travma 2013-1

Say› - Number 1 Ocak - January 2013Cilt - Volume 19

www.tjtes.org

Cilt - Volume 19 Sayı - Number 1

ISSN 1306 - 696x

Ocak - January 2013

TURKISH JOURNAL OF TRAUMA&

EMERGENCY SURGERY

www.tjtes.org

Index Medicus, Medline, EMBASE/Excerpta Medica, Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜB‹TAK-ULAKB‹M Türk Tıp Dizini’nde yer almaktadır.

Indexed in Index Medicus, Medline, EMBASE/Excerpta Medica and Science Citation Index-Expanded (SCI-E), Index Copernicus and the Turkish Medical Index of TÜB‹TAK-ULAKB‹M.

ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİTURKISH JOURNAL OF TRAUMA AND EMERGENCY SURGERY

Editör (Editor)Recep Güloğlu

Yardımcı Editörler (Associate Editors)Kaya Sarıbeyoğlu Hakan Yanar Ahmet Nuray Turhan

Geçmiş Dönem Editörleri (Former Editors)Ömer Türel Cemalettin Ertekin Korhan Taviloğlu

ULUSAL BİLİMSEL DANIŞMA KURULU (NATIONAL EDITORIAL BOARD)

Fatih Ağalar İstanbulYılmaz Akgün ÇanakkaleLevhi Akın İstanbulAlper Akınoğlu AdanaMurat Aksoy İstanbulŞeref Aktaş İstanbulAli Akyüz İstanbulÖmer Alabaz AdanaOrhan Alimoğlu İstanbulNevzat Alkan İstanbulEdit Altınlı İstanbulAcar Aren İstanbulGamze Aren İstanbulCumhur Arıcı AntalyaOktar Asoğlu İstanbulAli Atan AnkaraBülent Atilla AnkaraLevent Avtan İstanbulYunus Aydın İstanbulÖnder Aydıngöz İstanbulErşan Aygün İstanbulMois Bahar İstanbulAkın Eraslan Balcı ElazığEmre Balık İstanbulUmut Barbaros İstanbulSemih Baskan AnkaraM Murad Başar KırıkkaleMehmet Bayramiçli İstanbulAhmet Bekar BursaOrhan Bilge İstanbulMustafa Bozbuğa EdirneMehmet Can İstanbulBaşar Cander KonyaNuh Zafer Cantürk KocaeliMünacettin Ceviz ErzurumBanu Coşar İstanbulFigen Coşkun Ankaraİrfan Coşkun EdirneNahit Çakar İstanbulAdnan Çalık TrabzonFehmi Çelebi ErzurumGürhan Çelik İstanbulOğuz Çetinkale İstanbulM. Ercan Çetinus İstanbulSebahattin Çobanoğlu EdirneAhmet Çoker İzmirCemil Dalay AdanaFatih Dikici İstanbulYalım Dikmen İstanbulOsman Nuri Dilek SakaryaKemal Dolay AntalyaLevent Döşemeci AntalyaMurat Servan Döşoğlu DüzceKemal Durak BursaEngin Dursun Ankara

Şükrü Özer KonyaHalil Özgüç BursaAhmet Özkara İstanbulMahir Özmen AnkaraVahit Özmen İstanbulNiyazi Özüçelik İstanbulSüleyman Özyalçın İstanbulEmine Özyuvacı İstanbulSalih Pekmezci İstanbulİzzet Rozanes İstanbulKazım Sarı İstanbulEsra Can Say İstanbulAli Savaş Ankaraİskender Sayek AnkaraTülay Özkan Seyhan İstanbulGürsel Remzi Soybir TekirdağYunus Söylet İstanbulErdoğan Sözüer KayseriMustafa Şahin TokatCüneyt Şar İstanbulMert Şentürk İstanbulFeridun Şirin İstanbulİbrahim Taçyıldız DiyarbakırGül Köknel Talu İstanbulErtan Tatlıcıoğlu AnkaraGonca Tekant İstanbulCihangir Tetik İstanbulMustafa Tireli ManisaAlper Toker İstanbulRıfat Tokyay İstanbulSalih Topçu KocaeliTurgut Tufan AnkaraFatih Tunca İstanbulAkif Turna İstanbulZafer Nahit Utkan KocaeliAli Uzunköy UrfaErol Erden Ünlüer İzmirÖzgür Yağmur AdanaMüslime Yalaz İstanbulSerhat Yalçın İstanbulSümer Yamaner İstanbulMustafa Yandı TrabzonNihat Yavuz İstanbulCumhur Yeğen İstanbulEbru Yeşildağ TekirdağHüseyin Yetik İstanbulCuma Yıldırım GaziantepBedrettin Yıldızeli İstanbulSezai Yılmaz MalatyaKaya Yorgancı AnkaraCoşkun Yorulmaz İstanbulTayfun Yücel İstanbul

Atilla Elhan AnkaraMehmet Eliçevik İstanbulİmdat Elmas İstanbulUfuk Emekli İstanbulHaluk Emir İstanbulYeşim Erbil İstanbulŞevval Eren DiyarbakırHayri Erkol BoluMetin Ertem İstanbulMehmet Eryılmaz AnkaraFigen Esen İstanbulTarık Esen İstanbulİrfan Esenkaya MalatyaOzlem Evren Kemer AnkaraNurperi Gazioğlu İstanbulFatih Ata Genç İstanbulAlper Gökçe TekirdağNiyazi Görmüş KonyaFeryal Gün İstanbulÖmer Günal DüzceNurullah Günay KayseriHaldun Gündoğdu AnkaraMahir Günşen AdanaEmin Gürleyik BoluHakan Güven İstanbulİbrahim İkizceli İstanbulHaluk İnce İstanbulFuat İpekçi İzmirFerda Şöhret Kahveci BursaSelin Kapan İstanbulMurat Kara AnkaraHasan Eşref Karabulut İstanbulEkrem Kaya BursaMehmet Yaşar Kaynar İstanbulMete Nur Kesim SamsunYusuf Alper Kılıç AnkaraHaluk Kiper EskişehirHikmet Koçak ErzurumM Hakan Korkmaz AnkaraGüniz Meyancı Köksal İstanbulCüneyt Köksoy Ankaraİsmail Kuran İstanbulNecmi Kurt İstanbulMehmet Kurtoğlu İstanbulNezihi Küçükarslan Ankaraİsmail Mihmanlı İstanbulMehmet Mihmanlı İstanbulKöksal Öner İstanbulDurkaya Ören ErzurumHüseyin Öz İstanbulHüseyin Özbey İstanbulFaruk Özcan İstanbulCemal Özçelik Diyarbakırİlgin Özden İstanbulMehmet Özdoğan Ankara

ULUSLARARASI BİLİMSEL DANIŞMA KURULUINTERNATIONAL EDITORIAL BOARD

Juan Asensio Miami,USA Zsolt Balogh NewCastle,Australia Ken Boffard Johannesburg,S.Africa Fausto Catena Bologna,Italy Howard Champion WashingtonDC,USA Elias Degiannis Johannesburg,S.Africa Demetrios Demetriades LosAngeles,USA Timothy Fabian Memphis,USA Rafi Gürünlüoğlu Denver,USA Clem W. Imrie Glasgow,Scotland Kenji Inaba LosAngeles,USA Rao Ivatury Richmond,USA Yoram Kluger Haifa,Israel Rifat Latifi Tucson,USA Sten Lennquist Malmö,Sweden Ari Leppaniemi Helsinki,Finland Valerie Malka Sydney,Australia Ingo Marzi Frankfurt,Germany Kenneth L. Mattox Houston,USA Carlos Mesquita Coimbra,Portugal

Ernest E Moore Denver,USA Pradeep Navsaria CapeTown,S.Africa Andrew Nicol CapeTown,S.Africa Hans J Oestern Celle,Germany Andrew Peitzman Pittsburgh,USA Basil A Pruitt SanAntonio,USA Peter Rhee Tucson,USA Pol Rommens Mainz,Germany William Schwabb Philadelphia,USA Michael Stein Petach-Tikva,Israel Spiros Stergiopoulos Athens,Greece Michael Sugrue Liverpool,Australia Otmar Trentz Zurich,Switzerland Donald Trunkey Oregon,USA Fernando Turegano Madrid,Spain Selman Uranues Graz,Austria Vilmos Vecsei Vienna,Austria George Velmahos Boston,USA Eric J Voiglio Lyon,France Mauro Zago Milan,Italy

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

Başkan(President) RecepGüloğlu BaşkanYardımcısı(Vice President) KayaSarıbeyoğlu GenelSekreter(Secretary General) AhmetNurayTurhan Sayman(Treasurer) HakanYanar YönetimKuruluÜyeleri(Members) M.MahirÖzmen EdizAltınlı GürhanÇelik

İLETİŞİM (CORRESPONDENCE)

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

UlusalTravmaveAcilCerrahiDerneği Tel:+90212-5886246-5886246 ŞehreminiMah.,KöprülüMehmetPaşaSok. Faks(Fax):+90212-5861804 DadaşoğluApt.,No:25/1, e-posta(e-mail):[email protected] 34104Şehremini,İstanbul Web:www.travma.org.tr

UlusalTravmaveAcilCerrahiDerneğiadına Sahibi(Owner) RecepGüloğlu YazıİşleriMüdürü(Editorial Director) RecepGüloğlu YayınKoordinatörü(Managing Editor) M.MahirÖzmen Amblem MetinErtem Yazışmaadresi(Correspondence address) UlusalTravmaveAcilCerrahiDergisiSekreterliği ŞehreminiMah.,KöprülüMehmetPaşaSok., DadaşoğluApt.,No:25/1,34104Şehremini,İstanbul Tel +90212-5311246-5886246 Faks(Fax) +90212-5861804

Abonelik:2012yılıabonebedeli(UlusalTravmaveAcilCerrahiDerneği’nebağışolarak)75.-YTL’dir.HesapNo:TürkiyeİşBankası,İstanbulTıpFakültesiŞubesi1200-3141069no’luhesabınayatırılıpmakbuzdernekadresinepostaveyafaksyoluileiletilmelidir. Annual subscription rates: 75.- (USD)

p-ISSN 1306-696x • e-ISSN 1307-7945 • Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır. (Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus and Turkish Medical Index) • Yayıncı (Publisher): KARE Yayıncılık (karepublishing) • Tasarım (Design): Ali Cangül • İngilizce Editörü (Linguistic Editor): Corinne Can • İstatistik (Statistician): Empiar • Online Dergi & Web (Online Manuscript & Web Management): LookUs • Baskı (Press): Yıldırım Matbaacılık • Basım tarihi (Press date): Ocak (January) 2013 • Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur. (This publication is printed on paper that meets the international standard ISO 9706: 1994).

REDAKSİYON (REDACTION)ErmanAytaç

YAZARLARA BİLGİ

Ulusal Travma ve Acil Cerrahi Dergisi, Ulusal Travma ve Acil Cerrahi Derneği’nin yayın organıdır. Travma ve acil cerrahi hastalıklar konuların-da 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 Me-dicus 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 in-dekslerinde ve 2008 yılından itibaren Index Copernicus indeksinde yer almaktadır. 2001-2006 yılları arasındaki 5 yıllık dönemde SCI-E kapsa-mındaki dergilerdeki İmpakt faktörümüz 0,5 olmuştur. Dergide araştırma yazılarına öncelik verilmekte, bu nedenle derleme veya olgu sunumu tü-ründeki 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 dışın-da), başka bir yerde yayınlanmasının düşünülmediği ve Ulusal Travma ve Acil Cerrahi Dergisi’nde yayınlanmasının tüm yazarlar tarafından uy-gun bulunduğu anlamına gelmektedir. Yazar(lar), çalışmanın yayınlan-masının kabulünden başlayarak, yazıya ait her hakkı Ulusal Travma ve Acil Cerrahi Derneği’ne devretmektedir(ler). Yazar(lar), izin almaksı-zın 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 yazı-lar önce editör tarafından ön değerlendirmeye alınır; daha sonra incelen-mesi için danışma kurulu üyelerine gönderilir.Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; ge-rektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamam-lanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “ma-nuscript editing” sürecine alınır; bu aşamada tüm bilgilerin doğruluğu için ayrıntılı kontrol ve denetimden geçirilir; yayın öncesi şekline getiri-lerek yazarların kontrolüne ve onayına sunulur. Editörün, kabul edilme-yen yazıların bütününü ya da bir bölümünü (tablo, resim, vs.) iade etme zorunluluğu yoktur.Yazıların hazırlanması: Tüm yazılı metinler 12 punto büyüklükte “Times New Roman” yazı karakterinde iki satır aralıklı olarak yazılmalıdır. Sayfa-da her iki tarafta uygun miktarda boşluk bırakılmalı ve ana metindeki say-falar numaralandırılmalıdır. Journal Agent sisteminde, başvuru mektubu, başlık, yazarlar ve kurumları, iletişim adresi, Türkçe özet ve yazının İngi-lizce başlığı ve özeti ilgili aşamalarda yüklenecektir. İngilizce yazılan ça-lışmalara da Türkçe özet eklenmesi gerekmektedir. Yazının ana metnin-deyse şu sıra kullanılacaktır: Giriş, Gereç ve Yöntem, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekiller.Başvuru mektubu: Bu mektupta yazının tüm yazarlar tarafından okun-duğu, 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” bölü-münde, 10. aşamada yer alan dosya yükleme aşamasında yollanmalı-dır.Başlık sayfası: Yazının başlığı, yazarların adı, soyadı ve ünvanları, ça-lışmanın yapıldığı kurumun adı ve şehri, eğer varsa çalışmayı destekle-yen fon ve kuruluşların açık adları bu sayfada yer almalıdır. Bu sayfaya ayrıca “yazışmadan sorumlu” yazarın isim, açık adres, telefon, faks, mo-bil 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 Söz-cükler başlıklarını; İngilizce özet Background, Methods, Results, Conclu-sion ve Key words başlıklarını içermelidir. İngilizce olarak hazırlanan ça-lışmalarda da Türkçe özet yer almalıdır. Özetler başlıklar hariç 190-210 sözcük olmalıdır. Tablo, şekil, grafik ve resimler: Şekillere ait numara ve açıklayıcı bil-giler ana metinde ilgili bölüme yazılmalıdır. Mikroskobik şekillerde resmi açıklayıcı bilgilere ek olarak, büyütme oranı ve kullanılan boyama tekni-ği 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 açıklamasıy-la birlikte gönderilmelidir. Hastaların görüntülendiği fotoğraflara, hasta-nın ve/veya velisinin imzaladığı bir izin belgesi eşlik etmeli veya fotoğ-rafta 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. Ma-kale içinde geçen kaynak numaraları köşeli parantezle ve küçültülme-den belirtilmelidir. Kaynak listesinde yalnızca yayınlanmış ya da yayın-lanması 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 ya-zar durumunda altıncı yazarın arkasından “et al.” ya da “ve ark.” eklen-melidir. 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 du-odenal 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.trav-ma.org.tr adresli web sayfamızda eski yayınlara tam metin olarak ulaşa-bileceğiniz bir arama motoru vardır.Derleme yazıları: Bu tür makaleler editörler kurulu tarafından gerek ol-duğunda, konu hakkında birikimi olan ve bu birikimi literatüre de yansı-mış kişilerden talep edilecek ve dergi yazım kurallarına uygunluğu sap-tandıktan sonra değerlendirmeye alınacaktır. Derleme makaleleri; başlık, Türkçe özet, İngilizce başlık ve özet, alt başlıklarla bölümlendirilmiş me-tin ile kaynakları içermelidir. Tablo, şekil, grafik veya resim varsa yukarı-da belirtildiği şekilde gönderilmelidir.Olgu sunumları: Derginin her sayısında sınırlı sayıda olgu sunumu-na yer verilmektedir. Olgu bildirilerinin kabulünde, az görülürlük, eğiti-ci olma, ilginç olma önemli ölçüt değerlerdir. Ayrıca bu tür yazıların ola-bildiğince kısa hazırlanması gerekir. Olgu sunumları başlık, Türkçe özet, İngilizce başlık ve özet, olgu sunumu, tartışma ve kaynaklar bölümlerin-den 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 mektup-lar 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 ola-rak 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 bil-diren yazılarda, çalışmanın yapıldığı gönüllü ya da hastalara uygulana-cak prosedür(lerin) özelliği tümüyle anlatıldıktan sonra, onaylarının alındı-ğını gösterir bir cümle bulunmalıdır. Yazarlar, bu tür bir çalışma söz konu-su olduğunda, uluslararası alanda kabul edilen kılavuzlara ve T.C. Sağlık Bakanlığı tarafından getirilen yönetmelik ve yazılarda belirtilen hükümle-re uyulduğunu belirtmeli ve kurumdan aldıkları Etik Komitesi onayını gön-dermelidir. Hayvanlar üzerinde yapılan çalışmalarda ağrı, acı ve rahatsız-lık verilmemesi için neler yapıldığı açık bir şekilde belirtilmelidir.Yazı gönderme - Yazıların gönderilmesi: Ulusal Travma ve Acil Cer-rahi 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 “Onli-ne Makale Gönderme” ikonuna tıklandığında ulaşılan Journal Agent sis-teminden yollanmaktadır. Sistem her aşamada kullanıcıyı bilgilendiren özelliktedir.

INFORMATION FOR THE AUTHORS

The Turkish Journal of Trauma and Emergency Surgery (TJTES) is an official publication of the Turkish Association of Trauma and Emer-gency Surgery. It is a peer-reviewed periodical that considers for pub-lication clinical and experimental studies, case reports, technical con-tributions, and letters to the editor. Six issues are published annually.As from 2001, the journal is indexed in Index Medicus and Medline, as from 2005 in Excerpta Medica and EMBASE, as from 2007 in Science Citation Index Expanded (SCI-E) and Journal Citation Reports / Sci-ence Edition, and as from 2008 in Index Copernicus. For the five-year term of 2001-2006, our impact factor in SCI-E indexed journals is 0.5. It is cited as ‘Ulus Travma Acil Cerrahi Derg’ in PUBMED. Submission of a manuscript by electronic means implies: that the work has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis); that it is not under consideration for publication elsewhere; and that its publication in the Turkish Journal of Trauma and Emergency Surgery is approved by all co-authors. The author(s) transfer(s) the copyright to the Turkish Asso-ciation 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 lan-guage 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 ad-dition 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, re-jected manuscripts will not be returned to the authors, including ac-companying materials.TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medi-cal Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for re-views and case reports.Manuscript submission: TJTES accepts only on-line submission via the official web site (please click, www.travma.org.tr/en) and refuses printed manuscript submissions by mail. All submissions are made by the on-line submission system called Journal Agent, by clicking the icon “Online manuscript submission” at the above mentioned web site homepage. The system includes directions at each step but for fur-ther information you may visit the web site (http://www.travma.org/en/journal/).Manuscript preparation: Manuscripts should have double-line spac-ing, 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 institu-tions and correspondence address, abstract in Turkish (for Turkish au-thors only), and title and abstract in English are uploaded to the Journal Agent system in the relevant steps. The main text includes Introduc-tion, 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 submit-ted 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-tion, called “Upload Your Files”.

Abstract: The abstract should be structured and serve as an informa-tive guide for the methods and results sections of the study. It must be prepared with the following subtitles: Background, Methods, Results and Conclusions. Abstracts should not exceed 200 words.Figures, illustrations and tables: All figures and tables should be numbered in the order of appearance in the text. The desired position of figures and tables should be indicated in the text. Legends should be included in the relevant part of the main text and those for photo-micrographs 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 pre-pared. For recognizable photographs, signed releases of the patient or of his/her legal representatives should be enclosed; otherwise, patient names or eyes must be blocked out to prevent identification.References: All references should be numbered in the order of men-tion in the text. All reference figures in the text should be given in brack-ets without changing the font size. References should only include articles that have been published or accepted for publication. Refer-ence format should conform to the “Uniform requirements for manu-scripts submitted to biomedical journals” (http://www.icmje.org) and its updated versions (February 2006). Journal titles should be abbrevi-ated 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: Mc-Graw-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 ar-ticles 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 is-sue of the journal. The presented case(s) should be educative and of in-terest to the readers, and should reflect an exclusive rarity. Case reports should contain the title, summary, and the case, discussion, and refer-ences sections. These reports may consist of maximum five authors.Letters to the Editor: “Letters to the Editor” are only published elec-tronically 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 ex-ceed 500 words. The letter must clearly list the title, authors, publica-tion date, issue number, and inclusive page numbers of the publication for which opinions are released.Informed consent - Ethics: Manuscripts reporting the results of ex-perimental studies on human subjects must include a statement that informed consent was obtained after the nature of the procedure(s) had been fully explained. Manuscripts describing investigations in animals must clearly indicate the steps taken to eliminate pain and suffering. Authors are advised to comply with internationally accepted guidelines, stating such compliance in their manuscripts and to include the approval by the local institutional human research committee.

ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

C‹LT - VOL. 19 SAYI - NUMBER 1 OCAK - JANUARY 2013

İçindekiler - Contents

Deneysel Çalışma - Experimental Study

1-7 Medicinal plant extract (Ankaferd Blood Stopper) application in deep tissue injuries in rats: histopathological investigation of the effect on regional and systemic tissues Bitkisel özlü Ankaferd Blood Stopper’in sıçanlarda derin dokulara uygulamada bölgesel ve sistemik dokulara etkilerinin histopatolojik olarak incelenmesi OkumuşM,YükselKZ,ÖzbağD,ÇıralıkH,YılmazZ,GümüşalanY,BakanV,KalenderAM

8-12 Glucosamine-sulfate on fracture healing Glukozamin sülfatın kırık iyileşmesine etkisi UğraşA,GüzelE,KorkusuzP,Kayaİ,DikiciF,DemirbaşE,ÇetinusE

Klinik Çalışma - Original Articles

13-19 Appendicitis scores may be useful in reducing the costs of treatment for right lower quadrant pain Apandisit skorları, sağ alt kadran ağrısı için tedavi maliyetlerini düşürmede faydalı olabilir KırkılC,KarabulutK,AygenE,İlhanYS,YurM,BinnetoğluK,BülbüllerN

20-24 Management of acute appendicitis in pregnancy Gebelikte akut apandisit tedavisi KapanS,BozkurtMA,TurhanAN,GönençM,AlışH

25-28 Overlooked extremity fractures in the emergency department Acil serviste gözden kaçan ekstremite kırıkları ErE,KaraPH,OyarO,ÜnlüerEE

29-32 Prophylactic injection therapy is necessary for Forrest type 2b duodenal ulcers Forrest tip 2b duodenal ülserlerde profilaktik enjeksiyon tedavisi gereklidir ÖnerOZ,GönençM,KalaycıMU,BozkurtMA,KapanS,AlışH

33-40 Gastrointestinal kanal perforasyonlarında perforasyon bulgularının ve yerinin saptanmasında karın bilgisayarlı tomografisinin rolü The role of abdominal computed tomography in determining perforation findings and site in patients with gastrointestinal tract perforation IlgarM,ElmalıM,NuralMS

41-44 Inferior glenohumeral dislocation (luxatio erecta humeri): report of six cases and review of the literature İnferior omuz çıkığı (luksasyo erekta): Altı olgu sunumu ve literatürün gözden geçirilmesi İmerciA,GölcükY,UğurSG,UrsavaşHT,SavranA,SürerL

45-48 Does a penetrating diaphragm injury have an effect on morbidity and mortality? Penetran diyafram yaralanması morbidite ve mortaliteyi etkiler mi? ÖzoğulB,KısaoğluA,ÖztürkG,AtamanalpSS,AydınY,AydınlıB,YıldırganMİ

Cilt - Vol. 19 Sayı - No. 1 vii

ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

C‹LT - VOL. 19 SAYI - NUMBER 1 OCAK - JANUARY 2013

İçindekiler - Contents

49-52 Local differences in the epidemiology of traumatic spinal injuries Spinal yaralanma epidemiyolojisinde yerel farklılıklar ErdoğanMÖ,AnlaşDemirS,KoşargelirM,ÇolakŞ,ÖztürkE

53-57 The management of penetrating abdominal trauma by diagnostic laparoscopy: a prospective non-randomized study Penetran karın travmalarının tanısal lapararoskopi ile yönetimi: Prospektif randomize olmayan çalışma KaratekeF,ÖzdoğanM,ÖzyazıcıS,DaşK,MenekşeE,GülnermanYC,Baliİ,ÖnelS,GöklerC

58-64 Foreign body penetrations of hand and wrist: a retrospective study El ve el bileğinin yabancı cisim penetrasyon yaralanmaları: Retrospektif çalışma HocaoğluE,KuvatSV,ÖzalpB,AkhmedovA,DoğanY,KozanoğluE,MeteFS,ErerM

Olgu Sunumu - Case Reports

65-68 Unexpected colonic perforation in a renal recipient: a case report Böbrek nakli sonrası gelişen beklenmedik kolon perforasyonu: Olgu sunumu SerinKR,KeskinM,BakkaloğluH,TuncaF,AydınAE,EldegezCU

69-72 Post-traumatic sagittal sinus thrombosis: case report Posttravmatik sagittal sinüs trombozu: Olgu sunumu KhursheedN,AltafR,FurqanN,WaniA,JainA,AliY

73-76 Diffuse idiopathic skeletal hyperostosis and central cord syndrome after minor trauma: a case report Diffüz idiyopatik iskeletsel hiperosteozis ve minör travma sonrası santral kord sendromu: Olgu sunumu EserO,KaravelioğluE,BoyacıMG,AyçiçekA

77-79 Rotational head trauma with callosal contusion and C6 fracture: a high-speed motorcycle accident Kallozal kontüzyonla birlikte rotasyonel kafa travması ve C6 kırığı: Yüksek hızlı motosiklet kazası VyshkaG,TroshaniB,BozaxhiuD,MitrushiA

80-82 Unusual manifestation of acute retrocecal appendicitis: pericholecystic fluid Akut retroçekal apandisitin sıra dışı bulgusu: Perikolesistik sıvı AlgınO,ÖzmenE,ÖzcanAŞ,ErkekelŞ,KaraoğlanoğluM

83-85 Double acute appendicitis in appendical duplication Apendiks duplikasyonunda çift akut apandisit TutcuŞahinS,ErhanY,AydedeH

86-88 Barolith as a rare cause of acute appendicitis: a case report Akut apandisitin nadir bir nedeni; baryum taşı: Olgu sunumu İnceV,IşıkB,KoçC,BaşkıranA,OnurA

viii Ocak - January 2013

1

Turkish Journal of Trauma & Emergency Surgery

Experimental Study Deneysel Çalışma

Ulus Travma Acil Cerrahi Derg 2013;19 (1):1-7

Medicinal plant extract (Ankaferd Blood Stopper) application in deep tissue injuries in rats: histopathological investigation

of the effect on regional and systemic tissues

BitkiselözlüAnkaferdBloodStopper’insıçanlardaderindokularauygulamadabölgeselvesistemikdokularaetkilerininhistopatolojikolarakincelenmesi

Mehmet OKUMUŞ,1 Kasım Zafer YÜKSEL,2 Davut ÖZBAĞ,3 Harun ÇIRALIK,4

Zeki YILMAZ,2 Yakup GÜMÜŞALAN,3 Vedat BAKAN,5 Ali Murat KALENDER6

Departmentsof1EmergencyMedicine,2Neurosurgery,3Anatomy,4Pathology,5PediatricSurgery,6OrthopedicsandTraumatology,

SutcuImamUniversityFacultyofMedicine,Kahramanmaras,Turkey.

SütçüİmamÜniversitesiTıpFakültesi,1AcilTıpAnabilimDalı,2BeyinveSinirCerrahisiAnabilimDalı,3AnatomiAnabilimDalı,

4PatolojiAnabilimDalı,5ÇocukHastalıklarıAnabilimDalı,6OrtopediveTravmatolojiAnabilimDalı,Kahramanmaraş.

Correspondence(İletişim):MehmetOkumuş,M.D.SütçüİmamÜniversitesiTıpFakültesiAcilTıpAnabilimDalı,46050Kahramanmaraş,Turkey.Tel:+90-344-2151942e-mail(e-posta):[email protected]

BACKGROUNDThisstudywasplannedtoevaluateboththehistopathologi-calchangesunderlightmicroscopeaswellasthesystemicorgan effects following application of Ankaferd BloodStopper®(ABS)(amixtureoffiveplantextracts)inanani-malmodelofdeeptissuehemorrhage.

METHODSAtotalof50WistarAlbinoratsweredividedintofivegroupsof10ratseach.Theratsunderwentfemoralveinpunctureandwere treatedwithABS tampon,ABS spray, orSurgi-cel,andonegroupwasleftuntreated.Aftertwoweeks,eachgroupunderwentpartialtissueexcisionfromthesamefemo-ralregionaswellasfromthebrain,heart,kidney,andliver.

RESULTSThe specimens from all groups were obtained from thefemoralregionaftertwoweeksandevaluatedunderlightmicroscope.Thelightmicroscoperevealednohistopatho-logicalchangesinneurovascularstructuresorindeepcon-nectivetissuesinanyofthegroups.

CONCLUSIONABSprovidedhemostasisandwasobservedtostopbleed-ing.Therewerenohistopathologicalchangesatthetissuelevel and no pathological effects in other organs tissuesunder lightmicroscope, and the remote organ tissue re-mainedclear.Key Words: Ankaferd blood stopper; deep tissue injury; hemostasis.

AMAÇBuçalışmada,AnkaferdBloodStopper®(ABS)(beşbitkiözükarışımı),birhayvanmodelindederindokukanamala-rınauygulandığında,histopatolojikdeğişikliklerinvesiste-mikorganetkilerinin ışıkmikroskobualtındadeğerlendi-rilmesiplanlandı.

GEREÇ VE YÖNTEMToplamda50adetWistarAlbinosıçanlarherbirinde10’aradetolmaküzere5grubaayrıldı.SıçanlardafemoralvendelinerekABStampon,ABSsprey,Surgiceliletedaviedil-di,birgruphiçtedavialmadı.İkihaftasonrahergruptanaynıfemoralbölgedenveaynızamandabeyin,kalp,böb-rekvekaraciğerdenkısmidokualındı.

BULGULARİkihaftasonratümgruplardafemoralbölgedeneldeedilenörneklerışıkmikroskobuiledeğerlendirildi.Tümgruplar-danörovasküleryapılardaveyaderinbağdokularındaışıkmikroskobuincelemesindeherhangibirhistopatolojikde-ğişiklikortayaçıkmadı.

SONUÇAnkafer Blood Stopper’in hemostazı sağladığı ve kana-mayı durdurduğu gözlemlendi. Işıkmikroskobunda dokudüzeyindehistopatolojikdeğişikliklervediğerorganlardapatolojiketkileryoktu,uzakorgandokularıtemizdi.

Anahtar Sözcükler:Ankaferdkandurdurucu;derindokuyaralan-ması;hemostaz.

doi: 10.5505/tjtes.2013.65642

Ulus Travma Acil Cerrahi Derg

Approximatelyone-halfofthedeathsintraumaareassociated with hemorrhagic shock.[1] The first stepinmanaging traumapatients is to establish a secureairway, immobilize the cervical column, and obtainadequate breathing and circulation; control of hem-orrhage is the second crucial step.[2]Manymethodsandpharmacologicalagentsarebeingusedtostoporcontrol thehemorrhage thatcouldendmortally.Theaccustomed hemostasis comprises vasoconstrictionandclotformation,whichleadstocessationofbleed-ing.Hemostasisisachievedthroughtheactivationofplateletsandthecoagulationcascade.[3]

In cases of trauma including major arteries andveinsor internalorgans, it isessential tocontrol thehemorrhageinatimelymanner.Thevascularendothe-liumplaysapivotalroleintheregulationofhemosta-sis.Aftertheoccurrenceofvascularinjury,endothelialcellslimitclotformationtotheareaswherehemosta-sisisneededtorestorevascularintegrity.[4]

AnkaferdBloodStopper®(ABS)isauniquefolk-loricmedicinalplantextract.ABShasbeenapprovedinthemanagementofexternalhemorrhageanddentalsurgerybytheMinistryofHealthinTurkey.

ExposuretoABSresultsinaveryrapidformationofnetworkwithintheplasmaandserum.Thebasicmech-anism of action ofABS is through the formation ofan encapsulated protein network.[5]TheABS-inducedproteinnetwork formation involvesbloodcells,espe-ciallyerythrocytes,withoutaffectingthephysiologicalindividual coagulation systems.[5]ABS is a standard-ized extract from the following plants: Glycyrrhiza glabra, Vitis vinifera, Alpinia officinarum, Urtica dio-ica,andThymus vulgaris,inaweightratioof9:8:7:6:5,respectively.[5,6] Alpinia officinarum inhibits nitric ox-ideproductionby lipopolysaccharide-activatedmouseperitonealmacrophages.[7] Urtica dioicacausesvasodi-latationviainducingnitricoxideproductionbytheen-dothelium.[8] Glycyrrhiza glabrahasanti-inflammatory,anti-thrombin, anti-platelet, anti-oxidant, anti-athero-sclerotic,andanti-tumoractivities.Itinhibitsangiogen-esis and decreases vascular endothelial growth factorproductionandcytokine-inducedneovascularization.[9] Thymus vulgarishasanti-oxidativeactions,suchaspre-ventionoflipidperoxidation.[10] Vitis viniferaexertsan-ti-tumorandanti-atheroscleroticeffects.[11,12]Thus,themechanismsunderlyingthehemostaticcontrolbyABShavebeeninvestigatedthoroughlyinmanystudies.

ABSinducedveryrapid(<1second)formationofacellularproteinnetworkespeciallythroughvitalery-throidaggregateswithin theplasmaandserumsam-ples.[13]ABShas no toxic reactionswhen applied tomucosalsurfaceslikethemouthandthroughthegas-trointestinal tract.[13-17]However, the effects of long-termanddeeptissueexposuretoABSremainunclearinthesestudies.

Since the histopathological effect ofABS at thedeeptissuelevelandtheresultofthedarkclotcreatedarenotadequatelyknownatpresent,thisstudyaimedtoinvestigatethebasichistopathologicalchangesun-derlightmicroscopeindeeptissueinjuriesaswellasremoteorganswhenABSisapplieddeeplyinthetis-sues and to determine if the dark clot is reabsorbedaftertwoweeks.Inthisstudy,wecomparedtwoformsofABS(sprayandtampon)withSurgicel.

MATERIALS AND METHODSThis isanopen-label trialofABS ina ratmodel

offemoralveinpuncture.Atotalof50WistarAlbinoadult(280-320g)femaleratswereusedinthisstudy.Theanimalswerekept ina roomataconstant tem-peratureof22±1°Candfedwithstandardpelletchow,andtheroomwasmaintainedona12-hourlight/darkcycle.Foodandwaterwereavailablead libitum.Allexperimentswere performed in conformitywith theEuropeanCommunityCouncilDirective.Thisexperi-mental studywas carried out in the animal researchlaboratoryofauniversityhospitalandwasapprovedbytheKahramanmarasSutcuImamUniversityMedi-calFacultyAnimalEthicsCommittee.

The ratsweredivided intofivegroupsof10 ratseach.Theanimalswereanesthetizedintraperitoneallywithcombinationsofketamine(60mg/kg)andxyla-zine (10mg/kg).EachgroupexceptGroup5under-wentfemoralveinpuncturewithaneedle0.6mmindiameterinthemiddlepartof thefemoralveinafterskinincisionandtissuedissection(Fig.1a).

The tampon group treatedwithABS tamponun-derwent the conventional techniquewith hemostaticagentapplication(approximately0.5cm2ABStampon[containing~0.9ml]wasplacedonthepuncturedveinregion for30 secondswithmildpressure) (Fig.1b).ThespraygroupwastreatedwithABSspray(contain-ing0.1mlperpump).TheSurgicelgroupwastreatedwithSurgicel(approximately0.5cm2)(Fig.1c),andtheanimalsinthecontrolgroupwereleftwithoutanytreatment for bleeding after puncturing the vein; aspontaneously formedclot limited thebleeding.Theshamgroupunderwentonlyskinandtissuedissection.Aftertreatment,allratsunderwentsimpleclosurewith3/0silksuture.Allratssurvivedthrough14daysandwere fed and kept in the same conditions as beforethe experimental study. The rats were sacrificed byoverdoseanesthesiaonthe14thday.Then,eachgroupunderwentpartialtissueexcisioninthesamefemoralregion(includingfemoralartery,veinandnerve)thathadbeentreatedwithABSandSurgiceltwoweeksbe-fore.Inaddition,sampleswerealsoobtainedfromthebrain,heart,kidney,andlivertoinvestigatetheremoteorganeffectsofABS.Allspecimenswerekeptin10%neutralformaldehydesolution.Tissuespecimenswereprepared after routine procedures and then embed-

2 Ocak - January 2013

Medicinal plant extract (Ankaferd Blood Stopper) application in deep tissue injuries in rats

ded in paraffin. Sections (5 μm) were prepared from all specimens and stained with hematoxylin and eo-sin (H&E). All specimens were evaluated under light microscope histopathologically and photographs were taken (H&Ex40, H&Ex100, H&Ex200) by a patholo-gist blinded to the study groups. Light microscopic findings were graded semi-quantitatively from 0 (no histopathological change) to +3 (severe histopatho-logical change). This histopathological grading was performed for perivascular connective tissue as acute inflammation, chronic inflammation, hemosiderin-loaded macrophages, fibrosis, and necrosis by using the four-point scale of Bautista et al.[18]

Statistical analysis Statistical analyses were carried out using the Sta-

tistical Package for the Social Sciences (SPSS) soft-

ware (v. 16.0 for Windows, SPSS Inc.; Chicago, IL). All values were expressed as means ± SD. p values less than 0.05 were assumed to be statistically signifi-cant. Group comparisons were made by Kruskal-Wal-lis analysis, followed, in cases of significance, by the Mann-Whitney U-test.

RESULTSIn this study, cessation of bleeding was achieved

successfully after ABS tampon application to the punctured vein in the tampon group (Group 1). The ABS tampon took the excess clot after removal, and the hemorrhage area remained clear; the defective vein was closed with a wall-like clot formation with-out any sign of leakage (Fig. 1d). In the spray group (Group 2), after application of ABS spray to the fresh blood pool, a dark clot mass was formed very rapidly,

Cilt - Vol. 19 Sayı - No. 1 3

(a)

(c)

(e)

(b)

(d)

Fig. 1. (a) The view of the femoral vein. (b) Bleed-ing control with ABS tampon. (c) Treatment with Surgicel. (d) The view of the punctured vein after hemostasis. (e) The dark clot for-mation after ABS spray.

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


untreated after the puncture, and bleeding stopped spontaneously following a huge clot mass (Fig. 1c). After two weeks, no animals were lost. The animals were examined twice a day for local-systemic infec-tion or regional hematoma, and none occurred in ei-ther the treated groups or the controls. All rats sur-vived without any complication. The rats underwent incision in the same area two weeks after sacrificed with overdose anesthetics. In the tampon group, the macroscopic view was clear without any remarkable fibrosis or adhesion. In the spray group, there was a petechia-like appearance in the ABS spray-applied area. In the Surgicel group, Surgicel was absorbed and there were no signs of adhesion or fibrosis in the mac-roscopic view. In the control group, a hematoma for-mation-like appearance was seen in the macroscopic observation, while in the baseline group (sham), the macroscopic tissue appearance was normal.

After collecting the specimens from the brain, heart, kidney, and liver of each group, they were ex-amined under light microscope to determine any his-topathological changes. The neurovascular structures from the femoral region in all groups and remote or-gans remained normal. The specimens from the femo-ral region, especially the connective tissues, were also examined in all groups under light microscope, and the results are respectively mentioned. Light micro-scopic findings in the perivascular connective tissue of the rats on the 14th day are shown in Table 1. In the tampon group, the specimen included mild chronic inflammatory and hemosiderin-loaded cells and mild fibrosis in perivascular connective tissue, without any finding of cell degeneration or necrosis (Fig. 2a). In the spray group, the specimen included mild acute in-flammatory and moderate chronic inflammatory cells, and moderate hemosiderin-loaded macrophages and moderate fibrosis were observed in the perivascular connective tissue; however, neurovascular structures remained normal (Fig. 2b). There were significant differences in acute inflammatory cells, hemosiderin-loaded macrophages and fibrosis between the tampon and spray groups (p<0.05). There were mild chronic inflammatory cells and hemosiderin-loaded macro-phages in the perivascular connective tissue in the Surgicel group (Fig. 2c). While there was no statistical difference in any of the findings between the Surgicel and tampon group (p>0.005), in contrast, there were significant differences between the Surgicel and spray groups in acute inflammation and hemosiderin-load-ed macrophages (p<0.05). In the control group, the specimens included apparent congestion in vessels, and mild acute inflammatory cells and mild fibrosis were observed in the perivascular connective tissue. A comparison of the control group with the tampon, spray and Surgicel groups revealed that there were significant differences in all findings (p<0.05) except

which closed the view of the punctured vein, but it also achieved the presumed purpose in a very short time after the spray application (Fig. 1e). In Group 3, Surgicel also stopped the bleeding. Group 4 was left


Fig. 2. (a) The microscopic view of the tampon group after two weeks. (b) The microscopic view of the spray group after two weeks. (c) The microscopic view of the Surgicel group after two weeks.

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

(a)

(b)

(c)

fibrosis in the tampongroup,and thereweresignifi-cantdifferencesinallfindingsbetweenthesprayandSurgicel groups. In thebaselinegroup (sham), thereweremildchronicinflammatorycellsandmildfibro-sis in theperivascularconnective tissue.Thereweresignificantdifferencesinacuteandchronicinflamma-torycells(p<0.05),butnodifferenceinhemosiderin-loaded macrophages and fibrosis (p>0.05), betweenthe shamandcontrolgroups.Therewere significantdifferences inchronic inflammatorycellsandhemo-siderin-loadedmacrophagesandnodifferenceinacuteinflammatorycellsandfibrosisbetweentheshamandtampongroups.Thereweresignificantdifferencesinallfindingsbetweentheshamandspraygroups.Therewere significant differences in hemosiderin-loadedmacrophagesandfibrosis andnodifference inacuteandchronicinflammatorycellsbetweentheshamandSurgicelgroups.ComparisonsofthehistopathologicalchangesingroupsareshowninTable2.

DISCUSSIONAnkaferd Blood Stopper® (ABS) has been used

to stop hemorrhage on skin surfaces, during dental

procedures and on internal surfaces in many cases,withoutanytoxicreaction,buttherehasbeennoin-vestigationregardingthehistopathologicallong-termeffectsintissues.Theclinicalobservationsandmac-roscopic appearance of the applied area are enoughtoprove thesafetyofABS.[14-17,19-21]Therecentdata,especiallyinanimal-basedstudies,haveshowntheef-ficacyandnon-toxicityofABSinthemanagementofhemorrhage.[4,5,22-24] In vitrodataontheanti-infectivecharacteristicofABSandpreliminarysuccessfulap-plicationsinthegastrointestinaltractanddentalbleed-ingshaverepresentedincomingcluesregardingABSactivity.[19,20,22,25]

Inthisstudy,weplannedananimalmodeloffemo-ralvenipuncture inwhichdifferentmethodsofABSapplication were compared with Surgicel, and wealso investigated the histopathological changeswithrespect to the long-termeffects of theplant extracts(mixedinaprescribedratio)onregionalandsystemictissues inrats.Afterpuncturing thevein,applicationofABSrapidlystoppedthebleedinginbothformsoftamponandspray(in1second),andtheexcessforma-

Table 2. Thepvaluesofresultsofcomparisonsbetweenthegroupsaccordingtoacuteandchronicinflammatorycells,macrophagesandfibrosis

Histopathologicalchanges

Groups Acute Chronic Hemosiderin-loaded Fibrosis Necrosis Inflammation Inflammation macrophage

Tampon-Spray 0.020 0.189 0.000 0.006 N/ATampon-Surgicel 0.317 0.615 0.247 0.181 N/ATampon-Control 0.001 0.000 0.025 0.062 N/ATampon-Sham 0.626 0.028 0.025 0.062 N/ASpray-Surgicel 0.001 0.075 0.014 0.897 N/ASpray-Control 0.028 0.000 0.000 0.000 N/ASpray-Sham 0.028 0.003 0.000 0.000 N/ASurgicel-Control 0.000 0.000 0.012 0.029 N/ASurgicel-Sham 0.146 0.051 0.012 0.029 N/AControl-Sham 0.000 0.009 1.000 1.000 N/A

N/A:Notapplicable.

Table 1. Themeanvaluesofinflammation

Groups

Histopathologicalchanges Tampon Spray Surgicel Control Sham Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD

Necrosis None None None None NoneAcuteinflammation 0.3±0.95 0.7±0.48 0.0±0.00 1.2±0.42 0.2±0.42Chronicinflammation 1.3±0.48 1.6±0.52 1.2±0.42 0.2±0.42 0.8±0.42Hemosiderin-loadedmacrophage 0.8±0.63 2.4±0.52 1.3±1.06 0.2±0.42 0.2±0.42Fibrosis 1.1±0.74 2.0±0.47 1.7±1.25 0.5±0.53 0.5±0.53

0=None;1=Mild;2=Moderate;3=Severe.



tionof the formedblack clotwas remarkable in thespray group.Examination of the specimens that un-derwentABSapplicationinbothformsoftamponandsprayunderlightmicroscoperevealednohistopatho-logicaltoxicity,celldegenerationornecrosisevenaf-tertwoweeks.

Inflammationisaprotectiveresponse intendedtoeliminatetheinitialcauseofcellinjuryaswellasthenecrotic cells and tissues resulting from the originalinsult.Acute inflammation is rapid in onset and ofshortduration,lastingfromafewminutestoaslongasafewdays,andischaracterizedbyfluidandplasmaprotein exudation and a predominantly neutrophilicleukocyteaccumulation.Iftheinjuriousagentcannotbe eliminatedquickly, the resultmaybe chronic in-flammation. Chronic inflammationmay bemore in-sidious, is of longer duration (days toyears), and istypifiedbyaninfluxoflymphocytesandmacrophageswith associated vascular proliferation and fibrosis(scarring).[26]

In our study, as we compared the groups, therewasmildinflammationinallgroupsexceptthespraygroup.Only the spraygroupdiffered from theothergroups,andthedifferenceinseverityofinflammationwasstatisticallysignificant(p<0.05);whiletheinflam-mationseveritywasmoderateinthespraygroup,therewasonlymildinflammationintheothergroups.Thereason for this differencemay be the excessive useofABS spray.Whenusing theABS tampon to stopbleeding, the tampon contacts the hemorrhagic sur-face and leavesminimal residue of theABS extract(theapproximately0.5cm2ofABStamponcontained0.09ml extract). However, inABS spray form, ap-proximately0.1mlofABSextractwassprayedontothehemorrhagicarea.Theamountofbloodclotseemstobeirrelevantbecausetherewasasignificantdiffer-encebetween thesprayandcontrolgroup(p<0.001)in all findings except acute inflammatory cells.Thismay result from the amount of ABS extract used.Acute inflammationmayprogress tochronic inflam-mationwhentheacuteresponsecannotberesolved.[26] BecauseofthegreateramountofABSusedinsprayformthantampon,theinflammationmighthavepro-gressed to chronic inflammation, and hemosiderin-loadedmacrophageswerethedominantcellsthatwereclearingtheinjuredareafromclotandplantextract.

Inarecentstudy,Odabaşetal.[27]foundthatABSwascytotoxictohumanpulpfibroblasts.Thesensitiv-ityof cytotoxicitydependedon the concentrationofthematerialtested.ThegreaterdilutionsexhibitedlesscytotoxicitycomparedtothemoreconcentratedformsofABSextract.ThisnewstudysupportsourfindingsthathigherconcentrationsofABSmayresultinmoresevereinflammatoryreactionintheperivascularcon-nective tissue.However, therewere no signs of ne-

crosisorcelldegenerationinanyofthegroupsinourstudythatdemonstratedcytotoxicity.Thisresultneedstobeinvestigatedfurther.

Inonestudy,ABSwasusedinthedamagedblad-derwallinrats.Similartoourstudy,theauthorsfoundthattherewerenotoxicreactionsorfibrosisaftertwoweeks.[23]

In another study, no acute mucosal toxicity, he-matotoxicity, hepatotoxicity, nephrotoxicity, or bio-chemicaltoxicitywasobservedduringtheshort-termfollow-up of the animalswhenABSwas applied tointernaltopicalsurfaces.[28]Neitherlocalnorsystemicadverseeffectsor toxicitywereobserved inassocia-tionwithexperimentalandanecdotaltopicalapplica-tionofABS.ABSmayofferavaluableoptionduetoitseaseofapplicationandspeedofaction;itdoesnotrequirepreciselocalizationtothebleedingsite.Sim-ple topicalapplicationandeasyuseover thehemor-rhagicareawasabletostopthebleeding.[17]

Adouble-blinded,randomized,placebo-controlled,crossoverphaseIclinicalstudywithafive-daywash-outperiodbetweenthecrossoverperiodsdemonstrat-edthesafetyoftopicalABSadministrationinhealthyhuman volunteers. Following these findings, it wasconcluded that topical applicationofABS is safe.[29] Furtherinvestigationsincontrolofthebleedingwithapplication ofABS could shed light regarding saferuseinclinicalconditions.

TheeffectsofABSonvascularendothelium,bloodcells,angiogenesis,cellularproliferation,vasculardy-namics,andcellularmediatorsarebeinginvestigatedcurrentlytodetermineitspotentialroleinmanypatho-logical statesand tissue repair.[30,31]These resultsarepromising regarding the non-toxicity ofABS in theuseoftraumatichemorrhageindeeptissues.

In conclusion, based on its hemostatic actions,ABS, a traditional folkloricmedicinal plant extract,could be a candidate for use in clinicalmedicine inpre-hospital settings after trauma pending its abilitytoreducebloodlossandincreasesurvivalandinthemanagementofpatientswithcoagulopathydisordersorusinganticoagulant-antiaggregantdrugs.ABSsuc-cessfullystoppedhemorrhageindeeptissuetraumaslocally. No pathological changes were determinedunderlightmicroscopicexaminationtwoweekslater.WeconcludethatABScanbeusedsafelysinceitdoesnotleadtoanydegenerationofregionalandsystemictissues,butthereisaneedforfurtherinvestigationsinhumanmodels.

AcknowledgementThis experimental study was supported by Kah-

ramanmarasUniversityCouncilofExperts (decision2009/4-8m).



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

REFERENCES1. SauaiaA, Moore FA, Moore EE, Moser KS, Brennan R,

ReadRA,etal.Epidemiologyoftraumadeaths:areassess-ment.JTrauma1995;38:185-93.

2. Edward E. Cornwell III. Initial approach to trauma. In:TintinalliJE,KelenGD,StapczynskiJS,MaOJ,ClineDM,editors.Emergencymedicine:acomprehensivestudyguide.NewYork,NY:McGraw-Hill;6thed.2004.p.1537-42.

3. TellerP,WhiteTK.Thephysiologyofwoundhealing:injurythroughmaturation.SurgClinNorthAm2009;89:599-610.

4. CipilHS,KosarA,KayaA,UzB,HaznedarogluIC,GokerH,etal.Invivohemostaticeffectofthemedicinalplantex-tractAnkaferdBloodStopperinratspretreatedwithwarfa-rin.ClinApplThrombHemost2009;15:270-6.

5. Goker H, Haznedaroglu IC, Ercetin S, Kirazli S, AkmanU,OzturkY,etal.Haemostaticactionsofthefolkloricme-dicinalplantextractAnkaferdBloodStopper.JIntMedRes2008;36:163-70.

6. Ankaferdweb site.Available at: http://www.ankaferd.com/eng/abs-formul.phpAccessedMarch20,2010.

7. Matsuda H,Ando S, Kato T,MorikawaT,YoshikawaM.InhibitorsfromtherhizomesofAlpiniaofficinarumonpro-ductionofnitricoxideinlipopolysaccharide-activatedmac-rophagesandthestructuralrequirementsofdiarylheptanoidsfortheactivity.BioorgMedChem2006;14:138-42.

8. TestaiL,ChericoniS,CalderoneV,NencioniG,NieriP,Mo-relliI,etal.CardiovasculareffectsofUrticadioicaL.(Urti-caceae)rootsextracts:invitroandinvivopharmacologicalstudies.JEthnopharmacol2002;81:105-9.

9. SheelaML,RamakrishnaMK,SalimathBP.AngiogenicandproliferativeeffectsofthecytokineVEGFinEhrlichascitestumorcellsisinhibitedbyGlycyrrhizaglabra.IntImmuno-pharmacol2006;6:494-8.

10.LeeSJ,UmanoK,ShibamotoT,LeeKG.Identificationofvolatile components in basil (Ocimum basilicum L.) andthymeleaves(ThymusvulgarisL.)andtheiantioxidantprop-erties.FoodChem2005;91:131-7.

11.Zhao J,Wang J, ChenY,Agarwal R.Anti-tumor-promot-ing activity of a polyphenolic fraction isolated fromgrapeseeds in the mouse skin two-stage initiation-promotionprotocol and identification of procyanidinB5-3’-gallate asthe most effective antioxidant constituent. Carcinogenesis1999;20:1737-45.

12.YamakoshiJ,KataokaS,KogaT,ArigaT.Proanthocyanidin-richextractfromgrapeseedsattenuatesthedevelopmentofaorticatherosclerosisincholesterol-fedrabbits.Atheroscle-rosis1999;142:139-49.

13.HaznedarogluBZ,HaznedarogluIC,WalkerSL,BilgiliH,Goker H, KosarA, et al. Ultrastructural and morphologi-cal analyses of the in vitro and in vivo hemostatic effectsof Ankaferd Blood Stopper. Clin Appl Thromb Hemost2010;16:446-53.

14.KurtM,OztasE,KuranS,Onal IK,KekilliM,Hazneda-roglu IC.Tandemoral, rectal, andnasal administrationsofAnkaferdBloodStoppertocontrolprofusebleedingleadingtohemodynamicinstability.AmJEmergMed2009;27:631.e1-2.

15.TekerAM, KorkutAY, Gedikli O, Kahya V. Prospective,

controlledclinical trialofAnkaferdBloodStopper inchil-drenundergoingtonsillectomy.IntJPediatrOtorhinolaryn-gol2009;73:1742-5.

16.KurtM,KacarS,Onal IK,AkdoganM,Haznedaroglu IC.Ankaferd Blood Stopper as an effective adjunctive hemo-static agent for themanagementof life-threatening arterialbleedingofthedigestivetract.Endoscopy2008;40:E262.

17.KurtM,AkdoganM,OnalIK,KekilliM,ArhanM,ShorbagiA,etal.EndoscopictopicalapplicationofAnkaferdBloodStopperforneoplasticgastrointestinalbleeding:Aretrospec-tiveanalysis.DigLiverDis2010;42:196-9.

18.BautistaA,TojoR,VarelaR,EstevezE,VillanuevaA,Cadra-nelS.Effectsofprednisoloneanddexamethasoneonalkaliburnsoftheesophagusinrabbit.JPediatrGastroenterolNutr1996;22:275-83.

19.Kurt M, Disibeyaz S, Akdogan M, Sasmaz N, Aksu S,HaznedarogluIC.Endoscopicapplicationofankaferdbloodstopperasanovelexperimentaltreatmentmodalityforuppergastrointestinalbleeding:acasereport.AmJGastroenterol2008;103:2156-8.

20.DoganOF,OzyurdaU,UymazOK,ErcetinS,HaznedarogluIC.NewanticoagulantagentforCABGsurgery.EurJClinInvest2008;38:341.

21.IbisM,KurtM,OnalIK,HaznedarogluIC.Successfulman-agementofbleedingdue tosolitary rectalulcervia topicalapplicationofAnkaferdbloodstopper.JAlternComplementMed2008;14:1073-4.

22.BilgiliH,KosarA,KurtM,OnalIK,GokerH,CaptugO,etal.HemostaticefficacyofAnkaferdBloodStopperinaswinebleedingmodel.MedPrincPract2009;18:165-9.

23.KilicO,GonenM,AcarK,YurdakulT,AvundukMC,EsenHH,etal.Haemostaticroleandhistopathologicaleffectsofanewhaemostaticagentinaratbladderhaemorrhagemodel:anexperimentaltrial.BJUInt2010;105:1722-5.

24.KosarA,CipilHS,KayaA,UzB,HaznedarogluIC,GokerH, et al. The efficacy ofAnkaferd Blood Stopper in anti-thromboticdrug-inducedprimaryandsecondaryhemostaticabnormalitiesofarat-bleedingmodel.BloodCoagulFibri-nolysis2009;20:185-90.

25.Akkoc N,AkcelikM, Haznedaroglu I, Goker H,Aksu S,KirazliS,etal. InvitroantibacterialactivitiesofAnkaferdBloodStopper.IntJLabHematol2008;30:95.

26.KumarV,AbbasAK,FaustoN,MitchellR(editors).Rob-binsbasicpathology.Saunders,Elsevier;8thed.2007.

27.OdabaşME,ErtürkM,ÇınarÇ,TüzünerT,TulunoğluÖ.Cytotoxicityofanewhemostaticagentonhumanpulpfibro-blastsinvitro.MedOralPatolOralCirBucal2011;16:e584-7.

28.BilgiliH,CaptugO,KosarA,KurtM,KekilliM,ShorbagiA, et al. Oral systemic administration ofAnkaferd bloodstopperhasnoshort-termtoxicityinaninvivorabbitexperi-mentalmodel.ClinApplThrombHemost2010;16:533-6.

29.Adouble-blinded, randomized, placebo-controlled, cross-overphaseIclinicalstudyofAnkaferdBloodStopper.AN-KAFERDBloodStopperInvestigationalDrugResearchAc-tivitiesReport.2008.p.66-74.

30.HuriE,AkgülT,AyyildizA,UstünH,GermiyanoğluC.He-mostatic roleofa folkloricmedicinalplantextract ina ratpartialnephrectomymodel:controlledexperimental trial. JUrol2009;181:2349-54.

31.HaznedarogluIC.MolecularbasisofthepleiotropiceffectsofAnkaferdBloodStopper.IUBMBLife2009;61:290.




Experimental Study Deneysel Çalışma


Glucosamine-sulfate on fracture healing

Glukozaminsülfatınkırıkiyileşmesineetkisi

Akın UĞRAŞ,1† Elif GÜZEL,2 Petek KORKUSUZ,3 İbrahim KAYA,1 Fatih DİKİCİ,4 Emrah DEMİRBAŞ,1 Ercan ÇETİNUS1

1DepartmentofOrthopedicsandTraumatology,HasekiTrainingandResearchHospital,Istanbul;2DepartmentofHistologyandEmbryology,

IstanbulUniversity,CerrahpasaFacultyofMedicine,Istanbul;3DepartmentofHistologyandEmbryology,HacettepeUniversity,FacultyofMedicine,Ankara;4DepartmentofOrthopedicsandTraumatology,Istanbul

University,IstanbulFacultyofMedicine,Istanbul,Turkey.†Current affiliation: DepartmentofOrthopedicsandTraumatology,

IstanbulMedipolUniversity,FacultyofMedicine,Istanbul.

1HasekiEğitimveAraştırmaHastanesi,OrtopediveTravmatolojiKliniği,İstanbul;2İstanbulÜniversitesiCerrahpaşaTıpFakültesi,

HistolojiveEmbriyolojiAnabilimDalı,İstanbul;3HacettepeÜniversitesiTıpFakültesi,HistolojiveEmbriyolojiAnabilimDalı,Ankara;

4İstanbulÜniversitesiİstanbulTıpFakültesi,OrtopediveTravmatolojiAnabilimDalı,İstanbul.

†Şimdiki Kurumu:İstanbulMedipolÜniversitesiTıpFakültesi,OrtopediveTravmatolojiAnabilimDalı,İstanbul.

Correspondence(İletişim):AkınUğraş,M.D.İstanbulMedipolÜniversitesiTıpFakültesi,OrtopediveTravmatolojiAnabilimDalı,TEMAvrupaOtoyoluGöztepeÇıkışıNo:1,Bağcılar34214İstanbul,Turkey.

Tel:+90-212-5294400e-mail(e-posta):[email protected]

BACKGROUNDTheaimofthisstudyistodeterminewhetherglucosamine-sulfatehasanyeffectsonbone-healing.

METHODSA unilateral fracturewas created in the tibia of sixty-onefemalerats.Ratsweregivennodrugor230mg/kgglucos-amine-sulfatedaily.Fractureswereanalyzedduringthefirst,secondandfourthweeksaftercreationoffracture.Quantita-tivemeasurementfornewboneformationandosteoblastlin-ingweredeterminedhistologically.Semiquantitativescoreforfracturehealingwasusedforhistomorphometricanaly-ses.Bridgingboneformationwasassessedradiographically.

RESULTSNew bone formation and osteoblast lining were signifi-cantlyhigheringlucosamine-treatedgroupatweek1.Sur-rounding connective tissuewasmore cellular andvascu-lar,andthenewlyformedbonetrabeculeswerepresentingreater amounts in glucosamine-treated group, comparedtocontrolgroupatweek1and4.But radiologically, thecontrol group had better scores than that of the glucos-amine-treatedgroupatweek4.

CONCLUSIONThesedatademonstratethatdailyglucosamine-sulfatead-ministrationacceleratesearlyphaseoffracturerepairintherattibia,withincreasednewboneformationandosteoblastlininghistologically, but radiologicboneunion isnot fa-voredonradiographs.

Key Words: Bone;fracturehealing;glucosamine;osteoblast.

AMAÇBu çalışmanın amacı kıkırdak glukozaminin kırık iyileş-mesiüzerindeetkisiolupolmadığınınaraştırılmasıdır.

GEREÇ VE YÖNTEMAltmışbirdişişıçantibiasındatektaraflıkırıkoluşturuldu.Sıçanlaraya230mg/kgglukozaminsülfatverildiyadailaçverilmedi.Kırıklar,kırıkoluşumundansonrabirinci,ikin-ci ve dördüncü haftalarda incelendi.Yeni kemik oluşummiktarıveosteoblastsayısıhistolojikolarakölçüldü.His-tomorfometrik analiz için kırık iyileşmesi semikantitatifolarakskorlandı.Radyografikolarakkemikköprüoluşumudeğerlendirildi.

BULGULARGlukozamin verilen grupta yeni kemik oluşumu ve oste-oblastsayısı1.haftadaanlamlıderecedeyüksekti.1.ve4.haftalardakontrolgrubunagöre,glukozaminverilengruptaçevrebağdokusuhücresayısıbakımındanzengin,dahavas-külerveyenioluşankemiktrabekülleridahafazlasayıdaydı.Fakat radyolojikolarak4.haftadakontrolgrubu,glukoza-minverilengruptandahaiyiskorlaraldı.

SONUÇBuverilergünlükglukozaminverilmesininsıçantibiasındakırıkiyileşmesininerkenfazını,artmışyenikemikoluşu-muveosteoblastsayısı ilehistolojikolarakhızlandırdığı,fakatradyolojikolarakaynıetkiningörülmediğinigöster-mektedir.

Anahtar Sözcükler:Kemik;kırıkiyileşmesi;glukozamin;osteob-last.

doi: 10.5505/tjtes.2013.03256

8

Glucosaminehasbeenshowntohaveanumberoffavorableeffectsoncartilagemetabolismin vitro,in-cluding a reduction in articular cartilage breakdownandstimulationofsynthesisofmatrixcomponentsbycondrocytes.[1] Administration of glucosamine nor-malizescartilagemetabolism,by inhibitingdegrada-tion and stimulating the synthesis of proteoglycans,andrestoringthearticularfunctions.[2]

However, theeffectofglucosamineonboneme-tabolismhasnotbeeninvestigatedbefore.Wehypoth-esizedthatglucosaminecouldbeatherapeuticagentforthetreatmentofintraarticularfractures.Theaimofthisstudyistodeterminewhetherglucosamine-sulfatehasanyeffectsonbone-healing.Glucosamineexistsin several forms,usuallyasglucosamine-sulfateandglucosamine hydrochloride. Sulfate form has beenused inmost experimental studies.[3]We investigatetheroleofglucosamine-sulfateonfracturehealing.

MATERIALS AND METHODSThestudywasconductedinaccordancewithprin-

ciplesandproceduresapprovedbyIstanbulUniversi-ty,theLocalEthicsCommitteeonanimalexperimen-tation.Sixty-onefemaleWistarratswereusedforthisstudy.Onlythesixthgrouphad11rats(Glucosamine-treatedgroup).Twoorthreeratswerehousedineachcagewith a 12h-12h light-dark cycle and controlledtemperature of 24±3 ºC with humidity of 55±15%.Theywere fedwithwater and standard rat chowadlibitum.Ratswere6weeksoldandweighing200-250g.Three groups of rats received 230mg/kg glucos-amine-sulfate (Abdi Ibrahim, Dona, Turkey) intra-peritoneally(IP),daily.Theotherthreegroupsofratsservedasacontrolgroup.Doseselectionwasbasedonpreliminarystudies.[1,4]

Rats were anesthetized with ketamine (0.25mg/100g)andxylazine(10mg/100g) IP.Once theanimal was sedated, the skin overlying knee wasshaved.Aprophylacticdoseof60.000IUofprocainpenicillinwasadministeredintramuscularly.Theskinoverlying left kneewas incised.Anterior tibial cor-texwascutwithsagittalsawandposteriortibialcor-texwas broken.A 0.25mmmetal pinwas insertedin to themedullary canal of the tibia. The incisionwasclosed.[5-7]Theratswereallowedtorecoverandwere permitted to eat andwalk ad libitum. Subsetsof animals from each glucosamine-treated and con-trolgroupweresacrificedatfirst,second,andfourthweekspostoperativelybyadministeringalethaldoseofsodiumpentobarbitalIP.

Radiographsweremade of all tibia to determinewhetheradministrationofglucosamine-sulfateresult-edinradiographicevidenceofdelayedhealing.Boneformationwasscoredona6-pointscaleasfollows:0,noformationofbone;1,formationoflessthan25%

ofbone;2, formationofmore than25%ofbone;3,formationofmorethan50%ofbone;4,formationofmorethan75%ofbone;and5,formationof100%ofbone.[8]Theradiographswereblindlyscoredbythreeorthopedicsurgeonsforthepresenceofcalcifiedfrac-turecallusandevidenceofboneunion.Thefinalscorewasthemeanofallthreescores.

Boneswerefixedin10%neutralbufferedformalinat roomtemperature.AllspecimensweredecalcifiedinDeCastrosolution(chloralhydrate,nitricacid,dis-tilledwater)andembeddedinparaffin.Threetofivemicrometer thick sectionswere stainedwith haema-toxylin&eosin(HE),andMasson’strichrome(MT).

Quantitative measurement for new bone formation and osteoblast lining at fracture siteMTproduceshighcontrastimageswithred(bone),

green(osteoid-cartilage),andpurple(cellcytoplasm).Photomictographs of each fracture area were gen-erated by a lightmicroscope (LeicaDMR)with at-tachedcomputerizeddigitalcamera(ModelDFC480,LeicaWestlarGermany).Theentirefractureareawasvisible at the lowestmagnification. Bright-field im-ages were captured and analyzed quantitatively byimage processing program (Qwin Plus, Leica Inc.WestlarGermany).Thenumberofpixelscorrespond-ing to new trabecular bone area in each imagewasquantified,dividedbythetotalnumberofpixelscor-respondingtototalfracturearea,andconvertedtoμm2 ineachspecimen.OsteoblastswerequantifiedbasedontheirmorphologyonHEstainedsectionsforlengthoftheirlinearappositionalongosteoid-newbonesur-facesrelativetototalnewbone-osteoidsurfacelengthforthreerandomlyselectedhighpowerfields(200x)and are reported as a fraction (%) average for eachsample.[9]

Semiquantitative scoring for fracture healingA total fracture healing score was given to each

specimenregardingthecallusformation,boneunion,marrow changes, and cortex remodeling.[10] Regard-ing callus formation, (3) was given for presence offull callus formation across the defect, (2) for pres-ence ofmoderate callus formation, (1) for presenceofmildcallusformation,and(0)fornocallusforma-tion.Boneunionwasscoredas(3)forfullbonebridge(union),(2)formoderatebridge(>50%),(1)formildbridge(<50%),and(0)forthelackofnewboneinthefractureline(nonunion).Regardingmarrowchanges,(4)wasgivenforthepresenceofadulttypefattymar-row,(3)for2/3ofmarrowreplacedbynewtissue,(2)for1/3ofmarrowreplacedbynewtissue,(1)forthepresenceoffibrous tissue,and(0) for thered tissue.Regarding cortex remodeling, (2)was given for thepresenceoffullremodelingcortex,(1)forintramedul-larycanal,and(0)forthelackofcorticalremodeling.





[10]Fracturehealingscoreisthesumofcallusforma-tionscore,boneunionscore,marrowchangesscore,andcortexremodelingscore.

Statistical analysisIndependentvariableswerethedivisionofgroups

based upon glucosamine-sulfate administration, andthedependentvariableswere thehistologyandradi-ology parameters.The normality of distribution andthehomogeneityofvariancesofthesamplewerees-tablishedusingtheShapiro-Wilktest.Allweek1pa-rameters,osteoblast liningparameterofweek2,andosteoblastliningandbonehealingparametersofweek4wereanalyzedbyparametrictestonewayANOVA.All other parameterswere analyzed by nonparamet-ric tests.Kruskal-Walliswasused formultiplecom-parison andMann-Whitney U as post-hoc test with

Bonferronicorrection.Correlationbetweenthehisto-logicandradiologicmeasurementswereassessedus-ingSpearmantest.Radiologicscoringwasperformedby blind independent investigators (n=3).The intra-class(reliability)correlationcoefficientwascalculat-ed (r=0.80).Then themean of calculated radiologicscoreswasincludedinparametricandnonparametricanalyses.Descriptivestatisticalvalueswereexpressedasmedian,minimum,andmaximum.Thedifferencewasconsideredsignificantifp<0.05.

RESULTSThe radiographic appearance of films suggested

normalfracturehealing.Therewasneitherectopiccal-cificationnorunusual(e.g.,over-abundant)callusfor-mation.Completebonehealingwasobservedinbothgroups.Radiologicscoresdidnotshowanysignificant

Fig. 1. Radiographsofisolatedtibiaat(a) one,(b) two,and(c) sixweeksafterthefracture.Left:Glucosamine-treatedgroup,Right:Controlgroup.

(a) (b) (c)

Table 1. Thedataofvariablesbelongingtodifferentgroupsaregivenasmean,standartdeviationandpvalues

Sacrificationtime Groups Radiologic Newboneperfracture Osteoblast Fracture score lineratio(μm2) lining(%) healingscore

Firstweek Glc 2.85±0.89 0.22±0.07 30.36±8.92 3.9±1.28 Control 3.08±0.69 0.09±0.03 19.5±6.84 3±0.94 p 0.405 0.000* 0.007* 0.101 Secondweek Glc 3.8±1.12 0.29±0.07 35.29±11.25 6.6±1.26 Control 3.2±0.61 0.23±0.08 35.6±12.38 6.5±1.35 p 0.057 0.226 0.820 0.846 Fourthweek Glc 4.25±0.59 0.92±0.07 55.5±17.85 10.36±1.12 Control 4.85±0.36 0.93±0.06 59.56±17.02 10±1.41 p 0.036* 0.809 0.654 0.705

Glc:Glucosamine-treatedgroup;*p<0.005.



DISCUSSIONAccording to this data, glucosamine sulphate in-

creasednewboneformation,osteoblasticcell lining,bonetrabecules,andcellularityandvascularityofthecartilagematrix.Newboneformationwasacceleratedintheglucosamine-treatedgroupatweek1,whereasradiographicbonehealingwasdiminishedatweek4.

Fracturerepairisacomplexprocessthatinvolvesmesenchymal and/or surface osteoblasts and signal-ingmolecules including proinflammatory cytokines,transforming growth factor-beta (TGF-β) superfam-ilymembersandangiogenicfactors.[11,12]Therepairisinitiatedbyanimmediateinflammatoryresponsethatleads to the recruitment ofmesenchymal stem cellsandsubsequentdifferentiationintomesenchymalos-teoblasts that produce cartilagematrix.[12]Accordingtothisdata,glucosamine-sulfateaffectsthefirststagesof bone repair and increasesosteoblastic cell lining,bonetrabecules,andcellularityandvascularityofthecartilagematrix.

Kimandcollaborators[13]demonstratedthatglucos-aminesulfatecanincreaseAlchalenphospataseactiv-ity,collagensynthesis,osteocalcinsecretion,andmin-eralizationinosteoblasticcellsin vitro.Glucosaminesulfateexertsastimulatoryeffectondifferentiationin

differencebetweengroupsatweek1andweek2.Ra-diologically, the control group received significantlybetter scores than the glucosamine-treated group atweek4(p=0.036)(Fig.1,Table1).

Newboneperfracturelineratiowassignificantlyhigheringlucosamine-treatedgroupcomparingtothatofcontrolgroupatweek1(p=0.000).Newbonetrab-eculeslinedbyactivebone-formingcells(osteoblasts)werehigherintheglucosamine-treatedgroupincom-parisontocontrolonday7(p=0.007)(Fig.2,Table1).Histologicscoresdidnotshowanysignificantdiffer-encebetweengroupsatweek2.

Histomorphologically,ahighlyvascularandcellu-larconnectivetissuecallusinitiatedintramembranousand/or endochondral bone formation at the fracturearea in both groups. Surrounding connective tissuewasmorecellularandvascularandthenewlyformedbone trabeculesweremore numerous in the glucos-amine-treatedgroup,comparingtocontrolatweek1and4(Fig.2,Table1).

The radiologic and histologic bone healing pa-rametersgenerallyincreasedovertime(1to2,2to4,and1to4weeks)incontrolandglucosamine-treatedgroups(p≤0.05).Thisdatademonstratesthatahealthyhealingprocessoccurredinbothgroups.

Fig. 2. Fracturelineconsistsofafibrous,cartilaginous(Ca)andbonycallus(NBT:Newbonetrab-eculesingreen)at1week;inbothglucosamineandthecontrolgroups.Notethehighamountof new bone trabecules inBwith glucosaminewhen compared to control (D). Cartilageislandsareobvious inD.CB:Corticalbone;HE:Haematoxylineosin,MT:Masson’s tri-chrome.



3. MobasheriA, Vannucci SJ, Bondy CA, Carter SD, InnesJF,ArteagaMF,etal.Glucosetransportandmetabolisminchondrocytes:akeytounderstandingchondrogenesis,skel-etaldevelopmentandcartilagedegradationinosteoarthritis.HistolHistopathol2002;17:1239-67.

4. RezendeMU,GurgelHM,Vilaça Junior PR,KurobaRK,Lopes AS, Phillipi RZ, et al. Diacerhein versus glucos-amine in a ratmodel of osteoarthritis.Clinics (SaoPaulo)2006;61:461-6.

5. HollingerJO,OnikepeAO,MacKrellJ,EinhornT,BradicaG,LynchS,etal.Acceleratedfracturehealinginthegeriat-ric,osteoporoticratwithrecombinanthumanplatelet-derivedgrowthfactor-BBandaninjectablebeta-tricalciumhosphate/collagenmatrix.JOrthopRes2008;26:83-90.

6. MilesJD,WeinholdP,BrimmoO,DahnersL.Rattibialoste-otomymodelprovidingarangeofnormaltoimpairedheal-ing.JOrthopRes2011;29:109-15.

7. GardnerMJ,vanderMeulenMC,CarsonJ,ZelkenJ,Ric-ciardiBF,WrightTM, et al.Role of parathyroid hormoneinthemechanosensitivityoffracturehealing.JOrthopRes2007;25:1474-80.

8. YaskoAW, Lane JM, Fellinger EJ, RosenV,Wozney JM,WangEA.Thehealingofsegmentalboneefects,inducedbycombinanthumanbonemorphogeneticprotein (rhBMP-2).Aradiographic,histological,andbiomechanicalstudyinrats.JBoneJointSurg[Am]1992;74:659-70.

9. LuM.,RabieABM.Quantitativeassessmentofearlyheal-ingofintramembranousandendochondralautogenousbonegraftsusingmicro-computed tomographyandQwin imageanalyzer.IntJOralMaxillofacSurg2004;33:369-37.

10.AnYH,FriedmanRJ.Animalmodelsinorthopedicresearch.CRCPressUSA:1999.p.209.

11.TatSK,PelletierJP,VergésJ,LajeunesseD,MontellE,Fah-miH,etal.Chondroitinandglucosaminesulfateincombina-tiondecreasethepro-resorptivepropertiesofhumanosteo-arthritissubchondralboneosteoblasts:abasicsciencestudy.ArthritisResTher2007;9:R117.

12.WangSX,LavertyS,DumitriuM,PlaasA,GrynpasMD.The effects of glucosamine hydrochloride on subchondralbonechangesinananimalmodelofosteoarthritis.ArthritisRheum2007;56:1537-48.

13.KimMM,MendisE,RajapakseN,KimSK.Glucosaminesulfate promotes osteoblastic differentiation of MG-63cells via anti-inflammatory effect. BioorgMedChemLett2007;17:1938-42.

14.Kreider JM, Goldstein SA. Trabecular bone mechanicalproperties in patients with fragility fractures. Clin OrthopRelatRes2009;467:1955-63.

osteoblast-likeMG-63cellsin vitro.[13]Wethinkthatthe probable mechanism of glucosamine sulphate’seffect on bone healing is through the stimulation ofosteoblasticcells.

Wedidnotobservethesameeffectattheendofthehealing process. In comparison to the glucosamine-treatedgroup, radiologicboneunionwasnotasevi-dentasinthecontrolgroup.However,thehistologicparametersofboneuniondidnotdifferbetween thetwo groups at the fourthweek.We did not performmechanicaltestingtoaccuratelyinterprettheresults.However,bonestrengthismainlycharacterizedbyar-chitecturalstructure,themineralcontentofbone,ex-tracellularmatrixproperties,andcellularbiomechan-ics and these are accurately assessedbyhistologicalanalysis.[14]

Themajorlimitationofthisstudyistheabsenceofa dose-response studyof glucosamine-sulfate.How-ever,thisisthefirststudy,toourknowledge,evaluat-ingtheeffectsofglucosamine-sulfateonfractureheal-ing.Additionalstudiesarenecessarytodeterminetheeffectsofglucosamineonfracture-healing.

Giventhecentralroleofglucosamineincartilagemetabolism,itislikelytohaveaprofoundinfluenceonbonemetabolism.Insummary,dailyglucosaminesul-fateadministrationfollowingfractureincreasedboneformationintherattibia,withincreasednewbonefor-mationandosteoblastlininghistologically.However,thepresenceofradiologicboneunionwasnotdemon-stratedbyradiographsinthetreatmentgroup.


REFERENCES1. MaganhinCC,CorreaO,ReginaCtG,SimõesR,Baracat

EC,Soares-JrJM.Effectsofglucosamineonthetibialepiph-ysealdiskofovariectomizedrats:morphologicandmorpho-metricanalysis.Clinics(SaoPaulo)2007;62:607-12.

2. Hua J, SuguroS,HiranoS, SakamotoK,Nagaoka I. Pre-ventiveactionsofahighdoseofglucosamineonadjuvantarthritisinrats.InflammRes2005;54:127-32.

13


Original Article Klinik Çalışma


Appendicitis scores may be useful in reducing the costs of treatment for right lower quadrant pain

Apandisitskorları,sağaltkadranağrısıiçintedavimaliyetlerinidüşürmedefaydalıolabilir

Cüneyt KIRKIL,1 Koray KARABULUT,1 Erhan AYGEN,1 Yavuz Selim İLHAN,1 Mesut YUR,1 Kenan BİNNETOĞLU,1 Nurullah BÜLBÜLLER2

1DepartmentofGeneralSurgery,FiratUniversity,FacultyofMedicine,Elazığ;2DepartmentofGeneralSurgery,AntalyaTrainingandResearchHospital,

Antalya,Turkey.

1FıratÜniversitesiTıpFakültesi,GenelCerrahiAnabilimDalı,Elazığ;2AntalyaEğitimveAraştırmaHastanesi,GenelCerrahiKliniği,

Antalya.

Correspondence(İletişim):CüneytKırkıl,M.D.FıratÜniversitesiHastanesi,GenelCerrahiKliniği,23169Elazığ,Turkey.Tel:+90-424-2333555/2222e-mail(e-posta):[email protected]

BACKGROUNDUnnecessaryhospitaladmissionsandnegativeappendecto-miesincreasehealthcarecostsofpatientswithright lowerquadrant(RLQ)pain.Thisstudyaimedtoevaluatetheim-pactonthecostoftreatmentofappendicitisscoringsystems.

METHODSChartswere reviewed of patients admitted to the generalsurgerywardofourhospitalwithRLQpainwithinayear.AlvaradoandLintulascoreswerecalculated,andasimula-tionwasperformedtodeterminethetreatmentchargesthatwouldhavebeengeneratedhad thescoring recommenda-tionsbeenusedforadmissionandsurgicaldecision-making.

RESULTSOfthe114admittedpatients,64(56%)underwentappendec-tomy.Therateofnegativeappendectomywas17.2%.Theoverall accuracy rates of theAlvarado andLintula scoresforboth‘admit’and‘operate’decision-makingwere82.7%and 91.9%, respectively (p=0.102). Total charges for the114patientswere$39,655.IftheAlvaradoorLintulascorehadbeenused,thetotaltreatmentchargeswouldhavebeen$34,087and$25,772(p=0.015andp=0.000),withnegativeappendectomyratesof18.5%and3.6%,respectively.

CONCLUSIONTheimplementationofAlvaradoandLintulascoresforthedecision of hospital admission and appendectomywouldhavereducedoveralltreatmentchargesforacuteRLQpain.Key Words: Acute appendicitis; Alvarado scores; cost; Lintulascores;score.

AMAÇSağaltkadran(SAK)ağrısıolanhastalarıngereksizhasta-neyatışlarıvenegatifapendektomilertedavigiderleriniar-tırır.Buçalışmada,apandisitskorlamasistemlerinintedavimaliyetineetkisideğerlendirildi.

GEREÇ VE YÖNTEMBiryıliçindeSAKilehastanemizgenelcerrahikliniğinekabul edilen hastaların kayıtları incelendi.Alvarado veLintulaskorlarıhesaplandı.Hastaneyeyatışvecerrahite-davikararındaskorlamaönerilerikullanılmışolsaydı,te-davigiderlerininneolacağınısaptamakiçinbirbenzetimçalışmasıdüzenlendi.

BULGULARYüzondörthastanın64’üne(%56)apendektomiyapıldı.Negatif apendektomioranı%17,2 idi.AlvaradoveLin-tula skorlarının yatış ve tedavi kararı vermedeki geneldoğrulukoranlarısırasıyla%82,7ve%91,9idi(p=0,102).Hastalarıntümüiçintoplamtedavimaliyeti39,655$idi.AlvaradoveLintula skorları kullanılmış olsaydı toplamtedavigiderlerisırasıyla34,087$ve25,772$(p=0,015vep=0,000);negatifapendektomioranları%18,5ve%3,6olacaktı.

SONUÇAlvaradoveLintulaskorlarınınhastaneyekabulveapen-dektomikararıiçinkullanılmasıakutSAKağrısıiçinteda-vigiderlerinidüşürecektir.Anahtar Sözcükler: Akut apandisit; Alvarado skoru; maliyet;Lintulaskoru;skor.

doi: 10.5505/tjtes.2013.88714


Abdominalpainisacommonpresentingcomplaintof emergencydepartment (ED)patientswhoaread-mittedtogeneralsurgerywards.Makinganearlydi-agnosisofappendicitis,oneofthecausesofanacuteabdomen, can be difficult.Typical symptoms, signs,andsupportivelaboratorydataarenotpresentin20-33%ofacuteabdominalpainpatientsinwhomacuteappendicitisistheprimaryworkingdiagnosis.[1,2]De-lay in diagnosismay lead to perforation, periappen-dicularabscess,woundinfection,andintraabdominaladhesions. In thepast, itwasbelieved that themosteffective way to avoid these complications was tobroadensurgical indicationsat theexpenseofan in-creased rate (up to40%)ofnegativeappendectomy.[3-5]Thedownsidesofthisapproachareincreasedhos-pitalbedutilization,higher treatmentcosts,and lossofproductivity.

TheAlvarado(Table1)andLintula(Table2)scor-ingtoolsweredevelopedinanattempttoassistclini-cians indistinguishingacuteappendicitis fromothercauses of abdominal pain,with the aim of reducingthenegativeappendectomyrate.[6-12]Acuteabdominalpainpatientswithatotalscoreof≤3ontheAlvaradoand≤15ontheLintulascaleshavealowerprobabilityofacuteappendicitisandthusdonotrequirehospital-ization. Patientswith scores of ≥7 and ≥21, respec-tively, have a higher probability of acute appendici-tisrequiringemergencyappendectomy.PatientswithAlvaradoscoresbetween4and6andLintulascoresbetween16and20aresuspectedcasesforacuteap-pendicitis;closeinpatientfollow-upisrecommendedforthisgroup.[13,14]

We performed a retrospective simulation to de-terminehowchargeswouldhavechanged if theAl-varadoandLintulaappendicitis scoringsystemshadbeenusedinpatientsadmittedtoourdepartmentduetorightlowerquadrant(RLQ)pain.Asecondaryob-jective of the studywas to determine the diagnosticaccuracyoftheAlvaradoandLintulascoringsystems.

MATERIALS AND METHODSCharts of patients presenting with RLQ pain to

theEDofourhospitalbetweenNovember2009andNovember2010andadmitted to thegeneral surgeryinpatientwardwere analyzed. Exclusion criteria in-cluded prior appendectomy, concurrent antibiotictherapy,chronicRLQpain,abdominaltrauma,andin-guinalhernia.Allpatientsunderwentultrasound(US)examinationbyaradiologyresidentintheED.IftheUSfindingswerenotconsistentwithclinicalfindings,anoralandintravenous(IV)contrast-enhancedmulti-slice computed tomography (CT) was performed.“Clinicaldecision”wasdefinedasthetreatmentdeci-sionthatwasreachedaftertheevaluationofmedicalhistory, physical examination, laboratory tests, and

imagingstudies.Patientswithoutadiagnosisofacuteappendicitiswereadmitted for closeclinical follow-up;theywerekeptnilperos(NPO),receivedmainte-nanceIVfluids,andIVH2-receptorblockersasstressulcerprophylaxis.

TheAlvarado and Lintula scores of the patientswerecalculatedbyastaffsurgeon,andincaseappen-


Table 2. Lintulascore

Score

Gender Male 2 Female 0Intensityofpain Severe 2 Mildormoderate 0Migrationofpain Present 4 Absent 0Rightlowerquadrantpain Present 4 Absent 0Vomiting Present 2 Absent 0Bodytemperature ≥37.5°C 3 <37.5°C 0Guarding Present 4 Absent 0Bowelsounds Absent,tinklingorhigh-pitched 4 Normal 0Reboundtenderness Present 7 Absent 0Totalscore 32

Table 1. Alvaradoscore

Score

Symptoms Migratoryrightiliacfossapain 1 Anorexia 1 Nausea/vomiting 1Signs Rightlowerquadranttenderness 2 Rightiliacfossarebound 1 Elevationoftemperature 1Laboratoryfindings Leukocytosis 2 Leftshift(neutrophils) 1Totalscore 10


dectomyhadbeenperformed,thepathologyreportwasusedasthefinaldiagnosis.Patientswhoseabdominalpainresolvedspontaneouslywithinthefirst24hoursof observation, without undergoing appendectomy,were considerednot to have acute appendicitis.Thehospital charges incurred after evaluation in theEDwerecalculatedfromthesumofinvoicesissuedbythegovernmentinsuranceagencytothepatient.

Simulation study designLow-score group (≤3 for Alvarado, ≤15 for Lintu-

la):These patientswere considered to probably nothaveacuteappendicitis,andthusdischargehomefromtheEDwouldbeappropriate.Asthisgroupwouldnothave been hospitalized, their post-ED charges weretaken to be $0. The charges for patients who hadlow scores but who underwent appendectomy, andinwhomthepathologywaspositiveforappendicitis,wereusedastheywere,withoutadjustment.

Mid-score group (4-6 for Alvarado, 16-20 for Lintula):Thetreatmentcostsofthosewhounderwentappendectomy,andinwhomthepathologywasposi-tiveforappendicitis,andofthosewhowerefollowedcloselyonthewardwithoutsurgeryandwhohadnoprogression to appendicitiswere used as theywere,withoutadjustment.Incasesofnegativeappendecto-my,surgeryandanesthesia-relatedchargesweresub-tractedfromthepatient’stotaltreatment-relatedbill.

High-score group (≥7 for Alvarado, ≥21 for Lintu-la): The treatment costs of those who underwentpositiveornegativeappendectomywereusedastheywere.If thescoringsystemshadbeenusedfordeci-sion-making,thepatientswhosesymptomsspontane-ouslyresolvedinthisgroupwouldhaveundergoneanegative appendectomy. Their treatment costs wereassumed to be $454, the average invoice amount ofappendectomizedpatientsinthisstudy.

Outcome measuresThe sensitivity, specificity, positive predictive

value (PPV), negative predictive value (NPV), anddiagnosticaccuracyratesof thescoringsystemsand

chargesfortreatmentwerecalculated.

StatisticsDifferences between the actual and calculated

treatmentchargeshadtheAlvaradoandLintulascoresbeen used were analyzed with paired t-testing and95% confidence intervals. The differences betweenthesensitivity, specificity,PPV,NPV,anddiagnosticaccuracy ratesof the scoring systemsand theactualclinicaldecisionweretestedusingchi-squaretestingand95%confidenceintervals.Pearsoncorrelationco-efficientswerecalculatedinordertodeterminethere-lationshipbetweentheAlvaradoscore,Lintulascore,andpathologyresult.

RESULTSDuring the studyperiod, 127patientswith a pri-

mary complaint of RLQ painwere evaluated in theEDandreferredtothegeneralsurgeryclinic.Ofthese,datafromthechartsof13patientswereexcludedforthefollowingreasons:1forhavinghadapriorappen-dectomy,6 for concurrentuseof antibiotics, 4 for ahistoryofchronicabdominalpain,1forahistoryofabdominaltrauma,and1forpresenceofarightingui-nalhernia.

Intheremaining114patients,AlvaradoandLintu-la scoreswere calculated. In these patients,USwasconsistentwithacuteappendicitisin56(49.1%).Only4of22patientswhounderwentoralandIVcontrast-enhancedCThada radiologicdiagnosisofprobableacute appendicitis.Appendectomywasperformed in64ofthe114patients(56.1%;33laparoscopicappen-dectomies,31openappendectomies).Histopathologi-calexaminationwasnegativeforacuteappendicitisin11ofthese64patients(17%;1of33laparoscopicap-pendectomies,10of31openappendectomies).

Thetotalbillfortheservicesprovidedinthegen-eral surgerydepartmentwas$39,655:meanof$454per patient who underwent appendectomy ($345 intheopenappendectomygroupand$563 in the lapa-roscopic appendectomygroup) and$208per patient


Table 3. Sonographicandhistopathologicresultsin22patientswithrightlowerquadrantpainwhounderwentCTinadditiontoultrasoundscanning

Computedtomography Ultrasound Management No.ofpatients Histopathology

Normal Normal Observation 14 Appendectomy 3 Appendicitisinall3 Appendicitis Observation 0 Appendectomy 1 NormalappendixAppendicitis Normal Observation 1 Appendectomy 2 Appendicitisinboth Appendicitis Observation 0 Appendectomy 1 Appendicitis

tomy,and$4,516inchargeswouldhavebeenavoid-ed.All28patientswithascoreof≥21wereoperated,andallbut twohadapathologydiagnosisofappen-dicitis.HadtheLintulascorebeen implemented, thenegative appendectomy ratewouldhavebeen3.6%.Five of 58 patientswith a Lintula score <15 turnedout to have acute appendicitis, a false-negative rateof16.1%.Weassumedthat thechargesofthesefivepatients, who would have presented eventually andundergone emergent appendectomy,would not havechangedfromtheiractualcharges.Chargesofpatientswhosetreatmentdecisionswouldnothavebeendiffer-entiftheLintulascorehadbeenusedwereusedasis.Thus,iftheLintulascorehasbeenused,totalchargeswouldhavebeen$25,772.Thisfigureissignificantlylowerthanactualchargesincurredinourpatientgroup(p=0.000).

The sensitivity, specificity, PPV, NPV, and diag-nostic accuracy rates of theAlvarado score, Lintulascore, and clinical decisions are depicted in Table5. Sensitivity of the Lintula score was significantlylower than of clinical decision-making (p=0.006),but the difference between the sensitivity of theAl-varado and Lintula scores was not statistically sig-nificant (p=0.118). On the other hand, the specific-ityoftheLintulascorewassignificantlygreaterthanboththeAlvaradoscoreandclinicaldecision-making(p=0.000 and p=0.018, respectively).The differenceinspecificitybetweentheAlvaradoscoreandclinicaldecision-makingwasinsignificant(p=0.140).TheAl-varadoandLintulascorescorrelatedhighlywith thehistopathologicalresults(Pearsoncorrelationtesting,p=0.001andp=0.000,respectively).

DISCUSSIONThelifelongincidenceofacuteappendicitisranges

between 5-25%, and appendectomy is themost fre-quently performed emergency abdominal surgery intheworld;intheUnitedStatesalone,250,000appen-

whowasobservedonthewardwithoutappendectomy.Ofthe56patientswhohadUSfindingscompatible

with acute appendicitis, 10 recovered spontaneouslyduring inpatient observation, and 46 underwent ap-pendectomy (6negative,40positive).Of the58pa-tientswhodidnothaveUSfindingscompatiblewithacuteappendicitis,40recoveredspontaneouslyduringinpatientobservation,and18underwentappendecto-my(5negative,13positive).TheUSandhistopathol-ogyresultsof22patientswhowerealsoinvestigatedbyCTaresummarizedinTable3.

Table4liststhedistributionofAlvaradoandLintu-lascoresofthepatients.HadtheAlvaradoscorebeenimplemented for decision-making, 22 patients withascoreof≤3wouldnothavebeenhospitalized,and$7,319wouldnot havebeen charged.Eight patientswithascoreof<7wouldnothaveundergoneanega-tiveappendectomy,and$4,017wouldnothavebeencharged.Had anAlvarado score of ≥7 been used tooperateandperformanappendectomy,nineadditionalpatientswouldhaveundergoneanegativeappendec-tomy(anegativeappendectomyrateof18.5%),result-ingin$4,085incharges.Theactualtotalchargesforthesepatients,whowereinfactobserved,was$1,649.TwopatientswithinitialAlvaradoscoresof≤3turnedout tohaveacuteappendicitison theirpathologyre-ports, a false-negative rate of 4.5% if theAlvaradoscorehadbeenusedfordecision-making.Weassumedthatthechargesofthesetwopatients,whowouldhavepresentedeventuallyandundergoneemergentappen-dectomy,would not have changed from their actualcharges.Thus,totalchargeswouldhavebeen$34,087insteadof39,655,a14%difference(p=0.015).

HadtheLintulascorebeenusedfordecision-mak-ing,58patientswitha scoreof≤15wouldnothavebeenunnecessarilyhospitalized.Thetreatmentcostofthesepatientswas$15,519.Ninepatientswithscores<21wouldnothaveundergoneanegativeappendec-



Table 4. PatientmanagementandhistopathologicalresultsaccordingtotheAlvaradoandLintulascoresin114patientsadmittedwithrightlowerquadrantpain

Appendectomy

Observation Normalappendix Appendicitis

Alvaradoscore ≤3 22 3 2 4-6 19 5 9 ≥7 9 3 42Lintulascore ≤15 46 7 5 16-20 4 2 22 ≥21 0 2 26



dectomiesareperformedannually,usingonemillionhospital days and costing 3 billion dollars per year.[15-20] To minimize expenditures while providing thehighest quality of service, unnecessary appendecto-miesshouldbeavoided.Ourstudydemonstratedthatcommonscoringsystemsusedtoreducenegativeap-pendectomyratesalsosignificantlyreducedtreatmentcharges.

Thepreoperativediagnosisofacuteappendicitisisusuallybasedonclinicalfindings,buttheseareonly60-80%accurateduetoatypicalpresentationsandthepresenceofotherdiseases thatcauseRLQpain.[21,22] WhileUSisthemostfrequentlyusedimagingmethodto confirm the diagnosis, diagnostic accuracy rates(71%and97%)arelimitedbypractitionerexperience,localizationoftheappendix,thepatient’sbodymassindex,anddensityofbowelgases.[23-25]CTisamorereliableimagingmethodfordiagnosingacuteappen-dicitis,havingadiagnosticaccuracyrateof93-98%.[26]Thetrainingandexperienceoftheradiologistsig-nificantly affects the accuracyofCT imaging.[27]Ontheotherhand,CThasdisadvantagessuchascontrast-relatedcomplications,exposuretoionizingradiation,andhighcosts.Therefore,USis thepreferred imag-ingmodality in pregnant and breastfeedingwomen,aswell as in children.[28] For these reasons,US andCTshouldbeconsideredcomplementarytechniques,ratherthanrivals.InSCOAP(SurgicalCareandOut-comesAssessmentProgram),theprevalenceofnega-tiveappendectomywasfoundtobehigherinpatientswithconflictingUS/CTfindings.[29]Inourseries, thediagnostic accuracy of CT (74.6%) was lower thaniscommonlyreported in the literature,probablydueto the fact that radiology residentswere reading theemergencyCT scans. In addition, CT scanningwasperformedinonlyasmallproportionofourpatients,makingmeaningfulstatisticalcomparisonsoftheCTresultswithotherparametersimpossible.

Inourpatients,adiagnosticaccuracyrateof90.4%wasachievedbyclinicalexaminationaidedbylabo-ratoryandimagingfindings.In1986,whenAlvaradoproposedascoringsystemfor theearlydiagnosisofacuteappendicitis,CTandUSimagingwerenotcom-

monlyused.[6] Insubsequentyears,othersdevelopedscoringsystemsbasedonsymptomsaswellasassoci-atedclinicalandlaboratoryfindings.[7-12]Thesensitivi-ty,specificity,anddiagnosticaccuracyoftheAlvaradoscore were reported to be between 84.2-92%, 66.7-91.2%, and 87-92%, respectively.[30-33] The sensitiv-ity,specificity,anddiagnosticaccuracyof theLintu-la score in adults are reported tobe87%,98%, and91%,respectively.[14]AllthreearticlesfoundthroughaPubMed-basedliteratureresearchontheLintulascor-ingsystemarewrittenbyLintulaetal.[7,14,34]Accord-ingtotheresultsof thepresentstudy, thediagnosticaccuracyoftheAlvaradoandLintulascoringsystemsinourpatientswasconsistentwiththeexistinglitera-ture.WefoundthespecificityoftheLintulascoretobe very high; thus, had theLintula score been usedfordecision-making,ournegativeappendectomyrateswouldhavebeensignificantlylower.

TheAlvaradoscorehasbeenfoundtobemostac-curateinmenandchildren.[35]HavingusedamodifiedAlvarado score,Kanumba et al.[36] found sensitivity,specificity,anddiagnosticaccuracyratestobediffer-ent formen andwomen (95.8%, 92.9%, and 91.5%versus88.3%,89.7%and87.6%,respectively).IntheLintulascoringsystem,however,thesexofthepatientis considered a separate parameter. In our patients,onlytwowomenhadaLintulascoreof≥21;thus,sub-groupanalysesbysexeswerenotperformed.

WefoundhighNPVsfortheAlvaradoandLintu-la scoringsystems (91.4%and92.6%, respectively),which means a low false-negativity rate in patientswithalowscore.Therefore,imagingofpatientswitha low appendicitis score is not recommended. Sup-portingthis,McKayandShepherd[13]reportedthatCTimagingin52outofthe55patientswithanAlvaradoscoreof≤3wasnegative(94.5%),andtheincidenceofdelayedpresentationofacuteappendicitiswasonly3.6%.TheyevenarguedthatbecausetheincidenceofacuteappendicitisinpatientswithanAlvaradoscoreof≥7was77.7%,thesepatientsshouldbereferreddi-rectlytosurgerywithoutCTimagingintheED.

Althoughacuteappendicitisisconsideredtoresultfrom progressive inflammation, spontaneous resolu-

Table 5. Thesensitivity,specificity,positivepredictivevalue,negativepredictivevalueanddiagnosticaccuracyratesoftheAlvaradoandLintulascoresandclinicaldecisioninpatientswithrightlowerquadrantpain

Alvarado Lintula Clinicaldecision p

Sensitivity(%) 95.5 83.9 100 0.007Specificity(%) 67.6 96.4 82.0 0.001Positivepredictivevalue(%) 77.8 92.9 82.8 0.228Negativepredictivevalue(%) 92.6 91.4 100 0.111Diagnosticaccuracy(%) 82.7 91.9 90.4 0.133



tionhasalsobeenreported.[37-40]Ourassumptionthatspontaneously resolving cases were not true acuteappendicitis may be criticized. However, the inci-denceof spontaneouslyhealingacuteappendicitis isnot known. Scoring of patients with RLQ pain canbe repeatedduring active observationwhile patientsareworseningorimprovingclinically;symptomsandsignsresolvecompletelyinsomepatients.[41]

Inthisretrospectivestudy,boththeAlvaradoandLintulascoringsystemshadhighdiagnosticaccuracyratesforacuteappendicitis.Treatmentchargeswouldhave been significantly lower had these scores beenutilized for decision-making in patients with acuteRLQpain.


REFERENCES1. Lewis FR, Holcroft JW, Boey J, Dunphy E.Appendicitis.

Acriticalreviewofdiagnosisandtreatmentin1,000cases.ArchSurg1975;110:677-84.

2. Berry J Jr,Malt RA.Appendicitis near its centenary.AnnSurg1984;200:567-75.

3. VelanovichV,SatavaR.Balancingthenormalappendecto-myratewiththeperforatedappendicitisrate:implicationsforqualityassurance.AmSurg1992;58:264-9.

4. SimpsonJ,SpeakeW.Appendicitis.ClinEvid2005;14:529-35.

5. AnderssonRE.Meta-analysisoftheclinicalandlaboratorydiagnosisofappendicitis.BrJSurg2004;91:28-37.

6. AlvaradoA.Apracticalscorefortheearlydiagnosisofacuteappendicitis.AnnEmergMed1986;15:557-64.

7. LintulaH,KokkiH,KettunenR,EskelinenM.Appendicitisscoreforchildrenwithsuspectedappendicitis.Arandomizedclinicaltrial.LangenbecksArchSurg2009;394:999-1004.

8. ChristianF,ChristianGP.Asimplescoringsystemtoreducethe negative appendicectomy rate.Ann R Coll Surg Engl1992;74:281-5.

9. DadoG,AnaniaG,BaccaraniU,MarcottiE,DoniniA,Ri-salitiA,etal.Applicationofaclinicalscoreforthediagnosisofacuteappendicitisinchildhood:aretrospectiveanalysisof197patients.JPediatrSurg2000;35:1320-2.

10.Samuel M. Pediatric appendicitis score. J Pediatr Surg2002;37:877-81.

11.EskelinenM,IkonenJ,LipponenP.Acomputer-baseddiag-nosticscoretoaidindiagnosisofacuteappendicitis.TheorSurg1992;7:86-90.

12.Fenyö G, Lindberg G, Blind P, Enochsson L, Oberg A.Diagnostic decision support in suspected acute appendi-citis: validationof a simplified scoring system.Eur JSurg1997;163:831-8.

13.McKayR,ShepherdJ.TheuseoftheclinicalscoringsystembyAlvarado in the decision to perform computed tomog-raphy for acute appendicitis in the ED.Am J EmergMed2007;25:489-93.

14.LintulaH,KokkiH,PulkkinenJ,KettunenR,GröhnO,Es-kelinenM.Diagnosticscoreinacuteappendicitis.Validationofadiagnosticscore(Lintulascore)foradultswithsuspectedappendicitis.LangenbecksArchSurg2010;395:495-500.

15.FlumDR,KoepsellT.Theclinicalandeconomiccorrelates

of misdiagnosed appendicitis: nationwide analysis. ArchSurg2002;137:799-804.

16.FlumDR,MorrisA,KoepsellT,DellingerEP.Hasmisdi-agnosisofappendicitisdecreasedover time?Apopulation-basedanalysis.JAMA2001;286:1748-53.

17.GullerU,JainN,CurtisLH,OertliD,HebererM,PietrobonR. Insurance status and race represent independent predic-tors of undergoing laparoscopic surgery for appendicitis:secondarydataanalysisof145,546patients.JAmCollSurg2004;199:567-77.

18.MargenthalerJA,LongoWE,VirgoKS,JohnsonFE,OprianCA,HendersonWG,etal.Riskfactorsforadverseoutcomesafter the surgical treatment of appendicitis in adults.AnnSurg2003;238:59-66.

19.SugimotoT,EdwardsD. Incidence and costs of incidentalappendectomyasapreventivemeasure.AmJPublicHealth1987;77:471-5.

20.DaviesGM,DasbachEJ,TeutschS.Theburdenofappen-dicitis-relatedhospitalizationsintheUnitedStatesin1997.SurgInfect(Larchmt)2004;5:160-5.

21.BendeckSE,Nino-MurciaM,BerryGJ,JeffreyRBJr.Imag-ingforsuspectedappendicitis:negativeappendectomyandperforationrates.Radiology2002;225:131-6.

22.AshrafK,AshrafO,BariV,RafiqueMZ,UsmanMU,ChistiI. Role of focused appendiceal computed tomography inclinically equivocal acute appendicitis. J Pak Med Assoc2006;56:200-3.

23.Gamanagatti S,Vashisht S,KapoorA,Chumber S,Bal S.Comparison of graded compression ultrasonography andunenhancedspiralcomputedtomographyinthediagnosisofacuteappendicitis.SingaporeMedJ2007;48:80-7.

24.WilsonEB,Cole JC,NipperML,CooneyDR,SmithRW.Computed tomography and ultrasonography in the diag-nosis of appendicitis:when are they indicated?Arch Surg2001;136:670-5.

25.RaoPM,BolandGW.Imagingofacuterightlowerabdomi-nalquadrantpain.ClinRadiol1998;53:639-49.

26.RaoPM,Rhea JT,NovellineRA,MostafaviAA,McCabeCJ.Effectofcomputedtomographyoftheappendixontreat-mentofpatientsanduseofhospitalresources.NEnglJMed1998;338:141-6.

27.in’tHofKH,KrestinGP,SteijerbergEW,BonjerHJ,LangeJF,BeckingWB,etal Interobservervariability inCTscaninterpretationforsuspectedacuteappendicitis.EmergMedJ2009;26:92-4.

28.OldJL,DusingRW,YapW,DirksJ.Imagingforsuspectedappendicitis.AmFamPhysician2005;71:71-8.

29.SCOAPCollaborative,Cuschieri J,FlorenceM,FlumDR,JurkovichGJ,LinP,etal.Negativeappendectomyandim-aging accuracy in theWashingtonState SurgicalCare andOutcomesAssessmentProgram.AnnSurg2008;248:557-63.

30.InciE,HocaogluE,AydinS,PalabiyikF,CimilliT,TurhanAN,etal.EfficiencyofunenhancedMRIinthediagnosisofacute appendicitis: comparisonwithAlvarado scoring sys-temandhistopathologicalresults.EurJRadiol2011;80:253-8.

31.RezakA,Abbas HM,AjemianMS, Dudrick SJ, KwasnikEM.Decreaseduseofcomputedtomographywithamodi-fied clinical scoring system in diagnosis of pediatric acuteappendicitis.ArchSurg2011;146:64-7.

32.EscribáA,GamellAM,FernándezY,QuintilláJM,CubellsCL.Prospectivevalidationof twosystemsofclassificationforthediagnosisofacuteappendicitis.PediatrEmergCare2011;27:165-9.



33.KostićA, SlavkovićA,MarjanovićZ,Madić J,KrstićM,ZivanovićD,etal.EvaluationofusingAlvaradoscoreandC-reactiveprotein indiagnosingacuteappendicitis inchil-dren. [Article in Serbian]Vojnosanit Pregl 2010;67:644-8.[Abstract]

34.LintulaH,PesonenE,KokkiH,VanamoK,EskelinenM.Adiagnosticscoreforchildrenwithsuspectedappendicitis.LangenbecksArchSurg2005;390:164-70.

35.ShrivastavaUK,GuptaA,SharmaD.EvaluationoftheAl-varadoscoreinthediagnosisofacuteappendicitis.TropGas-troenterol2004;25:184-6.

36.KanumbaES,MabulaJB,RambauP,ChalyaPL.ModifiedAlvaradoScoringSystemasadiagnostictoolforacuteap-pendicitis atBugandoMedicalCentre,Mwanza,Tanzania.BMCSurg2011;11:4.

37.TempleCL,HuchcroftSA,TempleWJ.Thenatural histo-ryofappendicitis inadults.Aprospectivestudy.AnnSurg1995;221:278-81.

38.HanssonLE,LaurellH,GunnarssonU.Impactoftimeinthedevelopmentofacuteappendicitis.DigSurg2008;25:394-9.

39.MigraineS,AtriM,BretPM,LoughJO,HincheyJE.Spon-taneously resolving acute appendicitis: clinical and sono-graphicdocumentation.Radiology1997;205:55-8.

40.CobbenLP,deVanOtterlooAM,PuylaertJB.Spontaneouslyresolving appendicitis: frequency andnatural history in60patients.Radiology2000;215:349-52.

41.AnderssonM,Andersson RE. The appendicitis inflamma-toryresponsescore:atoolforthediagnosisofacuteappen-dicitis that outperforms theAlvarado score.World J Surg2008;32:1843-9.

20




Management of acute appendicitis in pregnancy

Gebelikteakutapandisittedavisi

Selin KAPAN, Mehmet Abdussamet BOZKURT, Ahmet Nuray TURHAN, Murat GÖNENÇ, Halil ALIŞ

DepartmentofGeneralSurgery,BakirkoyDr.SadiKonukTrainingandResearchHospital,Istanbul,Turkey.

Dr.SadiKonukEğitimveAraştırmaHastanesi,GenelCerrahiKliniği,İstanbul.

Correspondence(İletişim):SelinKapan,M.D.Dr.SadiKonukEğitimveAraştırmaHastanesi,GenelCerrahiKliniği,TevfikSağlamCad.No:11.,Zuhuratbaba,Bakirkoy34147İstanbul,Turkey.


BACKGROUNDAcute appendicitis is themost common surgical non-ob-stetricpathologyduringpregnancy.Inthisreport,pregnantpatientsoperatedwithadiagnosisofacuteappendicitisinthelastthreeyearsareevaluatedretrospectively.METHODSBetweenJanuary2009andJanuary2011,20pregnantpa-tientswereoperated foracuteappendicitis.Patientswereevaluatedregardingage,gestationalage,clinicalandlabo-ratory examinations, imaging studies, operative findings,meanhospitalstay,meanoperativetime,andoutcome.

RESULTSIn17of20patients,acuteappendicitiswasconfirmedandappendectomywas performed. Ten of the patients wereoperatedwith laparoscopic technique and the remaining10hadopenappendectomy.Therewasnofetalormater-nalmorbidityormortality inanypatient.All20patientsdeliveredhealthybabiesduringthepostoperativecourse.

CONCLUSIONAcuteappendicitisisachallengingdiagnosisinthepreg-nantpatient;however,earlysurgicalinterventionshouldbeperformedwithanysuspicion.Thetypeofsurgerydependsonthesurgeon’spreferenceandexperience.Key Words: Acute appendicitis; appendectomy; laparoscopy;pregnancy.

AMAÇAkut apandisit gebelikte en sık rastlanan obstetrik dışıcerrahipatolojidir.Buyazıdason3yıldaameliyatedilengebeliktekiakutapandisitolgularıgeriyedönükolarakde-ğerlendirildi.GEREÇ VE YÖNTEMOcak2009veOcak2011arasında20gebehastaakutapan-disitnedeniyleameliyatedildi.Hastalaryaş,gebelikyaşı,klinik ve laboratuvar bulguları, görüntüleme sonuçları,ameliyatbulguları,ortalamahastanedeyatışsüresi,ortala-maameliyatsüresivesonuçlaraçısındandeğerlendirildi.

BULGULARÇalışmayaalınan20hastanın17’sindeapandisitdoğrulan-dı ve apendektomiuygulandı.Hastaların10’u laparosko-pik,diğer10hastaiseaçıkameliyataalındı.Hastalarınhiç-birindefetalmorbiditevemortalitegörülmedi.Hastalarıntümü ameliyat sonrası gebelik sonunda sağlıklı bebeklerdoğurdular.

SONUÇAkutapandisitgebehastadazorbirtanıolmasınarağmenşüpheanındaerkencerrahigirişimyapılmalıdır.Cerrahinintipicerrahınseçiminevetecrübesinebağlıdır.Anahtar Sözcükler: Akut apandisit; apendektomi; laparoskopi;gebelik.

doi: 10.5505/tjtes.2013.81889

Acute appendicitis is the most common surgicalcondition requiring non-obstetric abdominal surgeryduringpregnancy,anditsincidenceisreportedtobebetween1:1250and1:1500pregnancies,with50%ofcases occurring in the second trimester.[1-3]Thehigh

prevalence of nausea, vomiting and abdominal paininthenormalobstetricpatientpopulationleadstothedelayedsurgicalintervention.[4,5]Inaddition,thereisageneralreluctancetooperateunnecessarilyonagravidpatient.Inanypregnantpatient,right-sidedabdominal

pain, associatedwith guarding and rebound and ac-companiedbyfevershouldalwaysbeconsideredap-pendicitisunlessprovenotherwise.Assessmentofthewhitebloodcellcountmaynotbeparticularlyhelpfulbecausepregnantpatientsoftenhaveaphysiologicalleukocytosis.Carefulphysical examination iskey tomaking the diagnosis.[6] Ultrasonography should beused to assess for the presence of an obstetrical pa-thologysuchasanovariancystortorsionofanadnex-almass. In the general population, there are severalscoringsystemsavailabletoaidtheaccuracyofdiag-nosisofappendicitis, includingtheAlvaradoscoringsystem.Nosuchsystemisavailablefortheobstetricpopulation.[3-5]

Inthisstudy,wepresentourcasesofacuteappen-dicitisduringpregnancyinlightoftherelatedlitera-ture.

MATERIALS AND METHODSTwenty pregnant women who were consulted to

the Emergency Surgery Clinic for acute abdominalpainfromJanuary2009toJanuary2011wereinclud-edinthisstudy.Clinicaldatacollectedretrospectivelyincluded physical examination findings, age of thepatients, week of pregnancy, presenting symptoms,ultrasonographic confirmation, leukocyte count, andpostoperative complications. All patients were as-sessedbyagynecologistandageneralsurgeonbeforeandaftersurgery.Thediagnosisofacuteappendicitiswas based on clinical examination, ultrasound (US)andleukocytecount,andpregnancywasconfirmedbyUS.EachpatientwasevaluatedbytheAlvaradoscor-ingsystem.Theperiodbetweensurgicalconsultationandsurgerywasevaluated.

Appendectomieswereperformedby laparoscopicor open approach. General inhalational anesthesiawasemployedroutinelyduringtheoperation.Urinarycatheterswereusedroutinely.

RESULTSThemeanageofthepatientswas26(19-35)years.

ThemeangestationalageatthetimeofLAwas17.6weeks(4-33weeks).Tenpatientswereinthesecondtrimester,6wereinthefirsttrimesterand4wereinthethirdtrimesterofpregnancy.ThemeanAlvaradoscorewas7.7(7-9).Themeanleukocytecountwas13920(7200-22300), and mean neutrophil % was 81.65%(91.4%-67.3%).All 20 patients were admitted withcomplaints of abdominal pain.Thirteenpatients hadadditional nausea and vomiting.Abdominal ultraso-nographywasperformedinallpatientsaftergyneco-logical examination.Ultrasonography revealedacuteappendicitisinsevenpatients.Allthesesevenpatientswereacuteappendicitis.Intheremaining13patients,inwhomultrasonographycouldnotvisualizetheap-

pendix,acuteappendicitiswasconfirmedin10duringtheoperation.Themediantimebetweenconsultationandoperationwas6hours(3-10).Themeanoperationtimewas54.1minutes(12-135min).Themeanopera-tiontimeinopenandlaparoscopicapproachwas51.7min(12-120)and56.5min(30-135),respectively.Themeanhospital staywas1.1 days (1-2days). In 8 ofthe10laparoscopicprocedures,thefirsttrocarwasin-sertedwithopentechnique; in theremaining,Veressinsufflationwasperformed.

In 10 patients, diagnostic laparoscopy was per-formedandsevenofthesepatientshadacuteappen-dicitis.Onepatienthadparaovariancyst,whereastheothertwopatientshadnopathology.

Intheremaining10patients,openappendectomywas performed, and all 10 had acute appendicitis.Therewasnomaternalorfetalmortality,morbidity,oruterineinjuryinanyofthepatients.Nocaseoffetalmortalitywasencountered.Twentypatientsdelivered20healthyinfants.Demographicdataof thepatientsaregiveninTable1.

DISCUSSIONCertainanatomicandphysiologicchangesspecific

to pregnancymaymake the cause of the abdominalpaindifficulttoascertaininpregnantpatients.[3,4]Theuterus becomes an abdominal organ at around 12weeks’ gestation and compresses the underlying ab-dominal viscera.This enlargementmaymake it dif-ficulttolocalizethepainandmayalsomaskordelayperitonealsigns.Thelaxityoftheanteriorabdominalwallmayalsomaskordelayperitonealsigns.Theure-tersbecamedilatedasearlyasthefirsttrimesterandremain dilated into the postpartum period.This dis-tensionmayleadtourinarystasis,increasingnotonlythe riskofurolithiasis,butalso infection. Increasingprogesterone increases respiratory drive. Functionalresidualcapacitydecreases.Hemostaticchangesalsoaddtothechallengeofevaluatingandcaringforpreg-nant women. Pregnancy produces a thrombogenicstate, with two-to-three-fold increase in fibrinogenlevels. In pregnancy, physiologic leukocytosis oc-curs,andinourstudy,allpatientshadleukocytosis.[4] Anatomicalchangesrelatedtothegraviduterus,ges-tationalsymptoms,thephysiologicalinflammatoryre-sponse,andawiderdifferentialdiagnosisinpregnantwomenresultinpoordiagnosticaccuracy,reportedtorange from36% to 86%.[2]Acute appendicitis has apeakincidenceinthesecondandthirddecadescoin-cidingwiththechildbearingyears,andtheincidenceinpregnancyappearsbroadlythesameasinthenon-pregnant,whereas the rateofperforationand subse-quentcomplicationsaregreater.[2,7]

Fetalmortality is given as 5%after appendicitis,whereasthisrateincreasestoapproximately20%ina





perforatedappendicitis.Similarly,maternalmortalityalsoincreasesinperforatedcases.[3]

Given the lack of sensitivity of the preoperativeevaluation, it is not surprising that the pathologicdiagnosis of appendicitis is confirmed in 36-50%ofcases.[5]Inourstudywithlaparoscopy,threepatientsweredetermined tohavenoacuteappendicitis.Sev-enteenof20patientswerediagnosedasappendicitis,andpathologicinvestigationofthe17specimenscon-firmedourdiagnosis.

Theaccuracyofthediagnosisisgreaterinthefirsttrimester,butmorethan40%ofpatientswhoundergoappendectomyinthesecondandthirdtrimesterhaveanormalappendix.Thenegativelaparotomyrateforsuspected appendicitis in obstetric cases is 25-50%,compared with 15-35% in general surgical cases innon-obstetricpatients.[2]Inourstudy,10of20patientsweresecondtrimester,andthreeofthemwenttonega-tivelaparoscopy.

It has been nearly 100 years since Balber statedthat‘themortalityofappendicitiscomplicatingpreg-nancyis themortalityofdelay’.Thewisdomof thisstatement has been repeatedly demonstrated. Delayinthediagnosisofappendicitisisassociatedwithsig-nificant complications.[2]Delay to surgery is equallyrisky,with rates of fetal loss reported to be 1.5-4%inuncomplicatedappendicitiscomparedwith21-35%

inthepresenceofrupturedappendicitis.[2]Afetallossrateof3-5%isobservedwithanunrupturedappendix;this rate increasesup to20%if theappendix is rup-tured.Theriskofpretermlaborisgreatestduringthefirstweekaftersurgery,butpretermdelivery is rare.[4,8] Furthermore, increasing gestational age reducesdiagnosticaccuracyand isassociatedwith increasedratesofappendicealperforationandhencecomplica-tions.[2,9]Weoperatedthepatientsinourserieswithin12hours.Contrarytotheliterature,inourstudy,therewasnofetallossorappendicealperforation.Therea-sonfor thisdifferencewas theshort timeperiodbe-tweenconsultationandoperationinourstudy.

The authors suggest that none of the clinical pa-rametersinvestigatedisusefulinpredictingappendi-citisinpregnancy.USandmagneticresonanceimag-ing(MRI)arenotassociatedwithionizingradiation,havenotbeenshowntohaveanydeleteriouseffectsonpregnancy,andshouldbeusedwhenfeasible.[4,9-11] RetrospectivestudieshavesuggestedthatMRIoftheappendix isuseful indelineatingthepresenceofap-pendicitis inpregnantwomen,but thesmallnumberofpatientsinthesestudieslimitstheinferencethatcanbedrawn.[12]Therearealsostudiesusingcomputedto-mography(CT)forthediagnosisofacuteappendicitisinpregnancy;however,duetothedeleteriouseffectsofionizingradiationonthefetus,itissuggestedtobeusedonly in severe traumapatientswithpregnancy.

Table 1. Demographicdataof20patients

Age Gestational Alvarado Leukocyte Neutrophil US MPT Typeof MOT HT age score count (%) operation

21 20 8 18000 90 App 8 LA 30 128 11 7 20100 91.4 Neg 3 OA 50 127 30 8 11200 89.6 Neg 4 OA 40 127 16 8 22300 91.3 App 8 LA 50 124 19 7 7200 75 Neg 7 OA 70 231 20 8 13300 93.1 App 6 OA 40 135 27 9 8000 71.6 Neg 9 LA 135 119 18 7 13900 83.2 App 3 OA 50 124 20 8 5900 81 Neg 9 DL 30 125 18 7 15100 68.9 Neg 8 DL 60 227 23 8 19500 89.8 Neg 4 OA 40 121 6 8 15700 81.1 App 5 OA 50 131 22 7 10800 75.8 Neg 4 LA 60 126 18 7 8800 67.3 Neg 6 DL 65 123 6 7 15500 91.1 App 10 OA 20 119 9 8 11600 67.4 App 9 OA 12 132 7 8 16800 78 Neg 3 LA 60 126 4 8 17000 84.4 Neg 4 LA 45 124 26 8 11400 68.9 Neg 4 LA 60 131 33 9 16300 93.2 Neg 6 OA 120 1DL:Diagnosticlaparoscopy;HT:Hospitalizationtime(days);LA:Laparoscopicapproach;MOT:Meanoperationtime(minute);MPT:Timeperiodbetweenconsultationandoperation(hours);Neg:Negative;OA:Openapproach.



pregnancy. There is no current possibility of devel-opingasufficientlyaccuratescoringsystemasinthenon-pregnantpatients.There isalso increasingcom-petenceintheuseoflaparoscopyinpregnancy.[2]

In view of the facts of rare occurrence but in-creasedincidenceofperforationinthethirdtrimesterandincreasedfetalmortalityinperforatedcases,earlysurgeryshouldbeconsideredinanypregnantpatientsuspected as having acute appendicitis. The type ofsurgery,whetheropenor laparoscopicapproach,de-pendsontheexperienceandpreferenceofthesurgeon.


REFERENCES1. UpadhyayA,StantenS,KazantsevG,HoroupianR,Stanten

A.Laparoscopicmanagementofanonobstetricemergencyinthethirdtrimesterofpregnancy.SurgEndosc2007;21:1344-8.

2. BrownJJ,WilsonC,ColemanS,JoypaulBV.Appendicitisinpregnancy:anongoingdiagnosticdilemma.ColorectalDis2009;11:116-22.

3. TurhanAN,KapanS.Akutapandisit.In:ErtekinC,GüloğluR,TaviloğluK,editors.Acilcerrahi.İstanbul:NobelTıpKi-tabevleri;2009.p.301-16.

4. KilpatrickCC,MongaM.Approachtotheacuteabdomeninpregnancy.ObstetGynecolClinNorthAm2007;34:389-402,x.

5. StoneK.Acuteabdominalemergenciesassociatedwithpreg-nancy.ClinObstetGynecol2002;45:553-61.

6. ButalaP,GreensteinAJ,SurMD,MehtaN,SadotE,DivinoCM. Surgical management of acute right lower-quadrantpain in pregnancy: a prospective cohort study. JAm CollSurg2010;211:490-4.

7. ColemanMT,TrianfoVA,RundDA.Nonobstetricemergen-ciesinpregnancy:traumaandsurgicalconditions.AmJOb-stetGynecol1997;177:497-502.

8. MouradJ,ElliottJP,EricksonL,LisboaL.Appendicitisinpregnancy:newinformationthatcontradictslong-heldclini-calbeliefs.AmJObstetGynecol2000;182:1027-9.

9. TerziA,YildizF,VuralM,CobanS,CeceH,KayaM.Acaseseries of 46 appendectomies during pregnancy.WienKlinWochenschr2010;122:686-90.

10.Wallace CA, Petrov MS, Soybel DI, Ferzoco SJ, AshleySW,TavakkolizadehA. Influence of imaging on the nega-tive appendectomy rate in pregnancy. J Gastrointest Surg2008;12:46-50.

11.Kilpatrick CC, Orejuela FJ.Management of the acute ab-domen inpregnancy:a review.CurrOpinObstetGynecol.2008;20:534-9.

12.BlumenfeldYJ,WongAE,JafariA,BarthRA,El-SayedYY.MR imaging incasesof antenatal suspectedappendicitis-ameta-analysis.JMaternFetalNeonatalMed2011;24:485-8.

13.PatelSJ,ReedeDL,KatzDS,SubramaniamR,AmorosaJK.Imagingthepregnantpatientfornonobstetricconditions:al-gorithms and radiation dose considerations. Radiographics2007;27:1705-22.

14.PatelSJ,ReedeDL,KatzDS,SubramaniamR,AmorosaJK.Imagingthepregnantpatientfornonobstetricconditions:al-gorithms and radiation dose considerations. Radiographics2007;27:1705-22.

[4,13-15]Wallace et al.[10] reported an overall negativeappendectomyrateof37%forpregnantpatientswithpresumed acute appendicitis. They also reported nodifferenceinthenegativeappendectomyratewiththeadditionofCT scan afterUS.Wedidnot useMRI,only physical examination with US. However, weoperated 13 patients with normal ultrasonographicfindings,andonlythreepatientsinthisgroupwenttonegativelaparoscopy(15%).

Currently, accumulating data support the use oflaparoscopy regarding safety and efficacy in all tri-mestersofpregnancyforacuteabdomen.[1,16-18]Lapa-roscopy is associated with decreased hospital stay,quicker return of bowel function, less postoperativepain,andsmallerchanceofwoundinfectionandher-nia.[3,19]HassontrocarandVeressneedlecanbeusedforinsufflation;however,wepreferredopentechniqueforfirsttrocarinsertionineightpatients.Manystudieshavedemonstratednoincreasedfetalriskwithlaparo-scopicprocedures.[20-24]Criticsoflaparoscopyinpreg-nantpatientsraiseconcernsover thepossibleeffectsof laparoscopic interventionon the developing fetusand emphasize that the limited literature regardinglaparoscopic appendectomy is concerning.[25-28] Thelaparoscopic approach has several advantages overopentechnique.Thepositionoftheincisionoverthedisplacedappendixisnolongeranissuewithamini-mallyinvasiveapproach.Inouropinion,thesuccessofthelaparoscopydependsonthesurgeon’sexperienceandskills.Anotherbenefitofdiagnostic laparoscopyisthatitdecreasesthenumberoffalse-positiveappen-dectomiesperformed.[1]Inourstudy,theoverallnega-tiveappendectomyratewas15%,andallofthemwerediagnosedbylaparoscopy.Thehigherrateofnegativeappendectomyinthelaparoscopicgroupmightreflectasurgical trendduringpregnancy inwhichearlydi-agnostic laparoscopy is considered minimally inva-siveandsaferthanobservationandre-evaluation.Thelatterapproachcanreducethenegativeappendectomyratebutmightraisetheperforationrate.Thatiswhywedidnothesitatetoperformsurgeryinourclinic.Itshouldbeconsideredthatitisnotthelaparoscopicap-proachitself,butthetypeofinfectionanddelayindi-agnosisthataretheprincipalcausesofadverseeffectsattributedtolaparoscopyduringpregnancy.Inourse-ries,noadverseeffectsonthefetusorthepregnancywereobservedaftersurgery.

Severalstudieshaverevealedthattheperformanceofearlydiagnosticlaparoscopyisbeneficialwhenap-pendicitis is suspected.[29-31]We operated 10 patientswithin12hourswithlaparoscopicapproach.Weusedopen technique for thefirst trocar insertion.Wedis-chargedpatientswithin24hourspostoperatively.

The symptom/sign complex does not sufficientlydiverge fromother causesof abdominal painduring



15.AmesCastroM,ShippTD,CastroEE,OuzounianJ,RaoP.Theuseofhelical computed tomography inpregnancy forthe diagnosis of acute appendicitis.Am J Obstet Gynecol2001;184:954-7.

16.JeongJS,RyuDH,YunHY,JeongEH,ChoiJW,JangLC.Laparoscopicappendectomyisasafeandbeneficialproce-dure in pregnant women. Surg Laparosc Endosc PercutanTech2011;21:24-7.doi:10.1097/SLE.0b013e3182051e44.

17.Corneille MG, Gallup TM, Bening T,Wolf SE, Brough-erC,Myers JG, et al.Theuseof laparoscopic surgery inpregnancy: evaluation of safety and efficacy.Am J Surg2010;200:363-7.

18.deBakkerJK,DijksmanLM,DonkervoortSC.Safetyandoutcome of general surgical open and laparoscopic proce-duresduringpregnancy.SurgEndosc2011;25:1574-8.

19.KapanS,KapanM.Gebelikveakutkarın.TürkiyeKlinikleriCerrahiTıpBilimleriDergisi2005;4:84-9.

20.Cohen-KeremR,RailtonC,OrenD,LishnerM,KorenG.Pregnancy outcome following non-obstetric surgical inter-vention.AmJSurg2005;190:467-73.

21.OrtegaAE,HunterJG,PetersJH,SwanstromLL,SchirmerB.A prospective, randomized comparison of laparoscopicappendectomywithopenappendectomy.LaparoscopicAp-pendectomyStudyGroup.AmJSurg1995;169:208-13.

22.PedersenAG, PetersenOB,Wara P, RønningH,Qvist N,LaurbergS.Randomizedclinicaltrialoflaparoscopicversusopenappendicectomy.BrJSurg2001;88:200-5.

23.SauerlandS,LeferingR,NeugebauerEA.Laparoscopicver-susopensurgeryforsuspectedappendicitis.CochraneData-

baseSystRev2004;4:CD001546.24.OelsnerG,StockheimD,SorianoD,GoldenbergM,Seid-

manDS, Cohen SB, et al. Pregnancy outcome after lapa-roscopyor laparotomy inpregnancy. JAmAssocGynecolLaparosc2003;10:200-4.

25.CostantinoGN,VincentGJ,MukalianGG,KliefothWLJr.Laparoscopic cholecystectomy in pregnancy. J Laparoen-doscSurg1994;4:161-4.

26.MotewM,IvankovichAD,BieniarzJ,AlbrechtRF,ZahedB,ScommegnaA.Cardiovasculareffectsandacid-baseandbloodgaschangesduringlaparoscopy.AmJObstetGynecol1973;115:1002-12.

27.IvankovichAD,MiletichDJ,AlbrechtRF,HeymanHJ,Bon-netRF.Cardiovasculareffectsofintraperitonealinsufflationwithcarbondioxideandnitrousoxideinthedog.Anesthesi-ology1975;42:281-7.

28.Thomas SJ, Brisson P. Laparoscopic appendectomy andcholecystectomy during pregnancy: six case reports. JSLS1998;2:41-6.

29.JacksonH,GrangerS,PriceR,RollinsM,EarleD,Richard-sonW, et al.Diagnosis and laparoscopic treatment of sur-gicaldiseasesduringpregnancy:anevidence-basedreview.SurgEndosc2008;22:1917-27.

30.Lemieux P, Rheaume P, Levesque I, Bujold E, BrochuG.Laparoscopicappendectomy inpregnantpatients: a reviewof45cases.SurgEndosc2009;23:1701-5.

31.TurhanAN,KapanS,KütükçüE,YiğitbaşH,HatipoğluS,AygünE.Comparisonofoperativeandnonoperativeman-agement of acute appendicitis. Ulus TravmaAcil CerrahiDerg2009;15:459-62.

25




Overlooked extremity fractures in the emergency department

Acilservistegözdenkaçanekstremitekırıkları

Erhan ER,1 Pınar H. KARA,1 Orhan OYAR,2 Erden E. ÜNLÜER1

Departments of 1Emergency Medicine, 2Radiology, Izmir Katip Celebi University Ataturk Research and Training Hospital, Izmir, Turkey.

İzmir Katip Çelebi Üniversitesi Atatürk Eğitim ve Araştırma Hastanesi, 1Acil Tıp Kliniği, 2Radyoloji Kliniği, İzmir.

Correspondence (İletişim): Erden E. Ünlüer, M.D. İzmir Katip Çelebi Üniversitesi, Atatürk Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği 35000 İzmir, Turkey.

Tel: +90 - 232 - 244 44 44 / 2696 e-mail (e-posta): [email protected]

BACKGROUNDThepurposeofthestudywastoanalyzetheaccuracyofinterpretationofextremity traumasbyemergencyphysi-cians(EP)todeterminethemostdifficultareasforinter-pretation in comparison to official radiology reports ofdirectX-ray.METHODSRadiologist reports andEP reports of directX-rays fromisolated extremity trauma patients were retrospectivelycompared from01.05.2011 to31.05.2011.A total of181fracturesin608caseswereconfirmed.

RESULTSThe locations of themisinterpreted fractureswere ankleandfoot(51.4%),wristandhand(32.4%),elbowandfore-arm(5.4%),shoulderandupperarm(5.4%),hipandthigh(2.7%),andkneeandleg(2.7%).ThediagnosticaccuracyoftheEPsandradiologistswerenotsignificantlydifferent(kappa=0.856,p=0.001).

CONCLUSIONKnowledgeaboutthetypesoffracturesthataremostcom-monlymissedfacilitatesaspecificallydirectededucationaleffort.Key Words: Emergency department; extremities; overlookedfractures;radiography.

AMAÇBu çalışmanın amacı izole ekstremite travmalarında, acilservisdoktorlarınınyorumlarının resmiradyoloji raporla-rıylakarşılaştırılmasıylaenzoryorumlamaalanınıbelirle-mekveacildoktorlarınınyorumlarınındoğruluğunuanalizetmektir.GEREÇ VE YÖNTEMRadyolog raporları ve acil servis doktorlarının yorumlarıizole ekstremite travmalı hastalarda geriye dönük olarak01.05.2011’den 31.05.2011 tarihine kadar karşılaştırıldı.Toplam608olguda181kırıksaptandı.

BULGULARYanlış yorumlanan kırıkların yerleri sırasıyla ayak bileğiveayak(%51.4),elbileğiveel(%32.4),dirsekveönkol(%5.4),omuzveüstkol(%5.4),kalçaveuyluk(%2.7),dizvebacak(%2.7)olarakbelirlendi.Acilservisdoktorlarınınve radyologların tanısaldoğrulukları arasındaanlamlıbirfarksaptanmadı(kapa=0.856,p=0.001).

SONUÇEnsıkatlanankırık tiplerininbilinmesi,bukonudaeğiti-minyoğunlaştırılmasıylaacilservislerdekaçırılanolgula-rınenazaindirilmesinisağlayabilir.Anahtar Sözcükler: Acil servis; ekstremite; kaçırılan kırıklar;radyografi.

doi: 10.5505/tjtes.2013.08555

Direct radiographic examinations frequently con-tributeimportantinformationtothemedicaldecision-makingprocessesintraumaunits(TU)ofemergencydepartments (ED). Radiographs are often initiallyinterpretedbyanemergencyphysician(EP),andde-cisions aremade based on this initial interpretation.

Studies analyzing errors in fracture diagnoses havefocusedon the nature of the fractures and the inter-pretationofX-rays.[1-4]MisdiagnosisofafractureisaverycommonoccurrenceinEDsandcanhaveseriousconsequencesbecauseofdelays in treatmentandre-sultinglong-termdisability.[1]Itisalsooneofthemost


commoncausesofmedicallegalclaimsintheUnitedStates.[5,6]Analysisofthecircumstancesinwhicher-rors inmedical practice occurmay suggestways toprevent them. Several strategies are available to re-duce themisdiagnosis rate: radiograph interpretationbyaradiologistwhoprovidesfull-time,on-sitecover-ageoftheED;coverageoftheEDwithteleradiology;coverage of theEDby radiology house staff duringoff-hours;eliminationofover-interpretationofEDra-diographsbyradiologists;andreductioninradiologydepartmentworkload.[7]Inexploringtheimplicationsofradiologistsworkloadreduction, it isnecessarytodeterminethepotentialareasofmisdiagnosisbyEPsinTUsandtodeveloparelevanteducationalprogram.Therefore, we conducted a study to analyze the ac-curacyinterpretationofextremitytraumasbyEPsincomparisontointerpretationsinofficialradiologyre-portsfollowingX-rayanalysis(goldstandard).

MATERIALS AND METHODSWe conducted a retrospective cross-sectional

studyfrom01.05.2011to31.05.2011atanacademic,adulttertiarycarecenterEDofauniversityhospitalinTurkey.ThisEDservesmore than240,000adultpatientsannually,and19%oftheseinvolveisolatedextremity trauma.The studyprotocolwas approvedbyour local ethicscommittee.AllEDpatientswhowere undergoing evaluation in the TU and had anisolatedextremitytraumawithdirectX-rayswerere-cruitedforthisstudy.Patientswereineligibleiftheyweremedicallyunstable,hadmultipletraumas,were<18 years old, orwere pregnant. In addition, caseslacking awritten radiography interpretation byEPswereexcluded.

We have also reviewed the radiology reports ofthe direct X-ray images. During the data collectionphase in the ED, fractures were categorized as up-per or lower extremity, long or short bone, articularorextraarticular,andshaftordistalfracturebyanEPwhowasblindedtothestudyprotocol.Theindepen-dent sample t-testwas used for descriptive analysesbetweengroups,andkappastatisticswerecalculatedforcomparingEPandGSresults.

A receiver operator characteristic curve (ROC)analysiswasconductedtoidentifythethresholdthatmaximized the sensitivity and specificity of theEPsinterpretation.Thesensitivity,specificity,thepositivelikelihood ratio (+LR), and the negative likelihood(-LR) were calculated. In this study, the maximumtype I error was 0.05 and the level of significancewasacceptedasp<0.05.Inthisstudy,MedCalcSoft-wareversion11.5andSPSSversion15wereusedforstatisticalanalyses.Confidence intervals for thesen-sitivity, specificity, positive, and negative likelihoodratioswerecalculated.

RESULTSDuring the study period, 608 patients, including

302(49.7%)menand306(50.3%)women,withiso-latedextremitytraumawereevaluatedusingtheGS.Themeanageof thepatientswas41.89±17.49.Thecharacteristics of the fractures are listed inTable 1.Of these, 181 (29.8%)were corroborated byGS re-portsand427(70.2%)werenegative.In405(94.8%)cases, the EPwas negative for fractures (true nega-tives),whereas22(5.2%)werediagnosedasfracturebytheEP(falsepositives).In166(91.7%)cases,theEPwaspositiveforfractures(truepositives),whereas15(8.3%)werediagnosednegativeforfracturesbyX-ray(falsenegatives)(Table2).Inaddition,47patientswereexcludedfromthedataanalysesbecausenore-portswere found in theEDfiles.Theresults for theEPandGSarelistedinTable2and3.ThediagnosticaccuracyoftheEPandtheGSwerenotsignificantlydifferent(kappa=0.856,p=0.001).

DISCUSSION It is critical to regularly evaluateourmethodsof

caring forpatientsadmitted toED inorder tobetterserve the needs of patients and to reduce costs. Inother national systems, the diagnostic error rate hasbeen evaluated systematically, with revisions madeaccordingly. In the literature, the observed rate ofdisagreementbetweenEPsandradiologistsinthein-terpretation of radiographs ranges from 8-11%[2,8-12] andachange in treatmentwas required for1-3%ofthesepatients.Theseerrorsininterpretingradiographs


Table 1.Thedistributionoffalsepositiveandfalsenegativecasesaccordingtoanatomicallocation,extremity,bonesizeandshaft-jointrates

False False Total positive negative

n % n % n %

Region Shoulder-upperarm 1 4.5 1 6.7 2 5.4 Elbow-forearm 2 9.1 0 0.0 2 5.4 Wrist-hand 11 50.0 1 6.7 12 32.4 Hip-thigh 0 0.0 1 6.7 1 2.7 Knee-leg 0 0.0 1 6.7 1 2.7 Ankle-foot 8 36.4 11 73.3 19 51.4Extremity Lowerextremity 8 36.4 13 86.7 21 56.8 Upperextremity 14 63.6 2 13.3 16 43.2Large-smallbone Smallbone 17 77.3 8 53.3 25 67.6 Largebone 5 22.7 7 46.7 12 32.4Shaft-joint Joint 14 63.6 7 46.7 21 56.8 Shaft 8 36.4 8 53.3 16 43.2

Overlooked extremity fractures in the emergency department

intheEDcanalsohavesignificantclinicalandlegalconsequences.[13]Thesestudiescoverednotonlyiso-latedextremityscansbutalsoalldirectX-raysinED.Between1974and1985 the liabilityprogramof theAmericanCollageofEmergencyPhysiciansidentifiedthemostfrequentcauseofmalpracticeactionsasthefailure to diagnose fractures among these direct im-ages. Inourcountry,becauseofdevelopingmedicallegal issues in practice, it not possible to obtain re-liabledataregardingthesemissedfracturesandtheirmedical-legal results. Perhaps in the future, clearerdatawillbeavailableregardingthisissue.

Inthisstudy,lowerextremityfractures(ankleandfoot)wereoverlookedmostfrequently(n=19,51.4%).The fractures were located at the proximal regionaroundthejoint.Thisresultwasconsistentwiththoseof previous studies.[2,5,14] Thewrist and hand (n=12,32.4%) was the second most common location ofmissedfracturediagnoses.Therewerenomissedmid-shaft fractures of any bone.The elbow and forearm(n=2, 5.4%) and the shoulder and upper arm (n=2,5.4%) were the third most common site of missedfracturediagnosis.Theseresultswerecorrelatedwiththoseintheliterature.[2,14]Noneofthefractureswereconsidered to be clinically important after followup.Thereareseveral limitationsofourretrospectiveanalysis.Itwasnotpossibletodeterminetheimpactoftheleveloftrainingamongindividualphysiciansonthepatternofoverlookedfractures.Wedidnotanalyzefracturesatspecificanatomicallocations,andwewereunabletodeterminethespecificdistributionoftibial

plateau fractures and tibial spine fractures becausetheseweregroupedtogether.

Studieshaveshownthatthereisaproblemregard-ingthespeedofX-rayreportinginEDs.Timeisama-jorfactorand48.9%ofreportsarenotavailablewithin48h.Wewouldthereforerecommendarapidreportingsystemtodecreasetherateofoverlookedfractures.[15]

Intheshort-term,teachingmethodsshouldbeim-provedandguidelinesontheuseofEDradiologyhavebeenpublished.[16]However, thiscannotbeexpectedtoeliminateall errorsand it is important todevelopfail-safemechanisms to detect errorswhen they oc-cur.Radiologydepartmentsshouldgiveprioritytore-portingEDfilmsand thebest solution is tohaveanimmediatereportingsystem.Markingofabnormalra-diographsbyradiographerscanassistinreducingdi-agnosticerrors[17]butthevalueofthismaybelimitedbyahighrateoffalsepositives.[18]

FewEDshavea full-time radiologist onduty24hours a day.When clinicians in an ED read X-rayfilms that are later reviewed by radiologists, over-lookedfractureswillinevitablyappear.Thefracturesthatweremissedmostoftenwereelbowandlegfrac-tures.Knowledgeaboutthetypesoffracturesthataremost commonly missed facilitates a specifically di-rectededucationaleffort.


REFERENCES1. Hallas P, Ellingsen T. Errors in fracture diagnoses in the

emergencydepartment-characteristicsofpatientsanddiurnalvariation.BMCEmergMed2006;6:4.

2. GulyHR.Diagnostic errors in an accident and emergencydepartment.EmergMedJ2001;18:263-9.

3. JuhlM,Moller-MadsenB, Jensen J.Missed injuries in anorthopaedicdepartment.Injury1990;21:110-2.

4. EspinosaAJ,NolanWT.Reducingerrorsmadebyemergen-cyphysiciansininterpretingradiographs:longitudinalstudy.BMJ2000;320:737-40.

5. WeiCJ,TsaiWC,TiuCM,WuHT,ChiouHJ,ChangCY.Systematic analysisofmissedextremity fractures in emer-gencyradiology.ActaRadiol2006;47:710-7.

6. Berlin L. Defending the “missed” radiographic diagnosis.


Table 2. Thedistributionofthediagnosesaccordingtoemergencyphysicianandradiologistevaluation

Radiologist

Positive Negative Total

n % n % n %

Emergency Positive 166 91.7 22 5.2 188 30.9physician Negative 15 8.3 405 94.8 420 69.1 Total 181 29.8 427 70.2 608 100.0

Table 3. Thestatisticalcalculationstocomparethesensitivitiesoftheemergencyphysicianandradiologistinterpretation

95%CI

Sensitivity 91.7 86.7-95.3Specificity 94.6 92.3-96.7Positivepredictivevalue(+PV) 88.3 82.8-92.5NegativePredictivevalue(-PV) 96.4 94.2-98.0Positivelikelihoodratio(+LR) 17.8 16.9-18.7NegativelikelihoodRatio(-LR) 0.09 0.05-0.20ROCareaunderthecurve(AUC) 0.933 0.910-0.951


12.RheaJT,PotsaidMS,DeLucaSA.Errorsofinterpretationaselicitedbyaqualityauditofanemergencyradiologyfacility.Radiology1979;132:277-80.

13.Guly HR. Missed tendon injuries. Arch Emerg Med1991;8:87-91.

14.FreedHA,ShieldsNN.Most frequentlyoverlooked radio-graphically apparent fractures in a teaching hospital emer-gencydepartment.AnnEmergMed1984;13:900-4.

15.JamesMR,BracegirdleA,YatesDW.X-rayreportinginac-cidentandemergencydepartments-anareaforimprovementsinefficiency.ArchEmergMed1991;8:266-70.

16.Touquet R, Driscoll P, NicholsonD. Teaching in accidentandemergencymedicine:10commandmentsofaccidentandemergencyradiology.BMJ1995;310(6980):642-5.

17.BermanL, deLaceyG,TwomeyE,TwomeyB,WelchT,EbanR.Reducingerrorsintheaccidentdepartment:asimlemethodusingradiographers.BrMedJ1985;290(6466):421-2.

18.RenwickIG,ButtWP,SteeleB.Howwellcanradiographerstriagex-rayfilmsinaccidentandemergencydepartments?.BMJ1991;302(6776):568-9.

AJRAmJRoentgenol2001;176:317-22.7. EngJ,MyskoWK,WellerGE,RenardR,GitlinJN,Bluemke

DA, et al. Interpretation of Emergency Department radio-graphs: a comparison of emergency medicine physicianswithradiologists,residentswithfaculty,andfilmwithdigitaldisplay.AJRAmJRoentgenol2000;175:1233-8.

8. Robinson PJ, Wilson D, Coral A, Murphy A, Verow P.Variation between experienced observers in the interpreta-tion of accident and emergency radiographs. Br J Radiol1999;72(856):323-30.

9. LufkinKC,SmithSW,MatticksCA,BrunetteDD.Radiolo-gists’reviewofradiographsinterpretedconfidentlybyemer-gency physicians infrequently leads to changes in patientmanagement.AnnEmergMed1998;31:202-7.

10.ScottWWJr,BluemkeDA,MyskoWK,WellerGE,KelenGD,ReichleRL,etal. Interpretationofemergencydepart-ment radiographs by radiologists and emergencymedicinephysicians: teleradiology workstation versus radiographreadings.Radiology1995;195:223-9.

11.FleisherG,LudwigS,McSorleyM.Interpretationofpediat-ricx-rayfilmsbyemergencydepartmentpediatricians.AnnEmergMed1983;12:153-8.


29




Prophylactic injection therapy is necessary for Forrest type 2b duodenal ulcers

Forresttip2bduodenalülserlerdeprofilaktikenjeksiyontedavisigereklidir

Osman Zekai ÖNER,1 Murat GÖNENÇ,2 Mustafa Uygar KALAYCI,2 Mehmet Abdussamet BOZKURT,2 Selin KAPAN,3 Halil ALIŞ2

1AntalyaTrainingandResearchHospital,Antalya;2Dr.SadiKonukTrainingandResearchHospital,Istanbul;

3KanuniSultanSuleymanTrainingandResearchHospital,Istanbul,Turkey.

1AntalyaEğitimveAraştırmaHastanesi,Antalya;2Dr.SadiKonukEğitimveAraştırmaHastanesi,İstanbul;

3KanuniSultanSüleymanEğitimveAraştırmaHastanesi,İstanbul.

Correspondence(İletişim):MuratGonenc,M.D.Dr.SadiKonukEğitimveAraştırmaHastanesi,TevfikSağlamCad.No:11.E-Blok.2.Kat.Zuhuratbaba,Bakirkoy34147İstanbul,Turkey.


BACKGROUNDWeaimedtoassesstheeffectofprophylacticinjectionther-apyduringtheindexgastroscopyonuppergastrointestinalbleedingduetoForresttype2bduodenalulcer.METHODSThepatientswhowereadmittedwithuppergastrointesti-nal bleeding andwho underwent emergency gastroscopybetweenJanuary2004andJanuary2011wererecruitedtothe study retrospectively.Among those, thepatientswithForrest type2bduodenalulcerwereselectedanddividedintotwogroups.ThepatientsinGroup1hadonlydiagnos-ticgastroscopy,whereasthoseinGroup2hadprophylacticinjectiontherapyduringtheindexgastroscopy.RESULTSEighty-seven patients were included in the study. Therewere41patients inGroup1and46patients inGroup2.Therewasasignificantdifferenceintheincidenceofre-bleeding (26.8% versus 6.5%, p=0.017). The mortalityrate was similar in the two groups (9.7% versus 2.1%,p=0.184).

CONCLUSIONWerecommendprophylactic injection therapy inpatientswithuppergastrointestinalbleedingwhohaveForresttype2bduodenalulcer.Key Words: Gastrointestinal bleeding; Forrest classification;rebleeding;mortality;injectiontherapy.

AMAÇBuçalışmadaForresttip2bduodenalülserlerdeilkendos-kopiişlemiesnasındayapılanprofilaktikenjeksiyonteda-visininülserintekrarkanamaoranıüzerineetkisininbelir-lenmesiamaçlandı.GEREÇ VE YÖNTEMÇalışmaya hastanemizde 2004-2011 yılları arasında üstgastrointestinal sistem kanaması nedeniyle yapılan acilendoskopilerindeForresttip2bduodenalülserbelirlenmişhastalaralındı.Olgularrastgeleolmayanikigrubaayrıldı.Birinci gruba yalnızca tanısal endoskopi yapılan hastalarve ikinci gruba tanısal endoskopiye ek olarak profilaktikenjeksiyon tedavisi yapılan hastalar alındı. Çalışmadakibirincilsonuçölçütleriyenidenkanamaveölümoranıidi.

BULGULARÇalışmaya87hastaalındı.Bunlardan41’ibirinci,46’sıikin-cigruptaidi.Tekrarkanamaoranıaçısındanherikigrupara-sındaanlamlı fark saptanırken (%26,8ve%6,5,p=0,017),ölüm oranı açısından iki grup arasında istatistiksel anlamtaşıyanbirfarklılıkgözlenmedi(%9,5ve%2,1,p>0,05).

SONUÇYenidenkanamariskinianlamlıdüzeydeazalttığıiçin,For-resttip2bduodenalülserlerdeprofilaktikenjeksiyonteda-visiuygulanmalıdır.Anahtar Sözcükler: Sindirim sistemi kanaması; Forrestsınıflaması;yenidenkanama;ölüm;enjeksiyontedavisi.

doi: 10.5505/tjtes.2013.88220


In spite of widely available effective therapeuticagentssuchasprotonpumpinhibitorsandincreasingrates of Helicobacter pylori eradication, complica-tionsofpepticulcerdiseasearestillamongthemostcommonproblemsthatcliniciansfaceintheemergen-cysetting.[1]Ifthepatientswithesophagealvaricesareexcluded,duodenalulceristheleadingcauseofuppergastrointestinalbleeding(UGIB),whichisassociatedwithsignificantmorbidityandmortality.[2]

Gastroscopynotonlyestablishes thediagnosis inmostpatientswithUGIBbutalsoleadsthecliniciantoassessthepropertreatmentoptiononanindividu-al basis.[3] In addition, endoscopicfindings form themajorcomponentofvariousscoringsystemsusedforstratificationofthepatientswithUGIB.[4]Forrestclas-sification, one of themost popular scoring systems,dependssolelyonendoscopicfindingsanddividesthepatientswithUGIBintothreecategories(Table1).[3] Forrestclassificationservesasausefultooltoestimatetherebleedingrate,whichisconsideredtobethema-jordeterminantforprognosisinpatientswithbleedingduodenalulcer.[3,4]

WhereastherapeuticendoscopyforForresttype1lesionsandprophylacticendoscopictreatmentforFor-resttype2alesionsarewidelyacceptedasthestandardcareinpatientswithUGIB,thenecessityofprophy-lacticendoscopictreatmentforForresttype2blesionsremainscontroversial.[5,6]Inthisrespect,weconductedaretrospectivestudytoassesstheefficacyofprophy-lacticendoscopic treatmentwith injection therapy inpatientswithForresttype2bbleedingduodenalulcer.Thestudyshowedthatprophylacticinjectiontherapyduringtheindexgastroscopyforsuchlesionsresultsinasignificantreductionintherebleedingrate.

MATERIALS AND METHODSThestudywasdesignedasa retrospectiveanaly-

sis,andwasstartedafterreceivingapprovalofthelo-calreviewboard.MedicalrecordsofthepatientswhoadmittedforUGIBtotheemergencydepartmentandwho underwent an immediate gastroscopy betweenJanuary2004andJanuary2011werereviewed.Inclu-sioncriterionwasthepresenceofForresttype2bduo-denalulcerlocatedattheposteriorwallofthebulbusonendoscopicexamination.

Group1was thecontrolgroup,and includedpa-tients who underwent only diagnostic gastroscopy,whereas Group 2 was the prophylactic treatmentgroup, and included thosewho received endoscopicinjection therapy in the same session.All of the en-doscopicprocedureswereperformedbyattendingen-doscopistsexperienced inbothdiagnosticand thera-peuticendoscopy,andthestandardequipmentusedforgastroscopywasFujinonEVE2200.A1/10000epi-nephrinesolutionwasusedforprophylacticinjection

therapy.Twomillimetersofthesolutionwasinjectedtoeachquadrantaroundtheduodenalulcerbyanen-doscopicneedle.

All of the patients were observed with hemody-namicmonitoring, andwere started routinely on in-travenousfluidsandparenteralformofprotonpumpinhibitors (pantoprazole, 80mg/day).Blood transfu-sionwas considered for patientswith a hemoglobinlevel<7g/dlandforthosewithsystemiccomorbidi-tiesandahemoglobin level less than10g/dl. In theevent of the development of the following findingsduringthefollow-upperiod,animmediatere-gastros-copywascarriedout:1.Deteriorationinhemodynam-icparameters(hypotension,tachycardia,oligoanuria);2.Progressivedecreaseinhemoglobinlevels;and3.Hematemesisandbrightredbleedingperrectum.Thepatientswithrebleedingweremanagedpreferentiallybytherapeuticgastroscopy.Immediatere-gastroscopywas avoided inpatientswithout clinical signsof re-bleeding.Thepatientsweredischargedattheendofa24-hourperiodwithouthemodynamicalterationoradecreaseof>2g/dlinhemoglobinlevels.

Allofthepatientswereaskedtoreturnforfollow-upgastroscopyafterasix-weekperiodwithmedicaltreatmentbyprotonpumpinhibitor(esomeprazole,40mg/day,peroral).SincetheCLOtestisnotreliableinpatientswithUGIB,thetestwasnotcarriedout,andacombinedantibiotherapywithclarithromycin(1000mg/day,peroral)andamoxicillin (2000mg/day,per-oral)forH. pylorieradicationwasprescribedonarou-tinebasisaswell.[4]

Exclusioncriteriawere:1.Hemodynamicinstabil-ityonadmission;2.Serious systemiccomorbidities;3.Use of anticoagulant or antithrombotic agents; 4.LesionscategorizedasotherthanForrest2b;5.Con-comitant gastric lesions ormultiple duodenal ulcersonendoscopy;6.Failuretocompletetheendoscopicexaminationdue topatient intolerabilityor technicalproblems;7.Noreturnforfollow-upendoscopyafter


Table 1. Forrestclassificationforuppergastrointesti-nalbleeding

Forrestclassification Rebleeding

Type1 Activebleeding 1aSpurtinghemorrhage 90-100% 1bOozinghemorrhage 80-85%Type2 Signsofrecentbleeding 2aNon-bleedingvisiblevessel 40-50% 2bAdherentclotonlesion 20-30% 2cHematin-coveredlesion 5%Type3 Lesionwithoutbleeding ≤3% (flatspot,cleanbase)

Prophylactic injection therapy is necessary for Forrest type 2b duodenal ulcers

thesix-weekperiod.The primary outcome measure was the rate of

rebleeding. Secondary outcome measures were thelengthofhospitalstayandmortalityrate.

The Statistical Package for the Social Sciences(SPSS)10.1forWindowswasusedforstatisticalanal-ysis.ThecomparisonbetweenthegroupswasmadebyMann-WhitneyUandFisher’sexacttest.Descriptivestatisticswereexpressedasmeanvalueandstandarddeviation.Apvaluelessthan0.05wasconsideredtobestatisticallysignificant.

RESULTSTotally,1148patientswererecruitedforthestudy.

Eighty-sevenpatientswithForrest2bduodenalulcerfoundatgastroscopywereincludedinthestudy.Therewere41patientsinGroup1and46patientsinGroup2.Themeanageandfemale-to-maleratioinGroups1and2were43.7±28.2(19-83)and39.6±18.4(21-73)and0.5(14/27)and0.9(21/25),respectively.

Thesuccessrateatre-gastroscopyinGroup1and2was70%(7/10)and66%(2/3),respectively.Onepa-tientinGroup1underwentimmediatesurgicaltreat-mentwithoutanattemptforare-gastroscopybecauseofsubconsciousness.Thepatientsinwhomre-gastros-copyfailedunderwentemergencysurgery.

TheresultsandcomparisonofoutcomemeasuresareshowninTable2.Thesolecauseofmortalityinbothgroupswasrebleeding.

DISCUSSIONRebleedinginpatientswithUGIBhasseveralclini-

calconsequences.Itstronglycorrelateswithmortality,andisusuallythemajorcauseofdeath.[3]Rebleedingalsohasasignificantimpactonmorbidity.Itapparentlydiminishesthephysiologicalcompensationmechanismthathasalreadybeeninsulted,whichmaybeofpara-mountimportanceinpatientswithlimitedphysiologi-calreserveduetosystemiccomorbidities.[7]Moreover,italsoincreasestheneedforbloodtransfusionaswellastheamountofbloodtransfusion.[8]Finally,rebleed-ingresultsinaprolongedlengthofhospitalstay,andthuscausesasignificantincreaseincosts.[9]

The rebleeding rate after diagnostic gastroscopyinpatientswithForresttype2bduodenalulcerinthe

presentstudyisconsistentwith theestimatedrate intheliterature[26.5%and20-30%].[10,11]Nevertheless,manyendoscopistsadvocateusingonlythediagnosticfeatureofendoscopyorthe“wait-and-see”strategyinthis setting inorder toavoidmanipulationof the le-sion thathas already stoppedbleedingandhasbeencoveredbyanadherentclot.[11]Inaddition, theyrelyon the availability of highly effective acid-reducingagentsandthefactthatmostsuchlesionsthatrebleedcan readilybe treatedbya secondendoscopic inter-vention.[11]

Ontheotherhand, thepresentstudyshowedthattheincidenceofrebleeding(26.8%vs.6.5%,p=0.017)significantly reduced in patients with UGIB due toForresttype2bduodenalulcerwhoreceivedprophy-lactic injection therapyduring the indexgastroscopywhen compared to thosewho underwent only diag-nostic gastroscopy. Moreover, this could be readilydoneusingasafe,relativelysimple,andcost-effectivemethod like injection therapy, which has a compli-cation rateof less than0.1%.[5]The reduction in theincidenceof rebleeding alsominimizes the need forre-gastroscopy,whichleadstoadditionalanxietyandfearofdeath for thepatient. Inaddition, in thecaseofre-gastroscopy,theendoscopisthastodealwithanuppergradelesion,andthus,thereisadecreaseinsuc-cessrateandincreaseincomplicationrate.Likewise,thesuccessrateatre-gastroscopywasfoundtobe66-70%inGroup2inthepresentstudy,whereasitwas100%intheindexgastroscopy.Finally,therewasalsoasignificantdifference in the lengthofhospital staybetweenthegroups,whichmeansitispossibletogaincost-effectivityusing amethodwith anegligible in-crease in costs.A recentmeta-analysis also reportedsimilarresults.[12]

Wefailedtoshowastatisticaldifferencebetweenthe mortality rates of the groups (9.7% vs. 2.1%,p=0.184)inspiteofthesignificantdifferencebetweenthe rebleedingrates.Whereas thisdisparity issome-whatsurprising,italsosupportsthefactthatthemor-talityrate inpatientswithUGIBremainsunchangedregardlessofemergingtreatmentmodalities.[2]

Themajorlimitationofthepresentstudyisitsret-rospective,non-randomizednature.Furthermore, thedecisiontocarryoutprophylacticinjectiontherapyinpatientswithForrest type2bduodenalulcerused to


Table 2.Theresultsandcomparisonofoutcomemeasures

Outcomemeasure Group1 Group2 p (n=41) (n=46)

Rebleeding 26.8%(11/41) 6.5%(3/46) 0.017Thelengthofhospital(h) 100.9±54.8(36-264) 65.2±35.6(36-192) 0.004Mortality 9.7%(4/41) 2.1%(1/46) 0.184


AmJEmergMed2007;25:774-9.5. Cannistrà F. Emergency endoscopic treatment of digestive

hemorrhagesofthegastroduodenaltract(Forrest1a,1b).[Ar-ticleinItalian]MinervaGastroenterolDietol1996;42:121-6.[Abstract]

6. Schröders CP, Glutig H, FrielingT, ImhofM, Röher HD.Ulcerhemorrhage:isaggressivesurgicaltherapystilldefen-sible?. [Article in German] LangenbecksArch Chir SupplKongressbd1997;114:1191-3.[Abstract]

7. CharatcharoenwitthayaP,PausawasdiN,LaosanguaneakN,BubthamalaJ,TanwandeeT,LeelakusolvongS.Character-isticsandoutcomesofacuteuppergastrointestinalbleedingaftertherapeuticendoscopyintheelderly.WorldJGastroen-terol2011;17:3724-32.

8. BarkunA,BardouM,Marshall JK;NonvaricealUpperGIBleedingConsensusConferenceGroup.Consensus recom-mendations for managing patients with nonvariceal uppergastrointestinalbleeding.AnnInternMed2003;139:843-57.

9. Saltzman JR,TabakYP,HyettBH,SunX,TravisAC, Jo-hannesRS.Asimpleriskscoreaccuratelypredictsin-hospi-talmortality,lengthofstay,andcostinacuteupperGIbleed-ing.GastrointestEndosc2011;74:1215-24.

10.BuffoliF,GraffeoM,NicosiaF,GentileC,CesariP,RolfiF,et al.Pepticulcerbleeding: comparisonof twohemostaticprocedures.AmJGastroenterol2001;96:89-94.

11.ParenteF,AnderloniA,BargiggiaS,ImbesiV,TrabucchiE,BarattiC,etal.Outcomeofnon-varicealacuteuppergastro-intestinalbleedinginrelationtothetimeofendoscopyandtheexperienceoftheendoscopist:atwo-yearsurvey.WorldJGastroenterol2005;11:7122-30.

12.KahiCJ,JensenDM,SungJJ,BleauBL,JungHK,EckertG,etal.Endoscopictherapyversusmedicaltherapyforbleed-ingpepticulcerwithadherentclot:ameta-analysis.Gastro-enterology2005;129:855-62.

bemadearbitrarilybecausestrongevidenceforsuchaprocedurewaslackinguntilrecently.However,afteranalysisofourownexperiencein2011,wewereen-couragedbytheincreasingdataandbeganperformingprophylacticinjectiontherapyinpatientswithForresttype2bduodenalulceronaroutinebasis.

Inconclusion,werecommendprophylactic injec-tiontherapyinpatientswithUGIBwhohaveForresttype2bduodenalulcer,asitsignificantlyreducestheincidenceof rebleedingandassociatedmorbidity. Inotherwords, it seemsrational toadopt the“nip it inthebud”policyratherthanthe“wait-and-see”policy.

AcknowledgementsAllof theauthorsdeclare that theyhavenocon-

flictsofinterestorfinancialtiestodisclose.

REFERENCES1. CourtneyAE,MitchellRM,RockeL,JohnstonBT.Proposed

risk stratification in upper gastrointestinal haemorrhage: ishospitalisationessential?EmergMedJ2004;21:39-40.

2. SchemmerP,DeckerF,Dei-AnaneG,HenschelV,BuhlK,HerfarthC,etal.Thevitalthreatofanuppergastrointestinalbleeding:Risk factor analysis of 121 consecutive patients.WorldJGastroenterol2006;12:3597-601.

3. KimBJ,ParkMK,KimSJ,KimER,MinBH,SonHJ,etal.Comparisonofscoringsystemsforthepredictionofout-comes in patients with nonvariceal upper gastrointestinalbleeding:aprospectivestudy.DigDisSci2009;54:2523-9.

4. ChenIC,HungMS,ChiuTF,ChenJC,HsiaoCT.Riskscor-ingsystemstopredictneedforclinicalinterventionforpa-tientswithnonvaricealuppergastrointestinaltractbleeding.


33




Gastrointestinal kanal perforasyonlarında perforasyon bulgularının ve yerinin saptanmasında karın

bilgisayarlı tomografisinin rolüTheroleofabdominalcomputedtomographyindeterminingperforationfindings

andsiteinpatientswithgastrointestinaltractperforation

Mehtap ILGAR, Muzaffer ELMALI, Mehmet Selim NURAL

OndokuzMayısÜniversitesiTıpFakültesi,RadyolojiAnabilimDalı,Samsun.

DepartmentofRadiology,OndokuzMayisUniversityFacultyofMedicine,Samsun,Turkey.

İletişim(Correspondence):Dr.MuzafferElmalı.OndokuzMayısÜniversitesiTıpFakültesiRadyolojiAnabilimDalı,Kurupelit55139Samsun,Turkey.Tel:+90-362-3121919e-posta(e-mail):[email protected]

AMAÇBuçalışmadagastrointestinalkanalperforasyonluhastalar-dakarınbilgisayarlıtomografisinin(BT)perforasyonbul-gularıveperforasyonyerinibelirlemedekirolüaraştırıldı.GEREÇ VE YÖNTEMTemmuz2007veTemmuz2010tarihleriarasında,gastroin-testinalkanalperforasyonuolduğucerrahiolarakkanıtlan-mış47hastanınameliyatöncesikarınBTgörüntülerigeri-yedönükolarakdeğerlendirildi.Herbirhasta içinBT’deserbest hava, kontrastmadde kaçağı, duvar kalınlaşması,duvar devamsızlığı, apse, flegmon ve serbest sıvı varlığıaraştırıldı.Belirlenenbubulgularışığındaperforasyonyeritahminedildivecerrahisonuçlarilekarşılaştırıldı.BULGULARKarın BT bulgularına göre gastroduodenal perforasyonuolan hastaların %85,7’sinde, ince bağırsak perforasyo-nu olanların %85,7’sinde, kalın bağırsak perforasyonuolanların %69,2’sinde, rektum perforasyonu olanların%100’ünde,apendiksperforasyonuolanların%90,9’unda,tüm hastaların ise %82,9’unda perforasyon yeri doğruolarak belirlendi. Gastrointestinal kanal perforasyonun-da BT’de en sık rastlananbulgu%89,4oranı ile karındaserbestsıvıidi.Diğerbulgularınrastlanmaoranlarıisesı-rasıylaşöyleydi;serbesthava%76.6,segmentalduvarka-lınlaşması%48.9,duvardevamsızlığı%25.5,apse%12.8,flegmon%10,6.Oralkontrastkullanılan30hastanın7’sin-de(%23,3)ekstraluminalkontrastkaçağısaptandı.SONUÇBTgastrointestinalkanalperforasyonbulgularınıveperfo-rasyonyerinibelirlemedeoldukçaetkilidir.Anahtar Sözcükler: Bilgisayarlıtomografi;intestinalperforasyon;spiralbilgisayarlıtomografi.

BACKGROUNDInthisstudy,weinvestigatedtheroleofabdominalcom-putedtomography(CT)indeterminingperforationfindingsandsiteinpatientswithgastrointestinaltractperforation.METHODSPreoperativeabdominalCTscansof47patientswhohadsurgicallyprovengastrointestinaltractperforationbetweenJuly 2007 and July 2010 were reviewed retrospectively.Thepresenceoffreeair,leakageofcontrastmaterial,wallthickness,walldiscontinuity,abscess,freefluid,andphleg-monwereinvestigatedforeachpatient.Thesiteofperfora-tionwasestimatedinlightofthesefindingsandcomparedwiththesurgicaloutcomes.RESULTSPerforation siteswere determined correctly in 85.7% ofpatients with gastroduodenal perforation, 85.7% of pa-tientswithsmallbowelperforation,69.2%ofpatientswithlarge bowel perforation, 100% of patients with rectumperforation,90.9%ofpatientswithappendixperforation,and82.9%ofallpatientsaccordingtotheabdominalCTfindings.ThemostcommonCTfindingingastrointestinaltractperforationwasfreefluid,witharateof89.4%.Theratesofotherfindingswereasfollows:freeair76.6%,seg-mentalwallthickening48.9%,walldiscontinuity25.5%,abscess12.8%,andphlegmon10.6%.Of30patientswhoreceivedoralcontrast,7(23.3%)hadextraluminalcontrastleakage.CONCLUSIONCTisveryeffectiveindetermininggastrointestinaltractper-forationfindingsandthesiteofperforation.Key Words:Computed tomography; intestinalperforation;spiralcomputedtomography.

doi: 10.5505/tjtes.2013.44538


Gastrointestinal kanal perforasyonu peptik ülserhastalığı, travma, iyatrojenik,yabancıcisim,apandi-sit,enflamasyon,tümörgibinedenlerleortayaçıkarveerkentanıvezamanındacerrahimüdahalegerektirir.[1]Gastrointestinalkanalperforasyonuiçinanatedaviyöntemi cerrahidir.Artık günümüzde konvansiyonellaparotomi yerine endoskopik ve laparoskopik yar-dımcı yöntemler tedavi aşamasında artan oranlardakullanılmaktadır.[2,3] Tedavi seçeneklerinin çeşitli ol-ması ve acil karar verme zorunluluğu nedeniyle gö-rüntülemede yanıtlanması gereken temel soru perfo-rasyonunyerivenedenininortayakonmasıdır.

Doğru tedavinin planlanması için perforasyonunvarlığı,yerivenedenibelirlenmelidir.Perforasyonye-rininklinik tanısızordur,çünküsemptomlar spesifikolmayabilir.Rutinkonvansiyonelradyografideserbestintra-peritonealhavagörülmesigenellikleperforasyo-naişareteder,ancakbaşkanedenlerledegörülebilir.Ayrıcaradyografiileperforasyonunyerivenedenites-bitedilemez.[4,5]

Akutkarınağrısıilegelenveperforasyondanşüp-helenilenhastalardabilgisayarlıtomografi(BT)yeter-libilgiyisağladığıiçinilkadımgörüntülemeyöntemikabul edilmektedir. Gastrointestinal kanal perforas-yonunyerinitanımlamadaBT’nindoğruluğu%82-90arasındadır.[1,3,6,7]PerforasyonyerinegöreBTbulgula-rıdeğişirvebubulgularperforasyonunyerinibelirle-medefaydalıdır.[8]Perforasyonyerininduvardevam-sızlığı şeklinde doğrudan gösterilmesi çoğu olgudamümkündeğildir.Bunedenleduvardevamsızlığınınyanında perforasyonda görülen diğer bulgular ve bubulgularıngörüldüğüyerlerkullanılarakperforasyonyerininbelirlenmesitedaviseçeneğinekararvermedeyardımcıdır.[8-10]

Buçalışmada,künttravmayaveyatravmadışıne-denlerebağlıgastrointestinalkanalperforasyonuolanhastalardaBT ileperforasyonbulgularınıvebubul-gularyardımıileperforasyonyerininbelirlenmesindeBT’nintanısaldeğeriniaraştırdık.

GEREÇ VE YÖNTEMTemmuz2007veTemmuz2010tarihleriarasında

akutkarınağrısı ileacilservispolikliniğinemüraca-at etmişvekarınBT’si çekilmişolan tümhastalarıntıbbidosyabilgilerigözdengeçirildi.Buhastalardanoperasyonlagastrointestinalkanalperforasyonutanı-sıalan47hastanınkarınBTgörüntülerigeriyedönükolarakyenidendeğerlendirildi.Özefagusperforasyon-larıayrıbirgrupolarakdüşünülüpçalışmadışıbırakıl-dı.ÇalışmayabaşlamadanönceYerelEtikKurulonayıalındı.

KarınBTgörüntülerispiralBT(Xpres/GX,TSX-002a,Toshiba,Japonya)ileeldeedildi.Tümhastalarsırtüstüpozisyondaalttorakalseviyedensimfizispu-

bisdüzeyinekadartarandı.Erişkinde150mAsve120kV,çocuklarda70mAsve120kVkullanılarak7mmkesitkalınlığındaaksiyelBTgörüntüleri eldeedildi.İyotlukontrastmaddekullanımıaçısındankontrendi-kasyonolmayanveböbrekfonksiyonlarınormalolanhastalarınhepsindeintravenöznoniyonikiyotlukont-rast madde (Ultravist 370, Bayer Schering Pharma,AlmanyaveyaIomeron400,BraccovePatheonS.p.A,İtalya)kullanıldı.Erişkinlerde100-120mlnoniyonikiyotlukontrastmadde2,5ml/snhızlaçocuklarda2ml/kgintravenöznoniyonikkontrastmadde1ml/snhızlaverildi.Görüntüler60-70saniyegecikmezamanıve-rilereksadecevenözfazdaeldeedildi.Geneldurumuuygunolan14’üerkek,16’sıkadıntoplam30hastayaincelemeöncesi45-60dakikaiçinde1000ml%3ora-nındasulandırılmışiyonikoralkontrastmadde(Urog-rafin%76,BayerScheringPharma,Almanya)verildi.

Kırk yedi hastanın operasyonöncesinde çekilmişBTgörüntüleribirbirindenhabersizikiradyologtara-fından değerlendirildi. Radyologlardan birisi acil veabdominalradyolojikonusunda6yıldeneyimliiken,diğer radyologgenel radyolojide10yıllık deneyimesahipti.Radyologlarasadecehastalarınoperasyonso-nuçlarınıngastrointestinalkanalperforasyonuolduğubilgisiverildi.Değerlendiricilerherbirhastaiçinayrıayrıserbesthava,kontrastmaddekaçağı,duvarkalın-laşması, duvar devamsızlığı, apse, flegmon, serbestsıvıvarlığınıaraştırıp,perforasyonyeriiçintahmindebulundular. Daha sonra iki radyolog arasında görüşfarklılığı olan hastalar birlikte tekrar değerlendirildivenihaisonucauzlaşmavarıldı.Perforasyonbölgele-ri;mide-duodenum1.kesimi,duodenumikincikesimibaşlangıcındanitibarenincebağırsak,kalınbağırsak,rektum ve apendiks olmak üzere 5 grupta toplandı.Bulgular analiz edilerek BT’nin perforasyon yerinisaptamadakitanısalduyarlılığıaraştırıldı.

Ayrıcahastalar“Treitzligamenti”referansalınaraküstve altgastrointestinalkanalperforasyonu şeklin-deikigrubaayrılaraküstvealtgastrointestinalkanalperforasyonuolanhastalarınBTbulgularıarasındakifarklılıkaraştırıldı.Bugruplamayapılırkenapendiksperforasyonunun kendine özel bazı bulgularının ol-masıveapendiksperforasyonuolanhastalardaserbesthavagörülmeoranınınazlığınedeniyleapendiksper-forasyonuolanhastalardeğerlendirmedışıbırakıldı.

Araştırmadaeldeedilenverilerinistatistikselana-lizleri“SPSSforWindows13.0”programıileyapıldı.İstatistiksel değerlendirmede ki-kare testi kullanıldı.İstatistikselanlamlılıkdüzeyip<0,05olarakbelirlen-di.

BULGULARÇalışmayaalınan47hastadan27’sierkek(%57,4),

20’sikadındı(%42,6).Yaşortalaması56olup,hastalar2 ile94yaşlarıarasındaydı.HastalaraBTçekimi ile


Gastrointestinal kanal perforasyonları ve bilgisayarlı tomografi

cerrahigirişimarasındageçenzaman1saatile2günarasındadeğişmekteydi.Hastalarınhiçbirindekontrastmaddeyekarşıciddialerjikreaksiyonoluşmamıştı.

Operasyon sonuçlarına göre 14 hastadamide-du-odenum1.kesim(%29,8),13hastadakalınbağırsak(%27,7),11hastadaapendiks(%23,4),7hastadaincebağırsak(%14,9),2hastadarektum(%4,4)perforas-yonumevcuttu.Bu47hastadaperforasyonnedenleriiseşöyleydi:apandisit11,peptikülser10,tümör10,küntkarıntravması8,divertikül4,diğernedenler4.

Kırkyedihastanın36’sında(%76,6)BT’deserbesthavagörülürken,11hastada(%23,4)serbesthavagö-rülmedi. Serbest hava görülmeyen hastaların 8’indeapendiks,2’sindekalınbağırsak,1’indeincebağırsakperforasyonuvardı(Tablo1).

Otuz hastada (%63,8) oral kontrast madde kul-lanılmış, 17 hastada (%36,2) kullanılmamıştı. Oralkontrastkullanılanhastalardansadecebiri6yaşında,diğerlerise21yaşınüzerindeydi.Oralkontrastverilenhastalardan7’sindekontrastmaddekaçağısaptandıvebuhastalarınhepsindemide-duodenum1.kesimper-

forasyonumevcuttu(Şekil1).Kırkyedihastanın12’sinde(%25,5)duvardevam-

sızlığıgörüldü.Duvardevamsızlığısaptananhastala-rın6’sındamide-duodenum1.kesim,2’sindekalınba-ğırsak,1’inderektum,3’ündeapendiksperforasyonuvardı.Başkabirdeyişlemide-duodenum1.kesimper-forasyonuolanhastaların%42,9’unda,apendiksper-forasyonuolanhastaların%27,3’ünde,kalınbağırsakperforasyonuolanhastaların%15,4’ündeperforasyonyeriduvardevamsızlığışeklindedirektgörüldü(Şekil2).

Apendiks perforasyonu olan hastalarda apendiksçapı8-13mmarasındaölçüldü.Apendiksperforasyo-nuolan11hastadan;4’ündekomşubağırsaksegment-lerindeduvarkalınlaşması,3’ündeapendikolit,2’sin-deperiapendikülerapse,4’ündeflegmonsaptandı.

Segmental duvar kalınlığında artış 23 hastada(%48,9) görüldü. Serbest sıvı en sık görülen bulguolup42hastada(%89,4) tespitedildi (Tablo2).Ser-bestsıvıgörülmeyenhastaların3’ündekalınbağırsak,2’sindeapendiksperforasyonuvardı.Altıhastadaapse


Tablo 1. PerforasyonyerinegöreBT’deserbesthavagörülenyerler

Perforasyonyeri KÇ MÇ Mezenter Pelvis RP

n(%) n(%) n(%) n(%) n(%)

Mide-duodenum(n=14) 12(85,7) 11(78,6) 4(28,6) 0(0,0) 0(0,0)İncebağırsak(n=7) 2(28,6) 1(14,3) 5(71,4) 0(0,0) 0(0,0)Kalınbağırsak(n=13) 6(46,2) 2(15,4) 6(46,2) 6(46,2) 2(15,4)Rektum(n=2) 0(0,0) 0(0,0) 0(0,0) 1(50,0) 2(100,0)Apendiks(n=11) 0(0,0) 0(0,0) 1(9,1) 3(27,3) 0(0,0)Toplam(n=47) 20(38,3) 14(29,8) 16(34,0) 10(21,3) 4(8,5)

KÇ:Karaciğerçevresi;MÇ:Mideçevresi;RP:Retroperiton.

Şekil 1. Pilor kanal ülserine bağlı perforasyonu olan 21 ya-şındakadınhastanınkarınBTaksiyelkesitinde;mideönünde,karaciğersollobvetransverskolonkomşulu-ğundayaygınkontrastmaddekaçağıizleniyor(oklar).

Şekil 2. Çekum tümörüne bağlı perforasyon gelişen 67 ya-şındakadınhastanınkarınBTaksiyelkesitinde;çe-kumdaileriderecededistansiyonvegaitaretansiyonuvar.Çekumsağlateraldenperforasyonabağlıduvardadevamsızlık(oklar)veperiçekalalandasıvıbirikimiizleniyor.



(%12,8), 5 hastada flegmon (%10,6) izlendi.Apsesiolanhastalardan4’ündekalınbağırsak,2’sindeapen-diksperforasyonu saptandı.Flegmonuolanhastalar-dan 4’ünde apendiks, 1’inde ince bağırsak perforas-yonuvardı.

Genelradyolojikonusundadeneyimliradyolog47hastadan 8’inde perforasyonun yeri hakkında yorumyapmadı.Diğer39hastanın35’indeperforasyonye-rini doğru olarak tahmin etti.Operasyonda saptananperforasyonyeriileburadyoloğunBT’detahminet-tiği perforasyon yeri arasındaki uyumkatsayısı 0,83bulundu.Perforasyonyerinisaptayabilmeyüzdesiise%74,5olarakhesaplandı.Acilvekarınradyolojisiko-nusundadeneyimliradyolog6hastadaperforasyonunyeri konusunda yorum yapmadı. Kalan 41 hastanın39’undaperforasyonyerinidoğruolaraktahminetti.Operasyondasaptananperforasyonyeriileburadyo-loğunBT’detahminettiğiperforasyonyeriarasındakiuyumkatsayısı0,93bulundu.Perforasyonyerinisap-tayabilmeyüzdesiise%82,9olarakhesaplandı.

Radyologlararalarındagörüşfarklılığıolanhasta-larbirlikte tekrardeğerlendirildiğinde2hastadaper-forasyonyeritekrarhatalıtespitedildi.Bu2hastadakalınbağırsakperforasyonumevcutikenileumdadu-var kalınlaşması saptanması nedeniyle ince bağırsakperforasyonu şeklinde yorumlanmıştı. Uzlaşma ilevarılannihaisonucagöre;toplamda6hastadaperfo-rasyonyerikonusundayorumyapılmadı.Bu6hasta-dan 2’sinde kalın bağırsak, 2’sindemide-duedenum,

1’indeincebağırsakve1’indedeapendiksperforasyo-numevcuttu.Kalan41hastanın39’undaperforasyonyeriBTiledoğruolaraktahminedildi.OperasyondatespitedilenperforasyonyeriileBT’detahminedilenperforasyon yeri arasındaki uyumkatsayısı 0,93 bu-lundu.BT’ninperforasyonyerinisaptayabilmeyüzde-siise%82,9olarakhesaplandı(Tablo3).

Araştırmayaalınanhastalarayrıcaüstvealtgastro-intestinalkanalperforasyonuşeklindeikigrubaayrıl-dı.Bugruplamayapılırken“Treitzligamenti”referansalındı.Apendiksperforasyonuolanhastalar(11hasta)değerlendirmedışıbırakıldı.Ameliyatsonucunagöregeriye kalan 36 hastadan 14’ünde üst, 22’sinde altgastrointestinalkanalperforasyonuvardı.Hastalarbuşekildegruplandığındaüstvealtgastrointestinalkanalperforasyonundaserbesthavagörülmesıklığı,serbesthavanıngörüldüğüyer,duvardevamsızlığıaçısındanfarklılıkolupolmadığınıdeğerlendirmekiçinki-karetestiyapıldı.

Üstgastrointestinalperforasyonlu14hastanınhep-sinde (%100), alt gastrointestinal perforasyonu olan22 hastanın 19’unda (%86,4) serbest hava saptandı.Üstvealtgastrointestinalperforasyonluhastalarara-sındaBT’deserbesthavagörülmesiaçısındananlam-lı bir fark bulunmadı (p=0,149).Üst gastrointestinalperforasyonluhastaların12’sinde(%85,7),altgastro-intestinalperforasyonuolanhastaların8’inde(%36,4)karaciğerçevresindeserbesthavasaptandı (Şekil3).Üstvealtgastrointestinalkanalperforasyonluhastalar

Tablo 2. Perforasyonyerinegörediğerbulgularıngörülmesıklığı

Perforasyonyeri DD DK Flegmon Apse SS

n(%) n(%) n(%) n(%) n(%)

Mide-duedenum(n=14) 6(42,9) 4(28,6) 0(0,0) 0(0,0) 14(100,0)İncebağırsak(n=7) 0(0,0) 4(57,1) 1(14,3) 0(0,0) 7(100,0)Kalınbağırsak(n=13) 2(14,4) 9(69,2) 0(0,0) 4(30,8) 10(76,9)Rektum(n=2) 1(50) 2(100,0) 0(0,0) 0(0,0) 2(100,0)Apendiks(n=11) 3(27,3) 4(36,4) 4(36,4) 2(18,2) 9(81,8)Toplam(n=47) 12(25,5) 23(48,9) 5(10,6) 6(12,8) 42(89,4)

DD:Duvardevamsızlığı;DK:Duvarkalınlaşması;SS:Serbestsıvı.

Tablo 3. PerforasyonyerinegöreBTdoğrulukoranları

Perforasyonyeri Gerçek(+) Yanlış(+) Belirtilmeyen

n(%) n(%) n(%)

Mide-duodenum(n=14) 12(85,7) – 2(14,3)İncebağırsak(n=7) 6(85,7) – 1(14,3)Kalınbağırsak(n=13) 9(69,2) 2(15,4) 2(15,4)Rektum(n=2) 2(100,0) – –Apendiks(n=11) 10(90,9) – 1(9,1)Toplam(n=47) 39(82,9) 2(4,3) 6(12,7)

Belirtilmeyen:Perforasyonyerikonusundayorumyapılmayanhastalar.



arasındakaraciğerçevresindeserbesthavagörülmesiaçısındananlamlıfarkbulundu(p=0,004).Üstgastro-intestinalperforasyonlu11hastanın(%78,6),altgast-rointestinal perforasyonlu 3 hastanın (%13,6) mideçevresinde serbest hava saptandı. Üst ve alt gastro-intestinalkanalperforasyonluhastalararasındamideçevresinde serbest havagörülmesi açısından anlamlıfarktespitedildi(p=0,001).

Üst gastrointestinal perforasyonlu hastaların4’ünde(%28,6),altgastrointestinalperforasyonuolanhastaların11’inde(%50)mezenterdeserbesthavagö-rüldü.Üstvealtgastrointestinalkanalperforasyonluhastalar arasındamezenterde serbest havagörülmesiaçısındananlamlıbirfarksaptanmadı(p=0,204).Üstgastrointestinal perforasyonlu hastaların hiçbirindepelvisdeserbesthavatespitedilmedi.Altgastrointes-tinalperforasyonuolanhastaların7’sinde(%31,8)pel-visdeserbesthavasaptandı.Üstvealtgastrointestinalperforasyonluhastalararasındapelviste serbesthavagörülmesiaçısındananlamlıfarkbulundu(p=0,019).

Üstgastrointestinalperforasyonluhastaların6’sın-da(%42,9),altgastrointestinalperforasyonuolanhas-taların 3’ünde (%13,6) duvar devamsızlığı saptandı(Tablo 4). Üst ve alt gastrointestinal perforasyonluhastalararasındaduvardevamsızlığıvarlığıaçısındananlamlıfarksaptandı(p=0,048).

TARTIŞMAGastrointestinal kanal perforasyonu tanısında di-

rektgrafi,ultrasonografi(USG)veBTkullanılmakta-dır, ancakBT ile kıyaslandığında doğrudan grafi veUSG’nintanıdeğeridüşüktür.Deneyselçalışmalarda1ml serbest havanınoptimal çekilen ayakta akciğergrafisindesağdiafragmaaltındagörülebileceğibelir-tilmektedir.[11] Perforasyon tanısında ilk adım direktradyografi olmakla birlikte duyarlılığı %50-70 ara-sındadır. Perforasyon tanısında kullanılan bir diğeryöntemUSG’dir.USG’ninBT’yeavantajıradyasyoniçermemesidir. Bu nedenle çocuklarda ve gebelerdekullanılabilir.PnömoperitonUSGiledesaptanabilir.Ayrıca USG ek tanısal bilgiler de sağlar. USG’ninpnömoperitonusaptamada radyografikadaretkinol-duğunu söyleyen çalışmalar olduğu gibi karın gazınedeniyleperforasyonunortayakonmasındayetersizolduğunu söyleyen çalışmalar da vardır.[12,13] SonuçolarakUSG’dedirektradyografideolduğugibiBTilekıyaslandığındadüşüktanısalduyarlılığasahiptir.

Gastrointestinalperforasyonunvarlığı,yeri,nedenivekomplikasyonlarınıbelirlemedeBTen iyi görün-tülemeyöntemiolarakkabulgörmüştür.[1,8,14,15]Araş-tırmamızdaBTbulgularındanyolaçıkarakgastroduo-denalperforasyonuolanhastaların%85,7’sinde,incebağırsak perforasyonu olan hastaların %85,7’sinde,kalınbağırsakperforasyonuolanhastaların%69,2’sin-de, rektumperforasyonuolanhastaların%100’ünde,apendiksperforasyonuolanhastaların%90,9’undavetüm hastalar birlikte değerlendirildiğinde hastaların%82,9’undaperforasyonyeridoğrutespitedilmiştir.

Imutavearkadaşları[10]8-slicemulti-dedektörBT(MDBT) ile 155 hastada geriye dönük bir çalışmayapmıştır.Buçalışmadakesitkalınlığı2,5mmolarak

Tablo 4. Üstvealtgastrointestinalkanalperforasyonundaserbesthavaveduvardevamsızlığıgörülmedurumu

Bulgu ÜstGİkanal AltGİkanal p

n(%) n(%) n(%)

Serbesthava(SH) 14(%100) 19(%86,4) 0,149KaraciğerçevresindeSH 12(%85,7) 8(%36,4) 0,004MideçevresindeSH 11(%78,6) 3(%13,6) 0,001MezenterdeSH 4(28,6) 11(%50) 0,204PelvisteSH 0(%0,0) 7(%31,8) 0,019Duvardevamsızlığı 6(%42,9) 3(%13,6) 0,048

Gİ:Gastrointestinal.

Şekil 3. Mideantrumülserinebağlıperforasyonuolan71ya-şındakadınhastanınkarınBTaksiyelkesitinde;ant-rumperforasyonunaaitanteriyordadefektifgörünüm(inceok)vekaraciğeretrafındayaygınserbesthavaizleniyor(kalınoklar).



kullanılmıştır.Hiçbirhastayaoralkontrastmaddeve-rilmemiş, 44 hastaya intravenöz kontrast verilmiştir.Imutavearkadaşlarınınbuçalışmasındayalnızcaaksi-yelimajlardeğerlendirildiğindehastaların%32’sinde,aksiyel imajlara ilaveten çok düzlemde görüntülemeimajları (multiplanar reformatting,MPR) kullanıldı-ğında%52’sindeperforasyonyeriduvardevamsızlığışeklinde direkt görüntülenmiştir. Yine bu çalışmadadirekt ve indirekt bulgular birlikte kullanıldığındahastaların %90’ında perforasyon yeri doğru tanım-lanmıştır. Imutavearkadaşlarının[10]buçalışmasındakontrast madde kullanımı oldukca düşük olmasınarağmendoğrulukoranlarıbizimçalışmamızdandahayüksektir.BudurumMDBTkullanımınınavantajlarıileaçıklanabilir.

Hainauxvearkadaşları[3]4-sliceMDBTile85has-ta ile ileriyedönükbirçalışmayapmıştır.Oralkont-rastmaddehiçbirhastadakullanılmamış,46hastayaintravenözkontrastmaddeverilmiştir.Hastalarınak-siyelveçokdüzlemdegörüntülemeimajlarıdeğerlen-dirilmişveoperasyonsonuçları ilekarşılaştırılmıştır.Bu çalışmada hastaların%86’sında perforasyon yeridoğru belirlenmiştir. Bu değer bizim çalışmamızdaeldeedilendeğerdenyüksektirancakbuçalışmadadaMDBTkullanılmıştır.

Ogurovearkadaşlarının[16]64-sliceMDBTile41hastada yaptıkları çalışmada 36 hastaya intravenözkontrast madde verilmiş, hastaların hiçbirine oralkontrastverilmemiştir.Belirtilenbuçalışmadaimajlariki şekildeoluşturulmuştur. İlkolarak7mmkalınlı-ğında aksiyel imajlar, 1 hafta sonra dayalnız 2mmkalınlıktaaksiyelimajlarve2mmaksiyel,1mmçokdüzlemli imajlar değerlendirilmiştir. Bu çalışmadaduvar devamsızlığının gösterilmesi direkt bulgu, di-ğer bulgular indirekt bulgular olarak sınıflanmış veMDBT’nindirektbulguyugöstermedekiavantajıtar-tışılmıştır.Ogurovearkadaşlarının[16]buçalışmasında7 mm’lik aksiyel imajlar değerlendirildiğinde duvardevamsızlığıhiçbirhastadagösterilememiştir.Yalnız2mm kalınlıkta aksiyel imajlar değerlendirildiğinde%48,8(41hastadan20’sinde),2mmaksiyelimajlar-la birlikte 1mmçok düzlemli imajlar kullanıldığın-da%80,5 (41 hastanın 33’ünde) duvar devamsızlığıdirektgörülmüştür(p=0,0009).Budeğerbizimçalış-mamızdadirektveindirektbulgularkullanılarakeldeedilendeğereyakındır.

Ghekierevearkadaşları[17]8ve16-sliceMDBTileyaptıklarıçalışmada40hastanınBTgörüntülerinige-riyedönükolarakdeğerlendirmişlerdir.Hiçbirhastayaoralkontrastverilmemiş,35hastayaintravenözkont-rastmaddeverilmiştir.Buçalışmadaperforasyonyeri-ninduvardevamsızlığışeklindedirektgösterilmesineodaklanılmış, perforasyon yerleri direkt belirtildiğigibianteriyor,posteriyor, lateral,mediyalduvargibiayrıntılılokalizasyonlardabelirtilmiştir.Buçalışmada

enyüksektanısaldoğrulukaksiyel,sajitalvekoronalgörüntülerbirliktekullanıldığındaeldeedilmiştir.Bi-zimçalışmamızveyukarıdasözedilendiğerçalışma-lar gastrointestinal kanal perforasyon yerininBT ileyüksek doğruluk oranları ile tahmin edilebileceğinigöstermektedir.

Serbest intraperitoneal hava akut karın ağrısı ilebirlikte gastrointestinal kanal perforasyonu tanısınınmajörbulgusudur.ÇoksayıdayazarBT’nin intrape-ritonealserbesthavanıntespitindeçokdeğerlibirgö-rüntülemeyöntemiolduğunugöstermiştir.[18,19]BT’deserbest hava değerlendirilirken akciğer penceresindebakmak faydalıdır. Akciğer penceresinde değerlen-dirme yapıldığında serbest havanın BT’de görülmeolasılığı artar.[15] Bizim araştırmamızda 47 hastanın36’sında(%76,6)serbesthavagörüldü.Serbesthavaen sık mide duodenum 1. kesim perforasyonu olanhastalarda(%100),enazapendiksperforasyonuolanhastalarda(%27,3)saptandı.

Gastroduodenal perforasyonda karaciğer vemideçevresinde bolmiktarda serbest hava saptanabilir.[14] Serbesthavayadahava-sıvıseviyesiortahattıgeçipfalsiformligamentibelirginhalegetirebilir(falsiformligament işareti). Serbest hava lasser sacdabulunu-yorsa perforasyon yeri muhtemelen duodenum yadamidenin posteriyor duvarındadır.[20] Sağ anteriyorpararenal alandakiekstraluminal serbesthavabulbersegment dışındaki duodenal perforasyon tanısındagüvenilir bir BT bulgusudur.[21] Literatür ile uyumluolarakbizimçalışmamızdadagastroduodenalperfo-rasyonuolanhastanınhepsindeserbesthavagörüldü.Buhastalardaserbesthavanınensıkgörüldüğüyerlerkaraciğervemideçevresiydi.

Apendiks perforasyonunda serbest hava görülmeoranıdüşüktür.Bununbaşlıcanedeni lümeninenfla-matuvar duvar kalınlaşması nedeniyle tıkanmasıdır.Bizim çalışmamızda da literatür ile uyumlu olarakserbesthavaenazapendiksperforasyonundagörüldü.

Ekstraluminaloralkontrastmaddegörülmesiper-forasyonunenspesifikbulgusudur.Ayrıcaoralkont-rastkullanıldığındaperforasyonyerininhipodensgö-rünümü daha belirginleşir. Bu avantajlarına rağmenoralkontrastkullanımıkonusutartışmalıdır.Nastanskivearkadaşları[22]BTgörüntülemeöncesiverilenoralkontrast maddenin aspirasyon riskini artırmadığınıvebağırsakperforasyonununtespitineyardımettiğiniraporlamıştır.Fakatbazıyazarlarparalitikileusuolanhastalardakontrastmaddeninyavaşilerlemesinedeniileoralkontrastkullanımınıtercihetmezler.[23,24]Oralkontrast peritoneal sıvının miktarını artırarak sepsisriskiniartırabilirdiyengörüşlerdevardır.[25]

Ekstraluminal kontrast madde varlığı tanı değe-ri yüksek bir bulgu olmakla birlikte görülme sıklığı%19-42gibidüşükdeğerlerdedir.[26]Shanmuganathan

vearkadaşları[27]penetrantravmalıhastalardaoralverektal kontrastmadde kullanarak yaptıkları çalışma-dahastalarınyalnızca%15’indekaçakgörmüşlerdir.Fultz ve arkadaşlarının[28] çalışmasında ise perforepeptik ülserli 11 hastanın tümü oral kontrastmaddealmış ve yalnızca 3 hastada kontrast madde kaçağısaptanmıştır.Oralkontrastmaddealırkenhastanınsır-tüstüpozisyondayatıyorolmasıveBTçekilirkenbupozisyondakalmasıanteriyorduvarperforasyonların-dakontrastmaddekaçağınıazaltabilir.

Bizim araştırmamızda 30 hastaya (%63,8) oralkontrastmaddeverilmişti.Oralkontrastverilenhas-talardan7’sinde(%23,3)kontrastmaddekaçağısap-tandı.Buhastalarınhepsindemide-duedenum1.ke-simperforasyonuvardı.Araştırmamızdaoralkontrastmadde kaçağının düşük olmasının başlıca nedenihastalarınacilkoşullardadeğerlendirilmesinedeniileçoğuhastadaverilenoralkontrastperforasyonyerineulaşmadançekiminyapılmışolmasıolabilir.

Duvar devamsızlığı perforasyonun primer bulgu-sudur. Devamsızlık duvarda hipodens kontrastlan-ma defekti şeklinde görülebilir. Bizim olgularımızın%25,5’inde(47hastanın12’sinde)duvardevamsızlığıgörüldü. Duvar devamsızlığının dağılımına baktığı-mızda6’sımide-duodenum1.kesim,2’sikalınbağır-sak,3’üapendiks,1’irektumperforasyonundagörül-dü.

Kim ve arkadaşlarının[29] çalışmasında duvar de-vamsızlığı %14 oranında görülmüştür. Miki ve ar-kadaşları[30] kolon rüptürü olan 6 hastada yaptıklarıçalışmada 6 hastadan 4’ünde duvar devamsızlığınıgöstermiştir. Imuta ve arkadaşlarının[10] çalışmasın-da155hastadan44’ünde intravenözkontrastmaddekullanılmışvebu44hastadan14’ünde(%32)aksiyelimajlarda duvar devamsızlığı gösterilmiştir. Aksiyelimajlarlabirlikte çokdüzlemli görüntüler kullanıldı-ğındabuoran%52’yeyükselmiştir.İntravenözkontrastmaddekullanılmayanhastalardaise%6gibidüşükbiroransaptanmıştır.Ghekierevearkadaşlarının[17]çalış-masındaüstgastrointestinalkanalperforasyonuolanhastalarda%72,altgastrointestinalkanalperforasyo-nuolanhastalarda%36oranındaduvardevamsızlığısaptanmıştır.Bizimçalışmamızdaüstgastrointestinalperforasyonluhastaların%42,9’unda,altgastrointes-tinalperforasyonuolanhastaların%13,6’sındaduvardevamsızlığısaptandı.Üstvealtgastrointestinalper-forasyonluhastalararasındaduvardevamsızlığıgörül-mesiaçısındananlamlıbirfarkvardı(p=0,048).

Görüldüğügibiduvardevamsızlığıperforasyonunyerinidirektgösterenönemlibirbulguolmaklabirlik-tegörülmeoranlarıçeşitliçalışmalardabelirginfark-lılıkgöstermektedir.İntravenözkontrastmaddekulla-nımıduvardevamsızlığınıntespitinikolaylaştırmakta,intravenözkontrast kullanılmadığındagörülmeoranıbelirginazalmaktadır.MDBTileyapılançalışmalarda

duvardevamsızlığınınsaptanmaoranıdahayüksektir.Çalışmalarincekesitveçokdüzlemedeoluşturul-

muşgörüntülerinkullanılmasınınperforasyonyerininsaptanmasını kolaylaştırdığını göstermektedir.BizimçalışmamızdagörüntülertekdedektörlüspiralBTileelde edilmiş ve hastaların değerlendirilmesi sadeceaksiyelplanda7mmkesitkalınlığıüzerindeyapılmış-tır.Geriyedönükolançalışmamızdaincekesitveçokdüzlemdeoluşturulmuşgörüntülerinmevcutolmama-sıçalışmamızınenönemlikısıtlılığıdır.Bununlabir-liktesonuçlartatminediciözelliktedir.

Sonuç olarakBT, gastrointestinal kanal perforas-yonlarında görülebilecek serbest hava, serbest sıvı,kontrast madde kaçağı, duvar devamsızlığı, duvarkalınlaşması,flegmonveapseyigöstermedeoldukçaetkilidir ve bu bulgular yardımı ile perforasyon yeriyüksekduyarlılıklabelirlenebilir.

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

KAYNAKLAR1. YeungKW,ChangMS,HsiaoCP,HuangJF.CTevaluationof

gastrointestinaltractperforation.ClinImaging2004;28:329-33.

2. SiuWT,ChauCH,LawBK,TangCN,HaPY,LiMK.Rou-tineuseoflaparoscopicrepairforperforatedpepticulcer.BrJSurg2004;91:481-4.

3. Hainaux B,Agneessens E, Bertinotti R, DeMaertelaerV,RubesovaE,CapellutoE,etal.AccuracyofMDCTinpre-dicting site of gastrointestinal tract perforation.AJRAm JRoentgenol2006;187:1179-83.

4. ChoKC,BakerSR.Extraluminalair.Diagnosisandsignifi-cance.RadiolClinNorthAm1994;32:829-44.

5. RiceRP,ThompsonWM,GedgaudasRK.Thediagnosisandsignificanceofextraluminalgasintheabdomen.RadiolClinNorthAm1982;20:819-37.

6. MindelzunRE,JeffreyRB.Theacuteabdomen:currentCTimagingtechniques.SeminUltrasoundCTMR1999;20:63-7.

7. Rosen MP, Siewert B, Sands DZ, Bromberg R, Edlow J,RaptopoulosV. Value of abdominal CT in the emergencydepartment for patients with abdominal pain. Eur Radiol2003;13:418-24.

8. KimSH,ShinSS,JeongYY,HeoSH,KimJW,KangHK.Gastrointestinaltractperforation:MDCTfindingsaccordingtotheperforationsites.KoreanJRadiol2009;10:63-70.

9. Singh JP, StewardMJ, BoothTC,Mukhtar H,MurrayD.Evolutionofimagingforabdominalperforation.AnnRCollSurgEngl2010;92:182-8.

10.ImutaM,AwaiK,NakayamaY,MurataY,AsaoC,Matsu-kawaT,etal.MultidetectorCTfindingssuggestingaperfo-rationsiteinthegastrointestinaltract:analysisinsurgicallyconfirmed155patients.RadiatMed2007;25:113-8.

11.MillerRE,NelsonSW.Theroentgenologicdemonstrationoftiny amounts of free intraperitoneal gas: experimental andclinical studies.AmJRoentgenolRadiumTherNuclMed1971;112:574-85.

12.MuradaliD,WilsonS,BurnsPN,ShapiroH,Hope-SimpsonD.Aspecificsignofpneumoperitoneumonsonography:en-





hancement of the peritoneal stripe.AJRAm JRoentgenol1999;173:1257-62.

13.GhekiereO,LesnikA,HoaD,LaffargueG,UriotC,TaourelP. Value of computed tomography in the diagnosis of thecause of nontraumatic gastrointestinal tract perforation. JComputAssistTomogr2007;31:169-76.

14.FurukawaA,SakodaM,YamasakiM,KonoN,TanakaT,NittaN,etal.Gastrointestinaltractperforation:CTdiagnosisofpresence,site,andcause.AbdomImaging2005;30:524-34.

15.LeschkaS,AlkadhiH,WildermuthS,MarincekB.Multi-de-tectorcomputedtomographyofacuteabdomen.EurRadiol2005;15:2435-47.

16.OguroS,FunabikiT,HosodaK, InoueY,YamaneT,SatoM,etal.64-Slicemultidetectorcomputedtomographyeval-uationofgastrointestinaltractperforationsite:detectabilityof direct findings in upper and lowerGI tract. EurRadiol2010;20:1396-403.

17.GhekiereO,LesnikA,MilletI,HoaD,GuillonF,TaourelP.Directvisualizationofperforationsites inpatientswithanon-traumaticfreepneumoperitoneum:addeddiagnosticvalueofthintransverseslicesandcoronalandsagittalref-ormationsformulti-detectorCT.EurRadiol2007;17:2302-9.

18.StapakisJC,ThickmanD.Diagnosisofpneumoperitoneum:abdominalCTvs. upright chest film. JComputAssistTo-mogr1992;16:713-6.

19.Earls JP,DachmanAH,ColonE,GarrettMG,MolloyM.Prevalence and duration of postoperative pneumoperitone-um: sensitivityofCTvs left lateraldecubitus radiography.AJRAmJRoentgenol1993;161:781-5.

20.ManiatisV,ChryssikopoulosH,RoussakisA,KalamaraC,KavadiasS,PapadopoulosA,etal.Perforationofthealimen-tary tract: evaluation with computed tomography.AbdomImaging2000;25:373-9.

21.KuninJR,KorobkinM,EllisJH,FrancisIR,KaneNM,Sie-gelSE.Duodenalinjuriescausedbybluntabdominaltrauma:

value ofCT in differentiating perforation fromhematoma.AJRAmJRoentgenol1993;160:1221-3.

22.NastanskiF,CohenA,LushSP,DiStanteA,TheuerCP.Theroleoforalcontrastadministrationimmediatelypriortothecomputed tomographic evaluationof theblunt traumavic-tim.Injury2001;32:545-9.

23.GrassiR,PintoA,RossiG,RotondoA.Conventionalplain-filmradiology,ultrasonographyandCTinjejuno-ilealperfo-ration.ActaRadiol1998;39:52-6.

24.BulasDI,TaylorGA,EichelbergerMR.ThevalueofCTindetectingbowelperforationinchildrenafterbluntabdominaltrauma.AJRAmJRoentgenol1989;153:561-4.

25.Ongolo-ZogoP,BorsonO,GarciaP,GrunerL,ValettePJ.Acute gastroduodenal peptic ulcer perforation: contrast-enhancedandthin-sectionspiralCTfindingsin10patients.AbdomImaging1999;24:329-32.

26.BeckerCD,MenthaG,SchmidlinF,TerrierF.Bluntabdomi-naltraumainadults:roleofCTinthediagnosisandmanage-ment of visceral injuries. Part 2:Gastrointestinal tract andretroperitonealorgans.EurRadiol1998;8:772-80.

27.Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL,ScaleaTM.Triple-contrast helical CT in penetrating torsotrauma: a prospective study to determine peritoneal viola-tion and the need for laparotomy.AJRAm J Roentgenol2001;177:1247-56.

28.FultzPJ,Skucas J,WeissSL.CT inuppergastrointestinaltractperforationssecondarytopepticulcerdisease.Gastro-intestRadiol1992;17:5-8.

29.KimHC,ShinHC,ParkSJ,ParkSI,KimHH,BaeWK,etal.Traumaticbowelperforation:analysisofCTfindingsaccord-ingtotheperforationsiteandtheelapsedtimesinceaccident.ClinImaging2004;28:334-9.

30.MikiT,OgataS,UtoM,NakazonoT,UrataM, IshibeR,etal.Multidetector-rowCTfindingsofcolonicperforation:directvisualizationofrupturedcolonicwall.AbdomImaging2004;29:658-62.

41




Inferior glenohumeral dislocation (luxatio erecta humeri): report of six cases and review of the literature

İnferioromuzçıkığı(luksasyoerekta):Altıolgusunumuveliteratürüngözdengeçirilmesi

Ahmet İMERCİ,1 Yalçın GÖLCÜK,2 Sabri Gökhan UĞUR,3 Hüseyin Tamer URSAVAŞ,4 Ahmet SAVRAN,4 Levent SÜRER5

1DepartmentofOrthopaedicsandTraumatology,ErzurumPalandokenStateHospital,Erzurum;2DepartmentofEmergency,BitlisStateHospital,Bitlis;3DepartmentofOrthopaedicsandTraumatology,KaramanStateHospital,Karaman;4DepartmentofOrthopaedicsandTraumatology,IzmirTepecikTrainingandResearchHospital,Izmir;5DepartmentofOrthopaedicsand

Traumatology,AcibademBodrumHospital,Mugla,Turkey.

1ErzurumPalandökenDevletHastanesi,OrtopediveTravmatolojiKliniği,Erzurum;2BitlisDevletHastanesi,AcilServis,Bitlis;

3KaramanDevletHastanesi,OrtopediveTravmatolojiKliniği,Karaman;4İzmirTepecikEğitimveAraştırmaHastanesi,OrtopediveTravmatolojiKliniği,İzmir;5AcıbademBodrumHastanesi,OrtopediveTravmatoloji

Kliniği,Muğla.

Correspondence(İletişim):Ahmetİmerci,M.D.ErzurumPalandökenDevletHastanesi,OrtopediveTravmatolojiKliniği,25000Erzurum,Turkey.Tel:+90-442-2355080e-mail(e-posta):[email protected]

BACKGROUNDInferior shoulder dislocation, also referred to as luxatioerecta,isararetypeofshoulderdislocation.Itsincidenceisabout1in200(0.5%)amongallshoulderdislocations.Theobjectiveofthisstudywastoreviewsixcasesofinferiorshoulderdislocation,includingtheirclinicalandradiologi-calpresentation,management,andfinaloutcome.METHODSFourmalesand two females, a totalof sixpatients,withthediagnosisofinferiorshoulderdislocationweretreatedbetween2007and2010.Ourpurposeistopresentourex-perienceinthetreatmentofthesepatientstogetherwiththeparallelresearchavailableintheliterature.RESULTSConstant score was used to evaluate shoulder function.Pain, position, daily activities, range of motion, andstrengthscoreswerenoted.Allpatientshadgoodtoexcel-lentresultswithfullfunctionalrecoverywithintwoyearsafterclosedreductionandshoulderrehabilitation.

CONCLUSIONDoctorsshouldbefamiliarwiththeoccurrenceofthisin-frequentconditionandshouldpreventpossiblecomplica-tionsthatmightresultfromearlyreductionsbyusingcor-rectmaneuversinlieuofordinaryreductiontechniques.Key Words: Closed reduction; emergency; inferior dislocation;luxatioerecta;shoulder;trauma.

AMAÇİnferioromuzçıkığı,ayrıcaluksasyoerektaolarakadlandı-rıpomuzçıkığınınnadirgörülenbirtipidir.Görülmesıklığıtümomuzçıkık arasındakiyaklaşık200’de1’dir (%0,5).Buçalışmanınamacı,inferioromuzçıkığınınklinikverad-yolojikolaraksunumu,tedavisivenihaisonucun6olguilegözdengeçirilmesidir.GEREÇ VE YÖNTEMDörterkekveikikadın,toplam6hastaaşağıomuzçıkığıtanısıile2007ve2010yıllarıarasındatedaviedildi.Tedaviettiğimizbuhastalarnedeniyle,bizimamacımızkaynaklarparalelindedeneyimimizipaylaşmaktır.

BULGULARHastalarınomuzfonksiyonlarınıdeğerlendirmekiçinCons-tant omuz skorlaması kullanılarak ağrı, pozisyon, günlükyaşamaktiviteleri,eklemhareketaçıklıklarıvegüçükayde-dildi.Hastaların tamamındakapalı redüksiyonve rehabili-tasyoniletedavisonrası2yıliçindetamfonksiyoneliyileş-mesağlanarakmükemmelyadaiyisonuçalındı.

SONUÇDoktorlar bu nadir durumun oluşumuna alışık olmalı vedoğru redüksiyon teknikleri dışındayapılan erken redük-siyonlar neticesinde oluşabilecek olası komplikasyonlarıönlemelerigerekir.Anahtar Sözcükler: Kapalı redüksiyon; acil; inferior çıkık;luksasyoerekta;omuz;travma.

doi: 10.5505/tjtes.2013.35305


Theshoulder joint is the jointwheredislocationsoccurmostfrequently.[1]Multi-directionalmobilityoftheshoulderjoint,itsanatomicstructureandfrequentexpositiontotraumasresultinthemorefrequentoc-currence of dislocations.[2] Forward and backwarddislocationsareobservedat ratesof95%and4-5%,respectively, in patients with shoulder dislocations.[1,3]Downwarddislocation(luxatioerecta-LE),withanoccurrencerateof0.5%amongallshoulderdislo-cations,ontheotherhand,isatraumaticcasethatisobservedquiterarely,whichgenerallyoccursduringhyperabductiontypetraumaofthearm.Insuchcases,it isusuallyobservedthat the inferiorcapsuleof thejoint is torn.[4,5]For the formationof theLE,agreatamountofforceisrequired;thus,manyotherinjuriescanbeseentogether.[6]

Thecurrentstudypresentssixcasesofdownwarddislocationoftheglenohumeraljointthatweretreatedwithclosedreduction.

MATERIALS AND METHODSFour males and two females, a total of six pa-

tients,with thediagnosis of inferior shoulderdislo-cation were treated between 2007 and 2010 (Table1).Causesofthetraumaincludedfallfromaheight(n=2), fall down stairs (n=2), motorcycle accident(n=1), and in-vehicle traffic accident (n=1).All sixcaseswereadmittedtotheemergencyservice.Threeof these patients had right shoulder trauma and theother three had left shoulder trauma; all stated thattheyhadpainandcouldnotbringtheirarmfromab-duction to neutral position. In their the clinical ex-amination, itwasobserved that theshouldersof thepatientswerepainfulandwerelockedintheabduc-tionposition. Inoneof thepatients,brachialplexusparalysiswasdiagnosed.Peripheralpulseswereopeninallpatients.Radiologicexaminationrevealedthatthehumerusheadhadbeendislocateddownwardsinall patients (Fig. 1), and in one patient, tuberculummajusfractureaccompaniedthedislocation(Fig.2a,b). Closed reductionwas applied to all six patientsunderanesthesia.

RESULTSThemeanfollow-updurationofthepatientswas32

monthsandthemeanagewas45(range,22-75).Con-stantshoulderscoringsystemwasusedfortheclinicalexamination as pain, position, daily activities, rangeofmotion,andstrengthwerenoted.Themeanshoul-derscorewas94points(range,86-100points).Inoneofthepatients,glenoidanteriorwallfracturewasdi-agnosedbycomputedtomography(Fig.3).Presenceofneurologicandvascularinjurywasfollowedafterreduction.Inoneofthepatients,itwasobserveddur-ingthesix-monthfollow-upthatcompleterecoveryofthebrachialplexuslesionwasachievedwiththereha-bilitationprogram.Duringthefollow-upexamination


Table 1. Detailsofthepatients

No Age/ Causeofinjury Anesthesia/ Associatedinjuries/ Follow-up Constantscore Outcome Gender management complications (months)

1 38/M Trafficaccident GA/CR – 41 100 Excellent2 22/M Fall SA/CR FractureofGT 55 96 Excellent3 75/F Fallfromheight GA/CR Glenoidfracture/RTC 29 86 Good4 50/M Trafficaccident SA/CR Axnervelesion 27 96 Excellent5 34/M Fallfromheight SA/CR – 20 100 Excellent6 51/F Fall GA/CR BPlesion 25 88 Good

Ax:Axillary;BP:Brachialplexus;CR:Closedreduction;GA:Generalanesthesia;RTC:Rotatorcufftear;SA:Sedoanalgesia.

Fig. 1. Anteroposteriorviewoftherightshoulderjointinanadultpatient.Therighthumeralheadisdislocatedin-feriorly(Case1).

Inferior glenohumeral dislocation (luxatio erecta humeri)

ofallpatients,itwasobservedthatanatomicrelationof the jointwas achieved and the fracture had beenreduced.

DISCUSSIONLuxatioerectaistheinferiordislocationofthegle-

nohumeral joint,whichwasdefinedbyMiddeldorpfandScharm.[7]Theclassicalview,whichisalsochar-acteristic,isthehyper-adductionoftheaffectedarm,flexionoftheelbow,andthehandpositionedoverorbehindthehead.[5,7,8]Theunaffectedhandsupportsthearminordertostabilizetheaffectedarmandalleviatethepain.Onphysicalexamination,theglenoidcavityisemptyandtheheadofthedislocatedhumeruscan

bepalpatedintheaxillaoroverthechestwall.Beforethereductionprocedure,conventionalscapularX-rayfilms should be obtained in all patients in order toconfirmthediagnosisanddemonstrateanyconcomi-tant fractures.TransscapularY-graphy, computed to-mographyandmagneticresonanceimagingwouldbehelpful in thediagnosisandtreatment.[1,2,9]TheearlydiagnosisofLEisofcriticalimportance.Inferiordis-locationoccursmostlyduetoindirectinjury.Inthein-directmechanism,inferiordislocationoftheshoulderdevelopsdue to the leverarmeffectof theproximalhumeruswhenastronghyper-abduction force isap-pliedtothearm.Becauseofthepullingeffectofthepectoralismajor,thearmstaysintheerectedposition.[7,10]Theremaybeseveresoft-tissueinjuryduetotheavulsionofthesupraspinatus,infraspinatusandteresminormuscles.TherearesomecomplicationsofLE.Tsuchidaet al.[10]foundaxillarynervepalsy in60%,fractureofthehumerusin37%androtator-cufftearin12%ofthepatients.Adhesivecapsulitisandrecurrentsubluxationordislocationcanbeseenaslatecompli-cations.[9,11,12]Inourseries,wefoundrotator-cufftearinonepatientandhypoesthesiaoftheaxillarysensoryareaofthelateralshoulderinanother.

Earlyreductionshouldbedonetopreventcompli-cations.[3,6]Adequatesedationandanalgesiaisfunda-mentaltotheprocedure,andmostoftheLEcasescanbe treated successfully in the emergency roomwithclosed reduction. Opposite-traction technique is themosteffectiveclosedreductionmethod.Inthistech-nique,tractionandmildabductionareappliedtotheaffected arm in the same direction of the humerus,


Fig. 2. (a)Patientwithrightluxatioerectahumeriand(b)radiographdisplayinginferiorshoulderdislocationwithfracturedgreatertuberosity(Case2).

(a) (b)

Fig. 3. Anteriorwallfractureoftheglenoidinapatient(ar-row)(Case3).


occurrencemechanismandclinicalpresentation.Doc-torsshouldbefamiliarwiththeoccurrenceofthisin-frequentconditionandshouldpreventpossiblecom-plications thatmight result fromearly reductionsbyusingcorrectmaneuversinlieuofordinaryreductiontechniques.


REFERENCES1. Rockwood CA,Wirth MA. Subluxations and dislocations

abouttheglenohumeraljoint.In:RockwoodCA,GreenDP,BucholzRW,editors.Fracturesinadults.Philadelphia:Lip-pincott-Raven;1996.p.1193-39.

2. YamamotoT,YoshiyaS,KurosakaM,NagiraK,NabeshimaY.Luxatioerecta(inferiordislocationoftheshoulder):are-portof5casesandareviewoftheliterature.AmJOrthop(BelleMeadNJ)2003;32:601-3.

3. SahinN,OztürkA,OzkanY,AtıcıT,OzkayaG.Acompari-sonofthescapularmanipulationandKocher’stechniqueforacute anterior dislocation of the shoulder. Eklem HastalikCerrahisi2011;22:28-32.

4. MallonWJ, Bassett FH 3rd, Goldner RD. Luxatio erecta:the inferior glenohumeral dislocation. J Orthop Trauma1990;4:19-24.

5. Yanturali S,Aksay E,HollimanCJ,DumanO,OzenYK.Luxatioerecta:clinicalpresentationandmanagementintheemergencydepartment.JEmergMed2005;29:85-9.

6. MatsumatoK,OharaA.YamamotoK,TakigamiI,NaganawaT.Luxatioerecta(inferiordislocationoftheshoulder):Are-portoftwocasesandareviewoftheliterature.InjuryExtra2005;36:450-3.

7. KaraogluS,GuneyA,OzturkM,KekecZ.Bilateralluxatioerectahumeri.ArchOrthopTraumaSurg2003;123:308-10.

8. MesaM,CarpinteroP,CarpinteroJ.Bilateralluxatioerectahumeri.ActaOrthopBelg1996;62:116-9.

9. GrohGI,WirthMA,RockwoodCAJr.Resultsoftreatmentof luxatioerecta (inferiorshoulderdislocation). JShoulderElbowSurg2010;19:423-6.

10.TsuchidaT,YangK,KimuraY,TaniwakiM,IshigakiS,ItoiE.Luxatio erecta of bilateral shoulders. J ShoulderElbowSurg2001;10:595-7.

11.MusmeciE,GaspariD,SandriA,RegisD,BartolozziP.Bi-lateralluxatioerectahumeriassociatedwithaunilateralbra-chialplexusandbilateralrotatorcuffinjuries:acasereport.JOrthopTrauma2008;22:498-500.

12.WangKC,HsuKY,ShihCH.Brachial plexus injurywitherectdislocationoftheshoulder.OrthopRev1992;21:1345-7.

13.CamardaL,MartoranaU,D’ArienzoM.Acaseofbilateralluxatioerecta.JOrthopTraumatol2009;10:97-9.

14.DurukanP,YıldızM,BarikA,KayaN,YılmazE.Inferiorglenohumeraldislokasyon (LuxatioErecta): İki olgu sunu-mu.TürkiyeAcilTıpDergisi2005;5:142-4.

15.EbrahimzadehMH,FattahiA.Inferiorglenohumeraldislo-cation(luxatioerectahumeri),reportoftwocases.EurJOr-thopSurgTraumatol2006;16:30-2.

16.FéryA,SommeletJ.Erectdislocationoftheshoulder(luxa-tioerectahumeri).Generalreviewaproposof10cases.[Ar-ticleinFrench]IntOrthop1987;11:95-103.[Abstract]

whileopposite-directionaltractionisperformedwitharoundedsheet.[1,2,12,13]Neurovascularexaminationandfollow-upradiographsareimportanttoexcludeiatro-genic fractures after reduction.Successfully reducedcasesshouldbeimmobilizedbyusingarm-bodyban-dage.Ifthereductionisunsuccessful,itshouldbere-peatedunderanesthesia.ThestandardclosedreductionofLEiscontraindicatedinneckandshaftfracturesofthehumerusandinthecaseofanysuspicionofma-jorvascularinjury.Inthesecases,openreductionwithsurgeryisindicated.[2,9,14]SinceLEoccursafterhigh-energytrauma,acompletesystemicexaminationmustbedoneinordernottomissanyotherorganorsysteminjuries.Theprognosisisexcellentinmostofthenon-complicatedLEcases.[2,4,7,9,15]

Although closed reduction is usually successfulwithoutdifficulty,failuresdooccur,usuallysecondarytoentrapmentofthehumeralheadinthetorninferiorjointcapsule.Ifthisoccurs,operativetreatmentwithopenreductionis thetreatmentofchoice.[1,7,10]Addi-tionally, if displacement of the tuberculummajus ismorethan5mmafterreduction,surgerywouldbein-dicated.Ifthefractureinvolvesmorethan25%oftheglenoidcavity,thensurgerywouldalsobeindicatedasinstabilitymayoccur.[1]

Inastudyof16consecutivepatientswith18shoul-derdislocations,initialtreatmentofclosedreductionfailedinfourpatients,andtheyweresurgicallytreat-ed;recurrentinstabilityoftheinjuredshoulderdevel-opedinsixpatients,whoweretreatedwithacapsularreconstruction.Themean follow-upwas nine years.Eighty-threepercentofthepatientshadgoodtoexcel-lent treatment outcomes, and none of the associatedneurovascular injuries affected final outcomes.[9] Intheirmeta-analysisof80cases,Mallonetal.[4]foundthat80%ofpatientssustainedafractureofthegreatertuberosity or a rotator cuff tear, and 60%had somedegreeofneurologiccompromise.Typically,however,theseinjuriesresolvedwithinoneyear.Ourstudyre-sultssupportthoseofGrohetal.[9]andMallonetal.[4] Almostallpatientsachievedgoodstrengthandmotionwithnon¬operativemanagement,andassociatedneu-rologic and associated injurydidnot affect thefinaloutcomes. There was no direct association betweenage and comorbidities sustained during the injuries.Noneofourpatientsneededsurgicalintervention,and100%ofthepatientshadexcellentorgoodoutcome.Post-traumaticfrozenshoulder iscommonand leadsto a poor functional result.[16] Post-traumatic frozenshoulderdidnotdevelopinanyofourpatients.

Inconclusion, in thisseries,alldislocationswerereducedwithclosereduction technique,andnoneofthe patients developed recurrent instability. LE is arare form of shoulder dislocation due to its specific


45




Does a penetrating diaphragm injury have an effect on morbidity and mortality?

Penetrandiyaframyaralanmasımorbiditevemortaliteyietkilermi?

Bünyami ÖZOĞUL,1 Abdullah KISAOĞLU,1 Gürkan ÖZTÜRK,1 Sabri Selçuk ATAMANALP,1 Yener AYDIN,2 Bülent AYDINLI,1 Mehmet İlhan YILDIRGAN1

Departmentsof1GeneralSurgery,2ThoracicSurgery,AtaturkUniversity,FacultyofMedicine,Erzurum,Turkey.

AtatürkÜniversitesiTıpFakültesi,1GenelCerrahiAnabilimDalı,2GöğüsCerrahisiAnabilimDalı,Erzurum.

Correspondence(İletişim):BünyamiÖzoğul,M.D.AtatürkÜniversitesiTıpFakültesi,GenelCerrahiAnabilimDalı,Yenişehir25070Erzurum,Turkey.Tel:+90-442-3166333/2216e-mail(e-posta):[email protected]

BACKGROUNDIn this study,we investigated the diaphragmatic rupturesthataccompaniedpenetratingabdominalinjury.

METHODSRecordsof237patientswithpenetratingabdominaltraumaseenintheGeneralSurgeryClinicbetweenJanuary1996and December 2010 were investigated retrospectively.Patientswithout diaphragmatic rupturewere allocated toGroupIandthosewithwereallocatedtoGroupII.

RESULTSDiaphragmaticinjurywasnotpresentin177patientsandpresent in 60 patients. Diaphragmatic injury was on theright side in 12, left side in 41, and bilateral in 7.Elev-enhad thoracic herniation, and themost commonherniacontentswerethecolon,stomach,greateromentum,smallbowel, and spleen. The postoperative complication ratewas50%inGroupI(n=89)and47%inGroupII(n=28),and there was no significant difference between the twogroups (p˃0.05).The lengthofhospital staywasslightlyincreasedinGroupII,butnotsignificant(p˃0.05).Seven-teenpatients(9.6%)inGroupIandfourpatients(6.6%)inGroupIIdied.Thedifferenceinmortalityratesbetweenthetwogroupswasnotsignificant(p˃0.05).

CONCLUSIONDiaphragmaticruptureisnotcommonamongpatientswithpenetrating abdominal trauma. There was no differencebetweenpatientswithpenetratinginjuriesandwithversuswithout diaphragmatic injuries in terms ofmortality andmorbidity.Key Words: Diaphragmaticinjury;morbidity;mortality.

AMAÇBuçalışmadapenetrankarınhasar ilebirlikteolandiyaf-ramyaralanmalarıincelendi.

GEREÇ VE YÖNTEMBu çalışmaya Ocak 1996-Aralık 2010 tarihleri arasındagenelcerrahikliniğindepenetrankarıntravmalı237hasta-nınkayıtlarıgeriyedönükolarakincelendi.Diyaframyır-tığıolmayanhastalarGrupI,diyaframyırtığıolanhastalarGrupIIolarakayrıldı.

BULGULARHastaların 177’sinde diyafram hasarı yoktu ve 60 hasta-da ise diyafram hasarı vardı. Diyafram hasarı hastaların12’sinde sağda, 7’sinde iki taraflı ve 41’inde sol taraftaidi.11olgudatoraksafıtıklaşmavardıveenfazlakolon,mide,omentum,incebağırsaklarvedalaktorakalkaviteyefıtıklaşıyordu.AmeliyatsonrasıkomplikasyonoranıGrupI’de%50 (n=89) veGrup II’de%47 (n=28) idi.Her ikigrup arasında istatistiksel olarak anlamlı bir fark yoktu(p˃0,05). Hastanede kalış süresi Grup II’de azmiktardafazla olmasına rağmen anlamlı bir fark yoktu (p˃0,05).GrupI’de17hasta(%9,6)veGrupII’de4hasta(%6,6)ha-yatınıkaybetti.Mortalitehızlarıikigruparasındaanlamlıdeğilidi(p˃0,05).

SONUÇPenetrankarıntravmalıhastalardadiyaframyırtılmasıyay-gındeğildir.Penetranyaralanmalardadiyaframyaralanma-sı olan hastalarla olmayan hastalar arasında fark buluna-mamıştır.

Anahtar Sözcükler:Diyaframyaralanması;morbidite;mortalite.

doi: 10.5505/tjtes.2013.14194


Diaphragmatic rupture (DR) is a commonly dis-cussedprobleminabdominal trauma. Injuriesof thediaphragm associated with blunt abdominal traumacan complicate the course of the patient because ofdifficulty in the diagnosis and delayed intervention.Severalpublicationsreportthatdiaphragmaticinjuriesinbluntabdominal traumacanhavesignificantmor-bidityandmortalityrates.[1]Inpenetratingabdominalinjuries, however, the contribution of diaphragmaticinjuriestothemortalityandmorbidityisnotclarified.

We report herein our diaphragmatic injury casesassociatedwithpenetratingabdominalinjury.

MATERIALS AND METHODSThe records of 398 cases admitted to our clinic,

Ataturk University Medical School, Department ofGeneralSurgery,withthediagnosisofpenetratingab-dominaltraumabetweenJanuary1996andDecember2010wereevaluatedretrospectively.Thechartsof83patientswere excluded because of inadequate infor-mation. Penetrating abdominal trauma index (PATI)score was defined according the description fromMoore et al.[2] Patientswhohad aPATI score lowerthan15orhigherthan50werealsoexcluded.Patientsweredividedintwogroups.GroupIconsistedofpa-tientswithoutDR,whileGroupIIconsistedofpatientswithDR.Theage,sex,mechanismoftrauma(gunshotwound(GSW)orstabwound), injuredorgans,PATIscore,presence, siteand lengthofdiaphragmatic in-jury, presenceof hemo-pneumothorax, postoperativecomplications,lengthofhospitalstay(LOS),andmor-bidity were recorded. Postoperative complications,LOSandmorbiditywerecomparedbetweenthetwogroups.InGroupII,thepatientswerefurtherdividedintwosubgroupsaccordingtothelengthoftherup-ture.Patientswitha ruptureof<5cmweregroupedasGroupIIaandthosewitharuptureof>5cmweregrouped as Group IIb. Postoperative complications,LOSandmorbiditywerecomparedbetweenthesetwosubgroups.

Statistical analysisResultsarepresentedasmeans±SD,medians,or

percentages.Analysis of variance andpost hoc testswereusedtocomparecontinuousvariables,andexacttestswereusedtocompareproportions.AcorrelationcoefficientwascalculatedusingSpearman’srho.TheStatisticalPackagefortheSocialSciences(SPSS)ver-sion12.0(SPSSInc,Chicago,IL)wasusedforanaly-sis.Apvalueof0.05wasconsideredstatisticallysig-nificant.Alltestsweretwo-tailed.

RESULTSThe records of 315 patients who were operated

forpenetratingabdominal traumaatAtaturkUniver-sityMedicalSchool,DepartmentofGeneralSurgery,

with the diagnosis of penetrating abdominal traumabetweenJanuary1996andDecember2007were re-viewed. From these patients, 237 had a PATI scorehigher than 15. Diaphragmatic injury was not pres-ent in177of thesepatients(GroupI)andpresent intheremaining60(GroupII).Table1shows theage,sex,mechanismoftrauma(GSWorstabwound),in-juredorgans,PATIscore,postoperativecomplications,LOS,andmorbidityofthetwogroups.Table2showsthecomparisonofpostoperativecomplications,LOSandmorbiditybetweenthetwosubgroupsofpatientswith diaphragmatic injuries, consisting of patientswithDRs<5cm(GroupIIa)and>5cm(GroupIIb).

InGroup II (patientswith diaphragmatic injury),diaphragmaticinjurieswerelocatedontherightsidein12cases,bothsides(rightandleft)in7casesandontheleftsidein41cases.Thesizeofthediaphragmat-icdefectvariedbetween1cmand12cm(mean4.6cm).Therewere29DRs>5cmlong(GroupIIb).In11cases,therewaspartialortotalherniationofsomeintraabdominalorgans,includingthecolon,stomach,greateromentum,smallintestines,andspleen,intothethoracic cavity.All herniations were uncomplicatedand there was no gangrene or circulatory problemsin the herniated organs.All herniations occurred inGroupIIb.Nofurtherresectionsorsurgicaltreatmentswere necessary for the herniated organs. All DRswereprimarilyrepaired.In31cases,achesttubewasplaced to treat hemo-pneumothorax accompanyingthe diaphragmatic injury.Thedaily amount of chesttubedrainagewasbetween50cc and420cc (mean260cc).Chesttubeswereremovedinamedianof4days.Therewerenoproblemswiththepulmonarypa-renchymaorthemediastinalorgans.Therewerealsono open thoracostomies or re-operations because ofhemo-pneumothorax.

Thestatisticalanalysisrevealedthattherewasnostatistical difference in age, gender, mechanism ofinjury,ormeanPATIscorebetweenGroupsIandII.Therewasalsonodifference in the involvedorgans(p>0.05forall).

The overall complication rateswere 50% (89 pa-tients)and47%(28patients)inGroupIandGroupII,respectively. The most common complications wereinfectiouscomplications(woundinfection,pulmonaryinfection, sepsis, intraabdominal abscess); others in-cluded wound dehiscence, pulmonary embolism andanastomotic leakage. When compared statistically,therewere no differences in postoperative complica-tionsbetweenthetwogroups(p>0.05).Thecompari-sonofcomplicationratesofthetwosubgroups(GroupsIIaandIIb)alsorevealednosignificantdifference.

The length of hospitalization (LOS) in the twogroupswas similar, with a slight increase in GroupII, but thedifferencewasnot statistically significant


Does a penetrating diaphragm injury have an effect on morbidity and mortality?

(p>0.05). There was also no statistically significantdifference in the LOS between the two subgroups(GroupIIa,GroupIIb)ofGroupII.

Atotalof17patients(9.6%)inGroupIand4pa-tients (6.6%) inGroup II died.Mortalitieswere notstatisticallydifferent(p>0.05).Themortalityratewasalsonotdifferentbetweenthetwosubgroups(GroupIIa,GroupIIb)ofGroupII.

DISCUSSIONDiaphragmatic injury is not common among ab-

dominal trauma patients, with an incidence varyingbetween4-12%.[3,4]TheincidenceofpenetratingDRisreportedtobe10-15%.[5]Theimportanceofdiaphrag-matic injuries has beenmentioned several times bydifferentpublications.[3,6]Themostcommonreportedadverseoutcomeinthisinjuryistheherniationofin-traabdominalorgansintothethoraciccavity.[6]There-fore, the most commonly discussed aspects of this

injuryarethedifficultiesindiagnosisandsubsequentproblemssecondarytomisdiagnosisandtheearlydi-agnosisofdiaphragmaticinjuries,especiallyinblunttraumavictimswhowillnotbeoperated.[3,4,6]

Weperformed this study todetermine the impor-tanceof adiaphragmatic injury that isdetecteddur-inganemergentoperationforpenetratingabdominalinjury.Tomakethegroupscomparable,weusedPATIscoringandexcludedpatientswithlowandhighPATIscores.Furthermore,todetermineifthelengthofdi-aphragmatic injury is important,we divided the pa-tientsintwogroupsaccordingthelengthoftheinjury(<5cmor>5cm).Weactuallyperformedthisstudytoshowthatdiaphragmaticinjuryisharmlesswhenitisdetectedduringtheoperationandrepairedproperly.

About 50% of all diaphragmatic injuries cannotbe detectedduring a routine investigationof traumapatients.They aremostly detected during an explo-rationforimmediateoperationofthetraumapatient.[4,7]ClinicalfindingsofDRarenotspecific.Thoracicandabdominalsymptomsmaybeminimalorevenab-sent,andpatientsmaynotpresentwithsymptomsformonthstoyearsafterthetrauma.[8]

It is reported thatpenetratingdiaphragmatic inju-riesareaccompaniedbyatleasttwoorthreeassociat-edinjuries,andpatientsareoperatedfortheseinjuries.[9]Therefore, during a routine explorationof the ab-dominalcavityinapatientwithpenetratingabdomi-naltrauma,especiallywhentheinjuryislocatedintheupperabdomen,thediaphragmmustbeobservedandevenexplored.[4,5,7]

ThemostimportantadverseoutcomeofDRistheherniationofintraabdominalorgansintothethoraciccavity.Theincidenceofherniationofintraabdominal


Table 1. Age,sex,mechanismoftrauma,injuredorgans,PATIscore,postoperativecomplications,LOS,andmorbidityaccordingtogroups

Table 2. Lengthofhospitalstayandmorbiditybetweenthetwosubgroupsofpatientswithdiaphragmaticinjuries

Age(Mean/Years)Gender(Female/Male)GunshotwoundStabwoundPATIscore(Mean)

Injuredorgans Liver Smallintestine Colon Spleen Stomach Pancreas Kidneyandurinary Majorvascular Other

Postoperativecomplications(overallrate)Infectious Woundinfection Pulmonaryinfections Sepsis IntraabdominalabscessWounddehiscenceAnastomoticleakagePulmonaryembolism

MortalityLOS(Days)

Postoperativecomplications(overallrate)Infectious Woundinfection Pulmonaryinfections Sepsis IntraabdominalabscessWounddehiscenceAnastomoticleakagePulmonaryembolism

LOS(days)

GroupI(n=177)

44.630/147

105(59.3%)72(40.7%)

24.5

69(38.9%)101(57%)79(44.6%)41(23.1%)35(19.7%)17(9.6%)29(16.4%)24(13.5%)45(25.4%)

89(50%)

69(38.9%)43(24.2%)10(5.6%)8(4.5%)8(4.5%)16(9%)3(1.6%)1(0.5%)

17(9.6%)13.4±5.1

GroupIIa(n=31)

15(48.3%)

13(41.9%)8(25.8%)3(9.6%)1(3.2%)1(3.2%)3(9.6%)1(3.2%)

–

14.9±6.5

GroupII(n=60)

44.19/51

43(71.6%)17(28.4%)

23.3

32(53.3%)21(35%)13(21.6%)13(21.6%)15(25%)5(8.3%)9(15%)5(8.3%)21(35%)

28(47%)

23(38.3%)14(23.3%)5(8.3%)2(3.3%)2(3.3%)4(6.6%)1(1.6%)

–

4(6.6%)14.2±6.3

GroupIIb(n=29)

13(44.8%)

10(34.4%)6(20.6%)2(6.8%)1(3.4%)1(3.4%)1(3.4%)

––

13.2±6

PATI:Penetratingabdominaltraumaindex;LOS:Lengthofhospitalstay.

LOS:Lengthofhospitalstay.


eningwhenoverlooked.Itisimportanttokeepinmindthatdiaphragmaticinjurycanassociatewithpenetrat-inginjuryofintraabdominalorgans,andthusroutineobservationofthediaphragmisnecessary.Whende-tected,thepenetratingdiaphragmaticinjurydoesnotinfluencetheoutcome.


REFERENCES1. TurhanK,MakayO,CakanA,SamancilarO,FiratO,Icoz

G,etal.Traumaticdiaphragmaticrupture:looktosee.EurJCardiothoracSurg2008;33:1082-5.

2. MooreEE,DunnEL,MooreJB,ThompsonJS.Penetratingabdominaltraumaindex.JTrauma1981;21:439-45.

3. SteinauG,BosmanD,DreuwB,SchumpelickV.Diaphrag-maticinjuries--classification,diagnosisandtherapy.[ArticleinGerman]Chirurg1997;68:509-12.[Abstract]

4. WirbelRJ,MutschlerWE.Right-sided diaphragmatic rup-turewithintrathoracicdisplacementoftheentirerightlobeoftheliver.[ArticleinGerman]Unfallchirurg1997;100:249-52.[Abstract]

5. MihosP,PotarisK,GakidisJ,ParaskevopoulosJ,Varvatsou-lisP,GougoutasB,etal.Traumaticruptureofthediaphragm:experiencewith65patients.Injury2003;34:169-72.

6. BalkanME,KaraM,OktarGL,UnlüE.Transdiaphragmaticintercostalherniafollowingapenetratingthoracoabdominalinjury:reportofacase.SurgToday2001;31:708-11.

7. Sadeghi N, Nicaise N, DeBacker D, Struyven J, VanGansbekeD.Rightdiaphragmatic ruptureandhepaticher-nia: an indirect signon computed tomography.EurRadiol1999;9:972-4.

8. ErenS,KantarciM,OkurA.Imagingofdiaphragmaticrup-tureaftertrauma.ClinRadiol2006;61:467-77.

9. ArakT,SolheimK,Pillgram-LarsenJ.Diaphragmaticinju-ries.Injury1997;28:113-7.

10.WirbelRJ,MutschlerW.Bluntruptureoftherighthemi-di-aphragmwithcompletedislocationoftherighthepaticlobe:reportofacase.SurgToday1998;28:850-2.

11.BoulangerBR,MilzmanDP,RosatiC,RodriguezA.Acom-parisonofrightandleftblunttraumaticdiaphragmaticrup-ture.JTrauma1993;35:255-60.

12.TribbleJB,JulianS,MyersRT.Ruptureoftheliverandrighthemidiaphragm presenting as right hemothorax. J Trauma1989;29:116-8.

13.ReinaA,VidañaE,SorianoP,OrteA,FerrerM,HerreraE,etal.Traumatic intrapericardialdiaphragmatichernia:casereportandliteraturereview.Injury2001;32:153-6.

14.KozakO,MentesO,HarlakA,YigitT,KilbasZ,Aslan I,etal.Latepresentationofbluntrightdiaphragmaticrupture(hepatichernia).AmJEmergMed2008;26:638.e3-5.

15.MihosP,PotarisK,GakidisJ,ParaskevopoulosJ,Varvatsou-lisP,GougoutasB,etal.Traumaticruptureofthediaphragm:experiencewith65patients.Injury2003;34:169-72.

16.AdesanyaAA,daRocha-AfoduJT,EkanemEE,AfolabiIR.Factorsaffectingmortalityandmorbidityinpatientswithab-dominalgunshotwounds.Injury2000;31:397-404.

17.Schneider C, Tamme C, Scheidbach H, Delker-Wegen-er S, Köckerling F. Laparoscopic management of trau-matic ruptures of the diaphragm. LangenbecksArch Surg2000;385:118-23.

organsintothepleuralcavityis58%inleft-sidedand19%inright-sidedDRs.[10-12]Inourseries,thehernia-tion ratewas 18.3%.We also observed that all her-niationsoccurredinpatientswhohadaDRlength>5cm.Herniations canhaveanacuteonsetbycausingsymptoms arising from both the herniated intraab-dominalorgansaswellasthethoracicorgansthatarecompressedbytheherniatedorgan.Thissubsequentlyresultsinsymptomsrelatedwithcirculatoryproblemsor obstruction of the herniated organs, or dyspnea,cyanosisor cardiaccompromisedue to compressionof the hernia.[13] Furthermore, herniations may notbecomesymptomaticuntilmonthsoryearsafter thetrauma.[14,15]

Oncedetected,treatmentisnotcomplex.Theop-erativetreatmentofdiaphragmaticinjurycanbedoneby either primary suture repair or replacement withprostheticmaterialsifneeded.Itisasimpletreatmentandcanbedonewithopensurgicalapproachorlapa-roscopically.[16]

MostofthecomplicationsareassociatedwiththeadverseoutcomesofDR.However, there is little in-formation about the DR that is uncomplicated andtreatedduringtheexploration.Isthisinjuryimportant,andcouldthepresenceofdiaphragmaticinjurycom-plicate thepostoperativecourseofa traumapatient?Theoretically it could.The impairment of diaphrag-matic movements during respiration could impairnormalbreathingandcauseatelectasiaandassociatedpulmonaryinfections.[17]

The comparison of the two groups showed thattherewasnodifferenceinthepostoperativecomplica-tions,LOSormortality.Wetriedtocreateahomoge-neousgroup,andthereforeusedthePATIscore.Thisshowsthatdiaphragmaticinjuriesthatwerediagnosedandrepairedduringtheoperationdidnotincreasethecomplications, LOS ormortality.The complicationsinbothgroupswerethesame,andinfectiouscompli-cations were seenmost commonly. In patients withdiaphragmatic injuries, the incidence of pulmonarycomplicationswasnotdifferentfromthat inpatientswithoutdiaphragmaticinjuries.

Although31patients inGroup IIhad tube thora-costomy,thisdidnotinfluencethepostoperativecom-plication rate or LOS. Chest drainswere applied toonly 31 radiologically detected hemopneumothoraxcases.Inothercases,diaphragmswereclosedtotallyintraoperativelywhilethelungswereheldatinspira-tionbytheanesthetist.Postoperativechestdrainwasnot needed in these cases.None of the patients hadpleuralcontamination,andempyemadidnotoccurinanycase.

Inconclusion,DRisnotcommoninpatientswithpenetratingabdominaltrauma,butcanbelife-threat-


49




Local differences in the epidemiology of traumatic spinal injuries

Spinalyaralanmaepidemiyolojisindeyerelfarklılıklar

Mehmet Özgür ERDOĞAN,1 Sibel ANLAŞ DEMİR,1 Mehmet KOŞARGELİR,2 Şahin ÇOLAK,1 Engin ÖZTÜRK1

1DepartmentofEmergencyMedicine,HaydarpasaNumuneTrainingandResearchHospital,Istanbul;2MinistryofHealth,DepartmentofEmergency

MedicalServices,Ankara,Turkey.

1HaydarpaşaNumuneEğitimveAraştırmaHastanesi,AcilTıpKliniği,İstanbul;2SağlıkBakanlığıAcilSağlıkHizmetleri

DaireBaşkanlığı,Ankara.

Correspondence(İletişim):MehmetÖzgürErdoğan,M.D.HaydarpaşaNumuneHastanesi,TıbbiyeCaddesi,Kadıköy34710İstanbul,Turkey.Tel:+90-216-5423232e-mail(e-posta):[email protected]

BACKGROUNDSpinal cord injury (SCI)has a serious lifetime impact aswell asobvious social andeconomiceffects forbothpa-tientsandsociety.Theaimofthisstudywastocollectre-centinformationandanalyzechangesintheepidemiologyoftraumaticspinalinjuries.METHODSData included traumatic SCI (TSCI) patients admitted totheemergencydepartmentofHaydarpaşaNumuneTrain-ingandResearchHospitalbetweenJanuary2007andDe-cember2011.409TSCIpatientswereincludedinthestudy.CategoricalvariableswereanalyzedwithFisher’sexacttestandparametricvariableswithindependentsamplesttest.RESULTSThemost common injurymechanismwas high falls. 85(20.8%)patientswereinjuredinlowfalls,whichwasthesecondmostcommoninjurymechanism.Themostcom-mon injurywas lumbarspine injury(196[48%]patientssufferedisolatedlumbarspineinjury),followedbythora-calspineinjuries.Lumbarspinalinjuries(p=0.00011)wereobservedatahigherrateinhighfalls.Lowfallwasasig-nificantmechanismforthoracalspineinjuries(p=0.003).Automobileaccidentshadasignificantrelationwithcervi-cal(p=0.00001)andlumbar(p=0.004)spinalinjuries.

CONCLUSIONAlthoughcervical injurieswerehigher in automobile ac-cidents,theratioofautomobileaccident-relatedTSCIwaslessthanreportedinotherstudies.Cervicalinjuryratioofthepopulationdecreasedduetothedecreaseinthenumberofautomobileaccident-relatedTSCIs.Key Words: City;epidemiology;spinaltrauma.

AMAÇSpinalkordyaralanmasıömürboyusürenetkiyesahiptir.Hastalar ve toplum için ağır sosyal ve ekonomik etkilerivardır.Buçalışmanınamacışehiryaşamınıntravmatikspi-nalkordyaralanmaları(TSKY)üzerindeyarattığıepidemi-yolojikfarklılıklarıtanımlamaktır.GEREÇ VE YÖNTEMHaydarpaşaNumune Eğitim veAraştırmaHastanesi acilservisine Ocak 2007-Aralık 2011 arasında başvuran 409TSKY hastası değerlendirildi.Kategorik değişkenler içinFischerkesintesti,parametrikverileriçinbağımsızörnek-lemt-testikullanıldı.

BULGULAREnsıkyaralanmaşekliyüksektendüşmelerdi,85(%20,8)hasta basit düşme sonucu yaralanmıştı. En sık ikinci ya-ralanma şekli basit düşmelerdi. Hastaların 196’sı (%48)lomberspinalyaralanmageçirmişti.Ensık lomberspinalyaralanmalargözlenmişti.Torakalbölgeensık ikinciya-ralanan bölgeydi. Lomber spinal yaralanmalar yüksektendüşmelerdedahasıktı(p=0,00011).Basitdüşmelerdetora-kalbölgeyaralanmalarıdahasıktı(p=0,003).Otomobilka-zalarındabelirginşekildeservikal(p=0,00001)velomber(p=0,004)yaralanmalardahasıktı.

SONUÇServikal yaralanmalar otomobil kazalarında daha sık ol-maktadır.ŞehirmerkezindeotomobilkazasınabağlıTSKYoranıdiğerçalışmalaragöredahaazdı.ServikalyaralanmaoranıdaotomobilkazasıilişkiliTSKYoranınınazalmasıileazalmıştır.Anahtar Sözcükler:Şehir;epidemiyoloji;spinaltravma.

doi: 10.5505/tjtes.2013.74501


Spinalcordinjury(SCI)hasaseriouslifetimeim-pact aswell as obvious social and economic effectsforbothpatientsandsociety.Nocurativetreatmentisavailable for the disease. It is thus imperative to bewellawareoftheetiologyinordertodevelopprecau-tionsforthepreventionofspinaltrauma.[1-3]

Theaimofthisstudywastocollectrecentinforma-tionandanalyzecitydifferencesintheepidemiologyof traumaticspinal injuries. Improvement inpreven-tionstrategiesmustbethemainconcernfortheman-agementofspinaltrauma.

MATERIALS AND METHODSRoadtrafficaccidents(RTAs)weregroupedascar,

motorcycleorpedestrianaccidents.Fallsweredividedashighfalls(>1m)andlowfalls(<1m).Allsports-relatedinjuriesweregroupedassportinjuries.Allpa-tientsweredefinedaccordingtoAmericanSpinalInju-ryAssociationImpairmentScale(ASIA)atdischargefrom the hospital. Data included all traumatic SCI(TSCI)patientsadmittedtotheemergencydepartment(ED)ofHaydarpaşaNumuneTrainingandResearchHospitalbetweenJanuary2007andDecember2011.FourhundredandnineTSCIpatientswereincludedinthestudy.

Datawere analyzedusing theStatisticalPackagefortheSocialSciences(SPSS)ver.17.0.CategoricalvariableswereanalyzedwithFisher’s exact test andparametricvariableswithindependentsamplesttest.Thelevelofsignificancewassetat0.05.

RESULTSTherewere 253 (61.9%)males and 156 (38.1%)

females.Themaletofemaleratiowas1.6/1.Theav-erage age was 46.82±19.05 years (43.75±17.85 formalesand51.80±19.90forfemales)(Fig.1).

Twohundredandseven(50.6%)patientssufferedahighfall,whichwasthemostcommoninjurymecha-nism. Eighty-five (20.8%) patients were injured inlowfalls,whichwasthesecondmostcommoninjurymechanism(Table1).

Themostcommon injurywas lumbarspine inju-ry;196(48%)patientssufferedisolatedlumbarspine

injury.Thoracalspine injurieswere thesecondmostcommoninjuries(Table2).Spinalfractureswereob-servedin375(91.7%)patients;27(6.6%)hadspinaldislocationsand7(1.7%)hadcombinedfracturesanddislocations.Lumbarspinalinjuries(p=0.00011)were


80

70

60

50

40

30

20

10

00-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

80-89

90-99

Fig. 1. Agedistributionofpatients.

Patients(n)

Table 1. Injurymechanisms

n %

Highfall 207 50.6Lowfall 85 20.8Pedestrianaccidents 35 8.6Automobileaccidents 57 13.9Motorcycleaccidents 11 2.7Sportinjuries 14 3.4Total 409 100

Table 2. Injurylevel

n %

Cervical 79 19.3Thoracal 120 29.3Lumbar 196 48.0Cervicalandthoracal 6 1.5Cervicalandlumbar 1 0.2Thoracalandlumbar 7 1.7Total 409 100

Table 3. Injurytypeandinjurylevelrelation

Cervical Thoracal Lumbar

Highfall 28 p=0.99 67 p=0.531 123 p=0.00011Lowfall 9 p=0.993 41 p=0.003 39 p=0.465Pedestrian 13 p=0.027 9 p=0.352 14 p=0.289Automobile 26 p=0.00001 17 p=0.548 18 p=0.004Motorcycle 3 p=0.706 5 p=0.52 3 p=0.22Sports 7 p=0.014 0 7 p=0.997

Local differences in the epidemiology of traumatic spinal injuries

observedatahigherrateinhighfalls,whilelowfallwasasignificantmechanismforthoracalspineinjuries(p=0.003).Automobileaccidentshadasignificantre-lationwithcervical(p=0.00001)andlumbar(p=0.004)spinalinjuries.Sports-relatedinjuries(p=0.014)hadasignificantrelationwithcervicalspinalinjuries(Table3,Fig.2).

Themostcommonseason forTSCIwas summer(Fig.3).Threehundredand forty-fourpatientswereclassifiedasASIAEand65patientswereclassifiedasASIAAtoD.Threehundredandtwenty-nine(80.4%)patients underwent surgical intervention. Eighty(19.6%)patientsweretreatedconservatively.

DISCUSSIONKadıköyisoneofthemostculturallyandeconomi-

cally developed parts ofTurkey, and as such, it hasuniquefeaturesinspinaltraumaetiology.Inourstudy,theaverageageforTSCIwas46.82±19.05years(Fig.1)andthemaletofemaleratiowas1.6.Priorstudieshaveshowna lowermeanageandamale tofemaleratioof2.5to4.4.[4,5]Itwasconsiderablylowerinourstudy.TheactiveparticipationofwomeninthesocialenvironmentmakesthemmorevulnerabletoTSCI.

Studiesusuallyshowautomobileaccidentsas themajor causeofTSCI.[5,6]Whileothershave reportedfallsastheprimarycauseofTSCI.[7]Inourstudy,themost common cause of injurywas high falls,whileautomobile accidents had a lesser role in the etiol-ogy (Table1).Useof automobiles is very common.NumeroustrafficaccidentsoccurinKadıköydaily,buthigh-speedtrafficaccidentsarerareduetotheheavytraffic.Furthermore,thepopulationusuallyusestech-nologicallyadvancedcars,andbecauseofstrictcon-trols,vehicleoccupantsareforcedtouseseatbelts.

Recent studies showcervical spinal injury as themost common injury level.[1,4,8] Different behavior

patternsindifferentpopulationscanaffectthespinalcordinjuryetiology.[8]Karacanetal.[4]foundthatthemostcommonlevelsofinjurywereT12andL1.Inourstudy,themostcommoninjurywaslumbarspinein-jury.Levelsofinjuryalsohaddifferingfeaturesduetodifferencesinthemostcommontraumamechanisms.Althoughcervicalinjurieswerehigherinautomobileaccidents (p=0.00001), the ratio of automobile acci-dent-relatedTSCIwaslessthanreportedinotherstud-ies.Thecervicalinjuryratioofthepopulationhasde-creasedduetoadecreaseinthenumberofautomobileaccident-relatedTSCIs.This is an innovation in thepreventionofTSCI.TheformermajorcauseofTSCIhasmovedtothebackgroundduetolowerspeeds,bet-tercartechnologyandseatbeltuse.

Lumbar spinal injuries (p=0.00011) were higherinhighfalls.HighfallswerethemostcommoncauseofTSCI.Highfallhasemergedastheleadingcauseastheincidenceofautomobile-relatedTSCIshasde-creased.Asthereasonsforthefallswerenotrecordedin patient files, our retrospective study design couldnotrevealthecausesofthehighfalls.

Low fall was a significantmechanism for thora-calspineinjuries(p=0.003),andwasthesecondmostcommonmechanismofTSCI.Theaverageageofpa-tientssufferinglowfallwas68.13±13.34years.Whencompared to the whole population, this populationwasolder(p<0.05).Astheelderlypopulationgrows,TSCI incidence will proportionally increase in thismorechallengingagegroup.

Inconclusion, theeffectsof thecityenvironmentcausechangesin theepidemiologyofspinal trauma.In view of the aging population, an increase in theprevalence andmodification in epidemiological fea-turesofspinaltraumacanbeexpected.



140

120

100

80

60

40

20

0

Patients(n)

Highfall

Lowfall

Pedestrian

Automobile

Motorcycle

Sports

CervicalThoracalLombar

Fig. 2. TraumamechanismandTSCIlevelrelation. Fig. 3. Seasonaldistributionofinjuries.

140

120

100

80

60

40

20

0

Patients(n)

Winter

Spring

Summer

Autumn


5. LenehanB,StreetJ,KwonBK,NoonanV,ZhangH,FisherCG, et al. The epidemiology of traumatic spinal cord in-jury in British Columbia, Canada. Spine (Phila Pa 1976)2012;37:321-9.

6. Draulans N, Kiekens C, Roels E, Peers K. Etiology ofspinal cord injuries in Sub-Saharan Africa. Spinal Cord2011;49:1148-54.

7. CourisCM,GuilcherSJ,MunceSE,FungK,CravenBC,VerrierM,etal.Characteristicsofadultswithincidenttrau-matic spinal cord injury in Ontario, Canada. Spinal Cord2010;48:39-44.

8. TuğcuI,TokF,YılmazB,GöktepeAS,AlacaR,YazıcıoğluK,etal.Epidemiologicdataofthepatientswithspinalcordinjury:sevenyears’experienceofasinglecenter.UlusTrav-maAcilCerrahiDerg2011;17:533-8.

REFERENCES1. KnútsdóttirS,ThórisdóttirH,SigvaldasonK,JónssonHJr,

BjörnssonA,IngvarssonP.Epidemiologyof traumaticspi-nalcordinjuriesinIcelandfrom1975to2009.SpinalCord2012;50:123-6.

2. Ackery A, Tator C, Krassioukov A. A global perspec-tive on spinal cord injury epidemiology. J Neurotrauma2004;21:1355-70.

3. SchoenfeldAJ,SielskiB,RiveraKP,BaderJO,HarrisMB.EpidemiologyofcervicalspinefracturesintheUSmilitary.SpineJ2012;12:777-83.

4. Karacan I, Koyuncu H, Pekel O, Sümbüloglu G, KirnapM,DursunH, et al.Traumatic spinal cord injuries inTur-key: a nation-wide epidemiological study. Spinal Cord2000;38:697-701.


53




The management of penetrating abdominal trauma by diagnostic laparoscopy: a prospective non-randomized study

Penetrankarıntravmalarınıntanısallapararoskopiileyönetimi:Prospektifrandomizeolmayançalışma

Faruk KARATEKE, Mehmet ÖZDOĞAN, Sefa ÖZYAZICI, Koray DAŞ, Ebru MENEKŞE, Yusuf Can GÜLNERMAN, İlhan BALİ, Safa ÖNEL, Cihan GÖKLER

DepartmentofGeneralSurgery,AdanaNumuneTrainingandResearchHospital,Adana,Turkey.

AdanaNumuneEğitimveAraştırmaHastanesi,GenelCerrahiKliniği,Adana.

Correspondence(İletişim):FarukKarateke,M.D.AdanaNumuneEğitimveAraştırmaHastanesi,GenelCerrahiKliniği,Adana,Turkey.Tel:+90-322-3550000e-mail(e-posta):[email protected]

BACKGROUNDPenetratingabdominal trauma(PAT)hasbeen traditionallytreatedbyexploratorylaparotomy(EL).Theaimofourstudywastoexaminetheuseofdiagnosticlaparoscopy(DL)inthemanagementofhemodynamicallystablepatientswithPAT.METHODSA prospective study was performed to compare the out-comesofhemodynamicallystablepatientswithsuspectedintra-abdominalinjuriesduetoabdominalstabwoundswhounderwenteitherELorDL.Dataextractedforanalysisin-cludeddemographic information,operativefindings, ratesof non-therapeutic laparotomy, operation time, length ofhospitalstay,mortality,andpostoperativecomplications.RESULTSFifty-twohemodynamicallystablepatientswereadmittedtothetraumaservice.Therewere45male(86.5%)and7female(13.5%)patients.Theaverageagewas34.5years-old(18-60).26(50%)patientsunderwentEL,and26(50%)patientsunderwentDL.Re-explorationbylaparotomywasrequiredin9of the26cases (34.6%).PatientswhounderwentDLhadsignificantlyshorterhospitalstays (1.82±0.63daysvs. 5.4±2.1days,p<0.05)andshorteroperationtime(17.9±6.38vs.68.4±33.2min,p<0.05)thanpatientswhounderwentEL.

CONCLUSIONSelectiveuseofDLinthehemodinamicallystablepenetrat-ingtraumapatientseffectivelydecreasedtherateofnega-tive laparotomies, minimized morbidity, and decreasedhospitalstay.Key Words: Exploratory laparotomy; diagnostic laparoscopy,penetratingabdominaltrauma.

AMAÇPenetrankarıntravmaları(PKT)gelenekselolaraktanısallaparotomi(TL)iletedaviedilmiştir.Buçalışmanınamacıhemodinamisi stabil olan PKT’li hastaların yönetimindediyagnostiklaparoskopi(DL)kullanımınıincelemektir.GEREÇ VE YÖNTEMHemodinamisi stabil olan delici-kesici alete bağlı karıniçiyaralanmaşüphesinedeniyleTLveyaDLyapılanhas-talarınsonuçlarıprospektifolarakkayıtedildi.Hastalarındemografiközellikleri,ameliyatbulguları,hastanedekalışsüresi,mortaliteveameliyat sonrasıkomplikasyonları ir-delendi.

BULGULARHemodinamisistabilolan52PKT’lihastatravmaservisinealındı.Hastaların 45’i (%86,5) erkek, 7’si kadın (%13,5)veyaşortalaması34,5idi(dağılım18-60yaş).Yirmialtı(%50)hastayaTL,26 (%50)hastaya iseDLyapıldı.DLyapılan hastaların dokuzuna (%34,6) laparotomi gereksi-nimioldu.DLyapılanhastalarınhastanedekalışsüresiveameliyatsüresiTLyapılanhastalaragöredahakısaidi(DL1,82±0,63,TL 5,4±2,1 gün, p<0,05), (DL 17,9±6,38,TL68,4±33,2dk.,p<0,05).

SONUÇHemodinamisistabilolanPKT’lihastalardaDLkullanımı-nınnegativelaparotomioranlarını,morbiditeyivehastane-dekalışsüresiniazalttığısaptandı.

Anahtar Sözcükler:Tanısallaparotomi;diyagnostiklaparoskopi;penetrankarıntravması.

doi: 10.5505/tjtes.2013.40799


Penetratingabdominal traumahasbeen tradition-allytreatedwithEL.Thehighnon-therapeutic/nega-tivelaparotomyrateandassociatedmorbidityafterELforabdominalstabwoundsledtothecurrentselectivenon-operativemanagementstrategy.[1-2]Inspiteofthevariousdiagnosticmethodsavailable,diagnosticperi-toneal lavage(DPL), focusedabdominalsonographyfortrauma(FAST),andcomputedtomography(CT),it is difficult to determine the presence and severityofintra-abdominalinjuriescausedbyabdominalstabwounds.EListhemostpopularprocedurefordefini-tiveevaluationofpatients sustainingpenetratingab-dominaltrauma(PAT),whichcarriesa0-5%mortalityrate,a20%morbidity rate,anda3%long termriskofbowelobstruction.[3]However,morerecentreportshave shown that 30-50% of all stabwounds do notpenetrate the peritoneum and another 20-40% withperitonealpenetrationdonotinvolvesignificantinju-ries, resultinginnon-therapeutic laparotomyratesashighas70%.[1,4]Laparoscopyhasrecentlybeensafelyused forPATpatients for diagnostic and therapeuticpurposes, avoiding unnecessary laparotomies, short-eningthelengthofhospitalstay,andreducingmedicalcosts.[5,6]

The aimof our studywas to examine the use ofdiagnosticlaparoscopy(DL)inthemanagementofhe-modynamically stable traumapatientswithpenetrat-inganteriorabdominalinjuries.

MATERIALS AND METHODSWeperformedaprospectivestudytocomparethe

outcomes of hemodynamically stable patients withsuspected intra-abdominal injuries from abdominalstabwoundswhounderwenteitherELorDL.Fifty-twohemodynamicallystablepatientswithabdominalstab wounds, admitted to Adana Numune TrainingandResearchHospitaloverthe1-yearperiodbetweenJune, 1 2010 and July, 1 2011were included in thestudy.Ourcenterservesasalevel1traumacenterforadistrictof3millionresidents.Criticallyinjuredpa-tientsareeither transporteddirectly toourcenterbytheemergencymedicalserviceoraretransferredfromlocal community hospitals after initialmanagement.The Ethical Committee of our center approved thestudyprotocol.

Patientswith stabwounds locatedat theflankorback,patientswithnopenetrationoftheperitoneumatlocalwoundexploration,andpatientswhowereoper-atedonimmediatelyduetoperitonitis,shock,orevis-cerationoforgansonadmissionwereexcludedfromthisstudy.OurclinicalalgorithmforabdominalstabwoundsisshownonFig.1.

All procedures were performed in the operatingroom under general anesthesia and all patients con-sented to possible conversion to laparotomy. After

induction of general anesthesia, Foley catheter andorogastric or nasogastric tubes were placed in eachpatient. Tube thoracostomy was performed beforelaparoscopy when chest radiography showed hemo/pneumothorax.AnumbilicaltrocarwasplacedbytheHasson technique and the abdomen was insufflatedwithCO2 to a pressure of 15mmHg.A30° 10-mmlaparoscope was used initially in all patients.Addi-tional5-mmportswereplacedunderdirectvisionasnecessary for manipulation of the bowel.All quad-rants were carefully inspected and the small bowelandcolonwereexamined.LavagesamplesweresentforGram staining in order to detect possible bowelinjuries.AllELwereperformedusingastandardmid-line incisionundergeneralanesthesia.Theoperativeprocedurewas performed by one of seven surgeonswhowereexperiencedinemergencylaparoscopyandlaparotomy.

DefinitionsRelative to penetrating injuries, several defini-

tionsarerequiredforfindingsofbothlaparoscopyandlaparotomyprocedures.Negativelaparoscopywasde-finedasthepresenceofperitonealpenetrationbutnointra-abdominal injury. Non-therapeutic laparoscopyisthepresenceoforganinjurythatdidnotrequirein-tervention.Therapeuticlaparoscopyisaprocedureinwhichtheorganinjurywasmanagedlaparoscopically.Re-explorationbylaparotomydefinesa laparoscopicexplorationfollowedbylaparotomy.Negativelaparot-omywastheabsenceofintra-abdominalinjury.Non-


Abdominal stabwounds

Hemodynamicallystable

Hemodynamicallyinstable (or peritonitis

evisceration)

Local woundexploration

Laparotomy

Equivocal violationof anterior fascia

No violation ofanterior fascia

Laparoscopy Discharge

Fig. 1. Our algorithm for the evaluation of abdominal stabwounds.

The management of penetrating abdominal trauma by diagnostic laparoscopy

therapeuticlaparotomyfoundorganinjurythatdidnotrequireintervention.Therapeuticlaparotomyrequiredsurgicaltreatmentoforganinjury.

Data collection and statistical analysisDataextractedforanalysisincludeddemographic

information,hemodynamics in theemergency room,operativefindings,operativetechniques,ratesofsig-nificantinjuries,ratesofnon-therapeuticlaparotomy,operationtime, lengthofhospitalstay,hospitalmor-tality,andpostoperativecomplications.Statisticalsig-nificance(p<0.05)wasdeterminedbythechi-squaretest(orFisher’sexact testwhenn<5)forcategoricaldata, and the Mann-Whitney U-test for continuousvariables.

RESULTSTherewere45male(86.5%)and7female(13.5%)

patients.Theaverageagewas34.5years-old(18-60).Locationsofthestabwoundswere:anteriorabdomenin36(69%)patientsandthethoracoabdominalregionin16(31%).Focusedabdominalsonographyfortrau-ma(FAST)waspositivein11patientsandcomputer-izedtomography(CT)waspositivein1patient.Table1showsthedemographiccharacteristicsandhemody-namicandlaboratoryparametersofthepatients.Theperitonealviolationratewas100%.

Of the total 52patients included in the study,26(50%)patientsunderwentEL,and26(50%)patientsunderwentDL.Re-explorationbylaparotomywasre-quiredin9ofthe26cases(34.6%),whichresultedintherapeuticoperationfor8patients,withanon-ther-apeuticlaparotomyfor1ofthe9cases.Thatspecialcase was converted to laparotomy because of falsepositivelavageperformedduringDL,whichrevealedGr. (-) bacteria. Re-exploration by laparotomy wasperformedforonepatientduetointrabdominalabscessdetected3daysafterDL.Inthatcase,theabscesswasconsideredtohaveoccurredduetothecontaminationofwashingsalineduringDL.Re-explorationbylapa-rotomywasperformed in3patients forsmallbowelinjury,2patientsforsplenicinjuryandin2patientsfor

gastricinjury.Therapeuticlaparoscopywasperformedin4patients.Inonepatientdiaphragmaticinjurywasrepaired and hemostasis of mesenteric and omentalbleedingsourceswereachievedinanother3patients.The surgical procedures performed for PAT patientsareshowninTable2.

Seventeen(32.7%)patientswereevaluatedbylap-aroscopy(group1)andatotalof35(67.3%)patientsunderwent laparotomy eventually (group 2). Therewere no significant differences between the demo-graphiccharacteristics,hemodynamicparametersandlaboratory findings in the emergency room betweenpatientsinthetwogroups.Patientsingroup1hadasignificantlyshorterhospitalstay(1.82±0.63daysvs. 5.4±2.1days,p<0.05)(Fig.2a)andshorteroperationtime(17.9±6.38vs.68.4±33.2minutes,p<0.05)(Fig.2b)thanpatientsingroup2.Therateofunnecessarylaparotomiesingroup2was40%.

Negative/non-therapeutic laparotomy was per-formed on 13 patients and negative/nontherapeuticlaparoscopy was performed on 13 patients. Patientswhounderwentnegative/non-therapeuticlaparoscopyhadasignificantlyshorteroperationtimeandshorterhospital stay than patientswho underwent negative/non-therapeuticlaparotomy.TherewasnosignificantdifferenceinICUstaybetweengroups.Therewasone


Table 1. Demographiccharacteristics,hemodynamicparametersinemergencyroom,andlaboratoryfindingsofhemodynamicallystablepatientswithsuspectedabdominalinjuries

Exploratorylaparotomy(n=35) Diagnosticlaparoscopy(n=17) p Mean±SD Mean±SD

Gender(Male/Female) 30/5 15/2Age 35.2±10.6 33.2±9,2 0.512InitialSBP(mmHg) 107.0±12.3 112.3±11.8 0.142InitialHR(beats/min) 94.8±12.2 91.7±12.0 0.390Hematocrit 38±6.6 42.9±2.0 <0.0001Multiplestabwounds(%) 20(7/35) 11.7(2/17) 0.342Dataarepresentedamean±standarddeviation(SD)ornumberandpercentage.SBP:Systolicbloodpressure;HR:Heartrate.

Table 2. Theoperativeproceduresofthepatientsadmittedwithpenetratingabdominaltrauma

Procedure n %

Exploratorylaparotomy(n=26,50%) Negative/nontherapeutic 13 25 Therapeutic 13 25Diagnosticlaparoscopy(n=17,32.7%) Negative/nontherapeutic 13 25 Therapeutic 4 7.7Re-explorationbylaparotomy(n=9,17.3%) (Laparoscopy/Laparotomy) Negative/nontherapeutic 1 1.9 Therapeutic 8 15.3


nostics tools to assistwith themanagement of theirpatients,includingobservationwithserialphysicalex-amination,DPL,FAST,andCT.Eachofthesemodali-tieshasstrengthsandweaknessesthatmustbeconsid-eredandnoneare100%reliable.Forthisreason,ELisoftenperformedinthecaseofstabwounds,butELin traumapatients isassociatedwithahighnegativelaparotomyrate,andprocedure-relatedmorbiditycanreachupto40%.[2]

Theincreasedavailabilityoflaparoscopynowof-fersevenmoreflexibilityduringtheworkupofinjuredpatients. Diagnostic laparoscopy has been proposedfortraumapatientstopreventunnecessaryexplorato-rylaparotomieswithassociatedhighermorbidityandcost.[6]

In a review by Villavicencio andAucar, DL forpenetrating trauma reported had sensitivity of 80-100%, specificity of 38-86%, and accuracy of 54-89%.[7]InanotherstudyconductedbyErtekinetal.[8] the specificity and sensitivity of DL were 100% in

complication among negative /non-therapeutic lapa-roscopy patients, although 5 patients had complica-tionsafternegative/non-therapeuticlaparotomy.Com-plicationsincludedwoundinfectionin4patientsandpneumoniain1patient(Table3).

Overall sensitivity for intra-abdominal injuriesusingDLwas 92.3%, and specificitywas 100% forpenetrating abdominal trauma in hemodinamicallystable patients. Similarly, positive predictive andnegative predictive values for intra-abdominal inju-rieswere 100%and 92.9%, respectively. SensitivityofDLforanytherapeuticinterventionwascalculatedas88.9%.

DISCUSSIONThe aim of our study was to assess the overall

benefits of DL in the evaluation of stable patientswithabdominalstabwounds.Emergencydepartmentevaluationof the injuredpatienthasevolvedgreatlyovertheyears,mainlyduetotheadvancesinimagingtechnology.Traumasurgeonshaveavarietyofdiag-


Groups Groups1 12 2

12 200

10

8150

6 100

4

502

0 0

Hos

pita

l sta

y (d

ays)

Ope

ratio

n tim

e (m

in)

44

18

15

(a) (b)

Fig. 2. (a)Comparisonofhospitalstaybetweenthegroups.(b)Comparisonofoperationtimebetweenthegoups.

Table 3. Comparisonofnegative/nontherapeuticlaparoscopyandnegative/nontherapeuticlaparotomypatients

Negative/nontherapeuticlaparotomy Negative/nontherapeuticlaparoscopy p

Operatingtime(min) 55.77±18.46 18.08±6.6 <0.0001ICUstay 1.00±0.00 1.00±0.00 >0.005Hospitalstay(days) 3.69±0.85 1.77±0.59 <0.0001

Complication 5(38.4%) 1(7.6%) 0.047Insignificantinjuries Liver 4 3 Omentum 3 5 Spleen 4 1Noorganinjury 2 4

Dataarepresentedamean±standarddeviation(SD)ornumberandpercentage.

The management of penetrating abdominal trauma by diagnostic laparoscopy


lowerthoracicpenetratingtrauma.Thepositivediag-nosticvalueandnegativepredictivevalueforperito-nealpenetrationwerefoundtobe100%.Laparoscopycanpreventlaparotomyin63%ofpatientswithava-rietyof injuries.[7]The laparoscopicapproachavoidsnegativelaparotomyin23-54%ofpatientswithstabwoundsandbluntabdominaltrauma.Laparoscopyismorecost-effectivethannegativelaparotomy.[7]

DeMariaetal.[9]comparedmandatoryceliotomytolaparoscopyinhemodynamicallystablepatientswiththoracoabdominalstabwounds.Non-therapeuticlapa-rotomywas significantly less common in the groupinitiallyevaluatedbylaparoscopy(19%vs.57%).Thesensitivity, specificity and accuracy of laparoscopicevaluationwerealsosuperiorwhencomparedtoDPLinpredicting theneed for therapeutic interventionatopenabdominalexploration. WeperformedDPLdur-ingDLprocedureinsomeofourpatientsinordertoruleoutpossiblehollowviscusinjuries.

In our study, patients who underwent DL hadshorterhospitalstaysandshorteroperationtimethanpatientswhounderwentEL.Therateofunnecessarylaparotomieswas40%.Inourstudygroup,DLcouldpotentiallydecreasetherateofunnecessarylaparoto-myasafigureof59.6%ifappliedtoallpatients.

SensitivityofDLwas92.3%,andspecificitywas100%inourstudy.Similarly,positivepredictiveandnegativepredictivevaluesforintra-abdominalinjurieswere100%and92.9%,respectively.SensitivityofDLforanytherapeuticinterventionwas88.9%.

Similarly, patients who underwent negative/non-therapeutic laparoscopy had a significantly shorteroperationtimeandshorterhospitalstaythanpatientswhounderwentnegative/non-therapeuticlaparotomy.Therewas no significant difference in ICU stay be-tween groups. There was one complication amongnegative/non-therapeutic laparoscopypatients, and5patients had complications after negative/nonthera-peuticlaparotomy.

Theopinionintheearly1990s,supportedbypub-lisheddata,thattherewasahigherincidenceofcom-plications with laparoscopy is now outdated due toincreasing experience and technical improvements.Procedure-relatedcomplicationsoccurinupto11%ofpatientsandareusuallyminor(levelI-III).[10]A1999reviewof37studies,whichincludedmorethan1,900patients, demonstrated a procedure-related complica-tionrateof1%.[7]Recentstudieshavereportedame-dianof0%(range0-10%)procedure-relatedmorbidityand0%mortality(levelI-III).Intraoperativecomplica-tionscanoccurduringcreationof thepneumoperito-neum,trocarinsertion,orduringthediagnosticexami-nation.[10] Similar to the literature, procedure-relatedcomplicationrateduetoDLwas7.6%inourstudy.

Although we currently use the laparoscope as ascreeningtoolforperitonealpenetration,thenextlogi-cal progression is to conduct amore effective lapa-roscopic treatment of specific organs in the traumasetting.This could potentially decrease or eliminatethenumberofnon-therapeuticconversionfromlapa-roscopy to laparotomy.The thresholdforconversionwould vary among surgeons based on laparoscopicexpertiseandconfidenceinthelaparoscopicexamina-tion.Thenextstepistoincreasetherapeuticinterven-tionaswegainmoreexperience.

SelectiveuseofDLinpenetratingtraumapatientseffectivelydecreasestherateofnegativelaparotomiesand minimizes patient morbidity and hospital stay,withitshighsensitivity,specificity,positiveandnega-tivepredictivevalues.Tooptimizeresults,thisproce-dureshouldbeincorporatedininstitutionaldiagnosticandtreatmentalgorithmsfortraumapatients.


REFERENCES1. SelmanU,KatrinD.Laparoscopyinabdominaltrauma.Eur

JTraumaEmergSurg2010;36:19-24.2. Leppaniemi A, Salo J, Haapiainen R. Complications of

negative laparotomy for truncal stab wounds. J Trauma1995;38:54-8.

3. ShihHC,WenYS,KoTJ,Wu JK, SuCH,LeeCh.Non-invasiveevaluationofbluntabdominaltrauma:Prospectivestudyusingdiagnosticalgorithmstominimizenontherapeu-ticlaparotomy.WorldJSurg1999;23:265-70.

4. FabianTC,CroceMA,StewartRM,PritchardFE,MinardG,KudskKA.Aprospectiveanalysisofdiagnosticlaparoscopyintrauma.AnnSurg1993;217:557-65.

5. ZantutLF,IvaturyRR,SmithRS,KawaharaNT,PorterJM,FryWR et al. Diagnostic and therapeutic laparoscopy forpenetrating abdominal trauma: amulticenter experience. JTrauma1997;42:825-31.

6. TanerAS,TopgulK,KucukelF,DemirA,SariS.Diagnosticlaparoscopydecreasestherateofunnecessarylaparotomiesandreduceshospitalcostsintraumapatients.JLaparoendoscAdvSurgTech2001;11:207-11.

7. VillavicencioRT,AucarJA.Analysisoflaparoscopyintrau-ma.JAmCollSurg1999;189:11-20.

8. ErtekinC,OnaranY,GüloğluR,GünayK,TaviloğluK.Theuseof laparoscopyasaprimarydiagnosticand therapeuticmethodinpenetratingwoundsoflowerthoracalregion.SurgLaparoscEndosc1998;8:26-9.

9. DeMariaEJ,Dalton JM,GoreDC,KellumJM,SugermanHJ.Complimentaryroleoflaparoscopicabdominalexplora-tionanddiagnosticperitoneallavageforevaluatingabdomi-nal stab wounds: a prospective study. J LaparoendoscopicAdvSurgTechniques2000;10:131-6.

10.HoriY;SAGESGuidelinesCommittee.Diagnosticlaparos-copyguidelines:ThisguidelinewaspreparedbytheSAGESGuidelines Committee and reviewed and approved by theBoardofGovernorsoftheSocietyofAmericanGastrointes-tinalandEndoscopicSurgeons(SAGES),November2007.SurgEndosc2008;22:1353-83.

58




Foreign body penetrations of hand and wrist:a retrospective study

El ve el bileğinin yabancı cisim penetrasyon yaralanmaları:Retrospektif çalışma

Emre HOCAOĞLU,1 Samet Vasfi KUVAT,1 Burhan ÖZALP,2 Anvar AKHMEDOV,1 Yunus DOĞAN,1 Erol KOZANOĞLU,1 Fethi Sarper METE,1 Metin ERER1

1Department of Plastic Reconstructive and Aesthetic Surgery,Istanbul University, Istanbul Faculty of Medicine, Istanbul;

2Department of Plastic Reconstructive and Aesthetic Surgery,Dicle University Faculty of Medicine, Diyarbakır, Turkey.

1İstanbul Üniversitesi, İstanbul Tıp Fakültesi,Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İstanbul;

2Dicle Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif veEstetik Cerrahi Anabilim Dalı, Diyarbakır.

Correspondence (İletişim): Emre Hocaoğlu, M.D. İ.Ü. İstanbul Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İstanbul, Turkey.Tel: +90 - 212 - 414 20 00 e-mail (e-posta): [email protected]

BACKGROUNDDespite significant practical knowledge and experience on foreign body penetration injuries to the hand and/or wrist, deficient management and complications can still be en-countered, and ignorance of its causative and eventual so-cial aspects unfortunately is a substantial fact. This study aims to cover the clinical and social properties and the man-agement of these kinds of injuries.

METHODSA retrospective analysis of 86 patients requiring evaluation and treatment in a Hand Surgery Division of a university hospital was performed.

RESULTSThe median age was 32 (min: 4, max: 63). Industrial workers constituted the largest occupational group (n=22, 25.6%). Twenty-three (26.7%) of the cases were elective admissions. Thirteen (15.1%) patients had various comor-bidities, and five (5.8%) had psychiatric diagnoses at the time of the injury. The index finger was the most frequent site of injury (n=29, 33.7%). General anesthesia was not necessary for the management of 94.2% of the cases. In 26 (30%) of the patients, neural, tendinous or osseous damage was observed. Twenty-four (30%) patients were included in a postoperative hand physiotherapy program.

CONCLUSIONThe practically well-known general features of the issue and those aspects that may still be overlooked currently are reevaluated herein, in light of our observational data.Key Words: Foreign body; hand; penetration injury; wrist.

AMAÇKonuyla ilgili ileri seviyedeki pratik bilgi birikimimize rağmen, el ve elbileğinin yabancı cisim penetrasyon yara-lanmaları, halen eksik tedaviler ve komplikasyonlarla gün-deme gelebilmektedir. Konunun sosyal, etyolojik ve huku-ki boyutu günlük yoğun pratik içinde atlanabilmektedir. Bu çalışmada, konunun sosyal, klinik ve terapötik özellikleri ele alındı.

GEREÇ VE YÖNTEMBir el cerrahisi kliniğince tedavisi yapılmış 86 hastanın ret-rospektif analizi yapıldı.

BULGULAROrtalama yaşı 32 olan popülasyonun %25,6’sı endüstriyel işçilerden (en kalabalık mesleki grup) oluşmaktaydı. Başvu-ruların %26,7’si elektif idi. Yaralanma döneminde ek hastalı-ğı olanlar popülasyonun %15,1’ini, psikiyatrik tanısı olanlar %5,8’ini oluşturuyordu. İşaret parmağı en sık yaralanan böl-ge (%33,7) idi. Ameliyatların %94,2’si lokal anestezi altında yapıldı. %30 hastada nöral, tendinöz ve/veya kemiksel hasar mevcuttu. Hastaların %30’u ameliyat sonrası el fizyoterapi programına dahil edildiler.

SONUÇEl ve elbileğinin yabancı cisim penetrasyon yaralanmaları genel yönleri ve pratikte gözden kaçabilen özellikleri ile ele alındı.

Anahtar Sözcükler: Yabancı cisim; el; penetrasyon yaralanması; el bileği.

doi: 10.5505/tjtes.2013.04453

Foreign body (FB) penetrations of the hand and wrist constitute an important type of injury that is fre-quently encountered in primary health care units, emer-gency rooms and hand surgery departments. These usually appear as emergency cases, but the number of patients met under elective conditions cannot be un-derestimated. A FB, stuck into an extremity, may lead to consequences such as tissue damage, inflammation, infection, delayed wound healing, toxic or allergic re-actions, and late injury as a result of migration.[1] When the anatomic properties are taken into consideration, even a tiny object, penetrated through a small skin lac-eration, may damage significant structures of the hand and wrist where many structures are tightly arranged.

There has been an increasing number of case re-ports in the literature presenting striking injuries of various body parts associated with FB penetrations. However, the number of observational studies about hand and wrist penetrations is limited when compared to the high prevalence of subjects. In spite of the sub-stantial experience of clinicians on this issue, there are a significant number of articles denoting defective management strategies, such as inadequate tetanus prophylaxis, and uncertainty in basic principles such as selecting the right solution for wound irrigation.[2,3] Moreover, wounds with neglected FBs form one of the high-risk emergency medicine categories re-sponsible for malpractice events.[4] Indeed, failure to diagnose or treat retained FBs has been reported to be the fifth leading claim against emergency physicians.[5] This study thus aims to reveal the basic features of the affected patients, the properties of the penetrated objects, the events causing this specific type of injury, the management of these injuries, and the outcomes of the patients. It is based on an analysis of a group of pa-tients who had FB injuries in a more specific anatomic location, i.e. the hand and wrist.

MATERIALS AND METHODSThis study was approved by the Institutional Eth-

ics Committee and is based on a retrospective analysis of patients who had hand and/or wrist injuries caused by FB penetration. Eighty-six patients, who had been treated by the staff of the Department of Plastic Re-constructive and Aesthetic Surgery (PRAS) between 01/12/2004 and 01/12/2011, were included in the study. Patients had been referred to the Hand Surgery Division (HSD) of the Department of PRAS either from the Emergency Department (ED) of the same hospital or from EDs of other hospitals and primary health care units.

Age, sex, occupation and social status, presence of any accompanying diseases or psychiatric disorders, specific anatomic localization of the FB penetration, injured structure(s), type of anesthesia used, nature of each FB, type of event that resulted in the injury, and

presence of any legal component of the event were noted for each case. Almost all of these data were ob-tained from the medical record cards. All the patients were also telephoned to obtain informed consent for the study, gather any data that were unavailable on the cards and query the patients regarding any complaints related to the site of injury.

Occupational features and social status of patients were incorporated in eight separate titles as: unem-ployed, housewives, retirees, students, industrial work-ers, service sector workers, civil servants, and others. For each case, the specific anatomic site of entrance of the FB was allocated into one of eleven groups as: first web space, thumb, index finger, middle finger, ring finger, small finger, hypothenar area, thenar area, hand dorsum, wrist, and carpal tunnel. In terms of injured structures, patients were categorized into one of eight groups as: skin laceration only, digital pulp laceration, nail bed injury, extensor tendon injury, flexor tendon injury, nerve injury, phalangeal fracture, and multiple structural injuries. The types of anesthesia used for the surgery were analyzed. Patients were also categorized as fully recovered or having at least one complaint re-lated to the specific injured site. Data obtained in terms of the structural properties of penetrated FBs could be distributed in 11 groups as: metal splinters, wooden splinters, glass pieces, dyestuff, sewing needles, fish hooks, bullets, nails, pencils, crochet hooks, and other metal objects. Events that resulted in FB penetrations to the hand and wrist were classified in 6 groups as: occupational accidents, accidents occurring during the conduct of daily chores, traffic accidents, deliber-ate behaviors aimed at secondary gains, pathological behaviors as part of psychiatric disorders, and injuries occurring due to criminal acts. Finally, whether the patient presented as an emergency case or the referral was elective was also noted for each case.

The presented results are objectified by adding re-markable case examples of different types of etiologic bases.

RESULTSThe median age of the 86 patients was 32 (min: 4,

max: 63). The demographic data including the distri-bution of patients to the age groups are demonstrated in Table 1. Sixteen (18.6%) patients were being treat-ed or followed up because of one or more additional health problems, including psychiatric disorders, at the time of their injury. The results of analysis of the data that pertains to the anatomical sites of entrance of the FBs, injured structures, affected side of the body, and frequency of postoperative complaints about the injured site are also listed in Table 1.

As summarized in Table 2, the underlying events and the etiologic bases of these injuries were com-

Foreign body penetrations of hand and wrist




posed of 44 (51.2%) accidents that occurred during the conduct of daily chores and hobbies (Figs. 1a, b), 30 (34.9%) occupational accidents (Figs. 1c, d), 4 (4.7%) traffic accidents, 4 (4.7%) pathological behaviors as consequences of psychiatric disorders, 3 (3.5%) crimi-nal activities (Fig. 1e), and 1 (1.2%) deliberate behav-ior for a secondary gain (Fig. 1f). After the operations, the follow-up of 40 (46.5%) patients was done in the HSD outpatient clinic, and 24 (60%) of these 40 pa-tients were included in a hand physiotherapy program. The analysis of admission patterns, the diagnostic and therapeutic workups of the patients and the features of the FBs are also demonstrated in Table 2.

Among 23 elective admissions, 7 patients stated that they had not sought any professional healthcare for their injuries; thus, they had not received any teta-nus prophylaxis within the acute phase of the injury although they had had received no vaccination dur-ing the previous 10 years. The remaining 63 patients who applied as emergency cases were given tetanus prophylaxis on the day of injury, according to the Ad-visory Committee on Immunization Practices recom-mendations.[6,7]

DISCUSSIONCompatible with our findings, FB penetrations of

the hand and/or wrist usually present as emergency cases, but elective applications of patients with em-bedded objects are not uncommon. Embedded FBs can also be removed from patients who are unaware or uncertain of FB entry.[8] Accidents that happen during the conduct of daily chores, hobbies and oc-cupational activities are the most frequent causes of FB penetrations. In fact, 86.1% of the cases analyzed in our study were due to such accidents, almost all of which resulted in isolated local injuries to the trauma site. On the other hand, they may also occur as minor or major components of multiple trauma cases, as in traffic accidents. Conscious behaviors performed for self-mutilation or secondary gain are other forms of etiologic bases for FB penetrations.

When an embedded FB is suspected due to the medical history and examination, plain radiography, ultrasonography or computed tomography may be used as imaging techniques. It is usually possible to find the embedded FBs through using two-view plain radiographs. We utilized two-view X-rays in 74.4% of our patients. For some cases, sticking radiopaque ma-terials to the skin or wound surface and/or inserting metal grids such as syringe needles to the soft tissue just before taking the radiographs was beneficial. In some centers, fluoroscopy is also being utilized as a routine component of the surgery.[9] Previously, it has been stated that the two-view X-rays have been shown to be equivalent to the three-view X-rays in detecting glass FBs.[10] In another study, when only plain films

Table 1. Demographic and clinical features of the patients

Variables n %

Age <1 0 0.0 1-4 2 2.3 5-14 10 11.6 15-24 19 22.1 25-34 20 23.3 35-44 21 24.4 45-54 7 8.1 55-64 7 8.1 65-74 0 0.0Gender Male 60 69.8 Female 26 30.2Extra disease None 70 81.4 Extra medical problems 13 15.1 Psychiatric disorder 5 5.8Occupation Industrial worker 22 25.6 Student 17 19.8 Service sector worker 13 15.1 Civil servant 8 9.3 Unemployed 7 8.1 Housewife 6 7.0 Retired 6 7.0 Others 5 5.8Foreign body entrance site Index finger 29 33.7 Middle finger 10 11.6 Wrist 10 11.6 Thenar area 9 10.5 Thumb 7 8.1 Hypothenar area 5 5.8 Carpal tunnel 4 4.7 First web 4 4.7 Small finger 4 4.7 Hand dorsum 2 2.3 Ring finger 2 2.3Injury Skin laceration 44 51.2 Digital pulp laceration 11 12.8 Nerve 8 9.3 Multiple tissue injury 8 9.3 Nail bed 5 5.8 Extensor tendon 4 4.7 Flexor tendon 4 4.7 Phalanx fracture 2 2.3Side Left 45 52.3 Right 41 47.7Postoperative complaint None 71 82.6



Fig. 1. (a) A 21-year-old university student was found hanging by his hand, through which a metallic extension of the garden wall had penetrated. This had occurred while attempting to jump over the wall. He presented with a large piece of the metal railing, which had penetrated through almost the entire length of his left hand. Under general anesthesia, the palmar skin surrounding the FB was opened using Bruner zigzag incisions, and the palmar fascia was passed. The FB was observed to extend between the branches of the median nerve and the digital neurovascular bundles, dissecting but not damaging them. The FB and the involved tissues were lubricated with sterile liquid petroleum jelly. The huge FB was extracted carefully from between the surrounding dissected nerves and vessels. (b) After an accident that had occurred during the conduct of household chores, a 14-year-old girl presented with a crochet-hook stuck in the ulnar side of her wrist. The depth and localization of the hooked tip was estimated through two-view plain radiographs. Even though there were no symptoms or clinical findings regarding a neurovascular or tendon injury, exploration of the site was carried out due to the possibility of damage to the ulnar artery or ulnar nerve. Under loupe magnification, it was seen that the FB had penetrated through the fascicles of the ulnar nerve without causing any ruptures. (c) A 27-year-old male industrial worker was brought to us with a metal mesh penetrating his wrist as a result of an occupational accident. He stated that during a sudden period of drowsiness, he had tried to hold the metal mesh to stop a fall, but the free edge of the object had penetrated his wrist. While radiographs were being taken, the FB was extracted spontaneously despite our routine effort to keep the object still in the wound. Exploration of the site revealed a partially damaged ulnar nerve. (d) A 37-year-old industrial worker with a metal object stuck in his finger was referred to us after an occupational accident. Under local anesthesia, the wound was extended with incisions made proximally and distally on the mid-lateral line. Next, the palmar neurovascular structures, the flexor and extensor tendons, were explored, and the FB was extracted. Finally, the radial collateral ligament and articular surfaces of the middle and distal phalanges were examined. After massive irrigation of the site, the partially damaged flexor tendon and the radial collateral ligament were repaired, and the skin was closed primarily. (e) An 11-year-old student was admitted to our clinic because one of his school friends had intentionally stuck a sharp-pointed piece of wood into his right thenar area. Just after the physical examination, a median and radial nerve block was performed at the wrist level. The two-view radiography showed the embedded tip of the object with no extra splinters of wood around it. Under general anesthesia, after extending the wound with incisions, the FB was extracted through the thenar muscles. Exploration revealed no neurovascular or tendinous damage. (f) A 42-year-old prison inmate presented with a nail stuck in his finger stump, which had been operated previously because of another accident. It was reported as an odd accident or was claimed to be an accident involving nail gun usage during voluntary repair work at the prison. The FB had penetrated the entire width of the finger by passing through the middle phalanx. The entrance and exit points of the nail were just on the mid-lateral lines. The nail was removed by traction under local anesthesia without extra incision, and the wounds were left for secondary healing.

(a)

(c)

(e)

(d)

(f)

(b)

(Col

or fi

gure

s can

be

view

ed in

the

onlin

e is

sue,

whi

ch is

ava

ilabl

e at

ww

w.tjt

es.o

rg).

(a)

(c)

(e)

(d)

(f)

(b)



were utilized, wood and glass FBs were missed in 93% and 25% of the cases, respectively, so ultrasound was suggested to be the more sensitive and preferred technique for imaging of wooden FBs.[11] We used no imaging in 25.6% of the cases in which significant parts of the FBs were visible externally. Whatever the chosen imaging technique, it is very important to keep still the injured extremity and the FB during the clini-cal evaluations and radiological investigations in order to prevent injury to surrounding structures.

In 55.7% of our cases, the FBs were metallic, while they were glass and wood in 23.3% and 11.6% of the cases, respectively. The chemical and physical proper-ties of the embedded FB influence the clinical evalu-ation and intervention processes. The risk of the dam-age that emerges as a consequence of leaving the FB in place and the risk of surgical intervention for explo-ration and removal of the object should be compared, and the action should be taken accordingly. Case re-ports of embedded organic FBs such as splinters of plants, wood and fish fin fragments demonstrate the typical clinical picture of inflammatory reaction that develops in days or weeks.[12] In this sense, metal ob-jects are less risky than the organic ones.[13] For this reason, if the exploration and extraction attempts have the risk of injury to the neighboring structures, it is bet-ter to leave an embedded inert metal object in its place unless it causes any symptoms or infection. However, it should not be forgotten that soft-tissue FBs that are missed on the initial evaluation may migrate to cause significant morbidity, or even mortality, months or years after the traumatic event.[1,8]

In case of penetrations with remarkable-sized ob-jects, estimation of the location and the course of the FB in the tissue are usually easier, but removal of the object without damaging the surrounding tissues is obviously the most challenging part of the management. Even if there are no symptoms or findings of a structural injury, removing the FB blindly just by extraction is indisput-ably an error. This action will most likely be detrimental to the regional structures. With respect to our findings, 36% of the cases had an injury of either a neurovascu-lar or a tendinous structure, or combinations thereof. In general, it is crucial to extend the wound with incisions that will allow exploration of the FB, or the penetrated part of it, and the structures in close proximity.

The type of anesthesia is determined by consider-ing the location of the FB, the depth of penetration, the most likely injured structure(s), the age and psy-chological status of the patient, and the predicted dura-tion of the operation. Our study demonstrates the great importance of local and regional anesthesia in cases of FB penetrations of the hand and wrist, as 94.2% of our cases were operated under local infiltrations, digital blocks, and blocks at the wrist, elbow and axilla.

The best means of preventing infection is debride-ment and massive irrigation of the site just after re-moval of the object. In general, decontamination is far more important than antibiotics.[14] We carry out the massive irrigation process -to which we add scrubbing for some wounds- first by diluted povidone-iodine (PVP-I) solution (1% PVP-I), followed by sterile nor-mal saline solution. Some authors suggest avoiding usage of anti-septic solutions such as PVP-I, chlorhex-idine, and hydrogen peroxide for irrigation due to the fact that they have toxic effects on the tissues and slow down the healing process.[13] On the contrary, in a re-view study, articles with superior level of evidence were analyzed, and it was seen that 71% of the litera-

Table 2. Characteristics of the injuries, events and details about the management

Variables n %

Status Emergency 63 73.3 Elective 23 26.7Etiology Daily chores accident 44 51.2 Occupational accident 30 34.9 Psychiatric disorder 4 4.7 Traffic accident 4 4.7 Criminal 3 3.5 Secondary gains 1 1Substance Glass 20 23.3 Sewing needle 13 15.1 Wooden splinter 12 14.0 Metal splinter 10 11.6 Crochet hook 5 5.8 Dyestuff 3 3.5 Nail 3 3.5 Pencil 3 3.5 Bullet 2 2.3 Fishhook 2 2.3 Other metal objects 13 15.1Radiology Two-view radiograph 64 74.4 None 22 25.6Anesthesia Local infiltration and/or digital block 75 87.2 Regional block 6 7.0 General anesthesia 5 5.8Postoperative follow-up By us 40 46.5 By family physician 30 34.9 None 16 18.6Rehabilitation None 62 72.1 Hand physiotherapy 24 27.9



ture supports the use of PVP-I, and refutes the hypoth-esis that there is a negative impact on tissue regenera-tion.[3] Another effective and more practical alternative for wound irrigation might be tap water, especially in pediatric cases.[15] The damaged tissues can be repaired and/or primary closure can be carried out provided the irrigation procedure is adequately accomplished. Our decision to use antimicrobials and to continue antibi-otic prophylaxis in the postoperative period is individ-ualized for each patient, and this modality parallels the recommendations in the literature.[16]

When any of the structures are repaired, a splint should be applied that provides stabilization in the appropriate position. We recommend hospitalization when there is a need for close follow-up in terms of hematoma and infection and occasionally when there is reason to suspect possible discontinuation of anti-biotic therapy at home. Another important issue to be considered is the tetanus prophylaxis, which has been shown to be overlooked in a significant number of cases. In one study, of the 377 patients who initially asserted having had a tetanus vaccine in the last five years, 98 (26.0%) were confirmed to not have received a tetanus vaccine.[17] Similar to a group of cases dem-onstrated in the study of Tuncer et al.,[9] seven of our 23 elective patients had ignored being examined for their wounds at the time of injury, and thus had not received the appropriate prophylaxis although it was needed. This analysis set forth the importance of the booster dose of tetanus toxoid-containing vaccine ev-ery 10 years.

Some comorbidities may have an impact on acci-dent development or sometimes constitute the main etiologic basis for the event causing the injury. Thus, investigating additional medical problems should not be overlooked, as 18.6% of our patients had comor-bidities including psychiatric disorders at the time of the injury.

In conclusion, despite the commonness of the sub-ject, some aspects may remain overlooked. Compared to the FB penetrations of the skin or soft tissues of the other body sites, modalities slightly differ when the injured site is the hand or wrist, where there is a higher probability of neurovascular, tendinous, capsu-lar, ligamentous, and bony injury. Overlooked partial injuries of these structures may result in sequelae. All penetrant FBs do not require removal; however, ex-ploration of the wound and removal of FBs in the hand and wrist can be regarded as more important because the detection and repair of underlying structural dam-age is necessary. Emergency physicians, trauma sur-geons and hand surgeons should be watchful about the limitations of direct films for imaging wooden FBs, additional health problems of the injured patients, and probable forensic aspects of the events causing this

type of injury. Malpractice lawsuits against physi-cians, concerning retained FBs, represent another con-siderable issue. A significant number of people fail to present to a healthcare unit after this kind of injury. It is thus important to check the continuity of routine tetanus boosters for people less than 44 years of age, especially industrial workers and those with hobbies that predispose to this kind of injury. Irrigation of the penetrated tissues with diluted povidone iodine solu-tions is still a preferred procedure. The retrospective nature of this study limits the power of these conclu-sions. Prospective, controlled, blinded studies will certainly improve our opinions.


REFERENCES1. Han KJ, Lee YS, Kim JH. Progressive median neuropathy

caused by the proximal migration of a retained foreign body (a glass splinter). J Hand Surg Eur Vol 2011;36:608-9.

2. Talan DA, Abrahamian FM, Moran GJ, Mower WR, Alagap-pan K, Tiffany BR, et al. Tetanus immunity and physician compliance with tetanus prophylaxis practices among emer-gency department patients presenting with wounds. Ann Emerg Med 2004;43:305-14.

3. Banwell H. What is the evidence for tissue regeneration im-pairment when using a formulation of PVP-I antiseptic on open wounds? Dermatology 2006;212:66-76.

4. Vukmir RB. Medical malpractice: managing the risk. Med Law 2004;23:495-513.

5. Kaiser CW, Slowick T, Spurling KP, Friedman S. Retained foreign bodies. J Trauma 1997;43:107-11.

6. Centers for Disease Control. Diphtheria, tetanus, and pertus-sis: recommendations for vaccine use and other preventive measures. Recommendations of the Immunization Prac-tices Advisory committee (ACIP). MMWR Recomm Rep 1991;40;1-28.

7. Kretsinger K, Broder KR, Cortese MM, Joyce MP, Ortega-Sanchez I, Lee GM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommen-dations of the Advisory Committee on Immunization Prac-tices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep 2006;55:1-37.

8. Ozsarac M, Demircan A, Sener S. Glass foreign body in soft tissue: possibility of high morbidity due to delayed migra-tion. J Emerg Med 2011;41:e125-8.

9. Tuncer S, Ozcelik IB, Mersa B, Kabakas F, Ozkan T. Evalu-ation of patients undergoing removal of glass fragments from injured hands: a retrospective study. Ann Plast Surg 2011;67:114-8.

10. Steele MT, Tran LV, Watson WA, Muelleman RL. Retained glass foreign bodies in wounds: predictive value of wound characteristics, patient perception, and wound exploration. Am J Emerg Med 1998;16:627-30.

11. Levine MR, Gorman SM, Young CF, Courtney DM. Clinical characteristics and management of wound foreign bodies in the ED. Am J Emerg Med 2008;26:918-22.

12. Hamnett NT, Tehrani H, McArthur P. Perch fin foreign body in a paediatric hand. J Plast Reconstr Aesthet Surg



2010;63:2198-9. 13. Halaas GW. Management of foreign bodies in the skin. Am

Fam Physician 2007;76:683-8.14. Hollander JE, Singer AJ. Laceration management. Ann

Emerg Med 1999;34:356-67.15. Valente JH, Forti RJ, Freundlich LF, Zandieh SO, Crain EF.

Wound irrigation in children: saline solution or tap water?

Ann Emerg Med 2003;41:609-16.16. American College of Emergency Physicians: Clinical policy

for the initial approach to patients presenting with penetrat-ing extremity trauma. Ann Emerg Med 1999;33:612-36.

17. Gindi M, Oravitz P, Sexton R, Shpak M, Eisenhart A. Unreli-ability of reported tetanus vaccination histories. Am J Emerg Med 2005;23:120-2.

65


Case Report Olgu Sunumu


Unexpected colonic perforation in a renal recipient: a case report

Böbreknaklisonrasıgelişenbeklenmedikkolonperforasyonu:Olgusunumu

Kürşat Rahmi SERİN, Metin KESKİN, Hüseyin BAKKALOĞLU, Fatih TUNCA, Ali Emin AYDIN, Cumhur Uluğ ELDEGEZ

İmmünite baskılayıcı ilaçlara bağlı olarakgelişengastro-intestinal kanama ve perforasyon gibi komplikasyonlarsıklıklasolidorgannaklisonrasıgörülmektedir.Elliikiya-şındaerkekhastacanlıvericidenböbreknaklinin7.günün-deyarayerindenakıntışikayetiilebaşvurdu.Herhangibirkarınağrısıyoktu.Üçlü immünsupresankullanmakta idi.Karıngrafisiveultrasonografisinormalsaptandıancakbil-gisayarlıtomografidekarıniçerisindeyaygınserbesthavagörüldü.Transplanteböbrekfonksiyonlarıdadahilolmaküzerelaboratuvarincelemesindeherhangibirpatolojikbul-gusaptanmadı.Tanısallaparoskopisonrasıaçığadönüldü.Antimezenterikyüzde sigmoidkolonperforasyonuvardı.Divertikülitve iskemibulgusuyoktu, travmayaaitbulguda görülmedi. Transrektal enstrümentasyon anamnezi deyoktu. Omentoplasti ve sigmoid loop kolostomi yapıl-dı.Ameliyatının dokuzuncu günüde hasta taburcu edildi.Ameliyatınınbirinciyılındadakolostomisikapatıldı.Gast-rointestinal komplikasyonlar ölümcülolabilir ancakuzundönemsağkalımıvegreffonksiyonunuetkilemedikleribi-linmektedir.Pekçoğuameliyat sonrası erkendönemveyarejeksiyon atakları gibi yüksek doz immünite baskılayıcıilaçkullanılandönemdegörülmektedir.Sağkalımdaerkentanıvetedavideagresifdavranmakönemliroloynar.Anahtar Sözcükler:Kolonperforasyonu;kolostomi;immünsup-resyon.

Gastrointestinal complications such as gastrointestinalbleeding and perforation due to immunosuppressant useare seenmore frequentlyafter solidorgan transplantation.A52-year-oldmalewasadmittedonthe7thdayofalivingdonorrenaltransplantationwithserousdrainageattheinci-sionsite.Hehadnoabdominalcomplaints.Hewasontripleimmunosuppressant therapy. Abdominal plain X-ray andultrasonographywere normal, but diffuse extraluminal airwasdetectedonthecomputedtomographyscan.Therewerenopathological laboratoryfindings regarding the functionoftherenalallograft.Webegantheoperationlaparoscopi-cally and then converted to laparotomy. Sigmoid colonicperforationwasdetectedontheantimesentericside.Neitherdiverticulitisnor ischemiawasobserved, andnoevidenceofiatrogenicinjurywasseen.Therewasnotransrectalin-strumentationhistory.Omentoplastyandsigmoid loopco-lostomywereperformed.Hewasdischargedonthe9thdayfollowingtheoperation.Hiscolostomywasclosedoneyearaftertheoperation.Gastrointestinalcomplicationscanbefa-tal,butdonotseemtoinfluencethelong-termsurvivalorre-nalallograftfunction.Mostofthemareseenafterusinghighdosesofimmunosuppressantstomanagetheearlypostop-erativeperiodorepisodesofacuterejection.Earlydiagnosisandaggressivetreatmentplayanimportantroleinsurvival.Key Words:Colonicperforation;colostomy;immunosuppression.

Following the development of solid organ trans-plantation, complications of transplantation surgeryand postoperative medications have appeared. Themostcommonearlysurgicalcomplicationsofkidneytransplantation are wound complications, bleedingandhematoma,acutevascularthrombosis,urineleak,

ureteralstenosis,andlymphocele.Late-onsetlympho-cele, renal arterial stenosis and ureteral stenosis arecommon.[1] Gastrointestinal (GI) complications suchasbleedingorperforationsarethemostcommonlife-threateningsurgicalcomplications, rangingfrom10-20%.[2-5]

DepartmentofGeneralSurgery,IstanbulUniversityIstanbulFacultyofMedicine,Istanbul,Turkey.

İstanbulÜniversitesi,İstanbulTıpFakültesi,GenelCerrahiAnabilimDalı,İstanbul.

Correspondence(İletişim):KürşatRahmiSerin,M.D.NeslişahMah.,SofalıÇeşmeSok.KörfezApt.No:100/18,34091Fatih,İstanbul,Turkey.Tel:+090-212-6211200e-mail(e-posta):[email protected]

doi: 10.5505/tjtes.2013.53496

CASE REPORTA52-year-oldmalewasadmittedtoourtransplan-

tationcliniconthe7thdayoflivingdonor-relatedre-nal allograft transplantation (right-sided, retroperito-neal approach surgery), after being discharged froma hospital in Egypt. He had end-stage renal failurebecauseofdiabetesandwasonmaintenancetherapybyhemodialysis.Onhisphysicalexamination, therewasnofindingimplicatingacuteabdomensyndromeorinfection.Onlyserousdrainageattheincisionwaspresent,buttherewasnosuspicionofintraabdominalinfection or peritoneal dehiscence. Laboratory testsand radiological examination were planned for thenextdayandthepatientwenthome.Thesamenight,hewasadmittedtotheemergencydepartmentbecauseofmildabdominalpain.Hehadpain throughout theabdomen and nausea, and tenderness and reboundweredetected.Hehaddyspneaduetopulmonaryede-ma,butnofeverwasdetected.Hewas takingmeth-ylprednisolone (60 mg/day), mycophenolate mofetil(1 g/day) and tacrolimus (8 mg/day). White bloodcell count, abdominal X-ray, abdominal ultrasonog-raphy (US), and abdominal computed tomography(CT)wereobtained.Leukocytecountwas20000/mm3

(normal range: 4000-10000), abdominal plainX-raywasnormal,andtherewerenopathologicalfindingsonabdominalUS.Diffuseextraluminalairintheab-domenwasdetectedonCT(Fig.1),buttherewasnofluidorcollection.Noabnormalitieswerefoundinhislaboratoryresultstoinfluencethefunctionoftherenalallograft.Underthesefindings(leukocytosis,reboundand CT findings), he was diagnosed with acute ab-dominalsyndrome,andthereasonwasluminalorganperforation.Webeganthesurgerylaparoscopically,atthe 24th hour of the onset of symptoms.Therewaspurulent inflammatory fluid of about 20 cc near thececumandappendix.Therestoftheabdominalcavitywasclear,andnosignsofinflammationweredetect-ed.Laparotomywasperformed,andasigmoidcolonperforation, 3mm in diameter,was seen on the an-

timesentericside,nearthececumandappendix(Fig.2).Neitherdiverticulitisnor ischemiawasobserved.Therewas no evidence of iatrogenic-traumatic inju-ry, thewholeperitoneum layerwas intact, and therewas no transrectal instrumentation history. The firstsurgerywasperformedwithretroperitonealapproachfromtherightside.Theperforatedareawasexplored,andfluidwassampledforculture.Theabdominalcav-itywas irrigated and drained. Exteriorization of theperforatedsitewasnotpossiblebecauseoftheedema.Omentoplasty was done, and sigmoid loop colos-tomywasperformedproximaltotheperforationareato decrease fecal contamination and divert the fecalpassage.On thefirstdayof theoperation, leukocytecountwasdecreased to13000/mm3,hehadgaspas-sage, and no complication was revealed concerningtherenalallograft.Diuresiswasforcedbecauseofthepulmonaryedema.On the2nddayof theoperation,he had defecation and began to take oral nutrition,and parenteral nutrition was stopped. Pseudomonas aeruginosawasidentifiedonhisintraabdominalfluidculture,andtreatedwellwithantibiotics.Onthe8thdayoftheoperation,thedrainswereremoved,nosur-gicalcomplicationorrenalallograftdysfunctionwasdetected, the leukocytecounthadregressedto7800/mm3, theC-reactiveproteinlevelwas4.2mg/L,andcytomegalovirus (CMV) antigenswere negative.Hewasdischargedfromthehospitalonthe9thdayoftheoperation.Hiscolostomywasclosedoneyearaftertheoperation(duetothepatient’sownhesitation).Onhis40th-month follow-up, therewasnoproblemrelatedtotheemergencyGIsurgeryorrenalallograft.

DISCUSSIONColonperforation,especiallyiatrogenic,isaseri-

ouscomplicationinthepostoperativecourseofkidneytransplantation.Inthepastthreedecades,theincidencehas decreased from1.4% to 0.67%, and themortal-ity ratehas improved from70% to32%.[3]Approxi-mately300 renal transplantationswereperformed in



Fig. 1. ExtraluminalairintheabdomenonCT. Fig. 2. Sigmoidcolonperforationontheantimesentericside.


ourclinic, and thispatientwas thefirst spontaneouscolonperforationcaseduetohigh-doseimmunosup-pression.Themostcommoncauseofcolonperfora-tionisdiverticulitis,andthemostcommonsiteisthesigmoidcolon.[3]Wedidnotfindanycausessuchasdiverticulitisorischemiccolitis.Hehadnotransrectalinstrumentationhistory,andtherewasnoevidenceofiatrogenicinjury.Wethusdecidedthatourpatienthadspontaneouscolonicperforationbecauseofimmuno-suppressantuse.

SpontaneousperforationoftheGItractaftertrans-plantationsurgeryisseenespeciallyinthe3rdto6thmonths of the transplantation because of the high-dose immunosuppressant use, uremia and fecal im-paction. In immunosuppressedpatients, diagnosis ofcolonic perforation is a challenge.Abdominal pain,fever,tenderness,andleukocytosisarefrequentinco-lonicperforation,but theclinicalpresentationin im-munosuppressedpatientsmaybeatypicalwithvagueabdominal symptoms.The symptomsare sparseandcanbemaskedbytheimmunosuppressant,andthedi-agnosisisusuallydelayed.[6]Nghiemetal.[1]reportedtheaveragetimeofsymptomstosurgeryas5.8days.ReMineetal.[7]reportedthedelayaslessthan8.3daysinpatientsreceivinggreaterthan20mgofprednisonedaily. Successful management of the problem oftendependsuponearlydiagnosisandprompttherapy.Ourpatientwasintheearlyperiodoftransplantation.Wehave no information about the dosage of the induc-tion therapy, althoughhehadbeen takinghigh-dosetriple therapy, as methylprednisolone (60 mg/day),mycophenolate mofetil (1 g/day) and tacrolimus (8mg/day).Hehadtypicalsymptomssuchasabdominalpain,tenderness,andrebound,aswellasleukocytosis.

TheradiologicevaluationusuallystartswithplainX-rays.Becauseof thechallengeof thediagnosis inimmunosuppressedpatientsbasedonphysicalexami-nationandplainX-rayfindings,thiscanbefollowedby contrast administration orally and rectally underfluoroscopyorCT.[8]TheCTdiagnosisofperforationwasbasedondirect and indirectfindings.[8]Extralu-minalairunderthediaphragmonplainX-raycanbeidentifiedinonly50-70%ofthesepatients.CTismoresensitiveindetectingextraluminalairandcontrast.CTcan also evaluate the bowelwall and extraintestinalstructures.ThemostspecificfindingforGIperforationis thepresenceof extraluminal air, bariumor radio-contrastfluid.[8]

Inourpatient,therewerenopathologicalfindingsonplainX-rayor abdominalUS.Weperformedab-dominalCT,andfoundextraluminalair intheentireabdomen.Nofluidorabscesswasdetected.Allfind-ingsdirectedustoGItractperforation,buttherewasnosignregardingtheperforationsite.

Diverticulitis,colorectalcancer,andidiopathicarethemostcommoncausesofcolonperforation(>60%ofcases).[4,9]Colonicischemia,iatrogenic(especiallyduring colonoscopy), infections (especially CMV),foreignbody, trauma,andgynecologicalpathologiesare other reasons.[10] Spontaneous perforation of thecolon, especially of the sigmoid colon, which wasrevealedasbeingrelatedtoimmunosuppression,hasbeen reported previously.[1,4,5,9] Spontaneous perfora-tionoftheGItractusuallyoccursintheearlyperiodaftertransplantation.Themeandurationtimeis3to6monthsaftertransplantation.[5]Thedifferencesinpa-tient characteristics, such asmedical problems, gen-eralcondition,peritonitisgrade,orcauseofperfora-tion,influenceboththesurgicaldecisionandoutcome.Acumulativeeffectofsepsisandmedicalconditionsmayberesponsibleforthehighpostoperativemortal-ity,whichrangesbetween30-55%.[2,11]Earlydiagnosisandsurgicalrepairofperforationsarethemainstaysoftreatment.To evaluate the current diagnosis and theleveloftheperforation,laparoscopyisasafeandmin-imallyinvasivediagnostictool.Laparoscopycanalsobetherapeutic.[12]Inourpatient,weusedlaparoscopyas adiagnostic tool to explore the abdominal cavityandtoconfirmanddefinetheleveloftheperforation.

Theoptimalsurgicalapproachtocomplicatedco-lonic disease remains controversial. Without bowelpreparation, intraluminal and intraperitoneal fecalcontamination at the anastomotic site is the majorproblemwhendecidingthesurgical technique.Hart-mann’sprocedurehasgained inpopularity as an al-ternative to others, and currently, is the most com-monly used technique for emergency colon surgery,especially in severely infected peritonitis.[13] How-ever, Hartmann’s procedure has frequent complica-tions,andthemorbidityrateafterrestorationishigh.[14]ArandomizedprospectivestudybyRavoetal.[15,16] concludedthatiffecescouldbeexcludedfromintra-luminalcontactwiththeanastomoticsite,ananasto-mosis canbeperformed safely even in thepresenceof peritonitis. Richter et al.[17] reported a perforatedsigmoid diverticulosis serieswith treatment by one-stagesigmoidcolon resectionafterperitoneal irriga-tion with saline in non-immunosuppressed patients.Nevertheless,manyothershaveconcludedthatimmu-nosuppression,septicshock,fecalperitonitis,orhighcardiacriskpatientsatadmissionwerecorrelatedwithhighermorbidityandmortalityrates,andthatusageofatwo-stageprocedurewithorwithoutprimaryanas-tomosiswouldbesaferthanone-stagesurgery.[1,5,16,18] Thereisnocommentaboutthetimingofthesecondstageof theoperation,butmostof theauthorsfavordelaying the second stage,usuallypreferring toper-formit6monthsafterthefirststage.[14,18]

In conclusion, colon perforation due to immuno-

Unexpected colonic perforation in a renal recipient


suppressantuse in renalallograft recipients isa rarebut serious complication, with high mortality andmorbidityrates.Itmustbediagnosedearlyandtreatedaggressively. With the improvements of antibioticsandimmunosuppressants,themortalityandmorbidityrateshavebeendecreasedinrecentdecades,butitcanstillbefatal.


REFERENCES1. NghiemDD,CorryRJ.Colorectalperforationinrenaltrans-

plantrecipients.AmSurg1983;49:554-7.2. Ponticelli C, Passerini P. Gastrointestinal complications in

renaltransplantrecipients.TransplInt2005;18:643-50.3. KonishiT,WatanabeT,KitayamaJ,ShibaharaJ,Hiramatsu

T,HaraK,etal.Successfullytreatedidiopathicrectosigmoidperforation 7 years after renal transplantation. JGastroen-terol2004;39:484-9.

4. BiondoS,ParésD,MartíRaguéJ,DeOcaJ,ToralD,Boro-biaFG,etal.Emergencyoperationsfornondiverticularper-forationoftheleftcolon.AmJSurg2002;183:256-60.

5. MeyersWC,HarrisN,SteinS,BrooksM,JonesRS,Thomp-sonWM, et al.Alimentary tract complications after renaltransplantation.AnnSurg1979;190:535-42.

6. Lederman ED, Conti DJ, Lempert N, Singh TP, Lee EC.Complicated diverticulitis following renal transplantation.DisColonRectum1998;41:613-8.

7. ReMine SG, McIlrath DC. Bowel perforation in steroid-treatedpatients.AnnSurg1980;192:581-6.

8. ManiatisV,ChryssikopoulosH,RoussakisA,KalamaraC,

KavadiasS,PapadopoulosA,etal.Perforationofthealimen-tary tract: evaluation with computed tomography.AbdomImaging2000;25:373-9.

9. CarsonSD,KromRA,UchidaK,YokotaK,WestJC,WeilR3rd.Colonperforationafterkidneytransplantation.AnnSurg1978;188:109-13.

10.IqbalCW,ChunYS,FarleyDR.Colonoscopicperforations:aretrospectivereview.JGastrointestSurg2005;9:1229-36.

11.KriwanekS,ArmbrusterC,DittrichK,BeckerhinnP.Perfo-ratedcolorectalcancer.DisColonRectum1996;39:1409-14.

12.GeisWP,KimHC.Useoflaparoscopyinthediagnosisandtreatment of patientswith surgical abdominal sepsis. SurgEndosc1995;9:178-82.

13.FinlayIG,CarterDC.Acomparisonofemergencyresectionand stagedmanagement in perforated diverticular disease.DisColonRectum1987;30:929-33.

14.DallaValleR,CapocasaleE,MazzoniMP,BusiN,BenozziL,SivelliR,etal.Acutediverticulitiswithcolonperforationinrenaltransplantation.TransplantProc2005;37:2507-10.

15.RavoB,MetwallyN,Castera P, PolanskyPJ,GerR.Theimportance of intraluminal anastomotic fecal contact andperitonitisincolonicanastomoticleakages.Anexperimentalstudy.DisColonRectum1988;31:868-71.

16.BiondoS,JaurrietaE,MartíRaguéJ,RamosE,DeirosM,Moreno P, et al. Role of resection and primary anastomo-sisoftheleftcoloninthepresenceofperitonitis.BrJSurg2000;87:1580-4.

17.RichterS,LindemannW,KollmarO,PistoriusGA,MaurerCA, SchillingMK.One-stage sigmoid colon resection forperforatedsigmoiddiverticulitis(HincheystagesIIIandIV).WorldJSurg2006;30:1027-32.

18.SeahDW,IbrahimS,TayKH.Hartmannprocedure:isitstillrelevanttoday?ANZJSurg2005;75:436-40.


69




Post-traumatic sagittal sinus thrombosis: case report

Posttravmatiksagittalsinüstrombozu:Olgusunumu

Nayil KHURSHEED, Ramzan ALTAF, Nizami FURQAN, Abrar WANI, Ashish JAIN, Yawar ALI

Posttravmatiksüperiorsagittalsinüstrombozunadirengö-rülmektedir.Olağanbelirtilerikafa içibasınçsemptomla-rının ortaya çıkmasıdır.Bu yazıda, bilgisayarlı tomografitaramasının parasagittal kontüzyonlarla birlikte verteksteçökmekırığınıgösterdiğibirposttravmatiksuperiorsagit-taltrombozolgususunuldu.Çökmekırığınıncerrahiyollaelevasyonuvesuperiorsagittalsinüsünonarımınarağmenhastadamotorsegmentteçifttaraflıhemorajikinfarktlarlabirliktesuperiorsagittalsinüsünönyarısındatrombozge-lişti. Bu olgu seyrek görülmesi ve bu hastalarda dikkatliameliyatsonrasıgözleminöneminivurgulamakiçinsunul-du.Buortamlardazamanındatanıveantikoagülantedaviyüzgüldürücüdür.Anahtar Sözcükler:Kafatravması;sagittalsinüstrombozu;man-yetikrezonansvenogram.

Post-traumatic superior sagittal sinus thrombosis is rare.Theusualpresentationisraisedintracranialpressuresymp-toms.We report a case of post-traumatic superior sagit-tal sinus thrombosis inwhich the computed tomography(CT) scan revealed depressed fracture of the vertexwithparasagittal contusions. Despite surgical elevation of thefractureandrepairofthesuperiorsagittalsinus,thepatientdeveloped thrombosisof theanteriorhalfof the superiorsagittalsinuswithbilateralhemorrhagicinfarctsinthemo-torstrip.Thiscaseisreportedforitsrarityandtohighlighttheimportanceofcarefulpostoperativeobservationofsuchpatients.Insuchsettings,timelydiagnosisandanticoagu-lanttherapyarerewarding.Key Words:Headinjury;sagittalsinusthrombosis;magneticreso-nancevenogram.

Post-traumatic superior sagittal sinus thrombosisis rare.Adepressed skull fractureoverlyingamajorvenous sinus in the brainmay result in sinus injuryandconsequentvenousthrombosis.[1]Variousmecha-nisms have been postulated.[2] The diagnosis can beoverlooked, especially in the setting of concomitantparasagittalcontusions,whichcan lead toadelay inthediagnosis.

Wereportacaseofvertexfracturewithparasagit-talcontusionssuperimposedbysuperiorsagittalsinusthrombosis.

CASE REPORTA20-year-oldmalereportedtoourhospitalwithin

2hoursofheadinjurywithahistoryofweaknessofbothlowerlimbs.Onexamination,therewasalacer-atedwound at the vertexwith underlying depressedfracture.HisGlasgowComaScale(GCS)scoreatad-missionwas13/15.Thepowerintheupperlimbswas

normalandinthelowerlimbswas2/5.Plain computed tomography (CT) of the head

showedacomminuteddepressedfractureofthevertexwith bilateralmid-parasagittal hyperdensities,whichwere thought tobehemorrhagiccontusions(Fig.1a,b). Intraoperatively, a7cmx5cmcomminutedde-pressed fragmentofboneat thevertexandapartialtear in the sagittal sinus were seen. The depressedfragmentswereelevatedandthetearwassealedwithgelatin foam.Thepatientwasmaintainedondecon-gestants, anticonvulsants and antibiotics. The GCSwas13/15,andhecontinuedtohaveparaparesis,butonthe5thpostoperativeday,hisGCSscoredroppedto10/15.PlainCTscanoftheheadshowedanincreaseinthesizeofthemid-parasagittalhemorrhagiclesionswith perilesional edema (Fig. 2a).We reviewed ourdiagnosis,andthepossibilityofsuperiorsagittalsinusthrombosiswasconsidered.Brainmagneticresonanceimaging(MRI)revealednon-visualizationof thean-

DepartmentofNeurology,Skims,Kashmir,India. Skims,NörolojiBölümü,Keşmir,Hindistan.

Correspondence(İletişim):NayilKhursheed,M.D.Sher-i-KashmirInstituteofMedicalSciences(SKIMS),NeurologyDepartment,Kashmir,India.Tel:+09419999465e-mail(e-posta):[email protected]

doi: 10.5505/tjtes.2013.79745

teriorhalfofthesuperiorsagittalsinuswithfeaturesofhemorrhagic infarcts inbilateralmedialmotorar-eas(Fig.2b,c).Systemicanticoagulationwasstartedwithheparinonthe5thpostoperativeday.Completebloodcountsrevealedmildleukocytosis.Theerythro-cytesedimentationrate(ESR)wasraised(15mm1sthour).Bloodcultureswerenegative.Thepatientwasmonitoredwithserialcoagulograms.Bythe3rdpost-operativeweek,theGCSofthepatienthadimprovedto15/15,withnoimprovementinpower.Hewasdis-chargedonanticoagulantsandanti-epileptics.At the8th-month follow-up, power in the lower limbs hadimprovedto3-4/5.ThebrainMRIshowedrecanaliza-tionofthesuperiorsagittalsinus(Fig.3).

DISCUSSIONThefirstcaseoftraumaticsagittalsinusthrombo-

sis was reported by Ecker.[3] The incidence of post-traumaticsinusthrombosisis4%inpenetratingheadinjury.[4] The pathogenesis is: (a) abnormal clottingmechanism,(b)disturbanceofbloodflow,and(c)en-dothelial injury.[2] The most common symptoms arealteredsensorium,headacheandseizures.[5]PlainX-

raylateralviewoftheskullmayrevealadoubleden-sity of the fractured region.[6]Non-contrastCT scanmayrevealhyperdensityofthesinus.[7]Thiswasnotseen in our patient as theCT scanwas donewithin2 hours of injury,which is too early, and the sagit-talsinusthrombosismighthavesupervenedlater.MRvenogramisthegoldstandardfordiagnosis.Itshowsnon-visualization of the sinus.[8] Multi-detector CTvenography is another usefulmodality in the detec-tionofsinusthrombus.[9]Sinusthrombosismaycauseincreasedlevelsoffibrinogendegradationproductsintheserum.[10]

Untreated depressed fractures of the vertex havebeenmentionedfor theirdelayedpresentationofse-vere raised intracranial pressure features.[11] Interest-ingly, even a delayed effort of surgical debridementandsubsequentreleaseofthecompressiononthesag-ittal sinus has been rewarding. However, this entirescenariohasbeenreportedthusfarinfracturesofthevertexcausingdirectmechanicalobstructionofthesi-nuswithout inducing sagittal sinus thrombosis.[1,12-14]



Fig. 1. (a) PlainCTscanshowingbilateralparasagittalpos-teriorfrontalhemorrhagiccontusionsand(b) commi-nuteddepressedfractureofthevertex.

(a) (b)

Fig. 2. (a) RepeatCTscanand(b) MRIshowincreaseinthesizeofthehemorrhagiccontusions,with(c)MRvenogramshowingobliterationoftheanteriorhalfofthesagittalsinus.

(a) (b) (c)

Fig. 3. MRVonfollow-upshowingrestorationofthepatencyofthesinus.


Oncethrombosishasoccurred,therecoverymaynotbe dramatically fast.[15,16] Our case deviated slightlyfromthehistoricalexamples.Ourpatientwashitonthe vertex by a stone, and theCT scan donewithin2 hours of injury revealed bilateral mid-parasagittalcontusions in addition to vertex fracture.Most suchfractures, which have been managed conservativelyinthepastforfearofexsanguinationduringsurgery,ultimatelyhadtobetreatedsurgicallytoalleviatethesymptomsof raised intracranialpressure;[12,13,17] thus,wedecidedtosurgicallyaddressthefracturewithoutresorting to the conservative management. Surgerywas donewithin 4 hours of injury.Thewoundwasrelatively clean and all the bone fragmentswere re-moved. However, even then, the patient developedsinus thrombosispossiblybecauseof theendothelialinjurytothesinuswalls.Variousmethodstodealwiththe tear in the sagittal sinus have been mentioned,namely:temporalismuscleandfasciagraft,directre-pair,saphenousveingraft,andsiliconetubeinterpo-sition.[18-20] In view of the small tear in the sinus ofourpatient,wecouldmanageitsuccessfullyusingagelatin sponge as a sealant. Post-infectious superiorsagittal sinus thrombosis can also occur; however,in our case, thewoundwas relatively clean.Differ-entmodalitiesoftreatmenthavebeenoutlinedforthetreatmentofsinusthrombosis,namely:stents,catheterdeliveryofthrombolyticagents,andsystemicheparin.Urokinasehasbeeninfusedintothesinusviaajugu-larcathetercombinedwithmechanicalthrombusdis-ruptionorremovalwithaballooncatheterinpatientswithsuperiorsagittalsinusthrombosis.[21,22]Stentan-gioplasty for the thrombotic stenosed sagittal sinushasalsobeentried.[23]Inourcase,westartedheparinon the 5th postoperative daywhen the patient dete-riorated,andtheimagingperformedrevealedsagittalsinus thrombosis. In the past, the role of heparin inpost-traumatic sagittal sinus thrombosiswas thoughttobehazardous, inviewofconcomitanthemorrhag-ic lesions,whichmayworsen after heparin therapy;however,recentliteraturesupportsitsuseasitinhibitstheextensionofthethrombosisintoadjoiningsinusesandcorticalveins,[8,24]andaMRvenogram,especiallyinthelatephase,usuallyshowsrestorationofthepa-tencyofthesinusinthefollow-up.

Inconclusion,evenafterpromptsurgicalelevationof depressed fractures of the vertex, possibility of adelayedsuperiorsagittalsinus thrombosisshouldal-waysbeconsidered.


REFERENCES1. duPlessisJJ.Depressedskullfractureinvolvingthesuperior

sagittalsinusasacauseofpersistentraisedintracranialpres-sure:acasereport.JTrauma1993;34:290-2.

2. CarrieAW,JaffeFA.Thrombosisof superiorsagittal sinuscaused by trauma without penetrating injury. J Neurosurg1954;11:173-82.

3. BeckerG,BogdahnU,GehlbergC,FröhlichT,HofmannE,SchliefMD.Transcranialcolor-codedreal-timesonographyofintracranialveins.Normalvaluesofbloodflowvelocitiesandfindingsinsuperiorsagittalsinusthrombosis.JNeuro-imaging1995;5:87-94.

4. OchagaviaAR,BoqueMC,TorreC,AlonsoS,Sirvent JJ.Duralvenoussinusthrombosisduetocranialtrauma.Lancet1996;347:1564.

5. HesselbrockR,SawayaR,TomsickT,WadhwaS.Superiorsagittalsinusthrombosisafterclosedheadinjury.Neurosur-gery1985;16:825-8.

6. ReillyHPJr,ErbengiA,SachsEJr,DykeJR.Penetrationof the sagittal sinus by a depressed skull fracture. Roent-genographic diagnosis in an asymptomatic boy. JAMA1967;202:841-2.

7. Rao KC, Knipp HC, Wagner EJ. Computed tomographicfindingsincerebralsinusandvenousthrombosis.Radiology1981;140:391-8.

8. BousserMG,Chiras J,Bories J,CastaigneP.Cerebralve-nousthrombosis-areviewof38cases.Stroke1985;16:199-213.

9. DelgadoAlmandoz JE,KellyHR,SchaeferPW,LevMH,GonzalezRG,RomeroJM.Prevalenceoftraumaticduralve-noussinusthrombosisinhigh-riskacutebluntheadtraumapatientsevaluatedwithmultidetectorCTvenography.Radi-ology2010;255:570-7.

10.MisraUK,Kalita J,BansalV.D-dimer isuseful in thedi-agnosis of cortical venous sinus thrombosis. Neurol India2009;57:50-4.

11.YokataH,KurowaA,OtsukaT.SignificanceofMRIinacuteheadinjury.JTrauma1991;1:351-7.

12.MeltzerH,LoSassoB,SoboEJ.Depressedoccipital skullfracturewith associated sagittal sinus occlusion. JTrauma2000;49:981.

13.UzanM,CiplakN,DashtiSG,BozkusH,ErdinçlerP,Ak-manC.Depressedskullfractureoverlyingthesuperiorsagit-talsinusasacauseofbenignintracranialhypertension.Casereport.JNeurosurg1998;88:598-600.

14.vandenBrinkWA,PietermanH,AvezaatCJ.Sagittalsinusocclusion,causedbyanoverlyingdepressedcranialfracture,presentingwithlatesignsandsymptomsofintracranialhy-pertension:casereport.Neurosurgery1996;38:1044-6.

15.deBruijnSF,deHaanRJ,StamJ.Clinicalfeaturesandprog-nosticfactorsofcerebralvenoussinusthrombosisinapro-spectiveseriesof59patients.ForTheCerebralVenousSinusThrombosis Study Group. J Neurol Neurosurg Psychiatry2001;70:105-8.

16.StiefelD,EichG,SacherP.Posttraumaticduralsinusthrom-bosisinchildren.EurJPediatrSurg2000;10:41-4.

17.SatohH,UozumiT,KiyaK,AritaK,KurisuK,SumidaM,IkawaF.Venousthrombosisafterclosedheadinjury:areportoftwocasespresentingasintracranialhypertension.[ArticleinJapanese]NoShinkeiGeka1993;21:953-7.[Abstract]

18.MaJ,SongT,HuW,MuhumuzaME,ZhaoW,YangS,etal.Reconstructionofthesuperiorsagittalsinuswithsiliconetubing.NeurosurgFocus2002;12:15.

19.SaniS,JobeKW,ByrneRW.Successfulrepairofanintracra-nialnail-guninjuryinvolvingtheparietalregionandthesu-periorsagittalsinus.Casereport.JNeurosurg2005;103:567-

Post-traumatic sagittal sinus thrombosis



9.20.SindouM,AuqueJ,JouanneauE.Neurosurgeryandtheintra-

cranialvenoussystem.ActaNeurochirSuppl2005;94:167-75.

21.StamJ,MajoieCB,vanDeldenOM,vanLiendenKP,Reek-ers JA. Endovascular thrombectomy and thrombolysis forseverecerebralsinusthrombosis:aprospectivestudy.Stroke2008;39:1487-90.

22.YamashitaS,MatsumotoY,TamiyaT,KawanishiM,Shindo

A,NakamuraT,etal.Mechanicalthrombolysisfortreatmentofacutesinusthrombosis-casereport.NeurolMedChir(To-kyo)2005;45:635-9.

23.LiB,GuoM,LiS,WangM.Endovascularthrombolysisandstentangioplastyforobliterationincerebralvenoussinuses.[ArticleinChinese]ZhonghuaWaiKeZaZhi2002;40:890-2.[Abstract]

24.FerreraPC,PauzeDR,ChanL.Sagittalsinusthrombosisaf-terclosedheadinjury.AmJEmergMed1998;16:382-5.

73




Diffuse idiopathic skeletal hyperostosis and central cord syndrome after minor trauma: a case report

Diffüzidiyopatikiskeletselhiperosteozisveminörtravmasonrasısantralkordsendromu:Olgusunumu

Olcay ESER,1 * Ergün KARAVELİOĞLU,2 † Mehmet Gazi BOYACI,1 # Abdullah AYÇİÇEK3 ¶

Diffüz idiyopatik iskeletselhiperosteozis (DİİH)vertebrakorpusununönvelateralininkemikleşmesiylekendinigös-teren bir durumdur.Buyazıda,DİİH’li bir olgudaminörtravmasonrasısantralkordsendromunusunduk.Hastacer-rahiolaraktedaviedildi.AyrıcaDİİH’ninsemptomlarınıvekordyaralanmasınınortakmekanizmalarınıtartıştık.Anahtar Sözcükler:Santralkordsendromu;diffüzidiopatikske-letalhiperosteozis;disfaji;Forestierhastalığı;travma.

Diffuseidiopathicskeletalhyperostosis(DISH)ischarac-terizedbyanteriorandlateralossificationofthevertebralbody.WepresentacasereportofcentralcordsyndromeinapatientwithDISHafterminor trauma.Thepatientwastreatedsurgically.WealsodiscusssymptomatologyandthecommonmechanismofcordinjuryinDISH.Key Words:Centralcordsyndrome;diffuseidiopathicskeletalhy-perostosis;dysphagia;Forestier’sdisease;trauma.

Diffuse idiopathic skeletal hyperostosis (DISH)ischaracterizedbyanteriorandlateralossificationofthevertebralbody.[1,2]ThisrareentityisalsoknownasForestier’sdisease,occursmostlyinmalesandinthefifthdecadeoflife,andisrarelyassociatedwithsys-temicdiseasessuchasdiabetesmellitusandobesity.[3] Theosteophytesaregenerallylocatedinthethoracic,lumbar and cervical vertebrae (97%, 90%, 78%, re-spectively).Theentirevertebralcolumnisaffectedin70%ofallcases.[4]

Althoughmostofcasesareasymptomatic,dyspha-giaisthemostcommonsymptomduetoesophagealcompressionbyanteriorosteophytesattheC4-5level.Othersymptomsandsignsarecervicalsubaxialpain,stiffnessanddecreasingrangeofmotionofthecervi-calspine.

CASE REPORTA67-year-oldmaleappliedtoouremergencyde-

partmentwithdysphagia,numbnessandtetraparesis.Hiscomplaintsstartedafteraminortraumaonemonthbefore and worsened progressively. On his neuro-logicalexamination,hehad tetraparesis (+2/5motorstrength),hypoesthesiaonhisfourextremitiesandup-perneuronfindingssuchashyperreflexiaandBabin-skisign.Therewasnosensationorsphincterreflexbuthehadnormalanalreflex.

X-rays and cervical computed tomography (CT)revealedbonyankylosis fromC2 toC6withoutanyfractures or dislocation (Fig. 1a, b). Cervical spinemagneticresonanceimaging(MRI)demonstratedspi-nal stenosisat theC3-4 levelwithbothanteriorandposteriorcompression,myelomalaciaandslightcord

Departmentsof1Neurosurgery,3ENT,AfyonKocatepeUniversityFacultyofMedicine,Afyonkarahisar;

2BolvadinDr.HIOzsoyStateHospital,Afyonkarahisar,Turkey.Current affiliation:

*DepartmentofNeurosurgery,BalikesirUniversityFacultyofMedicine,Balikesir;†DepartmentofNeurosurgery,AfyonKocatepeUniversity

FacultyofMedicine,Afyonkarahisar;#DiyarbakirSilvanStateHospital,Diyarbakir;¶DepartmentofENT,AfyonKocatepeUniversityFacultyof

Medicine,Afyonkarahisar,Turkey.

AfyonKocatepeÜniversitesiTıpFakültesi,1NöroşirürjiAnabilimDalı,3KBBAnabilimDalı,Afyonkarahisar;

2BolvadinDr.H.İ.ÖzsoyDevletHastanesi,Afyonkarahisar.Şimdiki kurumu:

*BalıkesirÜniversitesiTıpFakültesi,NöroşirürjiAnabilimDalı,Balıkesir;†AfyonKocatepeÜniversitesiTıpFakültesi,NöroşirürjiAnabilimDalı,Afyonkarahisar;#DiyarbakırSilvanDevletHastanesi,Diyarbakır;¶AfyonKocatepeÜniversitesiTıpFakültesi,KBBHastalıkları

AnabilimDalı,Afyonkarahisar.

Correspondence(İletişim):ErgünKaravelioğlu,M.D.AfyonKocatepeÜniversitesiTıpFakültesiNöroşirurjiAnabilimDalı,Afyonkarahisar,Turkey.Tel:+090-272-2463301e-mail(e-posta):[email protected]

doi: 10.5505/tjtes.2013.81593

edema (Fig. 2).At surgery,C3-4 total laminectomy,C2-C5 lateralmassscrewsandC3-4anteriormicro-discectomyandfusionwithcageandplatewereper-formed(Fig.3).Hehadminimaldysphagiaatthesix-monthfollow-upaftersurgery.

DISCUSSIONDiffuse idiopathic skeletal hyperostosis is char-

acterizedbycalcificationandossificationoftheliga-ments,tendonsandfascia.Ithasanestimatedpreva-lencerateofupto10%.[5]Thespineismostlyinvolvedfollowedbythepelvis,patella,calcaneus,andolecra-non.[4]

ThesuggestedpathogenesisofDISHindicatesthatossificationandnewboneformationaretheresultofabnormal osteoblast cell growth/activity in the bonyligamentous region.[6] In the literature, studies havereported that patients with DISH have high insulinandgrowthhormone levels.[7]As iswell known, in-sulin-likegrowthfactor1(IGF-1)stimulatesalkalinephosphataseactivityand type IIcollagenproductioninosteoblasts,andgrowthhormonecaninducethelo-cal development of IGF-1 and IGFbindingproteinsin chondrocytes and osteoblasts,which explains theosteoblastcellgrowthandproliferation.[8]

Diffuse idiopathicskeletalhyperostosis incidenceincreaseswithageandisveryrareinthefirstfourde-cadesoflife.Obesityandtype2diabetesmellitusaremajor risk factors.Other risk factors include hyper-vitaminosisA,highbodymassindexandhyperurice-mia.[4,9,10]

This raredisease isusuallyasymptomaticanddi-agnosedincidentally.ThemostcommonsymptomsofDISHarepainandstiffness,dysphagiaanddecreased



Fig. 1. (a, b) BonyankylosisfromC2toC6withoutanyfracturesordislocation.

(a) (b)

Fig. 2. SpinalstenosisattheC3-4levelwithbothAPcom-pression,myelomalaciaandslightcordedema.

range of motion.[4] Dysphagia can be explained byfourdifferenthypotheses:1)anteriorbonyfragmentsprojectingbetweentheC4-C6level,causingrigidandfixedpharynxandesophagus,whichcannotmoveeas-ilywhileswallowing;2)thepresenceoflargeanteriorosteophytesanddirectcompressionoftheesophagus;


3)inflammationaroundtheesophagus,causingswell-ingofsurroundingtissues,and4)reflexspasminthecricopharyngealsegmentprovokedbypressureofsol-idbolusonosteophytes.

Involvement of the cervical spine is the primarycauseoftheneurologicalfindings.Thisisduetothereducedflexibilityof thespine,spinalcanalnarrow-ingsecondarytoossificationofanteriorandposteriorlongitudinalligamentsandatlantoaxialsubluxationofthecervicalspine.[4]

ThediagnosisofDISHisbasedmainlyondataob-tained from the radiological evaluation: 1) Presenceofflowingnewboneformationonat least fourcon-tiguousvertebralbodies;2)Absenceofdegenerativediscdiseaseandrelativepreservationofintervertebraldischeight;and3)Absenceofinflammatorychangesinfacetorsacroiliacjoints.[4,11,12]

ThemanagementofpatientswithDISHismostlyconservativeincludingnonsteroidalantiinflammatorydrugs(NSAID)andsteroidtherapy.Surgeryincludinganterolateral,posterolateral and transoral approachescouldbeanappropriatechoiceinpatientswithsevereandprogressivesymptoms.[13,14]Theanterolateralap-proachinparticularprovidesbetterexposureoflargeosteophytesand the largecervicalvesselsandvagus

nerve, butmore attention shouldbegiven regardingrecurrentlaryngealnervepalsy.[9]

WhileseveralarticleshavereportedDISHpresent-ing with compressive symptoms, the authors reporthereinDISHcausing cervical cord compression andcentralcordsyndrome.TherearefewreportedcasesofDISHcoexistingwithossifiedposteriorlongitudi-nalligamentgivingrisetoneurologicalsequelaeasaresultofminortraumatotheneck.


REFERENCES1. CarlsonMJ,StaufferRN,PayneWS.Ankylosingvertebral

hyperostosis causing dysphagia.Arch Surg 1974;109:567-70.

2. LadenheimSE,MarloweFI.Dysphagiasecondarytocervi-calosteophytes.AmJOtolaryngol1999;20:184-9.

3. ResnickD,ShaulSR,RobinsJM.Diffuseidiopathicskeletalhyperostosis (DISH): Forestier’s disease with extraspinalmanifestations.Radiology1975;115:513-24.

4. Cammisa M, De Serio, Guglielmi G. Diffuse idiopaticskeletalhyperostosis.EurJRadiol1997;27:7-11.

5. BessetleL,KatzJN,LiangMH.Differentialdiagnosisandconservativetreatmentofrheumaticdisorders.In:FrymoyerJW,DuckerTM,WeinsteinJN,editors.Theadultspine:Prin-ciplesandpractice.2nded.,Philadelphia:Lippincott-Raven

Diffuse idiopathic skeletal hyperostosis and central cord syndrome after minor trauma

Fig. 3. Atsurgery,C3-4totallaminectomy,C2-C5lateralmassscrewsandC3-4anteriormicrodiscectomyandfusionwithcageandplatewereperformed.



Publishers;1997.p.821.6. elMiedanyYM,WassifG,elBaddiniM.Diffuseidiopathic

skeletalhyperostosis(DISH):isitofvascularaetiology?ClinExpRheumatol2000;18:193-200.

7. AtzeniF,Sarzi-PuttiniP,BevilacquaM.Calciumdepositionandassociatedchronicdiseases(atherosclerosis,diffuseid-iopathicskeletalhyperostosis,andothers).RheumDisClinNorthAm2006;32:413-26,viii.

8. VetterU,ZapfJ,HeitW,HelbingG,HeinzeE,FroeschER,etal.Humanfetalandadultchondrocytes.Effectofinsulin-likegrowthfactorsIandII,insulin,andgrowthhormoneonclonalgrowth.JClinInvest1986;77:1903-8.

9. AkhtarS,O’FlynnPE,KellyA,ValentinePM.Themanage-mentofdysphasiainskeletalhyperostosis.JLaryngolOtol2000;114:154-7.

10.SmytheH,LittlejhonG.Diffuseidiopathicskeletalhyperos-tosis.In:KlippelJH,DieppePA,editors.Rheumatology.2nded.,London:Mosby;1997.810.1-10.6.

11.ResnickD,NiwayamaG.Radiographicandpathologicfea-turesofspinalinvolvementindiffuseidiopathicskeletalhy-perostosis(DISH).Radiology1976;119:559-68.

12.ResnickD.Degenerativediseasesof thevertebral column.Radiology1985;156:3-14.

13.OgaM,MashimaT,IwakumaT,SugiokaY.Dysphagiacom-plicationsinankylosingspinalhyperostosisandossificationof the posterior longitudinal ligament. Roentgenographicfindingsofthedevelopmentalprocessofcervicalosteophytescausingdysphagia.Spine(PhilaPa1976)1993;18:391-4.

14.MeeksLW,RenshawTS.Vertebralosteophytesanddyspha-gia.AnnOtolRhinolLaryngol1970;79:1091-7.

77




Rotational head trauma with callosal contusion and C6 fracture: a high-speed motorcycle accident

KallozalkontüzyonlabirlikterotasyonelkafatravmasıveC6kırığı:Yüksekhızlımotosikletkazası

Gentian VYSHKA,1 Blerti TROSHANI,2 Dorjan BOZAXHIU,3 Arben MITRUSHI4

Buyazıda,yüksekhızlamotosikletsürerkendörttekerlibiraracaçarpmış34yaşındakibirArnavuterkeğiolgususu-nuldu.Çarpmaanındahavadaeksenietrafındaüçkezdön-düktensonra motosikletindenyeredüşenolgu,dahasonraderinkomakliniktablosuylayoğunbakımünitesinde,bi-lincineyenidenkavuşanakadardokuzgüntedaviedilmişve uzun dönemli rehabilitasyon prosedürleri uygulanmış.Manyetik rezonans ve bilgisayarlı tomografi görüntülerirotasyonelkafatravmasıaçısındançokaydınlatıcıydı.Ger-çekten kafatası kırıkları olmaksızın birden fazla kallozalkanamaodağınailavetenC6vertebrasında lineer komplekskırıkhattıizlenmekteydi.Buolguboyunomurgasınıhare-ketsizdurumda tespitediportopedik tedaviuygulanmayauygundu. Rotasyonel açısal akselerasyonun diffüz beyinve/veyaaksonalhasarınanedenolanönemlibirnedenselfaktör olduğu görünmektedir. Doğrudan kafatasına gelendarbenin etyolojik önemi tartışma konusuysa da asla gö-zardıedilmemelidir.Anahtar Sözcükler:Aksonaltravma;beyintravması;rotasyonelaçısalakselerasyon;trafikkazası.

Wepresent thecaseofa34-year-oldAlbanianmalewhowas riding amotorcyclewhen he collided at high-speedwithafour-wheelvehicle.Afteratriplepivotalrotationintheairatthemomentofimpact,hefellfromthemotorcycleto the ground.The clinical picture thereafterwas one ofdeepcoma,treatedintheintensivecareunitforninedays,untilhe regainedconsciousnessand long-termrehabilita-tionprocedureswereputinplace.Themagneticresonanceandcomputedtomographyimageswereveryillustrativeofa rotationalhead traumamechanism, since inaddition tomultiplecallosalhemorrhagesandthelackofcranialfrac-tures,alinearcomplexfractureoftheC6vertebrawasseen,justifyingorthopedictreatmentthroughimmobilizationofthecervicalspine.Rotationalangularaccelerationseemstobeanimportantcausativefactortowardprovokingdiffusebrain and/or axonal injury; the etiological importanceonthedirectskullimpactiscontroversial,butinanycasenotnegligible.Key Words:Axonalinjury;braintrauma;rotationalangularaccel-eration;trafficaccident.

CASE REPORTA34-year-oldmale(height176cm,weight85kg)

wasridinghismotorcycleonasecondaryruralroadincentralAlbaniawhenthemotorcyclecollidedathighspeedwith a four-wheeldrivevehicle.According towitnesses, the injured personwaswearing a helmetandwasdrivingapproximately50km/hr.At thesiteoftheaccident,tracksonthegroundindicatingatriplepivotal rotationof themotorcyclewereevident.Theinjured lostconsciousness immediatelyat thesiteof

the collision; thedriver of the car causing the crashand other witnesses accompanied the patient to thenearesthospital.

Upon arrival, he was in a deep coma (GlasgowComa Scale score: 5 points) with flexion provokedonly by painful stimuli; an anisocoria with left butreactivemydriasiswaspresent.Thepatientwasoth-erwise stable from the hemodynamic point of view.HewasadmittedintheIntensiveCareUnit(ICU)andintubated; appropriate therapy followed, and a com-

Departmentsof1Neurology,4RadiologicAnatomy,TiranaUniversityFacultyofMedicine,Tirana;Departmentsof2Radiology,3Surgery,

HygeiaHospital,Tirana,Albania.

TiranÜniversitesiTıpFakültesi,1NörolojiAnabilimDalı,4RadyolojikAnatomiAnabilimDalı,Tiran;HygeiaHastanesi,

2RadyolojiBölümü,3CerrahiKliniği,Tiran,Arnavutluk.

Correspondence(İletişim):GentianVyshka,M.D.TiranaUniversityFacultyofMedicine,DepartmentofNeurology,Tirana,Albania.Tel:+035542375808e-mail(e-posta):[email protected]

doi: 10.5505/tjtes.2013.40374

pletediagnosticworkupwasperformedwithinthedayofadmittance.

Magnetic resonance imaging (MRI) performedupon admission showedmultiple contusions, almostallofwhichwereremarkablyconcentratedinthemid-line structures: callosal gyrus and upper brain stem;noskull fractureswereseen(Figs.1a,b).Adiscretesubdural temporal-occipital hematoma requiring noneurosurgical intervention resolved under conserva-

tive treatment. On the computed tomography (CT)scanofthecervicalspine,alinearcomplexfractureoftheposteriorarchofC6wasalsoevidentandtreatedthroughimmobilization(Fig.1c,d).

ThepatientlefttheICUninedaysafteradmittanceandwasdischargedfromthehospitalthreeweeksaf-ter being released from the ICU; amnesia regardingthetraumaticeventandanosmiaweretheonlysequel-ae.Hewas referred to a neuropsychological facility



Fig. 1. (a) Callosalcontusionandhemorrhagicupperbrainstemfoci(MRIimageT2-weighted,FLAIR).(b)Contusivehem-orrhagicfociconcentratedonthemidlineandonthecentralstructures,suggestingtheexistenceofashearmomentum,probablyrelatedtothefactthattheouter[cortical]structures[insetschema,aboveright]hadahighertangentialspeedduringacceleration-decelerationwhencomparedtotheinnerandmediallypositionedareas(MRIimageT2-weighted,FLAIR).(c)Alinearcomplexfractureattheleftposteriorarchofthe6thcervicalvertebrawastreatedthroughim-mobilization(CTimage).(d)Afollow-upcranialCTwasperformedfivedaysaftertheMRI;callosalhemorrhagicfocianddiffusewhitematteredemaarevisible,withaslightmidlineshift.

(a)

(c)

(b)

(d)


abroadforlong-termcognitiverehabilitation,andnopharmacologicaltherapywasadvisedupondischarge;noeventualclinicalandimagingfollow-uptookplace.

DISCUSSIONAngularandrotationalaccelerationhasbeenmen-

tionedas an important factor causinghead injuryofdifferent gravity, since1943.[1]Generally, all studiespoint to brain deformation, strain and shear forcescreatedduring thehigh-speedmotion,be it linearorangular,anddirectimpactwithhardstructures.Whenangularaccelerationwasproposedasacauseofglid-ingcontusion,creatingstrainandeventually lacerat-ingdeepsmallvessels,itwassuggestedthatthemaxi-mumshearzonedeepenedwithanincreasingangularacceleration speed.[2]On the other hand, intracranialmotionseemstobeslowerandfollowingthatoftheskull;inertiaofcentralmidlinestructuresmightplaya role in rapid accelerative rotation, evenmore dur-ing the deceleration phase prior to the final impactwith the hard structures (for example, during fall totheground).Theseverityofdiffusebraininjury(DBI)and diffuse axonal injury (DAI) has been correlatedwiththeamplitudeoftheangularacceleration.[3]

Differentmodelshavebeenproposedandexperi-mented,aimingforabettercomprehensionoftheheadtraumamechanisminhumans.Amongothers,rabbits,rats and even sheep have been selected and experi-mented, although the authors themselves sometimesacknowledge the structural and morphologic differ-encesincomparisontothehumanbrain,thusmakingthelaboratoryresultshardtoextrapolatetoeverydaysettings.[4,5]

It isaccepted that thebrain isheterogeneousandanisotropic. Furthermore, when studying soft tissueproperties, elastoplastic responses and viscoelasticmechanisms, authors suggest different mechanicalintrinsic properties of three cranial structures: graymatter(GM),whitematter(WM),andbrainstemwithcorpuscallosum(BSCC).[6]Thus,dataofferedforthelong-termshearmodulus (elastoplastic response)are6.80 kPa forGM, 8.20 kPa forWMand 11.60 kPafor BSCC.[6] The same source also offers differentfigures for the initial shearmodulus for all three of

theseratherschematicdivisionsofthecentralnervoussystem,whichmight correspond, in an approximateform,tothecortex(GM),tothecoronaradiata,withthe subcortical and periventricular areas (WM), andtothecentral-midlinestructures(BSCC).Thus,albeitauthorsgenerallyagreethatthebrainandspinalcordmoveasaunitwhenexposed toasagittal rotationalaccelerationoftheheadandneck,[7]ourcasesuggeststhatadifferentmomentummightexist,mainlyduringthe deceleration that follows the abrupt cessation ofanangularheadmotion,creatingan important shearfactorbetweenthecortical-externalstructuresandtheBSCContheotherside.Theangularspeedisbyfaraveryimportantaggravatingfactorfortheoverallclini-calpictureandprognosis.[8]Inourcase,thepresenceofavertebralfracturewarrantedevenmorethesuspi-cionofahigh-speedrotationalheadtrauma,causingmultiplecallosalandbrainstemcontusions.


REFERENCES1. HolbournAHS.Mechanicsofheadinjuries.Lancet1943;ii:

438-441.2. Löwenhielm P.Mathematical simulation of gliding contu-

sions.JBiomech1975;8:351-6.3. MarguliesSS,ThibaultLE.Aproposed tolerance criterion

fordiffuseaxonalinjuryinman.JBiomech1992;25:917-23.4. KraveU,Al-OlamaM,HanssonHA. Rotational accelera-

tion closed head flexion trauma generates more extensivediffuse brain injury than extension trauma. JNeurotrauma2011;28:57-70.

5. Davidsson J, RislingM.A newmodel to produce sagittalplanerotationalinduceddiffuseaxonalinjuries.FrontNeurol2011;2:41.

6. El Sayed T, MotaA, Fraternali F, Ortiz M.A variationalconstitutive model for soft biological tissues. J Biomech2008;41:1458-66.

7. BaylyPV,BlackEE,PedersenRC,LeisterEP,GeninGM.Invivoimagingofrapiddeformationandstraininananimalmodelof traumaticbrain injury. JBiomech2006;39:1086-95.

8. KingAI,YangKH,ZhangL,HardyW,VianoDC.Isheadin-jurycausedbylinearorangularacceleration?ProceedingsoftheIRCOBIConference,LisbonPortugal:September2003.p.1-12.

Rotational head trauma with callosal contusion and C6 fracture

80




Unusual manifestation of acute retrocecal appendicitis: pericholecystic fluid

Akutretroçekalapandisitinsıradışıbulgusu:Perikolesistiksıvı

Oktay ALGIN, Evrim ÖZMEN, Ayşenur Şirin ÖZCAN, Şehnaz ERKEKEL, Mustafa KARAOĞLANOĞLU

Subhepatik alana uzanan retroçekal yerleşimli apandisit,nadirbirdurumdurve tanısıoldukçazordur.Karınağrısıilebaşvuranveatipikklinik,laboratuvarveultrasonogra-fi (USG)bulguları olanhastalarda akut apandisit bilgisa-yarlıtomografi(BT)ileekarteedilmelidir.ÇokdetektörlüBT(ÇDBT)ileretroçekalapandisittanısı,ekbirhazırlığagerekkalmaksızınkonulabilir.Buyazıda,klinikveUSGbulgularıakutkolesistititaklitedenveÇDBTiletanıkonu-lansubhepatik-retroçekalyerleşimliakutapandisitolgususunuldu.Bizimbilgimizegöreliteratürdeyalnızcaperiko-lesistiksıvıizlenmesiileşüphelenilenveÇDBTiletanıko-nulan,akutretroçekalyerleşimliapandisitolgusubulunma-maktadır.Subhepatik-retroçekalapandisitoldukçanadirbirdurumdurveatipikklinik,labaratuvarveradyolojikbulgu-larlakarşımızaçıkabilir.Ultrasonografitanıkonulmasındasıklıklayetersizdir.BudurumdaÇDBT,hızlıveetkinbirtanıaracıolarakkullanılabilir.

Anahtar Sözcükler:Bilgisayarlıtomografi;retroçekalapandisit;ultrasonografi;üstkadranağrısı.

Subhepatic-retrocecalappendicitisisarareentityinwhichthe diagnosis is challenging. In patients presenting withrightabdominalpainwithatypicalclinical,laboratoryandultrasound (US) findings, acute appendicitis should beeliminatedwithcomputedtomography(CT).Multi-detec-torCT(MDCT)canbeusedeffectivelyforthediagnosisofretrocecalappendicitiswithoutadditionalpreparationorfocusedexamination.Here,wepresentapatientwithacutesubhepatic-retrocecalappendicitisinwhomtheclinicalandUSfindingsmimicked acute cholecystitis.To thebest ofourknowledge,thereisnopreviousreportrelatedtoacuteappendicitispresentedonlywithpericholecysticfluidthatcouldbediagnosedwithMDCT.Retrocecal-subhepaticap-pendicitisisarareconditionthatmightpresentwithatypi-calclinical,laboratoryandradiologicalsigns.USisusuallyinsufficient for the definitive diagnosis. In this situation,MDCTcouldbearapidandefficienttoolforlocalizingtheappendixandforthedifferentialdiagnosis.Key Words:Computedtomography;retrocecalappendicitis;ultra-sonography;upperabdominalpain.

Acute appendicitis is the most common surgicalandradiologicalabdominalemergencyinthewesternworld,occurringin7-12%ofthegeneralpopulation.[1]The location and extent of the inflammatory pro-cesses of acute appendicitismayvary dependingonthelocationoftheappendix.[2]Whentheappendixisintheretrocecalposition,thesignsandsymptomsofacuteappendicitismightbeatypicalandcouldmimicright flank and hypochondriac pathologies includingacutecholecystitis,diverticulitis,acutegastroenteritis,ureteralcolic,acutepyelonephritis,intestinalneopla-

sia,andirritablebowelsyndrome.[3]Rapidandprecisediagnosiscouldreducethemorbidityandmortalityofacuteappendicitis.[1]

Here,wepresentacaseofacutesubhepatic-retro-cecalappendicitis,inwhomclinicalandsonographicfindings mimicked acute cholecystitis. In the ultra-sound(US)examination,theonlypathologicfindingwaspericholecysticfluid. In themulti-detectorcom-putedtomography(MDCT)examination,wenoticedaretrocecalinflamedappendix,whichextendedtothe

DepartmentofRadiology,AtaturkTrainingandResearchHospital,Bilkent,Ankara,Turkey.

AtatürkEğitimveAraştırmaHastanesi,RadyolojiBölümü,Bilkent,Ankara.

Correspondence(İletişim):EvrimÖzmen,M.D.AtatürkEğitimveAraştırmaHastanesi,RadyolojiBölümü,Bilkent,Ankara,Turkey.Tel:+090-312-2912525/3240e-mail(e-posta):[email protected]

doi: 10.5505/tjtes.2013.74508

pericholecystic-subhepatic area. To our knowledge,therehasbeennoreportedacuteappendicitiscasewhopresentedonlywithpericholecysticfluidandwaslaterdefinitivelydiagnosedwithMDCT.Wethinkthatthiscasereportcouldbeuseful for therapidandprecisediagnosisofsimilarcases.

CASE REPORTA 38-year-old male presented with right hypo-

chondriacpainlastingfor6hours.Therewasnosig-nificantfindinginhismedicalhistoryoronchestandabdominalroentgenograms.Inhisphysicalandlabo-ratory examination,Murphy’s signwas positive andleukocytosiswasdetected.Therefore,abdominalUSexamination was performedwith a pre-diagnosis ofacutecholecystitis;therewasnoabnormalfindingex-ceptpericholecysticfluid.Forthedifferentialdiagno-sis,MDCTwasperformedunderemergentconditionswithoutpreparation. In intravenouscontrast-materialenhancedMDCT,theappendixwassituatedintheret-rocecalregionwithanincreaseddiameterof2cm.Ap-pendicularwall thickeningwasobserved aswell. Inmultiplanar reformatted images, retrocolic-pericecalinflammation along with an inflamed appendix ex-tendingtothesubhepaticregionwasdetected(Fig.1).Moreover,inMDCT,pericholecysticfluidandappen-dicolithwithadiameterof8mmintheproximalpor-tionoftheappendixweredetected(Fig.2).NootherpathologicfindingwasobservedinMDCT.

Thepatientwasdiagnosedasacuteretrocecalap-pendicitisandoperatedbasedonthesefindings.Acuteappendicitiswasconfirmedwithsurgery,andthepa-tienthealedwithoutcomplication.Thehistologicex-aminationwas reportedasperforatedacuteappendi-citis.

DISCUSSIONAcuteappendicitisisoneofthemostcommonsur-

gical abdominal emergencies.[4] Early diagnosis andtreatment could reduce the mortality and morbidityof acute appendicitis significantly.[5] Themost com-monposition of the appendix is intraperitoneal, andthe second is in the retrocecal region.[3,6]More than50%of the patientswith retrocecal appendicitis canpresentwithatypicalfindings.[2]Thisconditioncouldevenmimicacutecholecystitisorgallbladderperfora-tion.[3,7]

AlthoughUSshouldbethefirst-linechoiceinthediagnosisofacuteappendicitis,itmightbeinadequateinretrocecalappendicitis.[4]Moreover,asUSisarapidtechniqueanditissignificantlyoperator-dependent,[4] MDCTcouldbeusefulinsuchpatients.Anincreasedappendiceal diameter (>6 mm), pericecal-retrocolicinflammation, and the presence of an appendicolitharediagnosticforacuteretrocecalappendicitis.[5,8]Asinourpatient,MDCTwashelpfulintheevaluationof

theperiappendiceal-pericecal regionandcoulddem-onstratetheappendixinhighresolution.Ontheotherhand,USexaminationisnotoptimalinpatientswithobesityandexcessivebowelgases.CTisadiagnosticmethodforsuchpatients.[9]

TechnicaldetailsoftheCTexamination,inpatientspre-diagnosedwithacuteappendicitis,arecontrover-sial.VariousCT techniqueshavebeendescribed fordiagnosing acute appendicitis, including intravenouscontrast-materialenhancedCTwithorwithoutorallyand/or rectally administered colon contrastmaterial,andtheyhaveahighdiagnosticaccuracy.[8]Someau-thors suggest that anon-contrast examinationwouldbesufficient.[1,9] Insuchcases inourdepartment,weperformMDCT examination after administration oforal and intravenous contrast material. However, inthepresentedpatient,wecouldnotgiveoralcontrast

Fig. 2. SequentialsagittalreformattedMDCTimages.Mor-phologyoftheappendix(longwhitearrow),pericho-lecysticfluid (black arrow), periappendiceal inflam-mation, and appendicolith (short white arrow) areclearlyseeninthereformattedimages.

Fig. 1. Coronal reformatted MDCT images of the patient.Morphologyoftheappendix(whitearrow,rightim-age), pericholecystic fluid (black arrow, left image)andperiappendicealinflammationareclearlyseeninthereformattedimages.


Unusual manifestation of acute retrocecal appendicitis



sincethepatienthadnauseaandvomiting.AccordingtothefindingsdetectedintheMDCTexamination,weunderstandthatMDCTwithoutoralandrectalcontrastmediaisavaluableandaccuratemethodinthediagno-sisofappendicitisandcanbeaneffectivediagnostictoolwhenthesonographicresultsareinadequate.[1]

Inconclusion,acuteappendicitismaypresentwithvariousatypicalclinicalsigns.Patientswithretrocecalappendicitismaypresentonlywithminimalperichole-cysticfluidaswell.Insuchcases,whentheappendixcannotbeseenclearlyorseemsinanunusuallocaliza-tion,MDCTcanbeausefulmethodforestablishingthe correct diagnosis. Furthermore, the radiologist’sdiagnosticconfidenceappearsgreaterwithMDCT.


REFERENCES1. ChalazonitisAN, Tzovara I, Sammouti E, Ptohis N, Soti-

ropoulouE,ProtoppapaE,etal.CTinappendicitis.DiagnIntervRadiol2008;14:19-25.

2. KimS,LimHK,LeeJY,LeeJ,KimMJ,LeeAS.Ascending

retrocecalappendicitis:clinicalandcomputed tomographicfindings.JComputAssistTomogr2006;30:772-6.

3. OngEM,VenkateshSK.Ascending retrocecalappendicitispresentingwithrightupperabdominalpain:utilityofcom-putedtomography.WorldJGastroenterol2009;15:3576-9.

4. BuluşH,CoşkunA.Subhepatikappendisit.KolonRektumHastDerg2010;20:29-32.

5. vanRandenA,LamérisW,vanEsHW,tenHoveW,BoumaWH,vanLeeuwenMS,etal.ProfilesofUSandCTimagingfeatureswithahighprobabilityofappendicitis.EurRadiol2010;20:1657-66.

6. PelettiAB,BaldisserottoM.OptimizingUSexaminationtodetectthenormalandabnormalappendixinchildren.PediatrRadiol2006;36:1171-6.

7. Algin O, Ozlem N, Kilic E, KaraoglanogluM,Arslan H.Gd-BOPTA-enhancedMRcholangiographyfindingsingallbladderperforation.EmergRadiol2010;17:487-91.

8. YeungKW,ChangMS,HsiaoCP. Evaluation of perforat-ed and nonperforated appendicitis with CT. Clin Imaging2004;28:422-7.

9. CağlayanK,GünerhanY,KoçA,UzunMA,AltınlıE,Kök-salN.Theroleofcomputerizedtomographyinthediagnosisofacuteappendicitisinpatientswithnegativeultrasonogra-phyfindings and a lowAlvarado score.UlusTravmaAcilCerrahiDerg2010;16:445-8.

83




Double acute appendicitis in appendical duplication

Apendiksduplikasyonundaçiftakutapandisit

Semra TUTCU ŞAHİN,1 Yamaç ERHAN,2 Hasan AYDEDE2

Appendiks vemiformis duplikasyonu nadir bir doğumsalanomalidir ve genellikle laparotomi esnasında tesadüfensaptanır. Apendikslerin birinin diğerine ve çekuma görelokalizasyonunu tanımlamadave aynı zamandaduplikas-yonunboyutunugöstermedemodifiyeCaveveWallbridgesınıflamasıkullanılır.Buyazıdaakutkarınağrısınedeniylelaparotomiuygulanan45yaşındabirhastasunuldu.Ope-rasyon bulguları, apendiks duplikasyonu ile birlikte çiftakutapandisitşeklindeidi.TipBduplikasyonolmasınede-niyleapendikslerayrıayrıalındı.Apendektomiensıkuy-gulananabdominalcerrahiolmasınedeniyletümcerrahlarbunadirklinikantiteyiakıldatutmalıdırlar.Anahtar Sözcükler:Apandisit;duplikasyon;appendiksvemiformis.

Duplicationofthevermiformappendixisararecongenitalabnormalityandusuallyfoundincidentallyduringlaparot-omy.TheModifiedCave-Wallbridgeclassificationisusedto describe the location of the appendixes in relation toeachotherandtothececumaswellastheextentofthedu-plication.Wereporta45-year-oldpatientwhounderwentlaparotomyforacuteabdominalpain.Theoperativefindingwas double acute appendicitis in appendical duplication.Theappendixeswereremovedseparately,asitwastypeBduplication.Sinceappendectomyisthemostcommonab-dominaloperation,allsurgeonsshouldkeepthisrareclini-calentityinmind.Key Words:Appendicitis;duplication;vermiformappendix.

Appendicalduplicationisarareabnormality,withanestimatedincidenceof0.004%amongpatientsun-dergoingappendectomy.[1,2]

Wereportacaseofappendicalduplicationpresent-edwithdoubleacuteappendicitis.

CASE REPORTA 45-year-old male presented with right lower

quadrant pain, anorexia, nausea, and vomiting. Thepain started in the epigastric region three days ago,andthenintensifiedinseveritywithmigrationtotherightlowerquadrant.Onphysicalexamination,rigid-ity and rebound tenderness were noted in the rightlower quadrant. The patient was febrile and tachy-cardic.Whitebloodcellcountwas21900/mm3.Otherlaboratory values were normal. Plain abdomen andchest X-rays appeared normal. Pelvic ultrasound intheemergencysuiteshowedminimalperiappendicu-larfluidandanon-peristaltic,non-compressibletubu-larstructurewithadiameterof10mm.

McBurney incision was extended with the helpofseveralretractorsforoptimaldisplayofthesurgi-calregion,asshowninFigure1.DuringexplorationthroughtheMcBurneyincision,asmallamountofin-flammatoryfluidwasnoted.Aftercecalmobilization,twoappendixeswere seen:oneon thecornerwherethetaeniacoliconverge,andtheotherjustnexttoit,with two separate bases.They shared the sameme-soappendix, and both were erectile, hyperemic andinflamed;however,onewasgangrenousandshowedserosal necrosis (Figs. 1, 2). Routine appendectomywasperformedforeach.Thepostoperativeperiodwasuneventful,andthepatientwasdischargedonthe3rdpostoperativeday.

Onpathologicalexamination,theappendixesmea-sured5x0.7cmand8x0.8cm.Thelumenofthefirstwas obstructed completelywith fecalith resulting inserosalnecrosis,whereas theother stillhada2mmluminalpassagedespite the fecalith.Bothappendix-

1AvukatCengizGökçekStateHospital,Gaziantep;2DepartmentofGeneralSurgery,CelalBayarUniversity

FacultyofMedicine,Manisa,Turkey.

1AvukatCengizGökçekDevletHastanesi,Gaziantep;2CelalBayarÜniversitesiTıpFakültesi,GenelCerrahiAnabilimDalı,

Manisa.

Correspondence(İletişim):SemraTutcuŞahin,M.D.AvukatCengizGökçekDevletHastanesi,65300Gaziantep,Turkey.Tel:+090-342-2210700e-mail(e-posta):[email protected]

doi: 10.5505/tjtes.2013.80557

es had lymphoid tissues infiltrated predominantly by neutrophils.

DISCUSSIONDuplicated appendix vermiformis is a quite un-

common entity, believed to be seen in 1 in 25000 ap-pendectomies.[1,2] Cave and Wallbridge classified ap-pendical duplication by their anatomical localization into three groups. Type A refers to incomplete dupli-cation, where both appendixes arise from a common base from the cecum. Type B is the complete duplica-tion, where one appendix is found in the usual loca-tion, where the taenia coli converge, while the local-ization of the other varies. Duplication of the cecum is classified as type C, where each cecum has its own appendix.[3-5] Mesko et al.[4] described one appendix connected to the cecum with two openings, horseshoe appendix, which can be classified as type D. In our case, two appendixes sharing the same mesoappendix were found next to each other, and thus were classified as type B duplication.

The majority of duplicated appendixes are be-lieved to be silent and only discovered when one of them becomes inflamed.[3-5] Our patient was 45 years old and had never experienced any symptoms regard-ing appendical duplication. Both appendixes appeared inflamed at the time of the operation.

It has been mentioned in the literature in a few re-ports that although barium enema may be helpful in the radiological diagnosis, the exact diagnosis can only be made during the operation and postoperative

pathological examination. All these anomalies are of great practical importance, and a surgeon must bear them in mind during an operation. They also carry le-gal importance in cases where repeated exploratory laparotomy reveals a “previously removed” vermi-form appendix.[6] During the first operation, insuffi-cient exploration may result in overlooking the second appendix. In the case of appendicitis at a later time, the presence of an appendectomy history may cause a delay in the diagnosis and the differential diagnosis for appendicitis, which can cause some complications and medicolegal problems.



Fig. 1. Two appendixes share the same mesoappendix with different openings to the cecum.(Color figure can be viewed in the online issue, which is available at www.tjtes.org).

Fig. 2. Gangrenous appendix (left) and fecaliths obstructing the lumen (right). Note each appendix has its own lu-men.(Color figure can be viewed in the online issue, which is available at www.tjtes.org).


Althoughseenrarely,duplicationoftheappendixshould be kept in mind since appendectomy is themost common abdominal operation. During routineappendectomy,thececumshouldbewellmobilizedtovisualizeanykindofpossibleduplication.


REFERENCES1. Travis JR,Weppner JL, Paugh JC2nd.Duplex vermiform

appendix:casereportofarupturedsecondappendix.JPedi-atrSurg2008;43:1726-8.

2. Chew DK, Borromeo JR, Gabriel YA, Holgersen LO.

Duplication of the vermiform appendix. J Pediatr Surg2000;35:617-8.

3. CaveAJ.AppendixVermiformisDuplex.JAnat1936;70:283-92.

4. Mesko TW, Lugo R, Breitholtz T. Horseshoe anomaly ofthe appendix: a previously undescribed entity. Surgery1989;106:563-6.

5. Kabay S,YucelM,Yaylak F,HaciogluA,AlginMC,Ol-gunEG,etal.Combinedduplicationof thecolonandver-miformappendixinanadultpatient.WorldJGastroenterol2008;14:641-3.

6. YanarH,ErtekinC,UnalES,TavilogluK,GulogluR,MeteO.Thecaseofacuteappendicitisandappendicealduplica-tion.ActaChirBelg2004;104:736-8.

Double acute appendicitis in appendical duplication

86




Barolith as a rare cause of acute appendicitis: a case report

Akutapandisitinnadirbirnedeni;baryumtaşı:Olgusunumu

Volkan İNCE, Burak IŞIK, Cemalettin KOÇ, Adil BAŞKIRAN, Asım ONUR

Baryum taşı, yoğunlaşmış baryum ile feçesten oluşur vegastrointestinalsistem(GİS)görüntülemeçalışmalarındansonranadirengörülür.Bu türgörüntülemeyöntemlerindekullanılanbaryumapendiks lümeninegirebilir ve lümenidaraltarak ya da tıkayarak nadiren akut apandisite sebepolabilir.Baryumyutularakyadalavmanlayapılanbugö-rüntülemetetkiklerinde,baryum%80-90apendikslümeni-nidoldururveapendiksgörüntülenirvebusağlıklıapen-diksbulgusuolarakkabuledilir.İncelemesonrası%90-95oranındabaryumapendikstekalırvebukalmasüresihasta-ların%10’unda72saattenuzundur.Baryumunapendikstekalışı2aydanuzunsürersekomplikeapendisitlesonuçla-nabilir.Buyazıda,baryumluçiftkontrastkolongrafisinden3aysonra,baryumtaşınabağlıakutapandisit tanısıalanve apendektomi yapılan 46 yaşında erkek hasta sunuldu.Baryumlugörüntülemelerden sonrabaryumunapendikstekalarakakutapandisitesebepolabileceğiyönündenhasta-larbilgilendirilmelikieğerkarınağrısıgelişirse,hızlıbirşekildeuyguntedaviiçinbirsağlıkmerkezineyönlendiri-lebilirveerkengirişimleakutapandisitinkomplikasyonlarıönlenebilir.Anahtar Sözcükler:Apandisit;baryum;baryumtaşı;fekalit.

Abarolithconsistsofinspissatedbariumassociatedwithfe-cesandisseen,rarely,afterbariumstudiesforimagingthegastrointestinalsystem.Thebariumusedinsuchstudiescanentertheappendiceallumenand,rarely,causeappendicitisbyobliteratingornarrowingthelumenoftheappendix.Theappendixfillswithbariumandtheentireappendixisvisual-ized in80-90%ofbarium swallowor enema studies, andthisisacceptedasareliablesignofanon-diseasedappendixPost-examinationretentionofbariumintheappendixisverycommon(90~95%),and10%ofthepatientsretainbariumintheappendixbeyond72hours.Ifthebariumisretainedformorethantwomonths,complicatedappendicitiscanresult.Wepresenta46-year-oldmalewhowasdiagnosedwithacuteappendicitisduetoabarolithandrequiredanappendectomythreemonths after a double-contrast barium enema study.Afterbariumstudies,patientsshouldbeinformedregardingretentionofbariumintheappendixandthepossibilitythatitcancauseacuteappendicitis.Thus,ifabdominalpaindevel-ops,thepatientcanbereferredquicklytoamedicalcenterfortheappropriatetreatmentandthecomplicationsofacuteappendicitiscanbepreventedwithearlyintervention.Key Words:Appendicitis;barium;barolith;fecalith.

Abarolithconsistsofinspissatedbariumassociatedwithfeces,andisseen,rarely,afterbariumstudiesforimagingthegastrointestinalsystem.Itmaycausedif-ferentclinicalconditions,dependingonitslocationinthegastrointestinalsystem,includingvolvulus,intus-susception,colonicobstruction,ulcerationorperfora-tion,andappendicitis.[1]

Wepresent a patientwhodeveloped appendicitisdue to a barolith threemonths after a barium swal-lowforanupperintestinalseriesandadouble-contrastbariumenema.

CASE REPORTA46-year-oldmalewasadmittedtoourcliniccom-

plainingofabdominalpainintherightlowerquadrantforoneweek.Hehadundergoneanupper intestinalseries and double-contrast barium enema to investi-gatetheetiologyofhischronicdiarrheathreemonthspreviously, and these had been reported as normal.An opacitywas seen in the right lower quadrant, atthelocationoftheappendix,onanabdominalX-ray(Fig.1a).Wereviewedthedouble-contrastbariumen-emaperformedthreemonthsearlierandsawthatthe

DepartmentofGeneralSurgery,InonuUniversityFacultyofMedicine,Malatya.

İnönüÜniversitesiTıpFakültesi,GenelCerrahiAnabilimDalı,Malatya.

Correspondence(İletişim):Volkanİnce,M.D.İnönüÜniversitesiTıpFakültesiTurgutÖzalTıpMerkezi,GenelCerrahiABD,44280Malatya,Turkey.Tel:+090-4223410660/3725e-mail(e-posta):[email protected]

doi: 10.5505/tjtes.2013.39327

appendixhadbeenfilledwithbarium(Fig.1b).Thepatientwasadmittedwithadiagnosisofacuteappen-dicitis. On physical examination, the patient’s vitalsignswerestable,buthehadtenderness,rigidity,andreboundintherightlowerquadrantoftheabdomen.Therewerenoabnormalitiesonlaboratorytesting,soa laparotomywasperformed.Theappendixwashy-peremic and erectile, and a barolithwas palpable inthedistalsection(Fig.1c).Anappendectomywasper-formed.When the specimenwascut, abarolithwasseeninthedistalpartandafecalithproximally(Fig.1d).Thepostoperativefollow-upwasuneventful,andthepatientwasdischargedonpostoperativeday1.

DISCUSSIONTheappendixfillswithbariumandtheentireap-

pendixisvisualizedin80-90%ofbariumswalloworenemastudies,andthisisacceptedasareliablesignofanon-diseasedappendix.[2]Post-examinationreten-tionofbariumin theappendixisverycommon(90-95%), and 10% of the patients retain barium in theappendixbeyond72hours.[3]The intervalbetweenabariumstudyandthepresentationofbariumappendi-

citisrangesfromfourdaystofouryears.[4]Ifthebari-umisretainedformorethantwomonths,complicatedappendicitiscanresult.[5,6]

The spontaneous evacuation of barium from theappendixinchildrenmaytakelongerthaninadults.[6] Patientsonalow-residuedietsufferingfromdehydra-tionhavealteredcolonicmotilityandareatpotentialriskofbarolithobstruction.[6]Inourcase,despitein-creased colonicmotility, the bariumwas retained intheappendixandacute appendicitisdeveloped threemonthsaftertheexamination.

An appendectomy is often performed in patientswhopresentwithsymptomsofacuteappendicitis,re-gardlessofahistoryofbariumimaging.Theliteraturediscussesthistopic,includingtheetiologyofbarium-inducedappendicitisandwhenweshouldperformanappendectomy.

Thepathogenesisofappendicitisduetobariumisstillunclear,buttheconsensusholdsthatinspissatedbariumtriggersinflammationbynarrowingorobliter-atingtheappendixlumen,likeanappendicolith,and

(a)

(c)

(b)

(d)

Fig. 1. (a)AppearanceoftheappendixontheabdominalX-ray.(b)Theappendixisfilledwithbariumduringthedouble-contrastbariumenema.(c)Theappendixishyperemicanderectile,withabarolithinthedistalpart.(d)Theappearanceofthebarolithandfecalithinthecutappendix.


Barolith as a rare cause of acute appendicitis



causesappendicitisorappendixperforation.[1-5]Bari-um is inert andhas littlephysiological effecton thegastrointestinal tract, so inflammation triggered viachemicalirritationisnotamorelikelypossibility.

Anappendectomy is not recommended for everypatientwhohasprolongedretentionofbariumintheappendix; theymaybefollowedunlesstheybecomesymptomatic.[2,5,6]These patients should be followedcloselybecausetheriskofdevelopingcomplicationsincreaseswiththedurationofbariumretention.Inourcase, the laboratory parameters were normal, whilethephysicalexaminationwassuggestiveofacuteap-pendicitis.Consequently, an appendectomywasper-formed.

Inconclusion,afterbariumstudies,patientsshouldbe informed regarding possible retention of bariumin theappendix,whichcancauseacuteappendicitis.Thus, ifabdominalpaindevelops, thepatientcanbereferredquicklytoamedicalcenterfortheappropriate

treatment,andthecomplicationsofacuteappendicitiscanbepreventedwithearlyintervention.


REFERENCES1. ChampmanAH,el-HasaniS.Colonischaemiasecondaryto

barolithobstruction.BrJRadiol1998;71:983-4.2. Palder SB, Dalessandri KM. Barium appendicitis. West J

Med1988;148:462-4.3. MaglinteDD,BushML,ArutaEV,BullingtonGE.Retained

bariumntheappendix:diagnosticandclinicalsignificance.AJRAmJRoentgenol1981;137:529-33.

4. NovotnyNM,LillemoeKD,FalimirskiME.Bariumappen-dicitis after upper gastrointestinal imaging. J Emerg Med2010;38:148-9.

5. FangYJ,WangHP,HoCM,LiuKL.Bariumappendicitis.Surgery2009;146:957-8.

6. NagataH,OhgaS,HattoriS,MasumotoK,TaguchiT,Mat-sumotoT,etal.Barium-associatedappendicitisinachildhoodcasewithCrohn’sdisease.ActaPaediatr2006;95:889-90.

Değerli Meslektaşlarım,

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

Saygılarımızla,

Recep Güloğlu Salih PekmezciUlusal Travma ve Acil Cerrahi Derneği Başkanı Kongre Başkanı

DÜZENLEME KURULU

Kongre BaşkanıSalih PEKMEZCİ

Kongre Eş BaşkanıTayfun YÜCEL

Genel SekreterM. Mahir ÖZMEN

Bilimsel SekreteryaKaya SARIBEYOĞLU

Hakan YANAR

ÜyelerEdiz ALTINLIAcar AREN

Gürhan ÇELİKCemalettin ERTEKIN

Recep GÜLOĞLUAhmet Nuray TURHAN

travma 2013-1

Documents

indexed in index medicus

science citation index

embaseexcerpta medica

january 2013cilt

index copernicus

orgindex medicus

number 1 ocak

volume 19www