendon therapy. [Article in German] Handchirurgie 1976;8:65-9. [Abstract] 16. Cambridge CA. Range of motion measurements of the hand. In: Hunter JM, Schneider LH, Mackin EJ, et al., editors. Rehabilitation of the hand: surgery and therapy. 3rd ed. St. Louis, MO: Mosby; 1990. p. 82-92. 17. Fess EE. Grip strength. In: Casanova JS, editor. Clinical assessment recommendations. American Society of Hand Therapists (Vol 5). 2nd ed. Chicago: 1992. p. 40-5. 18. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG) Am J Ind Med 1996;29:602-8. 19. Stern EB. Stability of the Jebsen-Taylor Hand Function Test across three test sessions. Am J Occup Ther 1992;46:647-9. 20. Sanal HT. El ve el bileği kemik doku yaralanmaları: nedenler, işgücü kaybı. Gülhane TD 2006;48:215-7. 21. Jaquet JB, van der Jagt I, Kuypers PD, Schreuders TA, Kalmijn AR, Hovius SE. Spaghetti wrist trauma: functional recovery, return to work, and psychological effects. Plast Reconstr Surg 2005;115:1609-17. 22. Michaels AJ, Michaels CE, Smith JS, Moon CH, Peterson C, Long WB. Outcome from injury: general health, work status, and satisfaction 12 months after trauma. J Trauma 2000;48:841-50. 23. Kitis PT, Buker N, Kara IG. Comparison of two methods of controlled

mobilisation of repaired flexor tendons in zone 2. Scand J Plast Reconstr Surg Hand Surg 2009;43:160-5. 24. Matsuzaki H, Narisawa H, Miwa H, Toishi S. Predicting functional recovery and return to work after mutilating hand injuries: usefulness of Campbell’s Hand Injury Severity Score. J Hand Surg Am 2009;34:880-5. 25. Altan L, Akin S, Bingöl U, Ozbek S, Yurtkuran M. The prognostic value of the Hand Injury Severity Score in industrial hand injuries. Ulus Travma Acil Cerrahi Derg 2004;10:97-101. 26. van der Molen AB, Matloub HS, Dzwierzynski W, Sanger JR. The hand injury severity scoring system and workers’ compensation cases in Wisconsin, USA. J Hand Surg Br 1999;24:184-6. 27. Urso-Baiarda F, Lyons RA, Laing JH, Brophy S, Wareham K, Camp D. A prospective evaluation of the Modified Hand Injury Severity Score in predicting return to work. Int J Surg 2008;6:45-50. 28. MacKenzie EJ, Morris JA Jr, Jurkovich GJ, Yasui Y, Cushing BM, Burgess AR, et al. Return to work following injury: the role of economic, social, and job-related factors. Am J Public Health 1998;88:1630-7. 29. Crook J, Moldofsky H, Shannon H. Determinants of disability after a work related musculetal injury. J Rheumatol 1998;25:1570-7. 30. Hou WH, Tsauo JY, Lin CH, Liang HW, Du CL. Worker’s compensation and return-to-work following orthopaedic injury to extremities. J Rehabil Med 2008;40:440-5. 31. Wong JY, Fung BK, Chu MM, Chan RK. The use of Disabilities of the Arm, Shoulder, and Hand Questionnaire in rehabilitation after acute traumatic hand injuries. J Hand Ther 2007;20:49-56.

ORIGINAL ARTICLE - ABSTRACT OLGU SUNUMU

Investigation of the relationship between severity of injury, return to work, impairment, and activity participation in hand and forearm injuries Negihan Çakır, P.T.,1 Ramazan Hakan Özcan, M.D.,2 Ali Kitiş, P.T.,3 Nihal Büker, P.T.3 Physical Therapy Unit, Bornova Türkan Özilhan State Hospital, İzmir; Department of Plastic, Reconstructive and Aesthetic Surgery, Pamukkale University Faculty of Medicine, Denizli; 3 Pamukkale University School of Physical Therapy and Rehabilitation, Denizli 1 2

BACKGROUND: Forearm and hand injuries are the main cause of work-related disability. This study was planned to investigate the relationship between severity of injury, time of return to work, impairment, and activity participation of patients with hand and forearm injuries. METHODS: One hundred and thirty patients who had patients who had had forearm or hand injuries with a mean age of 31±11.13 years participated in this study. Injury severity was evaluated using Modified Hand and Forearm Injury Severity Scoring (MHISS) after surgery. Patients were evaluated using the Jebsen Hand Function Test ( JHFT) and Buck-Gramko scoring eight weeks after injury. Additionally, grip strength was evaluated with a dynamometer, and disability/symptom score was evaluated using the Turkish version of the Disabilities of the Arm, Shoulder, and Hand (DASH-T) questionnaire twelve weeks after injury. RESULTS: A significant relationship between MHISS, hand strength, time of return to work, DASH-T, and Buck-Gramko scores of patients with forearm and hand injuries was identified (p≤0.05). Higher impairment was significantly related to body structure and body functions (1.86±1.47), and the most limited activity was writing (2.06±1.50) regarding ICF framework. CONCLUSION: Higher MHISS scores were associated with delays in returning to work and lower activity participation. The DASH-T score was the most strongly associated with time of return to work. Furthermore, there is a positive relation between time of return to work and activity participation of patients. Key words: Activity participation; disability; hand and forearm injury; severity of injury. Ulus Travma Acil Cerr Derg 2014;20(2):120-126

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doi: 10.5505/tjtes.2014.04741

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K Lİ NİK Ç A LI ŞM A

İnvajinasyonda kolay, güvenli ve etkili bir tedavi yöntemi: Ultrason eşliğinde hidrostatik redüksiyon Dr. Fatma Esra Bahadır Ülger,#1 Dr. Aykut Ülger,2 Dr. Ali Erdal Karakaya,3 Dr. Fatih Tüten,1 Dr. Ömer Katı,3 Dr. Mustafa Çolak4 1

Kahramanmaraş Necip Fazıl Şehir Hastanesi, Kadın Doğum ve Çocuk Hastalıkları Hastanesi Ek Binası, Radyoloji Kliniği, Kahramanmaraş;

2

Kahramanmaraş Pazarcık Devlet Hastanesi, Radyoloji Kliniği, Kahramanmaraş;

Kahramanmaraş Necip Fazıl Şehir Hastanesi Kadın Doğum ve Çocuk Hastalıkları Hastanesi Ek Binası, Çocuk Cerrahisi Kliniği, Kahramanmaraş;

3 4

Kahramanmaraş Pazarcık Devlet Hastanesi, Genel Cerrahi Kliniği, Kahramanmaraş

ÖZET AMAÇ: İnvajinasyon pediatrik yaş grubunda önemli bir intestinal tıkanıklık nedenidir. Ultrason eşliğinde hidrostatik redüksiyon invajinasyon tedavisinde popüler bir yöntemdir. Bu çalışmada ultrason ile invajinasyon tanısı konan hastaların demografik özellikleri, tedavi yaklaşımlarını paylaşmayı amaçladık. GEREÇ VE YÖNTEM: Ağustos 2011-Mayıs 2013 tarihleri arasında ultrason ile invajinasyon tanısı konan 41 olgu geriye dönük olarak incelendi. Bu olgulardan klinik kontrendikasyonu bulunmayan 24’üne ultrason eşliğinde hidrostatik redüksiyon ile tedavi uygulandı. BULGULAR: Olguların 24’ü erkek, 17’si kız olup erkek-kız oranı 1.4/1 olarak bulundu. Olguların çoğunluğu 6-24 ay ve 2-5 yaş aralığında saptandı. Yaş ortalaması 31.12±26.32 (dağılım 3-125) ay idi. Olgular en sık Nisan ve Mayıs aylarında saptandı. Klinik kontrendikasyonu bulunan 17 olgu doğrudan cerrahiye alındı. Ultrason eşliğinde hidrostatik redüksiyon yapılan 24 olgudan 20’sinde redüksiyon sağlandı. Bu olguların üçünde hastalık nüksetti. Üç olgudan ikisine tekrar hidrostatik redüksiyon yapılıp başarı sağlandı. Diğer olgu cerrahiye alındı. Toplamda 24 olguya 26 kez hidrostatik redüksiyon denenmiş olup 22’sinde başarı sağlandı (%84.6). Olgularda işleme bağlı komplikasyon görülmedi. SONUÇ: Ultrason eşliğinde hidrostatik redüksiyon, yüksek başarı oranları ve radyasyon riskinin bulunmaması nedeniyle invajinasyon tanısı alan çocuklara tedavi yaklaşımında ilk seçenek olmalıdır. Anahtar sözcükler: Hidrostatik redüksiyon; invajinasyon; ultrason.

GİRİŞ İnvajinasyon proksimal bağırsak segmentinin (intussusceptum) distal segment (intussuscipiens) içine teleskopik olarak girmesidir. Pediatrik yaş grubunda intestinal tıkanıklığın önemli bir nedenidir. İnvajinasyonun en sık görülme yaşı literatürde 6-24 ay olarak belirtilmiş olmakla birlikte kimi yayınlarda pik inŞimdiki kurumu: Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, İstanbul

#

Sorumlu yazar: Dr. Fatma Esra Bahadır Ülger. Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, E5 Karayolu Üzeri İçerenköy, 34752 Ataşehir, İstanbul Tel: 0216 - 578 30 00

E-posta: esrabahadir@hotmail.com Ulus Travma Acil Cerr Derg 2014;20(2):127-131 doi: 10.5505/tjtes.2014.37898 Telif hakkı 2014 TJTES

Ulus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2

sidansın üç yaşa kadar devam ettiği bildirilmiştir.[1,2] İnsidansı 1000 canlı doğumda 1.5-4’tür ve erkek kız oranı 3/2’dir.[3] Klinik olarak en sık görülen semptom karın ağrısı olup kusma ve kanlı gaitanın eşlik ettiği klasik triad hastaların ancak üçte birinde mevcuttur.[4] Direkt karın grafisinde intestinal tıkanıklığa ait bulgular ya da sağ alt kadranda hava yokluğu saptanabilirken ultrason ile tanı %100’e yakın duyarlılık ve özgüllük ile konabilir. [3,5] Ultrasonun tanıda ilk seçenek olmasının yanında, ultrason eşliğinde hidrostatik redüksiyon tekniği ile invajinasyonun cerrahi dışı tedavi yöntemi olarak da sıkça kullanılması oldukça önemlidir. Bu tedavi yönteminin başarı oranları değişmekle birlikte %80’in üzerindedir.[6] Ayrıca bu yöntemin kolay, etkili ve ekonomik olması; daha az morbiditeye yol açması ile hastane yatış süresinde kısalma gibi çok sayıda avantajı bulunmaktadır. Bu çalışmada, yaklaşık iki yıllık süreçte ultrason ile invajinasyon tanısı alan hastaların demografik özellikleri, tedavi yak127


Bahadır Ülger ve ark. Ultrason eşliğinde hidrostatik redüksiyon

laşımları (ultrason eşliğinde hidrostatik redüksiyon, cerrahi redüksiyon) ve deneyimlerimizi paylaşmayı amaçladık.

GEREÇ VE YÖNTEM Çalışmaya Ağustos 2011-Mayıs 2013 tarihleri arasında ultrason ile invajinasyon tanısı konan 41 olgu alındı. Olguların yaşları, cinsiyetleri, yakınmaları, başvuru ayı, invajine segmentin lokalizasyonu, tedavi yöntemleri açısından hasta kayıtları geriye dönük olarak incelendi. İnvajinasyon tanısı ve ultrason eşliğinde hidrostatik redüksiyon tedavisi, ultrason cihazı ile (Mindray, DC-3 ve DC-7 Nanshan Shenzhen P.R. China) 5-10 MHz lik lineer prob ve 2-5 MHz’lik konveks problar kullanılarak gerçekleştirildi. Ultrason eşliğinde hidrostatik redüksiyon tedavisi uygulanan olgular işlem öncesi tekrar sonografik olarak değerlendirildi (Şekil 1). Target (hedef ) bulgusunun devam ettiği görüldükten sonra çocuk cerrahı tarafından rektal tüp rektuma yerleştirilip balonu şişirildi ve sabitlendi. Serum fizyolojik hastadan 100

cm yükseklikte askıya asıldı. Isıtılmış serum fizyolojiğin kolona verilişi ve sıvının bağırsak içindeki hareketi ultrasonla takip edildi. Hedef görünümünün kaybolması, çekumdan ileoçekal valv aracılığı ile ileuma sıvı geçişinin görülmesi ile redüksiyonun sağlandığı kabul edildi (Şekil 2). İşlem süresince hasta olası komplikasyonlar açısından izlendi. Redüksiyon sağlanan olgular 24 saat boyunca gözlem altında tutuldu. Tam redüksiyonun sağlanamadığı kısmi redükte olan olgular cerrahiye alındı.

BULGULAR Olguların 24’ü erkek (%58.5), 17’si kız (%41.5) olup erkek kız oranı 1.4/1 olarak bulundu. Olguların %7.2’si ≤6 ay, %41.5’i 6-24 ay, %39’u 2-5 yaş ve %12.2’si ≥5 yaş olarak saptandı. Yaş ortalaması 31.12±26.32 (dağılım 3-125) ay idi. Olgularda en sık görülen klinik bulgular sırasıyla karın ağrısı (%73.1), bulantı kusma (%67.4), distansiyon (%24.3), kanlı mukuslu gaita (%19.5), diare (%17.1) idi. Olguların 16’sı (%39) Nisan ve Mayıs aylarında tanı aldı. Ultrason ile hedef görünümü 22 hastada karın sağ alt kadranda çıkan kolona uyan lokalizasyonda, 16

(a)

(b)

(c)

(d)

Şekil 1. İnvajinasyonun tipik sonografik görüntüleri. (a, b) Konveks ve lineer probla alınan transvers kesitlerde tipik “target görüntüsü”. (c, d) Konveks ve lineer probla alınan boyuna kesitlerde yalancı böbrek görüntüsü (oklar).

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Bahadır Ülger ve ark. Ultrason eşliğinde hidrostatik redüksiyon

(a)

(b)

Şekil 2. (a) Hidrostatik redüksiyon öncesi tipik target görünümünün izlendiği invajinasyon olgusunda (b) hidrostatik redüksiyon sırasında ileoçekal valvden sıvı geçişine ait görüntü.

hastada karın sağ üst kadranda transvers kolon ve hepatik fleksuraya uyan lokalizasyonda saptanmıştır. Kalan üç hastada karın sol kadranlarında inen kolona uyan lokalizasyonda saptandı. Peritonit bulgusu, genel durum bozukluğu, üç günden uzun süreli semptomları olan, hastaneye ulaşımı mümkün olmayan ve gerekli şartların sağlanamadığı 17 olguya doğrudan cerrahi tedavi uygulandı. Ultrason eşliğinde hidrostatik redüksiyon yapılan 24 olgudan 20’sinde redüksiyon sağlandı. Dört olguda hidrostatik redüksiyon sağlanamadı ve bu hastalar cerrahiye alındı. Bu hastalardan üçünde elle redüksiyon yapılırken diğerinde kısa segment rezeksiyon yapıldı. Hidrostatik redüksiyon sağlanan olguların üçünde kontrolde bir hafta içinde tekrarlayan invajinasyon saptandı. Kliniği uygun olan ikisine tekrar hidrostatik redüksiyon yapılıp başarı sağlanırken nüks saptanan bir olgu peritonit bulgusu varlığı ve perforasyon riski nedeniyle doğrudan cerrahiye alındı. Bu olguya ameliyatta bağırsak rezeksiyonu gerçekleştirildi. Toplamda 24 olguya 26 kez hidrostatik redüksiyon denenmiş olup 22’sinde başarı sağlandı. Ultrason eşliğinde hidrostatik redüksiyonda başarı oranı %84.6 olarak saptandı. Olgularda işleme bağlı komplikasyon görülmedi.

TARTIŞMA İnvajinasyon bebeklerde ve çocuklarda acil müdahale gerektiren bir durumdur. İnvajinasyon olgularının çoğunda kesin neden bilinemezken belirginleşmiş Payer plakları, mezenterik lenf nodları, polipler, Meckel divertikülü ve duplikasyon kistleri en sık etiyolojik faktörler arasında kabul edilmektedir.[1] Semptomların genellikle nonspesifik olduğu göz önüne alınırsa tanı ve tedavideki gecikme barsak iskemisine, perforasyona, peritonite ve hatta ölüme bile neden olabilir. Ulus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2

Bu çalışmada invajinasyon olgularında yaş, cinsiyet ve invajinasyonun en sık görüldüğü aylara ait dağılım literatür ile uyumlu olarak bulundu.[1-3] İnvajinasyonların %80’den fazlası ileoçekal bölgededir ve bunlardan en sık görülenler sırasıyla ileokolik ve kolokoliktir. İnvajinasyonların %80 ve üzerinde invajine segmentin apeksi çıkan veya transvers kolondadır.[1,7] Çalışmada olgularımızın %92.6’sında invajine segmentin apeksi çıkan veya transvers kolonda gözlendi. İnvajinasyon tanısında ultrasonun duyarlılık ve özgüllüğü yaklaşık %100 olarak belirtilmiş olup tanıda altın standarttır.[8] İnvajinasyon sonografik olarak aksiyel görüntüde hedef veya tatlı çörek (doughnut) bulgusu; uzunlamasına görüntüde yalancı böbrek veya sandviç görüntüsü olarak karşımıza çıkar. Ultrason ile invajinasyon tipi belirlenebileceği gibi varsa invajinasyona sebep olan sürükleyici noktayı (leading point) da görme şansımız vardır. Ayrıca uzamış olgularda renkli Doppler ultrason incelemesi ile akım yokluğunun saptanması invajinasyonun irreduktabl olduğunu kuvvetle düşündürür ve hastaya yaklaşım ona göre planlanır.[8] Cerrahi; invajinasyona ve sürece ait komplikasyonlara müdahalede kesin bir yöntem olmasına karşın birçok dezavantajı bulunmaktadır. Hasta morbiditesi yanında ameliyat öncesi ve ameliyat sonrası süreçler nedeniyle artmış maliyet ve iş yükü gerektirmektedir. Ayrıca hastada ameliyat sonrası düşük de olsa nüks gelişebilmektedir. Hastanın ileriki yaşamında karın içi yapışıklığa bağlı bağırsak tıkanıklığı görülme riski %3-6’dır.[5,7] Kontrendikasyon yokluğunda cerrahi dışı yaklaşım ilk seçenek olmalı, başarı sağlanamazsa cerrahiye başvurulmalıdır.[9] İnvajinasyonun klasik cerrahi dışı tedavi yöntemi barium enema ile sağlanan redüksiyondur. Ancak gerek bu yöntem gerek pnömatik redüksiyon olsun hastanın ve redüksiyonu sağlayan ekibin radyasyona maruz kalmasına neden olmaktadır.[6] Pnömatik redüksiyonun hastada yaratacağı belirgin rahatsızlık hissi, daha fazla perforasyon riskinin bulunması, tansiyon pnömoperitoneum riski ile barium enemadan kaynaklanabilecek kimyasal peritonit riski göz önüne alındığında bu olgulara cerrahi dışı yaklaşımda hidrostatik redüksiyon ön plana geçmektedir.[5,9] Ultrason eşliğinde hidrostatik redüksiyon ilk olarak 1982 yılında Kim ve ark. tarafından denenmiştir.[10] İnvajinasyonda hasta grubunun çocuklar olduğu düşünülünce bu yöntemde radyasyon riskinin bulunmaması çok önemli bir avantajdır. Hasta işlem sırasında gözlem altındadır ve olası komplikasyonların tanısı anında konabilir. Erken tanı ve tedavi şansı vermesi ile hastanın prognozunu kısa ve uzun dönemde olumlu yönde etkilemektedir.[11] Ultrasonla redüksiyonda başarı kriteri işlem sırasında ileoçekal valvden ileuma sıvı geçişini görmek olarak tanımlanmıştır. Aynı zamanda hedef bulgusunun kaybolması da redüksiyonun sağlandığını gösterebilir.[6] Biz olgularımızda her ikisine de baktık. Redüksiyonun sağlandığına dair ultrasonografik bulguların yanında işlem sonunda klinik düzelmeyi de gözledik. 129


Bahadır Ülger ve ark. Ultrason eşliğinde hidrostatik redüksiyon

Bu çalışmada klinik olarak perforasyon, peritonit düşünülmeyen olgularımızda cerrahi dışı tedavi yöntemi olarak hidrostatik redüksiyonu tercih ettik. Üç olguda ikişer kez olmak üzere 24 olguya yaptığımız 26 hidrostatik redüksiyonun 22’sinde başarılı redüksiyon sağladık. Hidrostatik redüksiyon yaptığımız dört olguda başarı sağlanamadı. Literatürde ultrason eşliğinde hidrostatik redüksiyon yapılan olgularda başarı oranının %80 üzeri olduğu bildirilmiştir.[1,6,8,12] Çalışmamızda başarı oranını %84.6 olarak saptadık. Cerrahi dışı yaklaşımla yapılan redüksiyonda nüks riski %10’dan az olarak bildirilmiştir.[9] Bu tamamlanamayan redüksiyona veya sürükleyici noktaya bağlı olabilir. Literatürde nüks saptanan olgularda klinik durum göz önüne alınarak hidrostatik redüksiyonun tekrarlanabileceği bildirilmektedir.[1,6,8,9] Bu çalışmada nüks oranı %12.5 olarak saptandı. İnvajinasyon açısından 48 saati aşkın süredir şüpheli kliniği olan olgulara yaklaşımda ultrason eşliğinde hidrostatik redüksiyonun başarı oranlarının daha düşük olduğu ve bu olgularda cerrahi yaklaşımın tercih edildiği bildirilmektedir. Bu olgularda leading point varlığının ve komplikasyon gelişme riskinin yüksek olduğu belirtilmektedir.[7,13] Bu çalışmada ultrasonla invajinasyon tanısı konan olgulardan semptomları üç günden daha fazla olanlar perforasyon riski nedeniyle doğrudan ameliyata alınmıştır. Literatürde üç yaş üzeri olgulara yaklaşımda leading point ihtimalinin göz önünde bulundurulmasını ancak yaşın herhangi bir kontrendikasyon oluşturmadığı belirtilmiştir.[1,6] Yaşça büyük olan çocuklarda ve tekrarlayan olgularda sürükleyici nokta varlığına ait ihtimali her zaman göz önününde bulundurmak gereklidir.[6] Özellikle çoklu nükslerde bu ihtimal daha fazladır.[6,7,14] Tander ve ark.[6] üç yaş üzeri hastalarda hidrostatik redüksiyonun başarı oranı düşük olsa bile denenebileceğini, ancak hastanın klinik ve radyolojik olarak iyi bir gözlem altında tutulması gerektiğini belirtmektedirler. Ultrason eşliğinde hidrostatik redüksiyonda oldukça düşük perforasyon oranları bildirilmiştir (%0.17-0.26).[8,11] Bu çalışmada 24 hastada 26 hidrostatik redüksiyon yapılmış olup olguların hiçbirinde perforasyona rastlanmadı. Sonuç olarak, ultrason eşliğinde hidrostatik redüksiyon, invajinasyon tanısı alan çocuklara tedavi yaklaşımında basit, etkili ve güvenilir bir yöntemdir. Klinik olarak doğru seçilmiş olgularda yüksek başarı oranlarına sahip olması ve komplikasyon riski-

130

nin çok düşük olması cerrahi girişimlerin sayısını ve dolayısıyla cerrahiye bağlı morbiditeyi azaltmaktadır. Ultrason eşliğinde hidrostatik redüksiyon tedavisi invajinasyon olgularına yaklaşımda ilk seçenek olarak görülmelidir. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR 1. Digant SM, Rucha S, Eke D. Ultrasound guided reduction of an ileocolic intussusception by a hydrostatic method by using normal saline enema in paediatric patients: a study of 30 cases. J Clin Diagn Res 2012;6:1722-5. 2. Vidmar D, Perović AV. Sonographycally guided hydrostatic reduction of childhood intusssusception. Radiol Oncol 2004;38:269-73. 3. Munir A, Falah SQ, Waheed D. Surgical management of childhood intussusception and its outcome in DHQ Teaching Hospital D.I.Khan. Gomal J Med Sci 2012;10:219-21. 4. Eliçevik M, Özcan R, Emre Ş, Topuzlu Tekant G, Sarımurat N, Erdoğan E ve ark. Çok iyi bilinen bir konunun hızlı tekrarı: İnvajinasyon. Cerrahpaşa Tıp Dergisi 2006;37:41-4. 5. Mensah Y, Glover-Addy H, Etwire V, Appeadu-Mensah W, Twum M. Ultrasound guided hydrostatic reduction of intussusception in children at Korle Bu Teaching Hospital: an initial experience. Ghana Med J 2011;45:128-31. 6. Tander B, Baskin D, Candan M, Başak M, Bankoğlu M. Ultrasound guided reduction of intussusception with saline and comparison with operative treatment. Ulus Travma Acil Cerrahi Derg 2007;13:288-93. 7. DiFiore JW. Intussusception. Semin Pediatr Surg 1999;8:214-20. 8. Krishnakumar, Hameed S, Umamaheshwari. Ultrasound guided hydrostatic reduction in the management of intussusception. Indian J Pediatr 2006;73:217-20. 9. Hesse Afua AJ, Abantanga FA, Lakhoo K. Intussusception. In: Ameh EA, Bickler SW, Lakhoo K, Nwomeh BC, Poenaru D, editors. Paediatric surgery: a comprehensive text for Africa. Seattle, WA, USA: 2011; vol II(chap 68). p. 404-12. 10. Sarin YK, Rao JS, Stephen E. Ultrasound guided water enema for hydrostatic reduction of childhood intussusception: a preliminary experience. Gastrointestinal Radiology 1999;9:59-63. 11. Khan MY, Uzair M, Fayaz M, Ullah K, Ullah N. Success rate of ultrasound guided hydrostatic reduction for childhood intussusception. J Med Sci 2012;20:3-6. 12. Nayak D, Jagdish S. Ultrasound guided hydrostatic reduction of intussusception in children by saline enema: our experience. Indian J Surg 2008;70:8-13. 13. van den Ende ED, Allema JH, Hazebroek FW, Breslau PJ. Success with hydrostatic reduction of intussusception in relation to duration of symptoms. Arch Dis Child 2005;90:1071-2. 14. Daneman A, Alton DJ, Lobo E, Gravett J, Kim P, Ein SH. Patterns of recurrence of intussusception in children: a 17-year review. Pediatr Radiol 1998;28:913-9.

Ulus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2


Bahadır Ülger ve ark. Ultrason eşliğinde hidrostatik redüksiyon

ORIGINAL ARTICLE - ABSTRACT OLGU SUNUMU

An easy, safe and affective method for the treatment of intussusception: ultrasound-guided hydrostatic reduction Fatma Esra Bahadır Ülger, M.D.,1 Aykut Ülger, M.D.,2 Ali Erdal Karakaya, M.D.,3 Fatih Tüten, M.D.,1 Ömer Katı, M.D.,3 Mustafa Çolak, M.D.4 Department of Radiology, Kahramanmaraş Necip Fazıl City Hospital Gynecology-Obstetric and Pediatric Hospital Outbuilding, Kahramanmaraş; Department of Radiology, Kahramanmaraş Pazarcık State Hospital, Kahramanmaraş; 3 Department of Pediatric Surgery, Kahramanmaraş Necip Fazıl City Hospital Gynecology-Obstetric and Pediatric Hospital Outbuilding, Kahramanmaraş; 4 Department of General Surgery, Kahramanmaraş Pazarcık State Hospital, Kahramanmaraş 1 2

BACKGROUND: Intussusception is one of the important causes of intestinal obstruction in children. Hydrostatic reduction under ultrasound guidance is a popular treatment method for intussusception. In the present study, we aimed to explain the demographic characteristics of and treatment approaches in patients diagnosed with intussusception by ultrasound. METHODS: Forty-one patients diagnosed with intussusception by ultrasound between August 2011 and May 2013 were retrospectively analyzed. Twenty-four of these patients who had no contraindications had been treated with ultrasound-guided hydrostatic reduction. RESULTS: Twenty-four of the patients were male and 17 were female, a 1.4/1 male-to-female ratio. The majority of the patients were between the ages of 6-24 months and 2-5 years. The mean age was 31.12±26.32 months (range 3-125). Patients were more frequently diagnosed in April and May. Seventeen patients who had clinical contraindications enrolled directly for surgery. In 20 of the 24 patients who underwent ultrasoundguided hydrostatic reduction, reduction was achieved. Three experienced recurrence. In two of these patients, successful reduction was achieved with the second attempt. The remaining patient was enrolled for surgery. Hydrostatic reduction was performed 26 times on these 24 patients, and in 22, success was achieved (84.6%). No procedure-related complications occurred in the patients. CONCLUSION: Ultrasound-guided hydrostatic reduction, with its high success rates and lack of radiation risk, should be the first choice therapeutic approach for children diagnosed with intussusception. Key words: Hydrostatic reduction; intussusception; ultrasound. Ulus Travma Acil Cerr Derg 2014;20(2):127-131

doi: 10.5505/tjtes.2014.37898

Ulus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2

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K Lİ NİK Ç A LI ŞM A

Çocuklarda künt böbrek travmaları: Kırk bir olgunun geriye dönük olarak değerlendirilmesi Dr. Mehmet Emin Balcıoğlu,1 Dr. Mehmet Emin Boleken,1 Dr. Muazez Çevik,1 Dr. Murat Savaş,2 Dr. Fatıma Nurefşan Boyacı3 1

Harran Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Şanlıurfa;

2

Harran Üniversitesi Tıp Fakültesi, Üroloji Anabilim Dalı, Şanlıurfa;

3

Harran Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Şanlıurfa

ÖZET AMAÇ: Çocukluk çağında, künt karın travma sonrası gelişen böbrek yaralanmaları ameliyatsız yöntemle başarıyla tedavi edilmektedir. Bu çalışmada, çocuklarda künt karın travmasına bağlı böbrek yaralanması olan olgular değerlendirildi. GEREÇ VE YÖNTEM: Bu çalışmada 2000 ile 2012 yılları arasında künt travmaya bağlı böbrek yaralanması nedeniyle çocuk cerrahi servisinde takip edilen olguların bilgileri geriye dönük olarak değerlendirildi. Olgular demografik özellikleri, klinik, tedavi ve sonuçları açısında değerlendirildiler. BULGULAR: Kırk bir olgu yatırıldı. Olguların yaş ortalaması 10±4.85 idi. Böbrek yaralanmalarının çoğu sınıf 1-2 idi. En sık böbrek yaralanma mekanizması düşmeydi. Bütün olgular başlangıçta konservatif takip edildi. Hemodinamik stabilitesi bozulan üç olgu (sınıf 4-5) ameliyata alındı. Pedikül yaralanmasından dolayı, üç olguya da nefrektomi yapıldı. SONUÇ: Çocuklarda böbrek parankim yaralanmalarında konservatif tedavi etkili ve güvenilirdir. Çoğu böbrek hasarı cerrahi gerektirmemesine rağmen, hasarın derecesine bakılmaksızın hayatı tehdit eden kanamalara cerrahi girişim yapılmadır. Anahtar sözcükler: Böbrek; çocuk; konservatif tedavi; travma.

GİRİŞ Çocukluk çağı travmalarının %80-90’ını künt travmalar oluşturmaktadır.[1] Bunların %10-20’si böbrek yaralanmalarıdır.[1-3] Yetişkinlere göre çocukların böbreklerinin boyutları vücuda göre daha büyük, hareketli, daha aşağıda, daha az perirenal yağ dokusuna sahip olduğundan, karın kasları daha zayıf ve göğüs duvarının koruyuculuğu daha az olduğundan dolayı daha sık yaralanmaktadır.[1-3] Çocuklardaki künt böbrek yaralanmalarının (KBY) çoğu (%85) düşük derecelidir (sınıf 1-3).[1,2] Böbrek yaralanmalarının değerlendirilmesi klinik ve radyolojik bulgulara göre yapılmaktadır.[1] Günümüzde görüntüleme

Sorumlu yazar: Dr. Muazez Çevik, Harran Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, 63100 Şanlıurfa Tel: 0414 - 318 33 51 E-posta: cevikmuazzez@gmail.com Ulus Travma Acil Cerr Derg 2014;20(2):132-135 doi: 10.5505/tjtes.2014.65392 Telif hakkı 2014 TJTES

132

ve takip ile cerrahi girişim oranı %4.6’lara kadar düşmüştür. [3] Böbrek yaralanmalarında ilk tedavi seçeneği konservatif olmakla birlikte yüksek dereceli yaralanmalarda ve idrar ekstravazasyonun olduğu durumlarda tartışmalıdır.[2,4-7] Bu çalışmada, KBY nedeniyle takip edilen olgular, klinik bulguları ve tedavi yaklaşımları açısında değerlendirildiler.

GEREÇ VE YÖNTEM Bu çalışmada Ocak 2000 ile Mart 2012 yılları arasında Çocuk Cerrahisi Kliniği’nde KBY nedeniyle yatırılan olguların verileri geriye dönük olarak değerlendirildi. Olgular yaş, cinsiyet, travma mekanizması, eşlik eden yaralanma yaralanmanın derecesi, hematüri, tedavi şekli, kan transfüzyonu hastanede kalış süresi ve sonuçlar açısında değerlendirildi. Ultrasonorafi’de (USG) KBY düşünülen tüm olgulara intravenöz kontrastlı bilgisayarlı tomografi (BT) çekildi. Bazen radyoloji uzmanına ulaşılmadığında da ilk olarak BT çekildi. Hemodinamisi stabillendikten ve/veya hematürisi kaybolduktan 24 saat sonra hastanede taburcu edildi. Hastalar genelde 21 gün sonra USG kontrolüne gerektiğinde kontrastlı BT ya da sintigrafi istendi. Takiplerdeki kayıtlar hasta dosyasına kayıt yapılamadığında ulaşılamadı. Yaralanmanın derecesi, American Association for the Surgery of Trauma (AAST) skorlanmasına göre yapıldı.[1] Ulus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2


Verilerin toplanması ve değerlendirilmesi “SPSS for Windows, 11.5” (SPSS Inc., USA) programı kullanılarak yapıldı. Yaralanma bulguları, demografik analizi (yaş, cinsiyet), yaralanma bulguları, sonuçları ve kliniğin değerlendirilmesi için tanımlayıcı istatistik analizi ve ki-kare testi ile sonuçlar değerlendirildi. Değişkenler için ortalama±standart sapma %95 güvenlik aralığı ile ifade edildi. P<0.05 değeri anlamlı olarak kabul edildi.

BULGULAR Bu çalışmada, KBY sebebi ile yatırılarak takip ve tedavisi yapılan toplam 41 olgu değerlendirmeye alındı. Olguların %53.7’si erkek (n=22) iken %46.3”ü kızdı (n=19). Ortalama yaşları 10±4.85 (2-15) yıldı. Künt böbrek yaralanmaları olguların %58.5’de yüksekten düşme (n=24), %36.6’da trafik kazası (n=15) ve %4.9’da diğer (at tepmesi) (n=2) nedenlerden dolayı meydana gelmişti. Olguların %48.8’inde sağ böbrek (n=20), %48.8’inde sol böbrek (n=20) ve %2.4’ünde iki taraflı böbrek (n=1) yaralanması

vardı. Yaralanmaların %31.7’si sınıf 1 (n=13), %31.7’si sınıf 2 (n=13), %14.6’sı sınıf 3 (n=6), %14.6’sı sınıf 4 (n=6) ve %7.3’ü sınıf 5 (n=3) idi (Şekil 1a-e, Şekil 2). Yirmi altı olguda izole böbrek yaralanması var iken 15’inde ek organ yaralanması vardı. Eşlik eden ek organ yaralanmaları akciğer (n=2), karaciğer (n=4), dalak (n=2), akciğer ve karaciğer (n=3), kolon (n=1), ileum (n=1), mesane (n=1) ve üretraydı (n=1). Otuz dört olgu konservatif olarak takip edildi. Yedi olguya cerrahi tedavi uygulandı. Cerrahi tedavi olarak olguların nefrektomi (n=3), mesane onarımı (n=1), piyeloplasti (n=1), ileum onarımı (n=1) ve üretra (n=1) onarımı yapıldı (Şekil 3). Üretra ve mesane onarımı yapılan hastaların yapılan incelemelerinde üretro-sistografide kontrast madde ekstravazasyonu tespit edildi. İdrar ekstravazasyonu rastlanan bu olgular cerrahi olarak tedavi edilmiştir. Üç olguda kanama kontrol altına alınmayınca ameliyata alındı, nefrektomi yapıldı.

(a)

(b)

(c)

(d)

(e) Şekil 1. (a) Sınıf 5 böbrek yaralanması; böbreğin çoklu laserasyonlarla parçalara ayrılması, renal arterde veya vende avülsiyon. (b) Sınıf 4 böbrek yaralanması; kortikomedüller bileşkeye ve toplayıcı sisteme kadar uzanan parankimal laserasyon. (c) Sınıf 3 böbrek yaralanması; parankim laserasyonu. (d) Sınıf 2 böbrek yaralanması; sınırlı perirenal hematom. (d) Sınıf 1 böbrek yaralanması; parankim hasarı olmadan kontüzyon veya sınırlı subkapsüler hematom.

Ulus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2

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Balcıoğlu ve ark. Çocuklarda künt böbrek travmaları

ları veya aktivite yaralanmaları sonucu meydana gelmektedir. [1] Bu çalışmada en sık KBY sebebleri, yüksekten düşme ve trafik kazalarıydı.

100

Yüzde

80

Böbrek yaralanmaları izole ya da ek organ yaralanmalarıyla beraber olabilir.[1] Çalışmamızdaki olguların %63.4 oranında böbrek yaralanmaları izole idi. En sık yaralanan ek organ karaciğerdi. Bulgularımız veriler literatürle uyumluydu. Yaralanmanın sıklığı açısında iki böbrek arasında fark yoktu.

60 %100

40

20 %31.70

%31.70 %14.60

%14.60

%7.30

(3 ) G

5

(6 ) G

3 G

4

(6 )

) (1 3 2 G

To p

G

1

la m

(1 3

(4 1

)

)

0

Şekil 2. Böbrek travma hastalarında yaralanma derecesi. 100.00 %82.90

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Şekil 3. Böbrek travma hastalarında uygulanan tedavi.

Radyolojik inceleme olarak ilk başvuru esnasında; olguların hepsine direkt grafi çekildi. Olguların %66.1’ine USG ve %33.9’una karın BT’si ile tanı konuldu. %7.2 olguya retrograd uretro-sistografi çekildi. İdrar incelemesi, tüm olgularda bakıldı. Yirmi beş olguda hematüriye rastlandı. Olguların %35.9’u da (n=14) makroskobikti. Makroskobik hematüri olguların (n=4) ikinci gün, olguların (n=6) üçüncü gün ve olguların (n=4) beşinci gün hematürisi kayboldu. Makroskobik hematüri ile böbrek yaralanmanın ciddiyeti arasında anlamlı ilişki vardı (p<0.05). Olguların %34.1’ine (n=14) eritrosit süspansiyonu replasmanı yapıldı. Olguların hastanede yatış süresine bakıldığında %19.5 olgunun (n=8) yatış süresi 1-3 gün arasındaydı. Geriye kalan diğer olguların (n=33) hastanede kalış süresi 4-10 gün arası olduğu görüldü. Takip ettiğimiz böbrek travmalı olgularda mortalite olmadı.

TARTIŞMA Çocukluk dönemindeki böbrek yaralanmalarının en sık nedeni künt travmalarıdır.[1] Künt yaralanmalar düşmeler, trafik kaza134

Böbrek yaralanmalardan tedavinin amacı, doğru evreleme, böbrek fonksiyonunu maksimum korunması ve minimal komplikasyondur.[1,4] Son yıllarda, tanı ve takip yöntemlerinin gelişmesi ve bu konuda hekimlerin tecrübelerin artmasıyla daha az invaziv tedavi yöntemleri kullanılmaya başlanmıştır.[4] Solid organ yaralanmalarındaki ameliyatsız yöntemle tedavinin başarı oranları günümüzde %90’ların üzerine çıkmıştır.[8-10] 1951 yılında King ve Schumacker’in postsplenektomi sepsisini göstermeleri ve çocuk cerrahlarının dalağı mümkün olduğunca koruma çalışmalarıyla başlayan bu süreçte başlangıçta çeşitli kısıtlamalara neden olan belirsizlikler ve kuşkular her gün çoğalan başarılı sonuçların görülmesiyle artık kaybolmuştur. [10] Bizim çalışmamızda da böbrek yaralanması nedeniyle takip ettiğimiz 41 olgunun sadece 7’si (%17.1) çeşitli nedenlerle cerrahi tedaviye alındı. Ameliyat edilen 3 olguya (%7.3) renal pedikül yaralanmasından dolayı nefrektomi uygulandı. Diğer 4 olgu eşlik eden yaralanmalara bağlı ameliyata alındı. Ameliyat oranın son yıllarda yapılan çalışmalara göre biraz daha yüksek olmasını olgu sayımızın az olmasına bağlı olduğunu düşünüyoruz. Olgularımızın hiçbirinde ölüm gerçekleşmedi. Bu sonuç çocuklarda KBY uygun tanı ve tedavisi sağlandığında mortalite olasılığının çok düşük olabileceği veya çalışmadaki olguların çoğunun düşük sınıflı yaralanmalarıyla ilgili olabileceğini düşünüyoruz. Solid organ yaralanmasının derecesi arttıkça ameliyatsız yöntemle tedavideki başarı oranı da azalmaktadır. Brasel ve ark.[11] 1998 yılında yaptıkları çalışmada yaralanmanın derecesi ile ameliyatsız yöntemle tedavinin başarısı arasındaki ters oranı ortaya koymuştur. Tüm çalışmanın başarı oranı %84 iken, sınıf 1’de %100, sınıf 2’de %90, sınıf 3’de %71, sınıf 4’de ise %20 başarı oranı saptamışlardır. Bu çalışmada da ameliyata aldığımız hastaların hepsi sınıf 5’ti. Karın travmalarının ilk değerlendirmesinde ve takibinde USG’nin noninvaziv olması, kısa sürede ve kolay uygulanabilir olması, ucuz olması, genellikle hasta nakli gerektirmemesi, gibi avantajları nedeniyle yaygın ve ilk kullanılan bir tanı aracıdır. Ultrasonografinin dezavantajı, yorumları yapan kişinin tecrübesine bağlı olmasıdır. BT renal travmaların tanısında ve ek organ yaralanmasının tespitinde altın standarttır. Bu çalışmadaki olgularda da ilk tanı aracı olarak en sık (%66.1) USG kullanılmıştır. Tespit edilen böbrek yaralanmaları intravenöz kontrastlı BT ile değerlendirildi. Pachter ve ark.[12] tarafından 1995 yılında yayınlanan 495 hastalık çalışmada konservatif tedavi başarı oranı %94, kan transfüzyonu ortalaması 1.9 İÜ ve hastanede kalış süresi ortalama 13 gün olarak saptanmıştır. Çalışmamızda kan transfüzyonu oranı ortalama 1.0 İÜ, hastanede kalış süresini ortalama 5.64±4.87 Ulus Travma Acil Cerr Derg, Mart 2014, Cilt. 20, Sayı. 2


Balcıoğlu ve ark. Çocuklarda künt böbrek travmaları

gün bulundu. Bu sonuçlar bizim hastalarımızın çoğunun yaralanmasının düşük dereceli olmasında kaynaklanmaktadır. Böbrek yaralanmalarında sonra olguların çoğunda hematüri görülebilmekle olguların %1.7-3.4’ünde hematüri görülmeyebilir.[1] Çalışmamızda hematüri insidansı %64.1 bulundu. Sonuç literatürle uyumluydu.[1] Bu konudaki çok sayıda çalışmada, ameliyatsız yöntemle takip ve tedavi için iyi bir klinik takip ve hemodinamik stabilitenin vazgeçilmez temel kurallar olduğu görülmüştür. Fizyolojik parametrelerin takibini temel alan, gerekli radyoloji olanaklarıyla desteklenen, deneyimli bir cerrahi ekibi tarafından uygulanan KBY’nin ameliyatsız yöntemle tedavisi en az cerrahi tedavi kadar etkili ve başarılı olabilmektedir.[13-15] Ameliyatsız yöntemle tedavi uygulanabildiği taktirde; anesteziye bağlı riskler ve olası komplikasyonlar, ameliyat sırasında iyatrojenik yaralanma riski, ameliyat sonrasında insizyonel herniasyon veya karıniçi yapışıklık riski, yüksek morbidite ve mortalite oranları, ameliyatın getirdiği yüksek maliyet, hastanede kalış ve işe dönüş süresinin daha uzun olması ve buna bağlı ekonomik kayıplar gibi ameliyatın getirdiği dezavantajlardan da kaçınılmış olunacaktır. Çalışmamız geriye dönük olarak dosya taraması olduğu için istenen tüm bilgilere ulaşılamamıştır. Ayrıca, geç takip sonuçlarının olmaması çalışmamızın eksikliklerinde bir diğeridir. Sonuç olarak, bu çalışma böbrek derecesi ne olursa olsun, hastaların tanı ve tedavisinin ameliyatsız yöntemle güvenli bir şekilde yapılabildiğini göstermektedir. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR 1. Brown RL, Falcone RA, Garcia VF. Genitourinary tract trauma.In:

Coran AG, Adzick NS, editors. Pediatric surgery. 7th ed. Philadelphia: Elsivier Inc; 2012. p. 311-25. 2. Tsui A, Lazarus J, Sebastian van As AB. Non-operative management of renal trauma in very young children: experiences from a dedicated South African paediatric trauma unit. Injury 2012;43:1476-81. 3. Santucci RA, Wessells H, Bartsch G, Descotes J, Heyns CF, McAninch JW, et al. Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee. BJU Int 2004;93:937-54. 4. Shariat SF, Jenkins A, Roehrborn CG, Karam JA, Stage KH, Karakiewicz PI. Features and outcomes of patients with grade IV renal injury. BJU Int 2008;102:728-33. 5. Rogers CG, Knight V, MacUra KJ, Ziegfeld S, Paidas CN, Mathews RI. High-grade renal injuries in children--is conservative management possible? Urology 2004;64:574-9. 6. Hai MA, Pontes JE, Pierce JM Jr. Surgical management of major renal trauma: a review of 102 cases treated by conservative surgery. J Urol 1977;118:7-9. 7. Bergren CT, Chan FN, Bodzin JH. Intravenous pyelogram results in association with renal pathology and therapy in trauma patients. J Trauma 1987;27:515-8. 8. Dreitlein DA, Suner S, Basler J. Genitourinary trauma. Emerg Med Clin North Am 2001;19:569-90. 9. King H, Shumacker HB Jr. Splenic studies. I. Susceptibility to infection after splenectomy performed in infancy. Ann Surg 1952;136:239-42. 10. Sartorelli KH, Frumiento C, Rogers FB, Osler TM. Nonoperative management of hepatic, splenic, and renal injuries in adults with multiple injuries. J Trauma 2000;49:56-62. 11. Brasel KJ, DeLisle CM, Olson CJ, Borgstrom DC. Splenic injury: trends in evaluation and management. J Trauma 1998;44:283-6. 12. Pachter HL, Knudson MM, Esrig B, Ross S, Hoyt D, Cogbill T, et al. Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma 1996;40:31-8. 13. Henderson CG, Sedberry-Ross S, Pickard R, Bulas DI, Duffy BJ, Tsung D, et al. Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center. J Urol 2007;178:246-50. 14. Mammadov R, Turna B, Gürer E, Ersel M, Sever A, Semerci B. Künt travma sonrası oluşan iki taraflı böbrek hasarının (derece IV) kısa sürede kendiliğinden iyileşmesi: Olgu sunumu. Türk Üroloji Dergisi 2011;37:159-66. 15. Umbreit EC, Routh JC, Husmann DA. Nonoperative management of nonvascular grade IV blunt renal trauma in children: meta-analysis and systematic review. Urology 2009;74:579-82.

ORIGINAL ARTICLE - ABSTRACT OLGU SUNUMU

Blunt renal trauma in children: a retrospective analysis of 41 cases Mehmet Emin Balcıoğlu, M.D.,1 Mehmet Emin Boleken, M.D.,1 Muazez Çevik, M.D.,1 Murat Savaş, M.D.,2 Fatıma Nurefşan Boyacı, M.D.3 1 2 3

Department of Pediatric Surgery, Harran University Faculty of Medicine, Sanliurfa; Department of Urology, Harran University Faculty of Medicine, Sanliurfa; Department of Radiology, Harran University Faculty of Medicine, Sanliurfa

BACKGROUND: The majority of renal injury secondary to blunt abdominal trauma can be successfully treated conservatively. In the present study, the clinical features and outcomes of children who presented with renal injury secondary to blunt abdominal trauma were evaluated. METHODS: This study was carried out retrospectively using data from children at the Department of Pediatric Surgery who were hospitalized for renal injury due to blunt abdominal trauma between 2000 and 2012. Patient characteristics, clinical presentation, management strategy, and outcome were evaluated. RESULTS: Forty-one patients were hospitalized. The mean age of the patients was 10±4.85 years. The majority of renal injuries were grade 1 and 2. Falling was the cause of most renal injuries. All patients were initially treated conservatively. Three patients underwent acute surgical exploration for life-threatening renal bleeding (grade 4-5 injury). Nephrectomy was performed in 3 patients due to injury to the pedicle. CONCLUSION: The conservative treatment of pediatric renal parenchymal injuries is safe and effective in children. Although the vast majority of renal injuries do not require surgical intervention, life-threatening renal bleeding, regardless of the grade of injury, should be treated surgically. Key words: Blunt trauma; children; renal; treatment. Ulus Travma Acil Cerr Derg 2014;20(2):132-135

doi: 10.5505/tjtes.2014.65392

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CAS E REP OR T

Acute liver failure secondary to hepatic compartment syndrome: case report and literature review Bei Ye, M.D., Yang De Miao, M.D. Department of Gastroenterology, Taizhou Municipal Hospital, Taizhou, Zhejiang, China

ABSTRACT We report a case of a patient with a delayed large intrahepatic hematoma and transient decline in hemoglobin to 62 g/L 18 days after liver injury. Abdominal computed tomography revealed seriously flattening of inferior vena cava, which was consistent with compression by the enlarging hematoma. Although traditionally there was no indication for surgical intervention, the patient developed acute liver failure with a progressive increase in liver enzymes and bilirubin.We postulated the ever-expanding hematoma might have led to dramatically elevated intrahepatic pressures that in turn restricted hepatic vein reflux and subsequently resulted in acute liver failure. Therefore, she underwent percutaneous drainage, and the decompression instantly reversed the liver injury. This phenomenon is similar to the well-described abdominal compartment syndrome, which is defined as new onset organ dysfunction or failure secondary to sustained intraabdominal hypertension and in which decompression is the standard treatment. Key words: Computed tomograghy; liver; hepatic compartment syndrome; trauma.

INTRODUCTION

CASE REPORT

Acute liver failure due to delayed intrahepatic hemorrhage after liver injury is a rare complication but potentially life threatening. We report a case of delayed intrahepatic bleeding 18 days after liver laceration, causing compression of the inferior vena cava and hepatic veins and consequently acute liver failure. Similar with the well-defined abdominal compartment syndrome,[1] we postulate that the expanding hematoma led to elevated intrahepatic pressure, and that in turn resulted in diminished hepatic perfusion and ischemia. To our knowledge, this â&#x20AC;&#x153;Hepatic Compartment Syndromeâ&#x20AC;? is an uncommon etiology leading to acute hepatic failure in clinical practice. Hence, we also review the literature with a comprehensive overview of major clinical characteristics and current management options in order to improve the outcomes for these patients.

A 35-year-old woman presented to our emergency department for chest distress for 30 hours due to traffic injury. She was struck by a car on the right chest and right upper quadrant. Computed tomography (CT) demonstrated multiple right rib fractures and pleural effusion, and liver laceration with hemoperitoneum. She had no history of liver disease or ethanol abuse and was on no medication. On admission, she was alert and vital signs were as follows: blood pressure was 100/60 mmHg on dopamine, heart rate was 110 beats/min, and oxygen saturation was approximate 90% on mask oxygen. On physical examination, right respiratory movement was greatly decreased and some crepitus was detected on the right side while the left lung was clear. Her abdomen was soft and there was slight right epigastric tenderness. Shifting dullness was positive and fresh blood was aspirated on abdominal paracentesis. CT scan of the abdomen revealed a grade IV laceration of the liver (Fig. 1).

Address for correspondence: Yang De Miao, M.D. No. 381 East Zhongshan Road, Taizhou 318000, Zhejiang, China Tel: +86 1395 8561 620 E-mail: myd1234@hotmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2014;20(2):136-138 doi: 10.5505/tjtes.2014.95825 Copyright 2014 TJTES

136

She underwent emergency laparotomy due to hemodynamic instability even with resuscitation. A chest tube was inserted and approximately 1500 ml blood was drained. There was approximate 2500 ml blood in the peritoneal cavity. Multiple lacerations were encountered in the lower pole of the spleen and splenic hilum. Severe damage in the VII segment, multiple lacerations, and subcapsular hematoma were founded in the liver. Hence, she underwent splenectomy, repair of the liver laceration and perihepatic packing with gauzes. Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2


Postoperatively, hemoglobin was stable and liver enzymes were greatly improved. Abdominal CT follow-up showed the liver laceration had partly recovered (Fig. 1). The recovery was unevenly. However, on postoperative day 16 (18 days post injury), she developed sudden severe right upper abdominal pain and fresh blood was drained from the abdominal drainage. Laboratory findings showed a drop in hemoglobin to 62 g/L, which was remained relatively stable thereafter. Liver enzymes were again elevated and an emergency CT scan of the abdomen showed a hyperdense mass within the right lobe of the liver, measuring 16.7x9.3 cm in diameter, traversing segments VII and VIII and bordering on segment IV (Fig 1), and flattening and effacement of the inferior vena cava and right and middle hepatic veins, consistent with compression by the enlarging hematoma (Fig 1). Simultaneously, the left hepatic lobe was compensatorily hypertrophic. This was consistent with restriction of hepatic reflux due the compression of liver veins and inferior vena cava by the enlarging hematoma. Over the next 24 hours, alanine aminotransferase and alkaline phosphatase elevated to 878 U/L and 858 U/L respectively, and total bilirubin increased to 203 umol/L. Her mental status and overall situation worsened. We postulate that the expanding hematoma led to elevated intrahepatic pressures that in turn resulted in diminished hepatic perfusion and ischemia. This â&#x20AC;&#x153;Hepatic Compartment Syndromeâ&#x20AC;? led to ischemic hepatic failure.[2] Hence, she underwent percutaneous drainage and fortunately, the liver enzyme decreased rapidly and thereafter recovery was unevenly. Then patient was discharged on day 47.

DISCUSSION The mortality of liver trauma is correlated with the grade of

injury, varying from 8% to 56% for Grade IV injuries to 80% for Grade V.[3,4] Complications after hepatic trauma include bile leaks, hemobilia, bile peritonitis, hemoperitoneum, hepatic necrosis, hepatic abscess, and delayed hemorrhage. The complication rate also increases with the grade of injury as those with Grade III had a complication rate of 1%, Grade IV at 21%, and Grade V approximate at 63%.[5] For this patient, alanine aminotransferase and total bilirubin dramatically elevated on 16 days post operation, with mental status and overall situation worsening simultaneously. This acute liver failure could be explained by the congestion of hepatic reflux on CT scan because the majority of patients with ischemic hepatitis had severe underlying cardiac disease that had often led to similar passive congestion of the liver as in this case.[6] These lead us to propose that resultant hepatic venous congestion due the compression of liver veins and inferior vena cava by the enlarging hematoma may predispose the liver to injury. In the new guideline for management of blunt hepatic injury, a routine laparotomy is not indicated in the hemodynamically stable patient without peritonitis.[7] Currently, nonoperative management is now the standard of care for hemodynamically stable patients with blunt hepatic trauma, with success rates ranging from 82% to 100%.[8] Surgery has been reserved for extensive lesions with the condition of hemodynamic instability or for the treatment of complications.[6] A 2008 study showed that 86.3% of hepatic injuries are now managed without operative intervention.[9] Indications for further intervention by embolization or laparotomy include hemodynamic stability that cannot be achieved after resuscitation,

(a)

(b)

(c)

(d)

Figure 1. Evolution of the liver injury was demonstrated serially by computerized abdominal tomography. (a, b) Extensive multiloculated liver lacerations were revealed on admission and 8 days later. (c) Eighteen days later, a CT section at approximately the same level demonstrated a delayed large intrahepatic hematoma, flattening and effacement of the inferior vena cava and disappearance of the right and middle hepatic veins. (d) Nine days later after percutaneous decompression of the intrahepatic hematoma, the inferior vena cava re-opened.

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Ye et al. Acute liver failure secondary to hepatic compartment syndrome

progressive fall of hemoglobin with recurrent blood transfusion, and clinical signs of peritonitis.[3] It is worth noting that the failure of conservative treatment does not necessarily lead to an increase in the incidence of complications or mortality in centers with continued intensive therapy and the immediate possibility of performing surgery.[6] Angiography with embolization should be considered as a first-line intervention for a patient before potential operative intervention.[7] Nearly half of the Grade III injuries and approximate all of the Grade IV injuries had active bleeding on angiography regardless of the presence of CT scan blush.[10] However, the majority of vascular injuries are venous in liver injury;[6] this may explain why few patients underwent angiographic embolization in some trauma centers.[3] If hemodynamic stability could not be achieved with embolization, conversion to laparotomy was used to evacuate the hematoma and acheive hemostasis. Surgeons can refer to the algorithm for operative management of blunt liver trauma but must tailor the surgical approach to the individual injury.[11] Our patient had a sudden delayed hemorrhage and the hemoglobin remained stable thereafter. Traditionally, there was no indication for surgical intervention. Nevertheless, the climbing intrahepatic pressure due to the enlarging hematoma caused hepatic venous congestion by compressing liver veins and inferior vena cava. Consequently, acute liver failure and worsening of the overall situation ensued. As expected, decompression by percutaneous drainage reversed the liver injury rapidly. This phenomenon is consistent with the well-described abdominal compartment syndrome in which new organ failure and vessel compromise caused by climbing intrabdominal pressure occur and decompression is the standard treatment.[1] Similarly, it is likely that hepatic parenchymal pressure, hepatic necrosis, and hypovolemia worked in concert to cause hepatic injury in our case.[2] Hence, we believe this syndrome could be termed as “Hepatic Compartment Syndrome”. In summary, acute liver failure in patients with rapidly expanding intrahepatic hematoma may be attributed to climbing

intrahepatic pressure and hepatic necrosis. Decompression by percutaneous drainage may be an effective way to reverse the liver injury. Conflict of interest: None declared.

REFERENCES 1. Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, et al. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions. Intensive Care Med 2006;32:1722-32. 2. Nissen NN, Geller SA, Klein A, Colquhoun S, Yamini D, Tran TT, et al. Percutaneous liver biopsy after living donor liver transplantation resulting in fulminant hepatic failure: the first reported case of hepatic compartment syndrome. J Transplant 2010;2010:273578. 3. Zago TM, Tavares Pereira BM, Araujo Calderan TR, Godinho M, Nascimento B, Fraga GP. Nonoperative management for patients with grade IV blunt hepatic trauma. World J Emerg Surg 2012;7 Suppl 1:8. 4. Ordoñez CA, Parra MW, Salamea JC, Puyana JC, Millán M, Badiel M, et al. A comprehensive five-step surgical management approach to penetrating liver injuries that require complex repair. J Trauma Acute Care Surg 2013;75:207-11. 5. Kozar RA, Moore FA, Cothren CC, Moore EE, Sena M, Bulger EM, et al. Risk factors for hepatic morbidity following nonoperative management: multicenter study. Arch Surg 2006;141:451-9. 6. Seeto RK, Fenn B, Rockey DC. Ischemic hepatitis: clinical presentation and pathogenesis. Am J Med 2000;109:109-13. 7. Stassen NA, Bhullar I, Cheng JD, Crandall M, Friese R, Guillamondegui O, et al. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73(5 Suppl 4):288-93. 8. Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg 2003;138:844-51. 9. Tinkoff G, Esposito TJ, Reed J, Kilgo P, Fildes J, Pasquale M, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg 2008;207:646-55. 10. Hagiwara A, Murata A, Matsuda T, Matsuda H, Shimazaki S. The efficacy and limitations of transarterial embolization for severe hepatic injury. J Trauma 2002;52:1091-6. 11. Kozar RA, Feliciano DV, Moore EE, Moore FA, Cocanour CS, West MA, et al. Western Trauma Association/critical decisions in trauma: operative management of adult blunt hepatic trauma. J Trauma 2011;71:1-5.

OLGU SUNUMU - ÖZET

Hepatik kompartman sendromuna bağlı akut karaciğer yetersizliği: Olgu sunumu ve literatürün gözden geçirilmesi Dr. Bei Ye, Dr. Yang De Miao Taizhou Belediye Hastanesi, Gastroenteroloji Kliniği, Zhejiang, China

Büyük ve gecikmiş intrahepatik hematomu olan ve karaciğer travmasından 18 gün sonra hemoglobin düzeyi geçici olarak 62 g/L’ye düşmüş bir hasta sunuldu. Karın bilgisayarlı tomografisi, genişlemiş hematomun basısıyla uyumlu olarak inferior vena kavanın ciddi derecede düzleştiğini ortaya koydu. Klasik olarak herhangi bir cerrahi girişim endikasyonu olmamasına rağmen hastada karaciğer enzimleri ve bilirubin düzeylerinde giderek artan yükselme ile akut karaciğer yetersizliği gelişti. Giderek daha fazla genişleyen hematomun dramatik derecede yüksek intrahepatik basınçlara ve sonuçta hepatik vende reflüyü kısıtlayarak ardından akut karaciğer yetersizliğine yol açabilmiş olduğunu varsaydık. Bu nedenle, uygulanan perkütan drenaj ve dekompresyon karaciğer travmasını anında geri döndürdü. Bu fenomen süregelen yüksek karıniçi basınca bağlı yeni başlangıçlı organ disfonksiyonu veya yetersizliği olarak tanımlanmış, abdominal kompartıman sendromuna benzemekte olup standart tedavisi dekompresyondur. Anahtar sözcükler: Bilgisayarlı tomografi; hepatik kompartıman sendromu; karaciğer; travma. Ulus Travma Acil Cerr Derg 2014;20(2):136-138

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doi: 10.5505/tjtes.2014.95825

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CAS E REP OR T

Endoscopic endonasal removal of a sphenoidal sinus foreign body extending into the intracranial space Ali Erdem Yıldırım, M.D., Denizhan Divanlıoğlu, M.D., Nuri Eralp Çetinalp, M.D., İbrahim Ekici, M.D., Ali Dalgıç, M.D., Ahmed Deniz Belen, M.D. Department of Neurosurgery, Ankara Numune Training and Research Hospital, Ankara

ABSTRACT Sphenoidal sinus foreign bodies are very rare entities that are often associated with a cranial and/or orbital trauma. In this paper, a case of a metallic foreign body that pierced the sphenoid sinus and penetrated into the intracranial space due to a work accident is presented. A 29-year-old male was referred to our clinic due to a right orbital penetrating trauma. Skull X-ray and computed tomography (CT) scans demonstrated a foreign body inside the sphenoidal sinus, extending to the left temporal fossa. The foreign body was removed using an endoscopic endonasal technique, and the skull base was reconstructed with a multilayer closure technique. There were no complications during or after the operation. Postoperative result was perfect after three months of follow up. Key words: Endoscopic endonasal; foreign body; intracranial; sphenoid sinus.

INTRODUCTION Paranasal sinus foreign bodies are very uncommon in the literature.[1] Most incidences of these objects usually occur with trauma, penetrating injuries, motor vehicle accidents, and iatrogenic and intracranial lesions.[2-5] In addition, paranasal sinus foreign bodies are found in the frontal and maxillary sinuses relatively more often than the ethmoidal and sphenoid sinuses.[2,6,7] The foreign body usually reaches the sphenoid sinus through the orbit or the nostril.[8] Their close relationship to the adjacent vascular and neural structures makes sphenoidal sinus injuries a potentially life-threatening occurrence.[9] An endoscopic endonasal approach is usually selected for the removal of these objects.[9-12] If the foreign body is completely intracranial, an open surgical approach could be selected.[3,5,10] Because of better illumination and direct visualization, the Address for correspondence: Ali Erdem Yıldırım, M.D. Ankara Numune Eğitim ve Araştırma Hastanesi, Beyin ve Sinir Cerrahisi Kliniği, Talatpaşa Bulvarı, No: 5, B-Blok, Kat: 3, Altındağ, 06100 Ankara, Turkey Tel: +90 312 - 508 52 76 E-mail: alierdemyildirim@gmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2014;20(2):139-142 doi: 10.5505/tjtes.2014.93902 Copyright 2014 TJTES

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endoscopic endonasal approach has proven accuracy for removal of these paranasal sinus foreign bodies. Furthermore, endoscopic endonasal approach demands a well-known anatomy of the spheno-ethmoidal region because of the presence of important and vital structures such as the ICA, optic nerves and the ethmoidal arteries.[13] In this paper, a successful endoscopic endonasal removal of an uncommon case of a metallic foreign body located in the sphenoidal sinus extending into the intracranial space due to an orbital injury is presented.

CASE REPORT A 29-year-old man, working as a professional mason, came to the emergency room for a work accident. The accident occurred when a metallic piece broke off of a marble cutting machine and became enlodged in his head through his right lower eyelid. His wound was sutured and the patient was referred to our clinic. He had a right periorbital ecchymosis, conjunctival hemorrhage and a sutured wound on his right lower eyelid (Figure 1). The neurological examination was completely normal without any vision impairment. A skull Xray showed a radiopaque foreign body in the sphenoidal sinus region (Figure 2). A computed tomography (CT) scan showed a probable metallic, 4 cm long foreign body that fractured the vomer and the nasal septum, pierced the lateral wall of the sphenoidal sinus and reached into the pteriogopalatine fossa, and settled next to the Internal Carotid Artery (ICA) (Figure 139


Y覺ld覺r覺m et al. Endoscopic endonasal removal of a sphenoidal sinus foreign body extending into the intracranial space

Later, the patient underwent surgery via binostril endoscopic endonasal transsphenoidal approach, using 0- and 30-degree rigid endoscopes. A 40x3 mm metallic foreign body that pierced into the vomer and nasal septum was visualized during the procedure (Figure 5a). There was no bleeding or cerebrospinal fluid (CSF) leakage. The posterior nasal septum and anterior wall of the sphenoidal sinus were removed to mobilize the foreign body before it was gently removed (Figure 5b). A 3 mm diamater laceration and CSF leakage was observed in the left lateral wall of the sphenoidal sinus where the deep end of the foreign body was enlodged. The dura defect was closed with multilayer skull base reconstruction technique using free fat and tensor fascia lata autografts combined with fibrin sealant. Nasal packing was not used.

Figure 1. Preoperative photograph of the patient demonstrating a right periorbital ecchymosis, conjunctival hemorrhage and a sutured lower eyelid wound.

There were no postoperative complications, neurological deficits or CSF rhinorrhea. Postoperative CT scan shows total removal of the foreign body (Figure 5c). The patient was

3). A digital subtraction angiography (DSA) was performed to determine if the left ICA was injured (Figure 4).

Figure 2. Preoperative lateral and anteroposterior (left to right respectively) x-rays showing a radiopaque foreign body extended into the sphenoid sinus.

(a)

(b)

Figure 3. Preoperative axial (a) and coronal (b) CT scan showing the localization of a probable metallic foreign body.

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Figure 4. Preoperative DSA images with lateral and anteroposterior projections (left to right respectively) demonstrating the relation of the foreign body with left ICA.

discharged three days after the operation. There were no complications or rhinorrhea after three months of follow up.

DISCUSSION Foreign bodies in paranasal sinuses are rare. They are found in the frontal and maxillary sinuses relatively more commonly than in the ethmoid and sphenoidal sinuses.[2,6,7] There are only few reported cases involving the sphenoidal sinus.[2] From a literature review, in the majority of cases, the foreign body was made of a metallic substance and was often associated with an orbital and/or maxillofacial trauma. [13] In this case, our patient was exposed to a high-energy orbital trauma and a metallic foreign body penetrated into

(a)

his sphenoidal sinus and intracranial space. To diagnose a foreign body of the brain or paranasal sinuses, CT scan is the most useful technique. Locating the exact position of the object and its relationship with nearby vital structures such as the basillary artery and ICA is very important. If the foreign body is not radiopaque, such as bamboo sticks, MRI can be used.[4,11] Digital subtraction angiography (DSA) can also be used to expose potential vascular injury and pseudoaneurysm of ICA or basillary artery. In the present case, cranial and paranasal CT as well as DSA were performed to locate the foreign body and to determine its relationship with the neighboring vital structures.

(b)

(c)

Figure 5. (a) Peroperative endoscopic image of the foreign body piercing the posterior nasal septum and vomer, through the sphenoidal sinus (asterisk showing the posterior nasal septum, arrow showing the middle turbinate). (b) Photograph of the metallic foreign body after removal (scale in centimeters). (c) Postoperative coronal CT scan proving the total removal of the foreign body.

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Intracranial penetrations of foreign bodies can cause sudden intracranial complications such as subarachnoidal or intraparenchymal cerebral hemorrhages, CSF rhinorrhea and pneumocephalus as well as delayed severe complications including meningitis or cerebral abscess.[13] If early and life threatening intracranial complications occur, the foreign body should be removed immediately with an open or endoscopic approach. If the neurological examination is normal without any early intracranial complications, the surgical approach for foreign body removal should be planned after radiological evaluation. All foreign bodies in the paranasal sinuses may serve as an infection nidus.[2] Because of the close relationship between the sphenoidal sinus, optic nerve, cavernous sinus, ICA and other important structures of the skull base, sphenoidal sinusitis secondary to a foreign body may cause catastrophic results. [14,15] For all these reasons, the sphenoidal sinus foreign body must be completely removed. In this paper, we presented a successful endoscopic endonasal removal of a 4 cm metallic foreign body pierced into the sphenoidal sinus through the orbit that penetrated into the intracranial space. Surgical technique usded depends on the surgeon’s experience. We preferred to use an endoscopic endonasal approach to remove the foreign body from the sphenoidal sinus and to repair the skull base. Endoscopic endonasal technique has some advantages such as direct visualization, good illumination and minimal morbidity as compared to open procedures. Also, skull base reconstruction is easier and more accurate with an endoscopic approach in experienced hands. In conclusion, sphenoidal sinus foreign body with intracranial extension is uncommon. Because of the potentially serious complications, all foreign bodies in the sphenoidal sinus should be treated. In recent years, with an increasing popularity, an endoscopic endonasal approach is becoming the choice of treatment due to its safe and efficient nature in these clinical events.

Conflict of interest: None declared.

REFERENCES 1. Krause HR, Rustemeyer J, Grunert RR. Foreign body in paranasal sinuses. [Article in German] Mund Kiefer Gesichtschir 2002;6:40-4. [Abstract] 2. Alsarraf R, Bailet JW. Self-inserted sphenoid sinus foreign bodies. Arch Otolaryngol Head Neck Surg 1998;124:1018-20. 3. Zaets VN, Marchenko LV. Combined penetrating injury of left orbit, ethmoidal labyrinth and sphenoid sinus. [Article in Russian] Vestn Otorinolaringol 2000;1:38. [Abstract] 4. Datta H, Sarkar K, Chatterjee PR, Kundu A. An unusual case of a retained metallic arrowhead in the orbit and sphenoidal sinus. Indian J Ophthalmol 2001;49:197-8. 5. Mori S, Fujieda S, Tanaka T, Saito H. Numerous transorbital wooden foreign bodies in the sphenoid sinus. ORL J Otorhinolaryngol Relat Spec 1999;61:165-8. 6. Dimitriou C, Karavelis A, Triaridis K, Antoniadis C. Foreign body in the sphenoid sinus. J Craniomaxillofac Surg 1992;20:228-9. 7. O’Connell JE, Turner NO, Pahor AL. Air gun pellets in the sinuses. J Laryngol Otol 1995;109:1097-100. 8. Wani NA, Khan AQ. Foreign body within sphenoid sinus: multidetector-row computed tomography (MDCT) demonstration. Turk Neurosurg 2010;20:547-9. 9. Kitajiri S, Tabuchi K, Hiraumi H. Transnasal bamboo foreign body lodged in the sphenoid sinus. Auris Nasus Larynx 2001;28:365-7. 10. Kayikçioğlu A, Karamüsel S, Mavili E, Erk Y, Benli K. Intrasphenoidal migration of a premaxillary Kirschner wire. Cleft Palate Craniofac J 2000;37:209-11. 11. LaFrentz JR, Mair EA, Casler JD. Craniofacial ballpoint pen injury: endoscopic management. Ann Otol Rhinol Laryngol 2000;109:119-22. 12. Bhattacharyya N, Wenokur RK. Endoscopic management of a chronic ethmoid and sphenoid sinus foreign body. Otolaryngol Head Neck Surg 1998;118:687-90. 13. Presutti L, Marchioni D, Trani M, Ghidini A. Endoscopic removal of ethmoido-sphenoidal foreign body with intracranial extension. Minim Invasive Neurosurg 2006;49:244-6. 14. Hadar T, Yaniv E, Shvero J. Isolated sphenoid sinus changes--history, CT and endoscopic finding. J Laryngol Otol 1996;110:850-3. 15. DeLano MC, Fun FY, Zinreich SJ. Relationship of the optic nerve to the posterior paranasal sinuses: a CT anatomic study. AJNR Am J Neuroradiol 1996;17:669-75.

OLGU SUNUMU - ÖZET

İntrakraniyal uzanımı olan sfenoid sinüs içi yabancı cismin endoskopik endonazal tedavisi Dr. Ali Erdem Yıldırım, Dr. Denizhan Divanlıoğlu, Dr. Nuri Eralp Çetinalp, Dr. İbrahim Ekici, Dr. Ali Dalgıç, Dr. Ahmed Deniz Belen Ankara Numune Eğitim ve Araştırma Hastanesi, Nöroşirürji Kliniği, Ankara

Sfenoid sinüs içi yabancı cisim genellikle kraniyal ve/veya orbital travma ve intrakraniyal lezyonlarla ilişkili olarak görülen çok nadir olaylardır. Biz bu yazıda iş kazası sonrasında gelişen, intrakraniyal uzanımı olan sfenoid sinüs içi metalik yabancı cisim olgusunu sunmaktayız. Yirmi dokuz yaşında erkek hasta sağ orbial travma sonrası kliniğimize gönderildi. Çekilen kafa grafisi ve bilgisayarlı tomografide sol temporal fossaya invazyon gösteren sfenoid sinüs içinde yabancı cisim saptandı. Hasta endoskopik endozal teknikle ameliyat edilerek yabancı cisim çıkartıldı ve defekt bulunan kafa kaidesi çok tabakalı olarak tamir edildi. Ameliyat anında ve sonrasında komplikasyon görülmeyen hastanın üç aylık takiplerinde de sorun yaşanmadı. Anahtar sözcükler: Endoskopik endonazal; intrakraniyal; sfenoid sinüs; yabancı cisim. Ulus Travma Acil Cerr Derg 2014;20(2):139-142

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Catastrophic necrotizing fasciitis after blunt abdominal trauma with delayed recognition of the coecal rupture - case report Vanja Pecic, M.D.,1 Milica Nestorovic, M.D.,1 Predrag Kovacevic, M.D.,2 Dragan Tasic, M.D.,1 Goran Stanojevic, M.D.1 1

Clinic for General Surgery, Clinical Center Nis, Nis, Serbia;

2

Clinic for Plastic and Reconstructive Surgery, Clinical Center Nis, Nis, Serbia

ABSTRACT Necrotizing fasciitis (NF) is a rare bacterial infection with dramatic course, characterized by widespread necrosis of the skin, subcutaneous tissue, and superficial fascia which can often lead to death. We present a case of a 27-year-old male with NF. One day after experiencing blunt abdominal trauma caused by falling over bike handlebars, the patient was admitted to a regional hospital and treated for diffuse abdominal pain and large hematoma of the anterior abdominal wall. Due to worsening of general condition, he was referred to our hospital the following day and operated on urgently. Surgery revealed rupture of the coecum with peritonitis and abdominal wall infection. After surgery, fulminant necrotizing fasciitis developed. Antibiotics were prescribed according to wound cultures and subsequent necrectomies were performed. After 25 days, reconstruction of the abdominal wall with skin grafts was obtained. Despite all resuscitation measures including fluids, blood transfusions, and parenteral nutrition, lung infection and MODS caused death 42 days after initial operation. Blunt abdominal trauma can cause the rupture of intestine, and if early signs of peritoneal irritation should present, emergency laparotomy should be performed. Disastrous complication are rare but lethal. Key words: Blunt abdominal trauma; necrotizing fasciitis.

INTRODUCTION According to available data, intestinal injuries occur in 5-15% of blunt abdominal trauma.[1] Early detection and proper surgical treatment are crucially important. Most authors suggest exteriorization of injured intestine.[2-5] Necrotizing fasciitis (NF) is a rare, potentially lethal bacterial infection characterized by widespread necrosis of the skin, subcutaneous tissue, and superficial fascia.[6,7] It develops from a bacterial infection, most often group A Streptococcus (GAS). However, mixed aerobic and anaerobic Gram posiAddress for correspondence: Vanja Pecic, M.D. Bul. Zorana Djindjica 48, 18000 Nis, Serbia Tel: +381 63 590 900 E-mail: acrepus@yahoo.com Qucik Response Code

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tive (G+) and Gram negative (G-) flora can also be identified. Bad local environment (local tissue hypoxia, depleted leucocytes function) allows the infection to spread much easier, particularly in patients with risk factors such as: medical compromise (e.g., systemic illnesses, immunosuppressive medications), trauma, recent surgery, recent birth, diabetes mellitus, vascular insufficiency, renal and hepatic failure, cancer, or organ transplants.[8] Early recognition and proper diagnosis of NF greatly increases a patientâ&#x20AC;&#x2122;s chance of survival. Descriptive terms vary based on the location, depth, and extent of infection (e.g., Fournierâ&#x20AC;&#x2122;s gangrene [necrotizing perineal infection], necrotizing fasciitis [deep subcutaneous infection]). Depending on the depth of invasion, necrotizing soft tissue infections can cause extensive local tissue destruction, tissue necrosis, systemic toxicity, and even death. Despite surgical advances and introduction of antibiotics, reported mortality rates for NF range from 6-76%.[9] Very often, patients with NF initially go to primary care physicians. Because of the importance of early diagnosis and treatment, primary care physicians need to maintain high index of suspicion for these infections and should be aware of possible presenting features.[9] 143


Pecic et al. Catastrophic necrotizing fasciitis after blunt abdominal trauma with delayed recognition of the coecal rupture

CASE REPORT A 27-year-old man was admitted to our hospital one day after the injury obtained by falling over the handlebar of a bike and hitting a lower part of the abdomen. After the injury, he was admitted to a local hospital with symptoms of abdominal tenderness and large haematoma on the right side of anterior abdominal wall. Abdominal ultrasonography did not show signs of free fluid in peritoneal cavity or intraabdominal injury, and plain abdominal and chest X-rays did not show irregularities. At admission, the patient’s blood pressure was 120/80 mmHg, heart rate 120/min, WBC 1900/l, PLT 76000/l, Hgb 131g/l, Hct 0.41. After initial resuscitation with 2000 ml Ringer lactate, urine output was low at 200 ml in first six hours. Urinary output was stimulated with 80 mg of furosemide. The patient was treated with antibiotics (Metronidazol 0.5 g/8 h and ceftriaxone 2 g). Twelve hours after admission, his platelet count fell to 55000/l, Hgb to 84 g/l, Hct to 0.27. Repeated abdominal X-ray after 12 hours showed presence of discrete free air in abdomen; repeated ultrasonograpy showed free fluid in ileoceecal region which was confirmed by computerized tomography. Due to new diagnostic findings, worsening of general condition, pancytopenia, and spread of abdominal wall muscle haematoma followed by diffuse abdominal muscle resistance, the patient was referred to our hospital. He was admitted to ICU 24 hours after the injury. An emergency operation was performed upon admittance. Intraoperative findings included the rupture of ileocoecal junction (destruction of Bauchini valve) with consequent diffuse stercoral peritonitis as well as anterior abdominal wall phlegmona. Right hemicolectomy with Brooke ileostomy was performed, followed by wide skin incisions and necrectomy of the anterior abdominal wall. The surgery was terminated with drainage of right retroperitoneal space and abdominal cavity. Postoperatively, blood pressure was 90/60 mmHg; heart rate was 90/min; WBC was 1,200/l; PLT was 50,000; urea was 18 mmol/l (normal range 2.5-8.3); creatinine was 189 umol/l (normal range 53-115); body temperature was 37.6°C; CRP was 542 (0-5); CPK was 3104 (24-195); procalcitonin was 126.2 (normal range <0.05). The patient was given antibiotics according to wound cultures and low molecular weight heparin as well as substitution of platelets. Over the next four days, general condition worsened due to the spread of infection on the right side of chest wall and right femoral region (Figure 1a). The patient’s body temperature was 38°C; PLT was 7000-1000; urea was 24; creatinine was 161; WBC was 6500; D-dimer was 5800. Six more units of platelets were added. On the eighth postoperative day, a necrectomy of the left lumbar region and scrotal region was performed. His general condition slightly improved: PLT-33000, CRP-112. On several occasions wounds were aggressively debrided under general anaesthesia (Figure 1b).Twenty days after operation, the abdominal wall skin defect was reconstructed with partial thickness skin grafts (Figure 1c). The patient’s vital 144

(a)

(b)

(c)

Figure 1. (a) Spreading of infection to the chest wall and femoral region. (b) Debridement of the wound. (c) Reconstruction of the abdominal wall with skin grafts.

signs were stable and body temperature was (BT) 38.4°C. Over the next eight days, his vitals were stable (BT 38°C, urine output 2700 ml/24h, PLT 68000) and the skin graft was mostly accepted. After 34 days, his condition got suddenly worse. He developed acute renal failure (with elevated blood urea nitrogen and creatinine), liver failure, and respiratory insufficiency requiring artificial respiration. He was intensively reanimated. Forty-two days after operation, the patient died.

DISCUSSION Blunt abdominal trauma (BAT) is common, and the prevalence of intra-abdominal injury (IAI) after BAT has been reported Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2


Pecic et al. Catastrophic necrotizing fasciitis after blunt abdominal trauma with delayed recognition of the coecal rupture

to be as high as 12-15%.[10] Diagnostic evaluation of patients with BAT include physical examination, focused ultrasonography, computed tomography (CT), diagnostic peritoneal lavage, laparoscopy, laparotomy, laboratory tests, and observation. Patients who have sustained BAT and have undergone otherwise negative diagnostic evaluation in the emergency department (ED) will also undergo CT of the abdomen and pelvis, admission to the hospital for an extended observation period, or both, in order to be evaluated for occult IAI.[10,11] However, the incidence of IAI in patients who are otherwise hemodynamically stable and have initially negative diagnostic evaluations in the ED is quite low, probably occurring in less than 1%.[11] The frequency of NF is about 0.40 cases per 100.000 and is correlated with inadequate oxygenation and nutrition of tissue. The course of NF varies and is often deceitful. The cardinal early symptom is a disproportionately strong pain in comparison to patient’s examination. The beginning ailment may suggest many other conditions, e.g., cellulitis, erysipelas, phlebitis, etc. It is known that 35% of patients with NF are initially misdiagnosed.[7] New and stronger antibiotics have been introduced over the last 30 years and, together with improved critical care and surgical techniques, have considerably changed the outcome of patients with sepsis. Source control is generally considered to be an important element in the management of these patients. The importance of “early” in the management of severe sepsis has gained much attention in the last few years. Intense research for biomarkers has been performed to help clinicians to diagnose infection early in the course of the disease. Regarding IAI, source control is often defined as the pure mechanical control of leaking content from the gastrointestinal (GI) tract. Surgeons often intuitively feel that source control is a part of a surgical intervention; however, the opposite is true: surgical intervention is part of a source control approach to the patient with IAI.[12] In some patients, tissue necrosis can rapidly advance, and “time is tissue:” hourly progression of soft tissue necrosis can be seen even after initiation of antibiotics. Boyer et al.[13] demonstrated that in patients in septic shock, surgery postponed for more than 14 hours after diagnosis increases the risk of mortality by a factor of 34. In our case, postponing surgery for more than 24 hours contributed further to the patient’s morbidity and possible mortality. After source control and treatment of infection, early closure of the wound is not recommended due to the risk of residual bacteria and poor wound healing. According to some authors, debridement and dressing changes are the method of choice for wound management, with slow granulation and muscle and skin grafting.[14] Skin and muscle grafts may be used only after the infection Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2

is cleared. In a study of 60 patients, Salcido[15] used skin and rotational flaps in approximately 48% and 5% of cases, respectively. Other treatments for NF include VAC (Vacuum Assisted Closure) or hyperbaric oxygen therapy (HBO). VAC (VAC; Kinetic Concepts, Inc., San Antonio, TX) is a wound care system that works on the basis of negative pressure vacuuming to regulate the wound pressure, reduce edema, eliminate fluid collections, decrease bacterial contamination and promote healing.[16] VAC was introduced by Fleischmann et al 1995 and Morykwas et al in 1997 and gained popularity among clinicians who started to use it for the treatment of chronic wounds. The VAC therapy has proved very useful in acute/chronic wounds treatment, especially in big traumas, diabetic ulcers, and in the poorly-vascularized post-traumatic lesions, but always after surgical debridement of the wound. [16-18] Both patients and physicians are more comfortable with VAC treatment compared to conventional methods; although it does not shorten the length of the hospital stay or the time from initial debridement to closure, it does decrease number of interventions. The main criticism of VAC therapy has been its cost.[16] VAC system was not available at the time of treatment of this particular patient. Hyperbaric oxygen therapy delivers multiples of atmospheric pressure and is capable of inducing arterial oxygen tensions of up to 2000 mmHg. Through this effect, HBO therapy may ameliorate tissue hypoxia induced by microcirculatory thrombosis in a number of ways. Heightened oxygen tension increases phagocytic bactericidal activity and even kills certain anaerobes independent of host immunity. Beyond the initial stages of infection, HBO therapy may also improve wound healing, which could lead to reductions in the number of debridements and amputations necessary in patients with NF. In a recent study conducted by Massey et al, HBO did not reduce mortality or decrease number of amputations in patients with NF.[19] German authors also agree that previously published human clinical studies do not confirm any therapeutic benefit of HBO in NF patients. Any time delay in the start of surgical therapy is not acceptable. They propose initiation of a register study to assess the benefit of HBO in NF patients.[20]

Conclusion Despite the small percent of risk, patient’s blunt abdominal trauma should always be considered for intestinal rupture even in cases with initial negative diagnostic evaluations. Unrecognized injuries, especially of hallow viscera, can lead to serious infections like NF. Since NF progresses rapidly, causing destruction of soft tissue, early recognition and management are crucial. Surgical management must be aggressive and meticulous. Source control is considered as essential element in the management of sepsis and should be done promptly after diagnosis. Patients with symptoms of rapidly progressive disease (e.g., necrotizing skin and soft tissue infections) 145


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or patients with GI tract perforation and diffuse peritonitis should be operated on within 1-2 hours after diagnosis. One must always bear in mind that clinical course of infection is unpredictable. Conflict of interest: None declared.

REFERENCES 1. Mukhopadhyay M. Intestinal injury from blunt abdominal trauma: a study of 47 cases. Oman Med J 2009;24:256-9. 2. Sasaki LS, Allaben RD, Golwala R, Mittal VK. Primary repair of colon injuries: a prospective randomized study. J Trauma 1995;39:895-901. 3. Lazović R, Krivokapić Z. The role of enterostomy in the management of colonic injuries. [Article in Serbian] Acta Chir Iugosl 2005;52:73-82. 4. Tzovaras G, Hatzitheofilou C. New trends in the management of colonic trauma. Injury 2005;36:1011-5. 5. Brasel KJ, Borgstrom DC, Weigelt JA. Management of penetrating colon trauma: a cost-utility analysis. Surgery 1999;125:471-9. 6. Angoules AG, Kontakis G, Drakoulakis E, Vrentzos G, Granick MS, Giannoudis PV. Necrotising fasciitis of upper and lower limb: a systematic review. Injury 2007;38 Suppl 5:19-26. 7. Hady HR, Mikucka A, Gołaszewski P, Trochimowicz L, Puchalski Z, Dadan J. Fatal necrotizing fasciitis following two suicide attempts with petroleum oil injection. Langenbecks Arch Surg 2011;396:407-13. 8. Smuszkiewicz P, Trojanowska I, Tomczak H. Late diagnosed necrotizing fasciitis as a cause of multiorgan dysfunction syndrome: A case report. Cases J 2008;1:125. 9. Headley AJ. Necrotizing soft tissue infections: a primary care review. Am Fam Physician 2003;68:323-8. 10. Kendall JL, Kestler AM, Whitaker KT, Adkisson MM, Haukoos JS.

Blunt abdominal trauma patients are at very low risk for intra-abdominal injury after emergency department observation. West J Emerg Med 2011;12:496-504. 11. Stephan PJ, McCarley MC, O’Keefe GE, Minei JP. 23-Hour observation solely for identification of missed injuries after trauma: is it justified? J Trauma 2002;53:895-900. 12. De Waele JJ. Early source control in sepsis. Langenbecks Arch Surg 2010;395:489-94. 13. Boyer A, Vargas F, Coste F, Saubusse E, Castaing Y, Gbikpi-Benissan G, et al. Influence of surgical treatment timing on mortality from necrotizing soft tissue infections requiring intensive care management. Intensive Care Med 2009;35:847-53. 14. Cainzos M, Gonzalez-Rodriguez FJ. Necrotizing soft tissue infections. Curr Opin Crit Care 2007;13:433-9. 15. Salcido RS. Necrotizing fasciitis: reviewing the causes and treatment strategies. Adv Skin Wound Care 2007;20:288-95. 16. 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. 17. Chiummariello S, Guarro G, Pica A, Alfano C. Evaluation of negative pressure vacuum-assisted system in acute and chronic wounds closure: our experience. G Chir 2012;33:358-62. 18. Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I, et al. Fournier’s gangrene and its emergency management. Postgrad Med J 2006;82:516-9. 19. Massey PR, Sakran JV, Mills AM, Sarani B, Aufhauser DD Jr, Sims CA, et al. Hyperbaric oxygen therapy in necrotizing soft tissue infections. J Surg Res 2012;177:146-51. 20. Willy C, Rieger H, Vogt D. Hyperbaric oxygen therapy for necrotizing soft tissue infections: contra. [Article in German] Chirurg 2012;83:96072.

OLGU SUNUMU - ÖZET

Künt abdominal travma sonrası katastrofik nekrotizan fasiitle birlikte çökal rüptürün tanınmasında gecikme - olgu sunumu Dr. Vanja Pecic,1 Dr. Milica Nestorovic,1 Dr. Predrag Kovacevic,2 Dr. Dragan Tasic,1 Dr. Goran Stanojevic1 1 2

Nis Merkez Kliniği, Genel Cerrahi Kliniği, Nis, Sırbistan; Nis Merkez Kliniği, Plastik ve Rekonstrüktif Cerrahi Kliniği, Nis, Sırbistan

Nekrotizan fasiit (NF) dramatik bir seyir çizen, yaygın deri, deri altı dokusu ve yüzeyel fasyanın nekrozu ile karakterize sıklıkla ölüme yol açabilen ve seyrek görülen bir bakteriyel enfeksiyondur. Bu yazıda, 27 yaşında bir erkek NF olgusu sunuldu. Hasta, künt karın travmasından bir gün sonra bölge hastanesine kabul edildi. Ertesi gün hastanemize sevk edildi ve acilen ameliyat edidi. Önceden yaralanmadan hemen sonra bir bölge hastanesinde yaygın karın ağrısı ve ön karın duvarında geniş bir hematom nedeniyle tedavi edilmişti. Bisiklet sürerken gidonun üzerine düşüp yaralanmıştı. Genel durumun kötüleşmesi üzerine hastanemize sevk edilmişti. Ameliyatta peritonitle ve karın duvarı enfeksiyonuyla birlikte çekum rüptürü saptandı. Ameliyattan sonra fulminan nekrotizan fasiit gelişti. Yara kültürlerine göre antibiyotikler reçetelendirildi. Daha sonra nekrotik dokular alındı ve 25 gün sonra deri greftleriyle karın duvarı rekonstrüksiyonu yapıldı. Sıvılar, kan transfüzyonları ve parenteral beslenme gibi tüm resüsitasyon önlemlerine rağmen akciğer enfeksiyonu ve çoklu organ işlev bozukluğu sendromu (MODS) nedeniyle ilk ameliyattan 42 gün sonra hasta kaybedildi. Künt karın travması intestinal rüptüre neden olabilirdi. Periton iritasyonunun erken belirtilerinde acil laparotomi uygulanmalıdır. Feci komplikasyonlar seyrek görülmesine rağmen ölümle sonuçlanır. Anahtar sözcükler: Künt karın travması; nekrotizan fasiit. Ulus Travma Acil Cerr Derg 2014;20(2):143-146

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Subcutaneous emphysema, pneumo-orbita and pneumomediastinum following a facial trauma caused by a high-pressure car washer Fevzi Yılmaz, M.D.,1 Orçun Çiftçi, M.D.,2 Miray Özlem, M.D.,1 Erdal Komut, M.D.,3 Ertuğrul Altunbilek, M.D.1 1

Department of Emergency Medicine, Numune Training and Research Hospital, Ankara;

2

Department of Cardiology, Baskent University Faculty of Medicine, Ankara;

3

Department of Radiology, Numune Training and Research Hospital, Ankara

ABSTRACT Pneumomediastinum is air leakage to mediastinal space from various potential sites, including lung, esophagus, trachea, and neck. It is a rare condition that develops either spontaneously with increased intraalveolar or intrabronchial pressure, or due to trauma. Although cases where face or neck trauma with subcutaneous emphysema that extended to mediastinal cavity via anatomical connections in face and neck have been reported, orbital traumas leading to pneumomediastinum are very rare occurrences that have seldom been reported. This paper documents a 17-year-old male who presented with diffuse subcutaneous emphysema involving paraorbital facial areas, which extended to neck and mediastinal cavity. Key words: Facial trauma; pneumomediastinum; subcutaneous emphysema.

INTRODUCTION

CASE REPORT

Pneumomediastinum (PM) is presence of air in mediastinum. It is either spontaneous or traumatic. Although posttraumatic facial subcutaneous emphysema is a well-known complication of facial injuries, diffusion of gas into the mediastinum is uncommon. As such, only a few cases of pneumomediastinum (PM) following an isolated facial trauma have been reported.[1]

A 17-year-old male presented to the emergency department with the inability to open his left eye because of severe left hemifacial pain and swelling that developed after his left eye was hit by a high-pressure car washer. He was hemodynamically stable, alert, and fully oriented. He had no loss of consciousness, visual disturbances, chest pain, or shortness of breath. His O2 saturation was 98%. He had no heart or lung disease.

The patient documented is a young male who presented with pneumo-orbita, subcutaneous emphysema, and pneumomediastinum after his left eye was hit by a high-pressure car washer.

Address for correspondence: Fevzi Yılmaz, M.D. Ankara Numune Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Altındağ, 06100 Ankara, Turkey Tel: +90 312 - 508 40 00 E-mail: fevzi_yilmaz2002@yahoo.com Qucik Response Code

Ulus Travma Acil Cerr Derg 2014;20(2):147-150 doi: 10.5505/tjtes.2014.14237 Copyright 2014 TJTES

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Physical examination revealed a widespread swelling and subcutaneous crepitation extending from scalp superiorly to 10th rib inferiorly, which involved left eye margin, zygomatic arch, left preauricular region, mandible, and neck (Figure 1). Breath sounds were normal and there was no evidence of airway obstruction or respiratory distress. With an initial diagnosis of facial and cervical fracture with orbital and facial subcutaneous emphysema, pneumothorax, and pneumomediastinum, computed tomographies (CT) of head, neck, and chest were obtained. Head CT demonstrated no intracranial pathology or facial fractures. Axial section of the facial CT showed a hypodense appearance consistent with air between subcutaneous tissue planes in left temporal, 147


YÄąlmaz et al. Subcutaneous emphysema, pneumo-orbita and pneumomediastinum following a facial trauma

and left eyelid. The patient was examined weekly for the next three weeks and no long-term complications occurred.

DISCUSSION

Figure 1. The gross view of the patientâ&#x20AC;&#x2122;s face. A marked left periorbital and hemifacial swelling is apparent. A small pinhole at the medial canthus is also seen, which is probably the entry point of high-pressure water from car washer.

bilateral paraseptal, bilateral intraorbital, and left retrobulbar areas. The coronal section of the neck CT demonstrated a diffuse hypodense appearance consistent with air that began from the mastoid portion of the temporal lobe and extended between the muscle planes caudally to thoracic inlet. Axial section of the neck CT showed a diffuse hypodense appearance consistent with air between the subcutaneous muscle planes and around the vascular structures at both sides of the neck (cervical subcutaneous emphysema). Axial section of the thorax CT showed diffuse hypodense appearance consistent with air in prevascular, paratracheal, and paraesophageal areas of mediastinum (pneumomediastinum). There was no pneumopericardium or pneumothorax. There was no sign of great vessel compression, either (Figure 2a-d). Based on these findings, the patient was diagnosed with pneumo-orbita, subcutaneous emphysema of face and neck, and pneumomediastinum. Ophtalmology and otorhinolaryngology consultations were requested. Ocular examination demonstrated a small, non-repairable laceration on the left lower medial canthus. The patient was hospitalized and a conservative treatment including bed rest, intravenous antibiotic therapy, and cessation of oral feeding was begun. His subsequent course was uneventful, and he was discharged the fifth day upon resolution of pneumomediastinum in control chest X-ray and improvement of subcutaneous emphysema involving neck, face, 148

Pneumomediastinum is the presence of extraalveolar air in mediastinum, first described by Laennec in 1819.[2] It either develops spontaneously or as a result of trauma. Spontaneous pneumomediastinum is usually seen in healthy young persons as a result of rupture of peripheral pulmonary alveoli due to a sudden increase of intraalveolar pressure after an exaggerated Valsalva maneuver.[3] Similarly, acute asthma attack,[4] strenous cough,[5] vomiting,[6] rapid vaginal birth,[7] barotrauma,[8] and even cocaine and similar drugs[9] have all been reported to cause pneumomediastinum and subcutaneous emphysema by leading to increased alveolar and intrabronchial pressures.[3,10] Traumatic pneumomediastinum, on the other hand, develops as a consequence of external head, neck, and thoracic traumas as well as iatrogenically with invasive medical procedures such as esophagoscopy, bronchoscopy, endotracheal intubation, and tooth extraction.[1,1014] Pneumomediastinum following cervicofacial emphysema is very rare and has been reported after orofacial trauma, head and neck surgery, or dental surgical procedures.[11-16] Orbital trauma leading to periorbital subcutaneous emphysema extending to neck and mediastinum is a very rare occurrence.[17] During isolated facial trauma, air may be forcefully introduced into the parapharyngeal and retropharyngeal spaces, follow the potential space at the prevertebral and fascial planes, and can lead to emphysema in the neck and mediastinum.[13,18,16] Air may pass to neck and mediastinum from the fascia of the the eye-socket rim, antero-superior pharynx, or sublingual and submental areas. Hence, no evidence of pneumothorax or tracheal and esophageal disruption was noted in the workup as an alternate explanation of pneumomediastinum. From a mechanistic viewpoint, laceration of the medial canthus may have provided a route for high-pressure water-air jet into the subcutaneous tissue in our patient. Generally, high pressure, high energy traumas are necessary to introduce air into subcutaneous tissues of face, neck, and down to mediastinum. Given that the commercial car washing companies use high-pressure car washer units with a water pressure of 3,000 - 6,900 PSI, the force our subject was subjected to was sufficient to drive air down to mediastinum. Clinical presentation of such patients is quite variable, ranging from subtle symptoms to life-threatening acute respiratory distress syndrome (ARDS). Chest pain, odinophagy, subcutaneous emphysema, dyspnea proportional to mediastinal compression, cyanosis, and pneumothorax are usually the most common symptoms.[7] Subcutaneous air often accompanies pneumomediastinum whereas pneumothorax is present in approximately 50% of cases.[16] Depending on presentation, initial diagnostic workup of pneumomediastinum may involve a chest X-ray which may Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2


Y覺lmaz et al. Subcutaneous emphysema, pneumo-orbita and pneumomediastinum following a facial trauma

(a)

(c)

(b)

(d)

Figure 2. (a) Axial section of the facial CT shows a hypodense appearance consistent with air (white arrow) between subcutaneous tissue planes in left temporal (thin arrow), bilateral paraseptal, bilateral intraorbital and left retrobulbar (thick arrow) areas. (b) Coronal section of the neck CT shows a diffuse hypodense appearance consistent with air (white arrows) that begins from the mastoid portion of the temporal lobe and extends between the muscle planes caudally to thoracic inlet. (c) Axial section of the neck CT shows a diffuse hypodense appearance consistent with air between the subcutaneous muscle planes and around the vascular structures at both sides of the neck (cervical subcutaneous emphysema). (d) Axial section of the thorax CT shows diffuse hypodense appearance consistent with air (white arrow) in prevascular, paratracheal, and paraesophageal areas of mediastinum (pneumomediastinum).

show an air column between left heart and the mediastinal pleura.[19] However, CT is more sensitive in diagnosis.[16] We proceeded directly to CT due to massive subcutaneous emphysema extending to thoracic region, which raised the possibility of pneumomediastinum, pneumothorax or pneumopericardium, conditions severe enough to warrant rapid diagnosis. In most cases the pneumomediastinum is a self-limiting condition that improves with conservative treatment,[1] as in our patient. The treatment approach usually consists of conservative management (bed rest, painkillers, antibiotics, and avoiding valsalva maneuver) if no tracheal or esophageal injury or Ulus Travma Acil Cerr Derg, March 2014, Vol. 20, No. 2

a source of air leakage such as a large bulla or a bleb is present. Caution should be exercised with noninvasive or invasive positive pressure ventilation.[1] Complications of pneumomediastinum are rare and mostly temporary. However, large volumes of air may lead to a condition called tension mediastinal emphysema characterized by compression of great vessels, diminished venous return, and hypotension, and requires mediastinotomy.[1] Severe cases can be managed with mediastinal needle aspiration, cervical mediastinotomy, tracheostomy, or urgent thoracotomy.[20] In conclusion, pneumomediastinum is a condition with high morbidity and mortality. It may develop as a result of blunt 149


Yılmaz et al. Subcutaneous emphysema, pneumo-orbita and pneumomediastinum following a facial trauma

neck, face, and eye traumas even with no concurrent tracheal or esophageal injuries, and pneumothrorax may accompany it.

10. Gouda HS, Shashidhar, Mestri C. Mediastinal emphysema due to an isolated facial trauma: a case report. Med Sci Law 2008;48:178-80.

Conflict of interest: None declared.

11. Ong WC, Lim TC, Lim J, Sundar G. Cervicofacial, retropharyngeal and mediastinal emphysema: a complication of orbital fracture. Asian J Surg 2005;28:305-8.

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12. Panerari AC, Soter AC, Silva FL, Oliveira LF, Neves MD, Cedin AC. Onset of subcutaneous emphysema and pneumomediastinum after tonsillectomy: a case report. Braz J Otorhinolaryngol 2005;71:94-6. 13. Josephson GD, Wambach BA, Noordzji JP. Subcutaneous cervicofacial and mediastinal emphysema after dental instrumentation. Otolaryngol Head Neck Surg 2001;124:170-1. 14. Afzali N, Malek A, Attar AH. Cervicofacial emphysema and pneumomediastinum following dental extraction: case report. Iran J Pediatr 2011;21:253-5. 15. López-Peláez MF, Roldán J, Mateo S. Cervical emphysema, pneumomediastinum, and pneumothorax following self-induced oral injury: report of four cases and review of the literature. Chest 2001;120:306-9. 16. Demers G, Camp JL, Bennett D. Pneumomediastinum caused by isolated oral-facial trauma. Am J Emerg Med 2011;29:841.e3-8. 17. Rzymska-Grala I, Palczewski P, Błaż M, Zmorzyński M, Gołębiowski M, Wanyura H. A peculiar blow-out fracture of the inferior orbital wall complicated by extensive subcutaneous emphysema: A case report and review of the literature. Pol J Radiol 2012;77:64-8. 18. Panacek EA, Singer AJ, Sherman BW, Prescott A, Rutherford WF. Spontaneous pneumomediastinum: clinical and natural history. Ann Emerg Med 1992;21:1222-7. 19. Maravelli AJ, Skiendzielewski JJ, Snover W. Pneumomediastinum acquired by glass blowing. J Emerg Med 2000;19:145-7. 20. Altınok T, Ceran S. Pnömomediastinum. Turkiye Klinikleri J Surg Med Sci 2007;3:39-42.

OLGU SUNUMU - ÖZET

Yüksek basınçlı oto yıkama sonucu oluşan yüz travması sonrası gelişen cilt altı amfizemi, pneumo-orbita ve pnömomediastinum Dr. Fevzi Yılmaz,1 Dr. Orçun Çiftçi,2 Dr. Miray Özlem,1 Dr. Erdal Komut,3 Dr. Ertuğrul Altunbilek1 Numune Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Ankara; Başkent Üniversitesi Tıp Fakültesi, Kardiyoloji Anabilim Dalı, Ankara; 3 Numune Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, Ankara; 1 2

Pnömomediastinum akciğer, özefagus, trakea ve boyun olmak üzere çeşitli potansiyel bölgelerden mediastinal boşluğa hava sızıntısının olmasıdır. İntraalveolar veya intrabronşial basınç artışı sonucu kendiliğinden veya travma sonucu gelişen nadir bir durumdur. Yüz veya boyun travması sonucu meydana gelen cilt altı amfizemin yüz ve boyunun anatomik bağlantıları yoluyla mediastinal boşluğa yayılımı bildirilmiş olmasına rağmen, Orbita travması sonucu meydana gelen pnömomediastinum çok nadir bir durumdur ve sadece birkaç raporda bildirilmiştir. Bu olguda 17 yaşında erkek hastada paraorbital ve yüz alanlarındaki yaygın cilt altı amfizemin boyuna ve mediastinal boşluğa yayılımı sunuldu. Anahtar sözcükler: Cilt altı amfizemi; pnömomediastinum; yüz travması. Ulus Travma Acil Cerr Derg 2014;20(2):147-150

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